Every finding on record at Serendipite Healthcare Group

Observed in HR File Review. In 1 of 9 HR files reviewed, it was noted that there was no initial emergency management training. For example, the Medical Director's HR file did not include initial emergency preparedness education. This was confirmed with the HR Coordinator present.

Observed in Record Review. In 4 of 10 patient records reviewed, it was noted that the initial bereavement assessment was not completed as part of the comprehensive assessment. For example, in records RRHV#2 and RRNHV#2 there was no initial bereavement assessment documented. For example, in record RRNHV#1 the initial bereavement assessment was not completed within the 5 days from admission, it was documented as completed on day 16. For example, in record RRNHV#5 the initial bereavement assessment was not completed within the 5 days from admission, it was documented as completed on day 10. This was discussed with the Administrator and DPCS designee.

Observed in Record Review. In 10 of 10 patient records reviewed, it was noted that the hospice did not individualize the written plan of care. For example, all goals in all 10 records time frames were for the next IDG meeting with the dates changed at each IDG to the next IDG date and goals were not measurable. Goals remained unchanged from admission with only the dates changed at IDG. For example, RRNHV#7 Pt/pcg will verbalize understanding of medication /treatment orders and side effects goal remained current for over 8 months. For example, RRNHV#6 Pt needs will be met on a day to day basis as communicated goal remained unchanged from admission, 17 months. For example Family to be able to cope with changes and Increase awareness of realistic expectations. This was confirmed with the Administrator and QAPI Coordinator present.

Observed in Record Review. In 10 of 10 patient records reviewed, it was found that the interventions in the POCs were not updated as the patient's condition changed. For example in RRNHV#5 the patient developed a coccyx wound that was documented in the nurses visit notes and a supplemental order was received for treatment. However, the POC was not updated with the wound care intervention. This was confirmed with the QAPI Coordinator present.

Observed in Record Review. In 2 of 10 patient records reviewed, it was noted that the staff did not follow the ordered frequency of visits. For example, in record RRHV#3 aide care was ordered 3 times a week and one week 2 visits were documented and there was no order or documentation of a missing visit to support the decrease in visits.  Also in RRHV#3 the MSW visit frequency was ordered 1 time a week and the MSW documented visits 1 time a month. This was confirmed with the QAPI Coordinator and DPCS designee present.

Observed in Patient Home. In 3 of 3 home visits conducted, it was noted that the organization had not implemented its infection prevention and control activities as planned; staff failed to perform hand hygiene consistent with organizational policy. For example, during HV#1 the nurse failed to perform hand hygiene when removing gloves while cleaning equipment. During HV#2 the nurse failed to perform hand hygiene when removing gloves. During HV#3 the aide failed to perform hand hygiene more than2 times after removing gloves. This was discussed with Administrator and DPCS designee. Observed in Patient Home. In 1 of 2 home visits conducted, that included staff to bring equipment into the home, it was noted that the organization had not implemented infection prevention and control activities when cleaning and performing disinfection of medical supplies and devices. For example, during HV#2 the nurse did not follow the 2 minute contact time (wet time) as specified by the purple top Sani Wipe manufacturer’s IFUs and stated on the product package. This was discussed with the Administrator, DPCS designee, and QAPI Coordinator.

Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement care it was noted that the bereavement care plans did not include specific, individualized interventions, and the timing and frequency were the exactly the same. Also in RRBR#1 and RRBR#2 the bereavement plan of cares included interventions, but no goals. This was confirmed with the Administrator and Bereavement program coordinator during the Bereavement session.

Observed in Patient Home. In 3 of 3 home visits conducted, it was noted that the organization did not provide the patient with an individualized emergency plan. For example, the organization had a form to be individualized to the patient's situation upon admission, however during HV#1 the form in the patient's home folder was discovered to be blank, with only the patient's name written on it. During HV#2, the individualized emergency document in the patient's folder was incomplete with no category indicated. During HV#3 there was no individualized EM plan in home folder and an incomplete individualized EM plan scanned into the electronic record. This was confirmed with the Administrator and DPCS designee.