Every finding on record at Sea Coast Hospice Care, Inc

Observed in Emergency Management Session. the organization failed of how to manage interruptions to information processes as evidence by, during a reported Cyberattack of the electronic medical record the organization was unable to provide the Surveyor with backup information of patient information from the medical record. This was validated and reviewed with the Director of Patient Services/Administrator Designee and the CEO.

Observed in Record Review. In 1 of 4 patient records reviewed, the Home Health Aide/Certified Nursing Assistant (HHA/CNA) failed to follow the plan of care. For example, in RRHV #1,the plan of care indicated HHA visits twice a week as of the date of the Start of Care (SOC). Twice a week visits were not made for the first week of the SOC. Another example, in RRHV #1 the initial order was written for daily Skilled Nurse (SN) visits. The SN wrote an additional order to change daily visits to three times a week but only did twice a week visits for the first week the order for 3 times a week visits became active. This was validated and reviewed with the Director of Patient Care Services/Administrator Designee. Observed in Record Review. In 14 of 19 patient records reviewed, the organization failed to provide teaching of the interventions established in the plan of care. For example, in RRHV #1, RRHV #2, and RRHV #3, and RRHV #4, RRDC #1 and 2, Bereavement #1, 2, and 3, RRNHV #3, 4, 5, 7, 8the Hospice Nurse documented, ADL teaching will be met in the next 14 days as exhibited by patient will be clean, dressed, and fed at SN visit. In the Hospice Nurse's documentation throughout all notes there is no documentation to support ADL teachings within the 14 days established. This was validated and reviewed with the Administrator Designee/Director of Patient Care Services.

Observed in Record Review. In 1 of 4 patient records reviewed, the Home Health Aide/Certified Nursing Assistant (HHA/CNA) failed to follow the aide care plan. For example, in benefit period 1 in RRHV #2 the HHA documented, encouraged fluids as tolerated. The initial care plan did not indicate encourage fluids as tolerated and the Director of Patient Care Services/Administrator Designee who was also the Registered Nurse who developed the plan of care stated to the Surveyor encourage fluids was not added to the care plan due to the patients difficulty with aspiration. This was validated and reviewed with the Director of Patient Services/Administrator Designee.

Observed in Record Review. In 1 of 13 patient records reviewed, the organization had not ensured the interdisciplinary group completed all initial assessments no later than 5 calendar days after the election of hospice care. For example in review of the record associated with HV2 the Spiritual Counsellor did not complete the initial spiritual care assessment until day seven of care. This was confirmed by the QAPI Coordinator.

Observed in Individual Tracer. In 1 of 3 home visits conducted, the organization had not ensured the assessment of potential medication related problems. For example, during HV3 the Registered Nurse did not do a medication reconciliation in the home as per the organizations policy. This was confirmed by the QAPI Coordinator.

Observed in Individual Tracer. In 1 of 3 home visits conducted, not the organization had not ensured the use of recommended standards of cleaning for pulse oximeters. For example, during HV3 the Nurse cleaned the pulse oximeter with a sani wipe instead the manufacturers recommended use of a cloth damp or isopropyl alcohol. This was confirmed by the QAPI Coordinator.