Every finding on record at Silverado Hospice North Houston

Observed in Record Review. In 9 of 14 patient records reviewed,  of active hospice patients, the Surveyor noted the initial assessment of Spiritual Care (SC) and/or Medical Social Worker (MSW) had not been completed within five calendar days of the Election of Hospice Benefit (EOHB). In RRHV #2, RRNHV #12 and RRNHV #13 there had been no spiritual care provider visit documented, nor had there been any documentation of patient contact. In RRHV #4, RRNHV #6, RRNHV #8, RRNHV #10 the MSW and the SC had not documented visit within 5 days of patient EOHB. In RRNHV #7, and RRNHV #14 the MSW had not made a visit within 5 days of EOHB. This was validated with the DPCS.

Observed in Record Review. In 11 of 14 patient records reviewed, the Surveyor noted goals that had not been specific, measurable or with an appropriate time frame. Examples include: for risk of bleeding, the goal was 'Pt will avoid any bleeding during hospice care; Patients infection process will be contained; Comfort will be promoted; Promote optimal patient safety and prevention of injury; Patient will be free from any falls during hospice care; Fall occurrences will be prevented/reduced whenever possible; Maintain an effective respiratory pattern free of cyanosis and other signs and symptoms of hypoxia Patient will achieve optimal breathing patterns, airway patency, and comfort; Avoid Falls. This had been seen in RRHV #2, RRHV #3, RRNHV #5, RRNHV #6, RRNHV #7, RRNHV #8, RRNHV #9, RRNHV #10, RRNHV #12, RRNHV #13 and RRNHV #14. This was validated with the DPCS.

Observed in Record Review. In 3 of 14 patient records reviewed, the Surveyor noted the plan of care (POC) had not addressed all patient care needs. For example, RRNHV #10 the patient had issues with pain and had been prescribed 2 different pain medications, however this had not been included on the POC. The same patient was identified as a high falls risk, and had repeated falls but this had also not been included on the POC. The patient in RRNHV #11 had frequent Urinary Tract Infections, but this had not been included on the POC. In patient RRNHV #14, the patient was bed bound and a high risk for skin breakdown and had upper respirator issues on chronic home oxygen; however, these had not been included on the POC. This was validated with the DPCS. Observed in Record Review. In 5 of 14 patient records reviewed, the Surveyor noted incomplete patient care or medication orders. For example, in RRHV #3 wound care orders had been incomplete, missing who was to complete the wound care as well as frequency of the care. In RRHV #4, the patient wound care orders had been missing who was to complete the care. In RRNHV #8 the medication orders for Morphine stated as needed for pain without specific indications. In RRNHV #12, the patient both Morphine and Tylenol ordered as needed for pain, without clear instructions for use. The patient also had Nystatin cream ordered with instructions to 'apply to affected area' without specifying the area. RRNHV #13 had Morphine tablet ordered every 4 hours as needed for pain, and Morphine Liquid ordered every 4 hours for breakthrough pain. The patient also had a lidocaine patch ordered without a specific area of application. This was validated with the DPCS.

Observed in Record Review. In 5 of 14 patient records reviewed, the Surveyor noted the patient plan of care (POC) had not been followed related to Medical Social Worker (MSW) and/or Spiritual Care (SC) ordered visits. For example, in RRHV #2, the MSW had orders for monthly visits; however, there had been no visit documented in August. RRHV #3 the MSW had orders for a monthly visit with the patient; however there had been no documented visit in the month of July. In RRHV #4, though ordered monthly, there had been no MSW and SC visits in the month of June, July and August and in RRNHV #8, the MSW visits had been ordered for monthly and yet there had been no documented visit in July, August, September and October and in RRNHV #14, the MSW had not documented a visit in September and October and the visits were ordered for monthly. This was validated with the DPCS.

Observed in Patient Home. In 2 of 4 home visits conducted, the Surveyor noted the clinicians had not cleaned their reusable equipment prior to returning the items to the clinical bag or had not followed the contact time (wet time) as specified by the disinfectant. For example, RRHV #1, the clinician had cleaned her equipment with Sani-wipes then placed them immediately into her clean bag. The nurse had been unable to identify the contact time required of the wipes. In RRHV #4, the clinician had utilized a computer and cell phone during the visit that had been placed on a kitchen table without a barrier. The clinician returned the items to her clinical bag without disinfecting them according to HCO policy. This was validated with the DPCS and the Clinician conducting the visit.

Observed in Record Review. In 7 of 12 patient records reviewed, where the patient had Hospice Aide (HA) Services ordered, care was not documented as being provided according to the plan of care. For example, in RRHV #3, RRHV #4, RRNHV #5, RRNHV #10, RRNHV #11, RRNHV #12 and RRNHV #14 the HA had orders to record the last bowel movement (BM) and report to the Case Manger if no BM in 3 days; however, this had not been completed. This was validated with the DPCS and Clinical Manager.

Observed in Tracer Activities. During a review of the Volunteer Program, the Surveyor noted the HCO had not met the 5% goal for the current year. They are currently at 2.82% for 2023. Of note, they did meet this standard in 2022 with 5.06%. This was validated with the Volunteer Coordinator and the DPCS.

Observed in Patient Home. In 1 of 4 home visits conducted, the Surveyor noted the medication list in the electronic medical record (EMR) had not contained all the medications the patient was being administered. For example, in RRHV #4, the patient was being administered a lidocaine patch to the L hip, and Albuterol and Budesonide inhalation treatments and these had not been included on the medication profile in the EMR. This was validated with the DPCS and the RN performing the patient visit.

Observed in Record Review. The surveyor observed in chart review that the social worker and chaplain goals had not been measurable or timeframe. This issue was discussed and confirmed with leadership

Observed in Record Review. The surveyor noted in record that the CHHA frequency had been ordered 10/25- 11/5 3X week . As of the week following 11/5 the CHHA had been seeing the patient 5 X a week and there had been no IDG update to care plan or order of any kind. This was confirmed with organization leadership.