Every finding on record at Signal Health Group Palliative Care

Upon personnel record review, 8 of 8 applicable (Personnel # 1, 2, 3, 4, 5, 6, 7, 8) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy.

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 2 of 11 (Patient #2,3) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #2 comprehensive assessment did not include an assessment of the personal care & support needs, the psychosocial status of the patient, and there was no documentation evidence that a comprehensive assessment was performed for the pressure wound it did not have the size, depth and description of the drainage of the stage 2 pressure ulcer wound. Patient #3 comprehensive assessment did not include an assessment of the personal care & support needs of the patient/family/caregiver.

Upon patient record review, 7 of 11 (Patient #2,3,4,5,7,9,& 10) did not have an evidence in the comprehensive assessment that the imminence of death was taken into consideration.

Upon patient record review, 5 of 11 (Patient #1,6,8,9 &10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #1 medication profile did not include the medications Tylenol, Prostate Relief, Colon Ultra Cleanse, Lactulose, Alfuzosin HCL ER which were observed and confirmed by patient during home visit as active and current medications. Patient #6,9,10 did not include a list of all the medications that the patient is actively taking. The nurses narrative note included that medications ordered by MD were reviewed, a reconciliation was performed, and teaching on all medications were provided to patient and caregiver but there was not a medication profile. Patient #8 nurses admission narrative note documented that comfort medications and Oxygen were ordered by MD. These were not included on the medication profile.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 2 of 11 (Patient #2,9) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient # 2 did not include that instructions and education/training was provided to the patient and family/caregiver on the wound management of the stage 2 coccyx pressure sore. Patient # 9 did not include that instructions and education/training was provided to the patient and family/caregiver on management and care for the nephrostomy, ostomy and feeding pump of the patient.

Upon patient record review, 1 of 11 (Patient #2) did not include an individualized plan of care was developed and did not reflect the interventions based on the problems identified in the initial comprehensive assessments, which are necessary for the palliation and management of the terminal illness and related conditions Patient #2 comprehensive assessment indicated patient has a diagnosis of protein calorie malnutrition, severe weight loss and anorexia and decreasing appetite. Plan of care did not include interventions and goals related to the the patient's primary hospice diagnosis.

Upon patient record review, 3 of 11 (Patient #1, 9, 10) the plan of care did not include all the active medications of the patients which are necessary for the palliation and management of the terminal illness and related conditions. Patient #1 plan of care did not include the following active medications of the patient: Tylenol, Prostate Relief, Colon Ultra Cleanse, Lactulose, Alfuzosin HCL ER as observed during home visit and confirmed by patient as active and long standing. Patient #9 plan of care did not include any of the patient's medication currently taken. Additionally, the plan of care did not include in the plan of care the specific orders for management and care of the colostomy and nephrostomy, feeding pump,of the patient which were identified in the initial comprehensive assessment. Patient #10 plan of care did not include any of the patient's medication currently taken.

Upon patient record review, 4 of 11 (Patient #2,3,8,&9) did not include all the equipment that the patient is using which are necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #2 plan of care did not include the hospital bed, walker, mattress overlay and over bed table that the patient was using as observed during home visit. Patient #3 plan of care did not include the electric scooter and the portable oxygen tank that the patient was using as observed during home visits Patient #8 plan of care did not include the Oxygen concentrator which was identified in nurses comprehensive assessment and nurses notes Patient #9 plan of care did not include the feeding pump which was identified in nurses comprehensive assessment and nurses notes.

Upon client record review, 2 of 11 (Patient #2,6) care was not provided in accordance with the plan of care. Patient #2: SN documents performing wound care to pressure ulcer on coccyx area. Missing evidence of orders for the wound care. Additionally, orders for spiritual counselor but missing evidence of any spiritual care visits or missed visit documentation. Patient #6: Orders for spiritual counselor but missing evidence of any spiritual care visits or missed visit documentation.

Upon personnel record review, 1 of 1 applicable (Personnel #5) did not have evidence in the personnel file that a competency assessment was completed.

Upon patient record review 1 of 8 applicable (Patient #3) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient #3: there was no aide visit on week of 9/19/21 to meet the aide frequency order of once a week in the POC. There was not evidence of documentation that patient refused the visit for that week.

Upon observation, there was no evidence the hospice maintains, documents and provides volunteer orientation and training that is consistent with hospice industry standards. The volunteer coordinator is both the VC and volunteer. There is no evidence of an orientation for this employee in either role.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. Missing evidence that the governing body provides human resource management - missing evidence that all staff have demonstrated a skills competency prior to providing independent patient care and are oriented to their job duties and the hospice philosophy. All personnel reviewed with exception to the alternate administrator/SC/BC is missing evidence of a competency. Missing evidence of an aide competency and the aide is providing independent care.

Upon personnel record review, 2 of 12 (Personnel #7,9) did not have evidence that an orientation on the hospice philosophy was conducted for this personnel.

Upon personnel record review, 3 of 12 (Personnel #7,9) did not have evidence that these hospice employees have received orientation on their specific job requirements.

Upon personnel record review, 7 of 8 applicable (Personnel #3,4,6,7,8,9,10) did not have a skills competency assessment performed or conducted.

Upon patient record review, 1 of 11 (Patient #2) did not have evidence that the medical director or physician designee provided written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. There was no physician certification statement in the record. The form was blank and not signed by Physician.

Upon patient client record review, 2 of 11 (Patient #2,3) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #2,3: comprehensive assessment did not include an assessment of the teaching needs of the patient/family/caregiver. Section was left blank

Upon personnel record review, 1 of 8 applicable (Personnel #10) did not have evidence that credentialing was conducted to verify qualifications and credential of this personnel in the position held at the time of hire.

Upon personnel record review, 1 of 7 applicable (Personnel #7) did not have evidence of a criminal background check.