Every finding on record at Spectrum Hospice

Observed in Record Review. In 1 of 2 patient records reviewed, it was noted by the surveyor that a copy of the Notice of Medicare Non-Coverage (NOMNC) was not provided to or signed as required by the patient when it was determined that the patient was going to be discharged for extended prognosis. For HOSRRDC#2 a copy of the Notice of Medicare Non-coverage (NOMNC) was signed byt the patient on the day of discharge, not two days before as required. Finding was discussed and verified with the Director of Nursing.

Observed in Record Review. In 10 of 10 patient records reviewed, active hospice patients, the nurse surveyor noted that the goals were not measurable. For example, “Patient to perform activities without distress”, “Patient to have regular bowel movements without complication”, and “Patient will experience optimal comfort with minimal distress related to feeding and nutritional needs. Additionally, all time frames for completion were at the end of the certification period. All findings were discussed and verified with the Director of Nursing.

Observed in Record Review. In 5 of 10 patient records reviewed, for active records, it was noted by the nurse surveyor that orders were not clear or complete. For HOSRRHV#2, HOSRRNHV#2, HOSRRNHV#3, HOSRRNHV#4, and HOSRRNHV#5 the oxygen orders were unclear. Orders were Oxygen BNC 2-4 liters per minute BNC PRN Shortness of Breath. There were no specific instructions on what liter to start the oxygen or how to titrate it . Finding was discussed with the Administrator and the Director of Nursing.

Observed in Record Review. In 1 of 10 patient records reviewed, it was noted by the nurse surveyor that for HOSRRNHV#5, the patient had an indwelling foley catheter that was to be changed as needed however, neither the plan of care or order included a catheter size. Finding was discussed with the Director of Nursing.

Observed in Record Review. In 5 of 9 patient records reviewed, for patients with a hospice aide, it was noted by the nurse surveyor that the hospice aide care plans did not include the information necessary for the hospice aide to effectively care for the patients. For HOSRRHV#2, HOSRRHV#3, HOSRRNHV#2, and HOSRRNHV#4 the patients were all on oxygen, however the Hospice Aide Care Plan did not give instructions as to what to do with the oxygen if the patient was using it at the time of the visit. Additionally, for HOSRRNHV#5, the Hospice Aide Care Plan had been updated but did not include information on when to notify the nurse. Findings were discussed and verified with the Director of Nursing.

Observed in Record Review. In 1 of 11 patient records reviewed, the initial comprehensive assessment was not completed within five calendar days of the patient electing the hospice benefit. In RR#7, the chaplain failed to complete the initial bereavement assessment within five days. It was completed on Day 6 and the surveyor could not find any documentation in the record that patient or family requested a visit at a later date. Performance Improvement Plan in place to address this deficiency. This was confirmed by the Director of Nursing.

Observed in Record Review. In 6 of 8 patient records reviewed, receiving aide services, HCO did not provide care according to the patient's individualized plan of care. In HV#1/RR#1, the surveyor noted that the patient received 4 aide visits during Weeks 1 and 2, instead of 5 visits as per the plan of care. In HV#2/RR#2, the aide performed additional visits in October that were not approved by the IDT. In HV#3/RR#3, RR#6, and RR#8, the patient missed a week of service in November. In RR#7, the patient received 2 aide visits during Week 1, instead of 5 visits as per the plan of care. In RR#8, the patient received 1 visit during Week 1, instead of 2 visits as per the plan of care. This was confirmed by the Director of Nursing.

Observed in Patient Home. In 1 of 3 home visits conducted, aide failed to perform hand hygiene consistent with policy. In HV#3/RR#3, the surveyor observed aide used a towel to dry her hands. According to the HCO's Hand Hygiene Policy IC.3, ...staff will dry hands and wrists thoroughly with a clean paper towel. This was confirmed by the Director of Nursing.

Observed in Record Review. In 1 of 8 patient records reviewed, receiving aide services, HCO failed to plan the patient's care. In HV#2/RR#2, the surveyor noted that the patient has a pressure ulcer of left buttock, stage II, which was not addressed in the aide plan of care. This was confirmed by the Director of Nursing.

Observed in Record Review. In 1 of 11 patient records reviewed, patient record contains information that does not reflect patient's services. In HV#1/RR#1, the surveyor noted that the registered nurse was completing LVN supervisory visits, even though an LVN was not visiting patient. This was confirmed by the Director of Nursing.

Observed in Document Review. In 1 of 5 contracts reviewed, there was no provision in the DME contract that the contracted entity obtain a criminal background check. Upon review of the contract with Tallwood Medical Equipment & Supply, Inc., the surveyor noted that the new contract signed on June 9, 2022 did not include a provision for criminal background checks. Administrator contacted the DME provider and obtained a signed addendum during survey. This was confirmed with the Administrator.