Every finding on record at Sj Hospice Services, LLC

Observed in Record Review. In 1 of 1 records reviewed where the patient revoked hospice care, there was no revocation statement found. In RRDC #1, it was noted in the patient chart that the caregiver called hospice to let them know they took the patient to the ER. The nursing note stated SN informed caregiver that the patient would be revoking Hospice Services due to her visit to the ER. There was no documentation in the record that a revocation statement was signed and the document was not located in the organization's electronic or paper record. This was discussed with agency leadership.

Observed in Record Review. In 1 of 10 active patient records reviewed, the Surveyor noted the registered nurse had not completed a comprehensive visit every 15 days. On RRNHV #1, there had been 3 weeks between registered nurse comprehensive visits. This was discussed with agency leadership.

Observed in Record Review. In 1 out of 10 active patient records reviewed, the organization failed to ensure the care and services were provided in accordance with the plan of care. On review of RRNHV #1 the spiritual counselor was scheduled for monthly visits but there have been no documented visits over the last three months. This was reviewed with agency leaders. Observed in Record Review. In 3 of 3 patient records where the patient had passed away on service, the bereavement plan of care was not followed. Agency policy for bereavement services is a combination of phone calls and mailings based on the assessed patient risk with the first contact being a sympathy card mailing in the first week, instead a call was made first and the bereaved declined services. On RRBR #1 and RRBR #2, the sympathy card was not mailed out per policy in the first week of death. On RRBR #3, the organization had no documentation that the sympathy card was mailed to the patient per policy. This finding was reviewed with the agency leadership.

Observed in Data Session. During review of the organization’s quality program, the organization had been collected data on areas of patient satisfaction, adverse events infections and complaints, however the data was not compiled in a manner it could be analyzed or used to identify performance trends or variances. This finding was reviewed with agency leadership. Observed in Data Tracer. During review of the organization’s quality program, the organization had been collecting data but it was not being aggregated, trended or analyzed so therefore it was not being utilized to identify areas for process improvement. For example the organization had HIS data that was below national and state averages in multiple areas and had not utilized the data for improvement.

Observed in Data Tracer. During review of the organization’s quality program, the governing body had not approved the frequency and detail of the data collection associated to QAPI measures for 2023 and 2024. This was reviewed and validated with agency leadership. This finding was reviewed with agency leadership.

Observed in Record Review. On 2 of 10 active patient records reviewed, Homemaker staff were not supervised effectively. Agency Policy for Homemaker services will supervise the homemaker every 30 days and documentation will be put in the Progress Note of the supervision. On RRHV #2, it was noted that the homemaker was not being supervised every 30 days since admission. On RRNHV #6, it was noted that the patient has been receiving homemaker services for the past 2 months and there has not been any supervision completed. On RRNHV #7 it was noted that patient has been receiving homemaker services for 2 months and no supervision has been documented in the clinical record. This finding was reviewed with Agency Leadership.

Observed in Tracer Activities. In review of the volunteer program the volunteer coordinator reported that she currently has no volunteers and has not had any for several months and is actively recruiting. Since there have been no volunteers available the agency was not able to demonstrate that volunteers provide at least 5% of the total patient care hours provided by the hospice. This finding discussed and reviewed

Observed in Record Review. In 2 of 2 discharge records reviewed, the discharge summary was not provided to the attending physician or notification that it was available on request. On RRDC #1, it was noted that the patient revoked hospice to go to the ER but there was no discharge summary created to be sent to the receiving provider. On RRDC #2, patient discharged from service and no discharge summary was created or sent to the attending physician. This finding was reviewed with agency leadership.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not provide education on the safe storage of oxygen cylinders in the home. On RRHV #2, it was noted on the visit that the oxygen cylinders were being stored upright without being secured. On review of the education provided the education did not discuss securing tanks when in the upright position or that if they couldn't be secured to place them lying down. This finding was reviewed with agency leadership.

Observed in Individual Tracer. In 2 of 11 patient records reviewed, the organization did not update the IDG with changes that had taken place since the initial assessment. It did not include information on the patient's progress toward desired outcome, as well as a reassessment of the patient's response to care. For example, HV3 had no update on 10/14 regarding pain, shortness of breath and status of the chest incision. The second example RR11 did not include an update on the patient's progress from liquids through the PEG tube to taking food in orally, and there was no report 9/30 or 10/14 on the status of a new abscess found 9/16. This was verified with the Administrator and Director of Patient Care.

Observed in Individual Tracer. In 2 of 11 patient records reviewed, the hospice surveyor noted that care plans established at admission did not include all care and interventions needed to provide the patients' care. For example, the care plan for RR10 did not include the need for PT/INR testing. In addition, the care plan for RR11 did not include service related to Foley catheter care. This was verified with the Administrator and Director of Patient Care.

Observed in Individual Tracer. In 8 of 11 patient records reviewed, the written plan of care did not consistently include measurable goals and time frames to achieve those goals. This is evidenced by the following examples: HV1 and HV2- there was no time frame on pain goal, other time frames included during episode of care, this goal was not measurable elimination needs met at acceptable level. HV3 -used during episode of care, no time frames on goals related to education, no time frame on completing advance directive RR7-used family will demonstrate improved coping skills, exhibit reduced stress, pain controlled at acceptable level, exhibit less shortness of breath, and using 'during episode of care or having no time frames, RR8-used exhibit reduced stress , no time frames or using during episode of care RR9- no time frame on pain goal, using during episode of care as time frame for decreased SOB and skin integrity, no goal for making decision regarding funeral arrangements and no time frame, no time frame for completing advance directive RR10- using bowel elimination within acceptable level, no time frame on pain, RR11- education goals to be met during episode of care. This was verified with the Administrator and Director of Patient Care.

Observed in Individual Tracer. In 2 of 11 patient records reviewed, the care plan was not revised based on information from updated information. For example, in HV2 the care plan was not updated when the Foley catheter was removed 11/19/2020. The information was still on the care plan as of 10/26/21. The second example, RR11 the care plan was not updated to reflect that the patient was now eating solid foods. The patient had five cans of Glucerna via PEG tube on admission. The care plan was not updated as of 10/41. This was verified with the Administrator and Director of Patient Care.

Observed in Individual Tracer. In 1 of 11 patient records reviewed, of which three were discharged the hospice did not provide the patient’s attending physician with a copy of the hospice discharge summary. This was verified with the Administrator and Director of Patient Care.

Observed in Individual Tracer. In 2 of 11 patient records reviewed, of which 3 were discharged, the discharge summaries for RR4 and RR5, patients who revoked, did not include a summary of the patient's stay including treatments, symptoms, and pain management. This was verified with the Administrator and Director of Patient Care.