Every finding on record at Safehaven Healthcare LLC

Observed in Record Review. The written plan of care is based on the patient’s and the time frames, settings, and services required to meet those goals .

Observed in Record Review. In 4 of 4 patient records reviewed, The organization did not provide a written summary to the patient’s physician or other licensed practitioner in accordance with law and regulation.For hospices that elect to use The Joint Commission deemed status option: Law and regulation require that the hospice inform the attending physician of the availability of a discharge summary. The summary is provided to the practitioner upon the their request and includes the patient's medical and health status at the time of .For home health agencies that elect to use The Joint Commission deemed status option: A completed summary is sent to the primary care provider or other health care professional who will be responsible for providing care and services to the patient (if any) after from the organization within five business days of the patient's . provides a written summary to the patient’s physician or other licensed practitioner in accordance with law and regulation.For hospices that elect to use The Joint Commission deemed status option: Law and regulation require that the hospice inform the attending physician of the availability of a summary. The summary is provided to the practitioner upon the their request and includes the patient's medical and health status at the time of discharge .For home health agencies that elect to use The Joint Commission deemed status option: A completed summary is sent to the primary care provider or other health care professional who will be responsible for providing care and services to the patient (if any) after from the organization within five business days of the patient's discharge .During review of records 11-14 it was noted that there was no record of the discharge summary being provided to the physician. this was confirmed by the Director of Nursing. Observed in Record Review. In 2 of 2 patient records reviewed, For hospices that elect to use The Joint Commission deemed status option: If the care of the patient is transferred to another Medicare/Medicaid-certified facility, the hospice provides the receiving facility with a copy of the hospice discharge summary and, if requested, a copy of the patient’s clinical record. During review of records 13 and 14 it was noted that there was no record of the discharge summary being sent to the hospitals that would be providing ongoing care to the patients. This was confirmed by the Director of Nursing.

Observed in Patient Home. In 2 of 2 home visits conducted, with a nurse the surveyor noted that the organization failed to reassess potential medication related problems. For example, during HV#1 and HV#2 the hospice nurse failed to conduct a medication assessment. This was discussed with the nurse and Administrator.

Observed in Record Review. In 13 of 13 patient records reviewed, the surveyor noted that the written plan of care was not based on individualized goals and the time frames, settings, and services required to meet those goals. For example, records BR#1, BR#2, and BR#3 all had the same one goal in the bereavement record, Facilitate normal grief process. Bereaved will demonstrate appropriate coping and behavior in process. This goal was not individualized, was not measurable and did not include a time frame. Second example; RR#1, RR#2, RR#3 and RR#4 records, in the old EHR system, were free texted and changed visit to visit. There were no time frames indicated and goals were not measurable. Third example; HV#1, HV#2, HV#3, RR#5 to RR#10 records in new EHR no time frames were indicated. RR#2, RR#8, and RR#7 the goals were not measurable. This was confirmed with RN present.

Observed in Record Review. In 8 of 13 patient records reviewed, the plan of care did not include a complete statement of the frequency of the services necessary to meet the patient’s and family’s needs. For example, HV#1 the POC included chaplain PRN visits with no direction for the reason to use these visits. HV#2, RR#6, RR#7, RR#8, RR#9, and HV#3 the POCs included Chaplain, MSW, and nurse PRN visits with no direction for the reason to use these visits. RR#10 the POC included nurse and MSW PRN visits with no direction for the reason to use these visits. This was confirmed with the Administrator.

Observed in Patient Home. In 2 of 2 home visits conducted, when the staff used equipment in the home, the surveyor noted that the hospice did not follow accepted standards of practice to prevent the transmission of infections. For example, HV#1 and HV#2 the nurse used Purrell wipes to disinfect the equipment after use. The Purrell packaging stated that the product was to be used for hand hygiene and did not include the disinfection of equipment. This was confirmed with the nurse present and discussion with the Administrator.

Observed in Record Review. In 6 of 13 patient records reviewed, the patient record did not contain all clinical information. For example; In HV#1, the Surveyor noted the medication profile indicated Midodrine per physician order. The medication profile included duplicate medications for cough/congestion prn: DuoNeb and Situssion-DM; however, there was no indication as to what medication to take first. The medication profile also included duplicate medications for shortness of breath prn: DuoNeb and oxygen; however, there was no indication as to what medication to take first. This was confirmed with the Administrator. In HV#2, the Surveyor noted the medication profile indicated DuoNeb, Sodium Chloride, and Biotene oral balance prn with no further direction. Second example, the medication profile included duplicate medications for shortness of breath prn: Morphine and oxygen; however, there was no indication as to what medication to take first. Third example, the medication profile included duplicate medications for constipation prn: biscodyl suppository, Palomcare and Lactulose; however, there was no indication as to what medication to take first. This was confirmed with the Administrator. In RR#1, the Surveyor noted the medication profile included duplicate medications for breathing comfort prn: Albuterol and oxygen; however, there was no indication as to what medication to take first. HV#3 and RR#5 the Surveyor noted the medication profile included duplicate medications for shortness of breath prn: morphine and oxygen; however, there was no indication as to what medication to use first. RR#10 the Surveyor noted the medication profile included duplicate medications for pain prn: Motrin, Tylenol, Tera-Gesic, Flexeril and Morphine; however there was no indication as to what medication to take first. This was confirmed with the Administrator.

Observed in Record Review. In 1 of 1 patient records reviewed, for a discharged patient, the surveyor noted that the Deemed HOS agency did not inform the physician of the availability of a discharge summary. This was confirmed with the nurse present.

Observed in Patient Home. In 2 of 2 home visits conducted, that included oxygen therapy, the surveyor noted that the organization had not addressed potential threats to the safety of the patient and property. For example HV#2 no action was taken by the RN on the freestanding oxygen cylinder in home. HV#1 the primary caregiver was not aware of a backup oxygen tank, e-tank, in the home and called another family member to learn where it was located. The caregiver was not aware of how to use the backup system. Multiple visits had been made to this patient's home with this caregiver and no education was documented related to location of backup oxygen or education on how to use it. This was confirmed with the nurse present.