Every finding on record at Sylacauga Healthcare Authority

Observed in Record Review. In 1 of 1 patient records reviewed, for discharge with extended prognosis, the organization failed to involve the patient in making decisions about their care, treatment, or services. On review of RRDC#1 the patient was discharged for extended prognosis yet there was no Notice of Medicare Non-Coverage noted on the clinical record. This observation was reviewed with the Hospice Director, and Clinical Manager.

Observed in Record Review. In 3 of 10 patient records reviewed, the organization failed to ensure the plan of care reflect patient and family goals that are specific, measurable, and time-bound. In review of RRHV#2 there were goals noted in the plan of care that were not specific and measurable. For example, a spiritual goal read In previous visits, pt has been hesitant to talk about spiritual matters. Chaplain will focus the next month on determining what level of spiritual interest she has and Chaplain will continue to explore pt’s level of interest in spiritual matters. In RRHV#3 a psychosocial goal read like an intervention as it read Linkage /advocacy/ referral to community resources as needed including meals on wheels/ frozen meals services. An example in RRNHV#5 an example of a non measurable goals were Patient/caregiver will demonstrate improved nutritional status with in the next month and Patient's symptoms will be consistent with stage of disease process and problems managed as well as disease process will allow during this certification period. These observations were reviewed with the Hospice Director and Clinical Manager.

Observed in Record Review. In 6 of 10 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#3 the patient was ordered CPAP yet the device and its use was not reflected on the plan of care. In RRNHV#4 the documentation noted the patient with difficulty swallowing and also had blood glucose monitoring that were not reflected on the plan of care. In RRNHV#6 the patient had a wound to the buttocks/sacrum yet the plan of care for skin integrity was not specific to the wound and did not guide the care. In RRNHV#7 and RRNHV#10 the patients were diabetic with insulin and blood glucose monitoring yet there was no care plan to guide the care. In RRNHV#8 there was a goal that specified Patient /caregiver will verbalize understanding of falls/injury prevention and home safety measures within the next month yet the only intervention was to assess for fall risk and did not address educating the patient/caregiver on fall/injury prevention to achieve the goal. These observations were reviewed with the Hospice Director and the Clinical Manager.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRNHV#4 the patient had a skin tear with orders for wound treatment yet the order lacked a frequency and who was to perform the care. There was also an order for blood glucose monitoring yet the order did not specify who was to perform the monitoring. In RRNHV#10 there was an order for insulin to be given as needed if blood glucose was greater than 150, however there were no physicians order for blood glucose monitoring. These observations were reviewed with the Hospice Director and the Clinical Manager.

Observed in Record Review. In 2 of 8 patient records reviewed, with hospice aide services, the organization failed to ensure the registered nurse prepare written patient care instructions for the hospice aide. On review of RRNHV#6 the patient had orders for wound treatments to heels and wound dressing to the sacrum yet there were no specific instructions for the aide to know how to handle the areas while providing care. In RRNHV#7 the patient was on Eliquis, Xarelto, and Aspirin but the aide plan of care did not instruct the aide that the patient was on bleeding precautions. This observation was reviewed with the Hospice Director and Clinical Manager.

Observed in Patient Home. In 1 of 1 home visits conducted, where medication reconciliation was performed, the organization failed to ensure the patient record reflect the patient's care, treatment, and services. On home observation of medication reconciliation for RRHV#1 the skilled nursing facility medication profile noted the patient was prescribed Antacid liquid as needed for gastric (GI) distress, and the facility offered the patient Mylanta during the visit, yet the Antacid liquid was not a part of the hospice plan of care. The medication order per the facility was dated for February. This observation was reviewed with the RN, Clinical Manager, and Administrator.

Observed in Record Review. In 2 of 3 patient records reviewed, for active patient records cared for in a Skilled Nursing Facility, the organization failed to ensure the hospice plan of care identify the care and services needed and specifically identify which provider is responsible for performing the respective functions. On review of RRHV#1 the patient resided in a Skilled Nursing Facility (SNF) and was receiving wound care treatments, and blood glucose monitoring yet the plan of care did not indicate who was to perform the care included in the plan of care. In RRNHV#4 the SNF patient had orders for a skin tear with wound care, and blood glucose monitoring yet there was no delegation of who was to perform the tasks in the plan of care. This observation was reviewed with the Hospice Director, and Clinical Manager.

Observed in Competency Session. In 1 of 4 contracts reviewed, the organization failed to ensure the contract with an outside agency providing contracted services for the hospice include all required elements. For example: on review of the contract for EHO - Pharmacy Management Services the was no 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 observation was reviewed with the Hospice Director.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to ensure the comprehensive assessment was completed no later than 5 calendar days after the election of hospice care. For example: in review of HOSRR#5 the MSW initial assessment for an admission on 2/18/22 had yet to be completed to date of survey. There is documentation that the patient/caregiver declined the initial visit until the next month. The next communication note in mid March stated a phone call was made with no answer, and to follow up the next month. There is no indication that any further attempts to obtain the initial assessment after the one phone call. In HOS RR#9 the patient was admitted in September and the initial assessment was not completed until November. This observation was reviewed with the Hospice Director and the Hospice Director of Business Operations.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to ensure the patient and primary caregiver received education and training as appropriate based on the patient's assessed needs. For example: in review of HOSRR#5 the patient was noted to be started on Glucophage as the med was found in the patient's home. All prior assessments note that the patient was not diabetic. There was documentation that the RN educated the family on the medication, yet there was no documentation on what was taught. Further there was no indication that any diabetes education such as disease process, potential risks, signs and symptoms of hyper and hypoglycemia was provided to the patient and family. This observation was reviewed with the Hospice Director and the Hospice Director of Business Operations.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization did not ensure that the individualized plan of care reflected goals based on the patient's needs, nor that the plan of care goals were individualized, specific, and measurable. For example: throughout all clinical records reviewed the established goals were found to not be individualized, specific, and measurable. For example in HOSHV#1 all care plans had goals that stated patient/caregiver will verbalize/demonstrate disease effect on (system). This statement of verbalize/demonstrate disease effect on was used as a goal for environment safety, cardiovascular, respiratory, pain, and skin. Goals utilizing this same statement of verbalize/demonstrate disease effect on was noted throughout all clinical records. Other examples of non-specific non-measurable goals can be seen in HOSRR#5 that states Patient will remain comfortable with current medication management and Pain control at patient acceptable level within 48 hours. In HOSRR#6 the nutrition goals beyond the statement of verbalize/demonstrate understanding of disease effect on nutrition state maintain comfort and oral hygiene and nutritional needs will be met with adequate nutrition as long as possible. Similar findings of goals that fail to be specific and measurable can be seen throughout all records reviewed. Additionally, it was noted throughout the record that the plan of care goals failed to be based on the patients needs. For example: In HOSHV#2 and HOSHV#3 there was no spiritual care plan although the chaplain was visiting the patient. In HOSRR#4 the patient was on O2 yet there was no respiratory care plan. In HOSRR#7 the patient was experiencing agitation and negative behaviors yet these were not reflected on the care plan. HOSRR#7 the patient was refusing any intake and experiencing constipation yet these issues were not reflected in the patient's goals and interventions. Similar findings care be noted throughout the records. These observations were reviewed with the Hospice Director and Hospice Director of Business Operations.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to revise the plan of care based on the comprehensive assessment considering changes that took place since the initial assessment. For example in review of HOSRR#6 the care plan remained unchanged with no information on patient's progress toward desired outcomes or response to care provided from the first IDG to the most recent IDG spanning a period of 7 weeks. In HOSRR#9 it is also noted the care plan appear identical, lacking information on patient's progress to goals and response to care provided from the 1st IDG in September of 2021 to the most recent IDG. This observation was reviewed with the Hospice Director, and the Hospice Director of Business Operations.

Observed in Tracer Activities. During the bereavement program review it was noted that the organizations bereavement plan of care for its bereaved lacked the kind of bereavement services to be offered and the frequency of the service delivery. For example: the two bereavement records reviewed indicated that the bereaved were getting counseling and phone calls however these services were not indicated on the plan of care. Further, all bereaved were receiving mailings, yet bereavement record #2 did not have mailings indicated on the plan of care. This observation was reviewed with the Hospice Director of Business Operations. .

Observed in Record Review. In 3 of 11 patient records reviewed, The organization failed to ensure the patient record contained documentation to reflect the patient's care, treatment, or services. For example: upon review of the aide services provided for HOSHV#1 the aide failed to document perineal care as specified in the aide assignment in weeks 6 and 7 of service. There was no indication that this task was refused or the omission reported to the case manager. Example 2: upon review of HOSRR#4 the bereavement risk assessment was initiated by the admissions nurse yet the bereavement risk factors and risk level were left blank. In another example in HOSRR#7 the spiritual initial assessment was documented however many sections, specifically the spiritual questions portion of the assessment were left blank. These observations was reviewed with the Hospice Director and Hospice Director of Business Operations.

Observed in Record Review. In 4 of 11 patient records reviewed, the organization failed to ensure that the clinical record contained pertinent information to reflect the patient's care, treatment, and services as related to physicians orders. For example: Upon review of HOSHV#2 and HOSRR#4 the patients were noted to be diabetic and the family was monitoring blood glucose levels. There was no indication in the record that the frequency of monitoring and parameters for reporting to the SN or MD were established. Example 2: in HOSHV#3 the SN documented in the record that the patient was on O2 2liters per nasal cannula yet the patient was not noted to be ordered O2. Example 3: In HOSRR#5 the SN noted that Glucophage was found in the home, the medication was reported to the MD and added to the medication profile, yet there was not indication of a response from the MD nor an order for the Glucophage in the record. These observation were reviewed by with the Hospice Director and the Hospice Director of Business Operations.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization did not ensure that the patient and/or caregiver was able to demonstrate how to properly administer insulin. For example: HOSHV#2 and HOSRR#4 were prescribed insulin subcutaneous injections. There was no indication in the record that the patient and/or caregiver was proficient in safely providing the injections. This observation was reviewed with the Hospice Director and the Hospice Director of Business Operations.

Observed in Patient Home. In 3 of 3 patient records reviewed, for a patient residing in a skilled nursing facility, the organization failed to ensure the patient's individualized plan of care reflected participation of the hospice, and SNF. For example upon record review and home observation of HOSHV#1 who resided in a SNF, the plan of care did not reflect the participation of the facility staff. There was no indication that the facility participated in the hospice plan of care, nor that the hospice had participated in the facility's care planning. Similar findings of a lack of the plan of care reflecting participation of the hospice and the SNF can be seen in HOSRR#6, and HOSRR#8. These observations were reviewed with the Hospice Director and the Hospice Director of Business Operations.

Observed in Competency Session. In was noted in the competency session that the organizations SNF contract with Sylacauga Health and Rehab did not contain a stipulation that the SNF obtain criminal background checks on their employees who have direct patient contact or access to patient records. This observation was reviewed with the Director of Business Operations.