Every finding on record at St Peter's Hospice Services

Observed in HR File Review. In 6 of 6 employee records that have been employees greater than 2 years, the organization had not provided ongoing training on their emergency management plan at least every two year. On review of HR #2, #3, #4, #5, #6, and #7 the employees had not received education on the emergency management plan in the last 2 years. This finding discussed with the RN Supervisor.

Observed in Record Review. In 1 of 2 patient records where there was a live discharge, the organization did not collect appropriate documentation for revocation. In RRDC #11, the patient revoked hospice to seek further treatment but there was no signed revocation in the chart. The finding was reviewed with the RN Supervisor.

Observed in Record Review. On 1 of 14 patient records reviewed the organization failed to complete initial assessment. On RRNHV #8, the social worker failed to complete an initial assessments within five days after the election of hospice and there was no documentation that refusal of the service took place in that 5 day window and no contact note for MSW contact and RN assessment stated need for MSW visit. This finding was reviewed with the RN Supervisor.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to address duplicate medication orders. In RRHV #2, there were duplicate medication orders for Ibuprofen on the medication one for 600mg every 8 hours PRN mild to mod pain and one for 600 mg every 6 hours PRN mild to moderate pain with no direction on which to follow or max dosing for the day. This was reviewed with the RN Supervisor.

Observed in Record Review. In 1 of 14 patient records, the organization did not provide training based on patient/caregiver needs. On review of RRBR #13, patient had a stage 4 hip ulcer with orders for daily dressing change and the nurse was only going 2 times per week but no indication that the caregivers at the board and care had been trained to perform those dressing changes on the days that the nurse was not there. This observation was review with the RN supervisor.

Observed in Patient Home. In 1 out of 3 home visits conducted, the hospice nurse surveyor noted that the organization had not implemented its infection prevention and control activities. The agency bag technique policy states that vital sign equipment will be cleaned with alcohol between patients and prior to be placing in bag. In RRHV #2 the LVN used Lysol Spray to clean vital sign equipment, he did not follow agency policy to clean with alcohol and he did not follow manufacturer guidelines for use which is a wet time of 3 minutes. This was discussed with the RN supervisor.

Observed in Patient Home. In 1 out of 9 patient records reviewed that had ordered aide services, the Aide Care Plan did not have specific instructions for the aide. During review of RRHV #3, the assigned tasks were to bath the patient with no instruction that the patient would need to transfer from the wheelchair to the shower chair and the assist level needed for this patient who is a fall risk. This finding was reviewed with the RN supervisor.

Observed in Patient Home. In 1 of 9 records reviewed with Aide services, the home health aide did not provide care according to the patient's plan of care. Upon review of the record for RRHV#3, the aide performed care that was not ordered on the Aide Care plan. Examples included: Brushing hair, and transfer from wheelchair to shower chair. This was reviewed with the RN Supervisor.

Observed in Record Review. In 2 of 2 discharged patient records reviewed where patient discharged from service, a discharge summary for care and treatment was not sent to the provider or a notification given that it was available. On review of RRDC #11, the discharge summary indicated patient was revoking hospice to seek medical attention a summary was written but it did not include a summary of care provided while on hospice and the summary was not sent to the physician or notified of its availability. In RRDC #12, the discharge summary indicated the patient went to hospital, a summary was written but it was not sent to physician and notification of it's availability was not completed. This was reviewed and validated with the RN supervisor.

Observed in Patient Home. On 3 of 3 home visits conducted, the surveyor noted that there was no documentation provided to the patient regarding the agencies policy on controlled substance disposal. Agency Controlled Substance Policy (3.005.2) states agency will provide written copy of the policy on controlled substance. On review of the admission packets in the home RRHV #1, #2 and #3, it was noted the organization did not provide a copy of its written policies and procedures on the management and disposal of controlled medications to patients and families/caregivers when controlled medication were ordered. This was reviewed and confirmed with the DPCS.