Every finding on record at Steward Hospice Care Inc

Observed in Record Review. In 1 of 8 patient records reviewed, the hospice's interdisciplinary group, did not complete the comprehensive assessment within five calendar days after the election of hospice care. For example, in RRNHV#3 MRN421 whose start of care date was 5 weeks prior to the survey date had no documentation of an initial comprehensive psychosocial visit completed. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 8 of 8 active patient records reviewed, the written plans of care for did not contain time frames required to meet any of the patients' goals. This was discussed and validated with the Administrator and the Director of Patient Care Services who shared that this was a gap in the abilities of the electronic medical record they are addressing.

Observed in Record Review. In 8 of 8 active patient records reviewed, the plans of care did not include all services needed for the palliation and management of the terminal illness and related conditions. Identified during the record review, the patients' lack of identified mortuary/burial plans were not included in their individualized plans of care. In 1 of 8 active patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. Identified during the review of RRNHV#1, the patient had a diagnosis of Diabetes Mellites type II, and was taking Glipizide daily. This problem was not included in the patient's plan of care. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 1 of 8 patient records reviewed, The organization did not provide the patient with care, treatment, or services according to the patient's individualized plan of care. For example, in RRNHV#2, the Medical Social Worker was added to the plan of care at the beginning of the second certification approximately four months prior to the survey with an order to Evaluate, yet there was no comprehensive psychosocial visit documented. This was verified with the DPCS.

Observed in Patient Home. In 3 of 3 home visits conducted, the organization did not implement the infection prevention and control activities it had planned in accordance with Policy No. 9-009.1. For example in the observation of HV#1, the Licensed Vocational Nurse (LVN) was observed before and after providing patient care, turning off the bathroom faucets following hand washing, not utilizing a paper towel per policy. Additionally, the LVN was observed removing gloves during wound assessment and not performing hand hygiene before obtaining additional wound supplies and re-donning gloves. Observed in HV#2, the Hospice Chaplain failed to perform hand hygiene upon exiting the patient's bedroom, and, observed in HV#3, the Medical Social Worker did not perform hand hygiene upon entering the Assisted Living Facility, and beginning her interaction with the patient where she made physical hand contact with the patient. This was reviewed with the Director of Patient Care Services following the home visits conducted.

Observed in Patient Home. In 1 of 1 home visits conducted where a medication reconciliation was completed, the organization had not maintained a complete and accurate patient record. Observed in HV#1, a prescription for Acetaminophen 500 mg tablets, take 1 tablet 3x daily, dated 6 days prior to the home visit was present but was not documented on the patient's medication profile.

Observed in Record Review. In 2 of 2 live discharge records reviewed, the organization did not ensure that the discharge summary included information about the care, treatment or services provided to the patient to other service providers who will provide the patient with care treatment, or services. For example, in RRLiveDC#1, MRN 384 was discharged for no longer being terminal. The discharge summary failed to include a summary of services provided, dates of services, a medication record, or plan of care. In RRLiveDC#2, MRN 369 revoked hospice services to seek aggressive treatment. There was no evidence that a discharge summary was provided to the receiving hospital or primary physician including a summary of services provided, dates of services, a medication record, or plan of care. This was reviewed and validated with the Director of Patient Care Services and the Administrator.

Observed in Patient Home. Identified during the review of the Start of Care Packet and confirmed during the review of the individual Patient Binders during home visits for HV#1 and HV#2, there was no evidence that the organization provided their patients or patient representatives with the hospice's policies and procedures for managing the safe use and disposal of controlled medications. This was reviewed with the Director of Patient Care Services.