Every finding on record at The Memorial Hospital

Observed in Record Review. In 3 of 10 patient records reviewed, for active patient records, the organization failed to ensure that a patient-specific comprehensive assessment identified the patient's need for hospice care and services. For example: on review of RRHV#1, RRHV#2, and RRHV#4 there was no documentation that an initial bereavement risk assessment was completed. This observation was reviewed with the Associate Manager of Home Health and Hospice.

Observed in Record Review. In 8 of 10 patient records reviewed, the organization failed to ensure the plan of care was based on the patient's goals that were specific, measurable, and time bound. For example: In review of RRHV#1 there were goals as part of the plan of care that were not specific and measurable such as patient maintains bowel function within limits of disease process/progression. In RRHV#2 an example was patient maintains adequate airway and respiratory function within limits of disease process. In RRHV#3 an example was Patient’s seizure activity is controlled within limits of disease process through 11/7/24 and Optimal safety throughout the disease process progression through 11/7/24. In RRHV#4 an example of non-specific goals that was not measurable was Patient will have minimized symptoms of infection Further examples of goals that were not individualized, specific and measurable could be seen in RRNHV#5, RRNHV#6, RRNHV#9 and RRNHV#10. These observations were reviewed with the Associate Manager of Home Health and Hospice.

Observed in Record Review. In 5 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 documentation noted the patient had multiple UTI's with antibiotics yet the infections were not reflected on the care plans. The documentation also noted the patient had been to respite care yet there was no care plan to guide the changes in level of care. In RRNHV#5 the documentation noted a UTI but no care plan to guide the care. In RRHV#4, and RRNHV#9 the documentation noted the volunteer was visiting the patient weekly yet the volunteer activity was not reflected in the plan of care. In RRNHV#10 the clinical record documentation noted multiple patient falls yet they were not reflected in the care plans. These observations were reviewed with the Associate Manager of Home Health and Hospice.

Observed in Record Review. In 3 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 RRHV#4, RRNHV#6, and RRNHV#8 there were medication orders for Morphine, Ativan, and Haloperidol that included a range of dosage yet there were no specific instructions to guide the one administering the medication on which dose to utilize for what situation. For example: Ativan 1-2 tabs as needed PO every 4 hours for anxiety/agitation and Roxanol 0.25 - 0.5 milliliter as needed PO every 4 hours for pain. This observation was reviewed with the Associate Manager for Home Health and Hospice.

Observed in Tracer Activities. During review of the retention and recruitment activities conducted by the volunteer coordinator over the last two years, the deemed status pharmacy surveyor noted that the only documentation provided was a newsletter and an email to a local college for recruitment and retention efforts included one volunteer appreciation lunch in 2024 for current volunteers. However, no ongoing efforts month-to-month in these two key areas were documented and available for review. This omission was validated with the volunteer coordinator and Hospice director. at the time of the survey

Observed in HR File Review. In 2 of 7 HR files reviewed, for the hospice program, the organization had not documented orientation of staff to key safety content. This documentation was not present in the file for the Medical Director as confirmed with the Hospice Director and Talent Management Director. Observed in HR File Review. In 2 of 7 HR files reviewed, the organization had not documented emergency preparedness training to staff, volunteers, and individuals providing on-site services under arrangement at the following intervals: Initial training. This documentation of training was not present in the file for the Medical Director nor the hospice aide as confirmed with the Hospice Director and Talent Management Director.

Observed in Record Review. In 1 of 13 patient records reviewed, the hospice’s interdisciplinary group, in consultation with the patient’s attending physician, had not completed the comprehensive assessment no later than five calendar days after the election of hospice care. In the chart for HSRR#1, the Spiritual Care assessment was not attempted nor completed until 6 days after the election of hospice care. This was discussed with the Hospice Manager.

Observed in Record Review. In 2 of 13 patient records reviewed, the written hospice plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for HSRR#5, the oxygen safety goal was not individualized to the patient. The goal was demonstrates comprehension of, and compliance with safety risks and interventions for oxygen safety by:___. The anticipated date of this safety goal was approximately 5 weeks post admission. In the chart for HSRR#9, the wound care goal had not been individualized to the patient. The wound care was ordered to be performed daily by the hospice RN or the primary caregiver. The anticipated achievement date of Patient/Caregiver verbalizes knowledge of wound treatment plan was more than 6 weeks post admission. The RN was seeing the patient twice weekly. This was discussed with the Hospice Manager.

Observed in Record Review. In 2 of 13 patient records reviewed, the hospice plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: Medications and treatment necessary to meet the patient’s needs. In the chart for HSRR#2, the RN noted that the patient was using compression stockings. This treatment was not included on the POC, nor was an order found. In the chart for HSRR#4, there was no order found for the enema that the RN documented was administered to the patient. This was discussed with the Hospice Manager.

Observed in Record Review. In 1 of 13 patient records reviewed, the IDG had not reviewed and revised the hospice plan of care at least every 15 calendar days. In the chart for HSRR#3, there were more than 15 days between the final IDG and the previous IDG. This delay was not related to an 1135 waiver as confirmed with the Hospice Manager.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization had not implemented its infection prevention and control activities. During HSHV#2, the RN placed her stethoscope and blood pressure cuff on the patients bedding. Organizational policy Clinical Staff Bag Technique required that staff place items on drape/clean field. This was observed by and discussed with the Hospice Manager.

Observed in HR File Review. In 2 of 7 HR files reviewed, the organization had not documented orientation of staff to relevant policies and procedures, specific job duties, including those related to infection prevention and control and assessing and managing pain. This documentation was not present in the file for the Medical Director nor the hospice aide as confirmed with the Hospice Director and Talent Management Director.

Observed in Record Review. In 2 of 2 patient records reviewed, the hospice had not developed a bereavement plan of care that specified the type of bereavement services to be offered and the frequency of service delivery. Neither the chart for BR#1 nor BR#2 had bereavement plans of care that included the types and frequencies of bereavement services as confirmed with the Chaplain and Social Worker who are responsible for the bereavement counseling program.

Observed in HR File Review. In 1 of 1 HR files reviewed, the supervisor had not documented the method of verification of the hospice aide's competence in performance of tasks. The documentation provided did not specify observation of the skill with a patient or pseudo-patient (versus verbalization or written testing, etc.). This was discussed with the Hospice Director and Manager of Education.

Observed in HR File Review. In 2 of 7 HR files reviewed, the hospice had not provided orientation about the hospice philosophy to all employees and contracted staff who have patient and family contact. There was no documentation of this orientation in the file for the Medical Director nor the hospice aide as confirmed with the Hospice Director and Talent Management Director.

Observed in Record Review. In 2 of 13 patient records reviewed, the patient record did not contain the following clinical information - any medications administered, including dose. In the chart for HSRR#4, the RN documented enema given and did not document what type/volume of enema that was administered. In the chart for HSRR#10, the documentation was inconsistent. The patient had oxygen ordered prn, which the patient had not been using recently. The oxygen safety risk assessment indicated there were no smoking materials in the home, yet the narrative note for this same recertification visit indicated that the patient still smokes a pipe. This was discussed with the Hospice Manager.

Observed in Record Review. In 2 of 2 patient records reviewed, the hospice discharge summary did not include the following: Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving physician. In the charts for HSRR#1 and HSRR#2, there were no discharge summaries present when the patients were discharged alive from the organization as confirmed with the Hospice Manager.

Observed in Record Review. In 3 of 13 patient records reviewed, at the time when controlled substances were first ordered, staff had not documented in the patient record that the written policies and procedures for managing controlled medications were provided and discussed as required. This documentation was not present in the chart for HSHV#1 which was discussed with the Hospice Manager. The patient's primary caregiver confirmed during the home visit that she did receive education and the policy was present in the home folder. In the charts for HSHV#3, and HSRR#2 the documentation of this education was not present.