Every finding on record at St. Rita Hospice, Inc

Observed in Record Review. In 1 of 10 patient records reviewed, the Surveyor noted the consent form for Hospice had not been signed. In RRHV 3, the consent for Hospice services had not been signed by the patient or family. This was validated with the Administrator.

Observed in Record Review. In 1 of 10 patient records reviewed, the Surveyor noted that the IDG had not been updated when a change in patient assessment had occurred. For example, in RRHV 1, the clinician identified a new stage 3 pressure injury on the patient. The IDG that occurred 2 days post assessment had no discussion of the new wound so the plan of care could be updated. This was validated with the Director of Patient Care Services.

Observed in Record Review. In 2 of 10 patient records reviewed, the Surveyor noted documentation in the patient record had not accurately reflected the patient and the care provided. For example, the patient in RRHV 1 had been documented in 2 visit notes as having a stage 3 pressure injury to her calf area that the clinician had provided care to. During the home visit, the surveyor had not observed any wounds on the patient. Then the patients in RRHV 1 and RRHV 2 both had a documented KPS/PPS of 40%; however, both patients actually had a KPS/PPS of 60% or higher, as they were both self-sufficient and ambulatory, not bedbound and debilitated. This was validated with the Clinician providing care to the patient.

Observed in Record Review. In 7 of 10 patient records reviewed, the Surveyor observed missing orders from the plan of care (POC), incomplete orders for wound care and/or medications. For example, in RRHV 1, the RN identified in patient visit 2 that a new stage 3 pressure injury was present and provided a skilled dressing; however, there had not been orders to provide the care. The following IDG meeting, 2 days post visit, had no discussion of the new wound nor update to the Plan of Care (POC) with orders to provide care. The same patient had 3 different pain medications: Tramadol Hydrochloride 50mg Tablet 1 tab every 8 hours PRN, Gabapentin 300mg Capsule daily at bedtime every 24 hours PRN and Ibuprofen 600mg Tablet twice a day all ordered for moderate 4-6 pain. RRHV 2, the patient had 'Pain Relief 500mg' listed on the medication profile; however, the medication had been Acetaminophen 500 mg. RRHV 3, the patient had a primary diagnosis of heart failure; however, this had not been included on the POC. In RRNHV 4, the patient had Clotrimazole 1% Topical Cream apply to affected area daily, without a specific site of application identified. RRNHV 5 had the patient had Diclofenac Sodium 1% Topical Gel apply to affected area as needed, without a specific site of application. In RRDC 1, the patient had Diclofenac Sodium 1% Topical Gel apply to affected area as needed and Hydrocortisone 2.5% Topical Cream apply to affected area as needed. In RRBR 1, the patient had Lidocaine Pain Relief 4% Patch Transdermal, 12 hours on and 12 hours off for Pain Relief, but there had been no specific site of application. This was validated with the Administrator.

Observed in Tracer Activities. The Surveyor noted no documented recruitment and retention activities as this had not been available during the survey. This was validated with the Administrator/Volunteer Coordinator.

Observed in Patient Home. In 2 of 3 home visits conducted, the Surveyor noted the medication list in the electronic medical record (EMR) had not been accurate to what the patient was being administered. For example, in RRHV 1, the patient had 2 different eye drops, Ketorolac 0.5% daily and Ofloxacin 3 times per day, that began prior to starting service with the HCO and these had not been included on the EMR medication list. In RRHV 2, the medication list in the EMR had both simvastatin and atorvastatin listed (Pt only taking Atorvastatin). This was validated with the clinician present during the visit.

Observed in Record Review. In 1 of 5 records the surveyor noted the organization did not maintain complete documentation needed to justify the patient’s care, treatment, or services. As evidenced In HV #2 record review it was noted that the LVN administered Amlodipine for high blood pressure. There was no documentation to support this. Unknown if the patient had not taken her medications, or if it was an extra dose. No documentation about communication with case manager. Validated with Administrator and DPCS

Observed in Record Review. Visit 2 record review, Surveyor observed the plan of care related to blood sugar monitoring did not include a plan, goals for care, treatment, or services based on patient's needs. Order for the blood sugar goal present. No order for frequency on testing, who will complete the testing, and the treatment for blood sugars. Additionally, there was an order for teaching on insulin; however, no insulin on patient medication list. Findings verified with Administrator and DPCS.

Observed in Record Review. In 2 of 5 patient records reviewed, the surveyor observed that the plan of care (POC) did not all services needed for management of terminal illness and related conditions , including interventions to reduce the patient's fall risks. Observed during record review for home visit #1, the patient had been identified as a high fall risk on the Fall Risk Assessment. However, the POC did not include any interventions or outcomes to reduce the patient's fall risks. In review of the Interdisciplinary Group (IDG) notes, there was no documentation that fall risk and interventions or goals, had been discussed. This observation was review and verified with the Administrator and Director of Patient Services Designee.

Observed in Individual Tracer. In 3 of 3 home visits conducted, the surveyor observed that the organization did not follow policy for hand hygiene as evidenced by during home visit #1, the clinician turned off the faucet with bare hands. Did not use a paper towel as required by agency policy 9.009. Additionally, when using hand sanitizer, the clinician did not rub hands together until hands were dry. The clinician's mask did not cover her nose while assessing the patient. These observations were discussed and verified with the Administrator. Observed in Patient Home. Surveyor observed that the organization did not follow policy for hand hygiene. In HV #2, Clinician was observed entering her nursing bag three times without cleansing hands. Validated with Administrator and DPCS Observed in Patient Home. in HV #3, clinician did not follow agency infection control policy. Clinician was observed to wear face mask over mouth and left her nose exposed. Additionally, clinician did not sanitize her hands prior to entering clean nursing bag. Validated with Administrator and DPCS

Observed in Patient Home. In 1 of 3 home visits records reviewed, the surveyor observed the list of medications, including dose, strength, frequency, route, date and time of administration for prescription and nonprescription medications, herbal products, and home remedies that relate to the patient's care, treatment, or services was not accurate. For home visit #2 the patient started on two new medications 2 weeks prior to surveyor HV. No documentation of the medications noted on the medication profile. It was noted that a registered nurse visit occurred in the interim and the medications not reconciled during that visit. Additionally, there were no MD orders for the medications documented. Validated with Administrator and DPCS

Observed in Document Review. In 1 of 4 contracts reviewed, the surveyor observed that the written agreement with a pharmacy, providing contracted services for the hospice did not include the following: -A stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This was discussed and verified with the Administrator.