Every finding on record at Soul Hospice Inc

Observed in Record Review. In 1 of 11 patient records reviewed, the organization did not plan the patient care by ensuring the plan of care included all services needed for the palliation and management of the terminal illness and related conditions, including interventions to manage pain and symptoms. In RR#4, the caregiver reported increased swelling to left ankle, with fracture confirmed per x-ray. The patient's plan of care did not include documentation of interventions related to ensuring comfort, safety, and management of symptoms related to the new fracture. This was reviewed and verified with the Director of Patient Care Services.

Observed in Regulatory Review. In 1 of 11 patient records reviewed, the plan of care did not include all services needed for the palliation and manage of the terminal illness and related conditions, including medical supplies and appliances necessary to meet the patient's needs. In RR#7, the plan of care included the order for the patient's #18Fr/10ml balloon suprapubic catheter to be changed by the skilled nurse every 30 days. Nursing visit note documentation and interdisciplinary team notes indicated the suprapubic catheter size was changed to a #16Fr/10ml during the patient's emergency room visit related to complications with insertion of the catheter. This change in the suprapubic catheter order was not reflected in the hospice plan of care. This was reviewed and verified with the Director of Patient Care Services.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization did not reduce the risk of infections by implementing infection prevention and control activities when cleaning and performing disinfection of medical supplies/devices/equipment. In HV#1, the aide cleaned the stethoscope and blood pressure monitor with Sani-Wipes and did not allow the equipment to dry for two (2) minutes prior to placing into an open pouch of the field bag. Per manufacturer's instructions/product label, the contact (dry) time for Sani-Wipes was 2 minutes. After use, the aide did not clean the digital thermometer before placing it back into the same open pouch of the bag with the clean equipment. In HV#3, the LVN cleaned the care equipment (stethoscope, BP monitor, pulse oximeter, and temporal thermometer) with a Sani-Cloth, but did not allow for the 2 minute contact (dry) time before placing items back into plastic bag with other clean equipment. This was reviewed and verified with the QAPI Coordinator and Director of Patient Care Services. Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not implement the infection prevention and control activities it had planned. In HV#1, the hospice aide did not use standard precautions and perform hand hygiene consistent with the organization's policy. The aide used Sani-Wipes to clean hands while providing care/services to patient. When asked by the surveyor if hand gel was available/used, the aide retrieved the hand gel from the car to used during the rest of the visit. This was reviewed and verified with the QAPI Coordinator.

Observed in Record Review. In 1 of 7 records reviewed with hospice aide services, the organization did not supervise staff effectively by ensuring the registered nurse supervised the hospice aide during an on-site visit to the patient's home no less frequently than every 14 days. In review of the record for HV#1, there was a 27 day period between documented aide supervisory visits by the RN. This was reviewed and verified with the QAPI Coordinator.

Observed in Document Review. The organization did not provide for its planned scope and level of care, treatment, and services. During contract review, it was noted that the SNF agreement for respite and general inpatient (GIP) care only had the contracted rate for respite care, with GIP services marked n/a. No other agreement/contract with a Medicare-certified hospital or skilled nursing facility for inpatient pain control and symptom management was documented. Organizational leadership contacted the skilled nursing facility and facilitated the correction/expansion of the agreement same day to include GIP level care and services. This was reviewed and verified with the QAPI Coordinator and DPCS.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not manage and take action to minimize identified safety issues. In HV#3, the facility caregiver indicted the patient's oxygen tank was stored in a closed closet in the patient's room. No action/re-education was provided by the hospice staff to minimize the identified safety risk. This was reviewed and verified with the Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not implement its infection prevention and control activities to minimize, reduce, or eliminate the risk of infections. In HV#1, the hospice aide did not follow the organization's bag technique policy. The aide placed cleaned equipment (stethoscope and BP monitor) and a used uncleaned digital thermometer in an open front pouch of the field bag. When asked what was stored in the zipped compartment of the bag, the aide indicated paper forms were stored in the closed compartment. This practice was not consistent with the organization's policy and procedure for bag technique. This was reviewed and verified with the QAPI Coordinator.