Every finding on record at Sourceone Hospice & Palliative Care, LLC

Observed in Record Review. In 3 of 3 records reviewed where the patient discharged from service due to revocation, there was no evidence that the organization notified the receiving provider of the availability of a discharge summary, or that a discharge summary was provided. In RRNHV#2, RRNHV#3, and RRLiveDC#1, the patients each revoked hospice services to seek care or treatment elsewhere, yet there is no documentation that the discharge summary was offered or provided to receiving healthcare providers. This was reviewed and validated with the Administrator and the Director of Patient Care Services.

Observed in HR File Review. In 6 of 8 HR files reviewed, the organization had not complied with their policy no. 7-001.5 Emergency Management and provided initial education and training of their emergency management plan and processes to staff at the time of hire. In review of the personnel files for HR 1, HR 2, HR 3, HR 4, HR 5, and HR 8 there was no evidence that education regarding the organization's emergency operations plan had been completed. This was validated by the Human Resource Manager.

Observed in Patient Home. In 5 of 5 home visits conducted, the organization had not informed the patient both orally and in writing of their financial responsibility. In review of the home folder for RRHV#1 the surveyor noted that the payment section on the consent form was blank. This was also observed in review of the home folders for RRHV#2, RRHV# 3, RRDC#4 and RRDC#5. This was validated with the DPCS and Administrator.

Observed in Record Review. the comprehensive assessment had not been completed no later than five calendar days after the election of hospice care. In review of the medical record for RRHV#1 the Psychosocial Assessment was completed on the 6th day following the election of the hospice benefit. This was validated with the Administrator and DPCS.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization did not include measurable outcomes and interventions for each identified problem on the Plan of Care. For example in review of the medical record for RRHV#1 the IDG team identified problems of Cognitive Loss/Dementia with the goal; Patient be able to be able to participate in ADLs and self care however, failed to include measurable outcomes (eg; patient will brush his teeth and comb his hair) and time frames for achieving goals. Also, in review of the medical record for RRHV#2 the IDG team identified the problem of Cognitive Loss/Dementia with the goal; staff will be able to assist patient in most of the ADLs for patient's comfort and safety. Patient unable to determine time and the need to move and think what needs to be done. Patient will be able to communicate non verbally to staff and caregiver if he is not feeling good or uncomfortable however, failed to include time frames for achieving goals. Additionally, in review of the medical record for RRHV#3 on admission the Plan of Care included a problem of skin breakdown with the goal of: avoid further breakdown of skin, provide interventions to promote healing and provide measures to provide comfort to patient however the Plan of Care failed to include measurable objectives including wound measurements, time frames for healing and identified interventions including wound care were not included on the plan of care. This was also observed in review of the medical records for RRDC#4 and RRDC#5. This was validated with the Administrator and DPCS.

Observed in Patient Home. In 1 of 3 home visits conducted, staff failed to perform hand hygiene at times required by standard precautions, manufacturer instructions or organizational policy no. 9-007.2 Standard Precautions as evidenced by; in observation of the home visit for RRHV#3 the hospice aide failed to perform hand hygiene between glove changes. This was observed at three different times throughout the home visit and was validated with the DPCS and Administrator.

Observed in Data Session. in review of the Infection Control Plan the organization had not identified infection risks based on the following the care, treatment, or services they provide or the population of patients receiving end of life care. This was validated with the Administrator and DPCS.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization failed to follow their policy no. 2-010.1 Bereavement Services which states after the initial bereavement risk assessment is completed, a plan will be developed to address bereavement/grief issues and will be implemented and updated as needed. In review of the medical record for RRHV#1 the care plan did not include a plan for bereavement/grief. This was also observed in review of the medical records for RRHV#2, RRHV#3, RRDC#4 and RRDC#5, This was validated with the Bereavement Coordinator.

Observed in HR File Review. In 2 of 2 HR files reviewed, for Hospice Aides, the organization had evaluated all hospice aide competencies through verbal evaluation only. In review of the personnel files for Hospice Aides HR 6 and HR 7 the entire competency had been evaluated verbally with no evidence of observation of the hospice aides performing required tasks with a patient or pseudo-patient as part of a simulation. This was validated by the Human Resource Manager.

Observed in Infection Control System Tracer. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by a condition level finding at 484.60 with lack of required elements in the Infection Control Plan and observed instances of infection control violations with patient care.