Every finding on record at St. Arsenius Hospice Care, Inc

Observed in Record Review. In 4 of 10 records reviewed, surveyor noted that the organization failed to plan the patient's care based on the patient’s goals and the time frames, settings, and services required to meet those goals. For example in RRNHV#1, the goal for the problem of loneliness stated to lower patient's loneliness and depression within the next 14 days. Example #2: in RRNHV#1, RRNHV#2, RRHV#3, and RRNHV#4, surveyor noted that goals were expected to be achieved in 14 days was not appropriate for the problem of pain, specifically. This was reviewed with the Administrator.

Observed in Record Review. In 1 of 10 records reviewed, surveyor noted that the organization failed to provide interdisciplinary, collaborative care, treatment, or services. For example, in RRNHV#1, the chaplain documented that the patient was lonely and depressed, however, there was no documentation that the nurse and physician was notified about patient's symptoms of depression to possibly implement pharmacological interventions to address patient's problem of depression, nor was there documentation that the IDT team assessed the patient for the need for volunteer services to address patient's problem of loneliness. This was reviewed with the Administrator.

Observed in Patient Home. In 1 of 3 home visits, the surveyor noted that the organization failed to implement activities for the prevention and control of infections and communicable diseases. For example, in HV#3, the chaplain did not follow the organization's policy for hand washing by disinfecting hands prior to and after having contact with patient; the chaplain entered patient's home and shook patient's hand before washing his (the chaplain's) hands with soap and water or disinfecting hands with approved hand sanitizer, increasing the risk of transmitting communicable diseases/ infection to the patient. This was reviewed with the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to assess potential medication-related problems for HOS 2. The hospice nurse conducted a medication assessment but failed to identify all medications, regime changes, and/or errors, for example the medication list included Labetalol 200mg one tablet two times a day by mouth, however the primary caregiver gives the patient 2 tablets two times a day per the patient's son's instructions which were written on the prescription label in Spanish. Finally, the medication list in Tresiba 100 unit/ml solution and the patient is on a sliding scale of blood sugar 150-200 = 2 units, blood sugar 201-250 = 4 units, blood sugar 251-300 = 6 units, blood sugar 301 - 350 = 8 units, blood sugar 351-400 = 10 units, blood sugar 401 and above = call Hospice, however the primary caregiver and granddaughter reported that the family gives the patient 30 units in the morning and 30 units in the evening. This was validated by the Registered Nurse.

Observed in Record Review. In 7 of 11 patient records reviewed, the registered nurse did not visit the patient every 15 days to update the comprehensive assessment in accordance with the organization's policy 2-030.1 Comprehensive Assessment. For example, in review of the medical record for HOS 1 who was admitted to hospice services more than 9 months ago there were four occasions where the registered nurse had not completed the update to the Comprehensive Assessment within the 15 days as required by the organization's policy. One update visit was 15 days late, one was 8 days late, one was 5 days late and one was 2 days late. In review of the medical record for HOS 2 the registered nurse was16 days late for the nursing visit to update the comprehensive assessment. Also, in review of the medical record for HOS 3 one update to the comprehensive assessment was 6 days late, two updates were each one day late and for one update the RN was 14 days late in visiting the patient. There were also late visits and submissions to the update of the comprehensive nursing assessment in review of RR 1, RR 2, RR 5 nd RR 6. This was validated with the Director of Nursing.

Observed in Record Review. In 3 of 3 patient records reviewed, the organization failed to provide care and services according to the patient's individualized plan of care and in accordance with their Bereavement Policy which includes a schedule of telephone calls, letters and mailings and invitations to the organization's Bereavement Support Group. In review of the record for BR 1 the organization planned for routine bereavement services although there was documentation that the survivor received a condolence call and was sent a letter at 1 month and 3 months after the death of the patient however, there was no evidence that the survivor was sent a letter at 1 week after the death, or that a bereavement visit was scheduled, or that a phone call was made to the survivor at 1 month after the death or that the survivor received a pamphlet on Grief or an invitation to the organization's bereavement group in accordance with policy. This also occurred in review of the records for BR 2 and BR 3 who also received condolence calls and mailings at 1 month but no other bereavement services as described in the organization's policy. This was validated with the Director of Nursing.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not use standard precautions when providing care for HOS 1. The surveyor observed that the LVN failed to perform hand hygiene between glove changes. For example, the LVN used her gloved hands to exam and clean the patient's perineal area then remove her gloves and apply new gloves without performing hand hygiene. She then examined and cleaned the patient's buttock and anal area and then changed her gloves without performing hand hygiene. This was validated by the LVN.

Observed in HR File Review. In 1 of 1 HR files reviewed, for hospice aides, the organization failed to evaluate the competencies of the hospice aide in accordance with their policy and federal regulation. In review of the personnel file for the Hospice Aide - HR 5 and in discussion with the Director of Nursing the Hospice Aide's competency were assessed verbally, in the office and not tasks were not observed with a patient or pseudo-patient as part of a simulation.

Observed in Document Review. the organization had not documented efforts to recruit and retain volunteers. This was validated by the Volunteer Coordinator.

Observed in Record Review. In 1 of 11 patient records reviewed, documentation in the patient's record was not accurate. For example in review of the medical record for HOS 1 documentation of the IDG/POC review at the start of care by the Spiritual Counselor was copied to the IDG/POC review notes on two subsequent meeting dates within the certification period. This was validated by the Director of Nursing.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to provide information in a manner tailored to the patient's age, language, and ability to understand. For example, for HOS 1 the preferred language for both the patient and spouse who was the primary care giver was Spanish, both written and spoken, however in review of the hospice home folder all written materials were in English including consents, the Hospice Election form, Patient Rights and Privacy documents and Medication List as well as all teaching materials. Additionally, all prescriptions were labeled in English for the primary caregiver who is responsible for medication administration in the home. During a discussion via the LVN visiting nurse the wife stated it would be helpful to have materials in her Spanish language. This was also observed in review of the materials in the home folder and medication list for HOS 2.

Observed in HR File Review. In 3 of 7 HR files reviewed, the organization failed to verify and document the credentials of staff with the primary source at the time of hire and renewal. For example, in review of the personnel file for the LVN - HR 2 the nursing license had expired more than 6 months ago and there was no evidence that the organization had verified the license had been renewed. Also, in review of the personnel file for the Director of Nursing - HR 6 the nursing license had expired more than 18 months ago and there was no evidence that the organization had verified the license had been renewed. Finally, in review of the personnel file for the Volunteer Coordinator - HR 3 who was required to have a college degree there was no evidence in the personnel file that the employee had the required education. This was validated with the Office Manager.