Every finding on record at Thedacare at Home

Observed in Individual Tracer. In 1 of 1 hospice patient visits, HOSHV1 during record review the medication list was not accurate. For example, upon admission Oxycodone order was Oxycodone 10- 20 mg/ml oral every hour as needed for severe pain, moderate pain, mild pain. There were no specific instructions on how to administer the medication. This was validated by the nurse and the nursing supervisor.

Observed in Individual Tracer. In 1 of 1 hospice visits conducted, While observing a med pass in the IPU, the nurse confirmed that she had not followed the current orders when giving the PRN pain medications. The patient's stated pain level was a 2 and FLACC score of 3. The orders stated: Oxycodone 20mg/ml 10-20 mg every hour as needed for acute pain, dyspnea. Administer 10 mg for moderate pain/dyspnea or 20 mg for severe pain or dyspnea The nurse administered Oxycodone 10 mg PRN for mild pain. This was validated by the nurse and the nursing supervisor.

Observed in Leadership Session. Upon review of the QAPI program presented, the organization did not demonstrate the involvement of all services provided by the organization, such as pharmacy, bereavement or volunteer services. They had not developed a hospice-wide data-driven quality assessment and performance improvement program. The QAPI meeting agenda presented to the surveyor included: Contract Services, Pharmacy, Volunteer and Bereavement as new standing agenda items. Subsequently presented to the surveyor, was an updated draft agenda for the QAPI meeting scheduled for August 28, 2023. The revised agenda included PIP Action plan items listing: Contract Services: DME and Pharmacy; Volunteer and Bereavement Services. However there was no supporting documentation or data presented regarding the reason for the selection of these QAPI items. This was discussed in detail with the System Quality Manager, the QI Specialist and the Hospice Manager.

Observed in Record Review. In 1 of 17 patient records reviewed, for active patients it was noted by the nurse surveyor that for HOSHV#2/RR#2, the bereavement risk assessment was not completed as part of the comprehensive assessment. This was confirmed with the Nursing Informatics Director and Nurse Educator.

Observed in Record Review. In 2 of 17 patient records reviewed, for active patients, it was noted by the nurse surveyor that the Interdisciplinary group meeting notes did not document decline, revisions to plans of care and goals. For example, for HOSHV#2/RR#2 and HOSIP#2/RR#17 the IDG notes did not reflect the patient’s condition and response to medications or assessed needs. All findings were verified by the Hospice Nurse Educator.

Observed in Record Review. In 17 of 17 patient records reviewed, for active hospice patients the nurse surveyor noted that the goals were not measurable. For example, “Patient’s concerns and wishes will be met” and “Patient will have regular bowel movements.” Additionally, there were no short-term goals at start of care to address issues of immediate needs such as understanding medication management, symptom management, pain management, mobility, or safety, most did not have a timeframe for completion. All findings were verified by the Hospice Educator and Informatics Director

Observed in Tracer Visit. While observing a med pass in the IPU, the nurse confirmed that she had not followed the current orders when giving the prn pain medications. The current orders were for Norco 5/325mg every fours hours for moderate pain and Roxanol 0.5mL every one hour for severe pain. The nurse administered both Norco 5/325mg and Roxanol 0.5mL concurrently as requested by the patient for a reported pain scale of 6.

Observed in Tracer Activities. Upon review of the QAPI meeting minutes presented to the governing body, the Hospice QAPI program did not demonstrate the involvement of all services provided by the organization, such as pharmacy, bereavement or volunteer services. Only incident reports that may have included those service lines were included. Therefore, they had not developed a hospice-wide data-driven quality assessment and performance improvement program.

Observed in Patient Home. In 1 of 5 home visits conducted, it was observed by the nurse surveyor that the nurse did not clean her equipment per the “Home Health Bag & Equipment” policy. For HOSHV#2/RR#2 the nurse cleaned her reusable barrier with an Oxiver wipe, rolled it up without allowing dry time and put it in her nursing bag, not in a resealable plastic bag per policy. Finding was verified by the Registered Nurse Supervisor who was present during the home visit. Observed in Patient Home. In 1 of 5 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned per their hand hygiene policy. HOSHV#2/RR#2 the skilled nurse performed the patient assessment starting with her feet, went to her back, and buttocks and completed the entire assessment with the same gloves on. Upon removing her gloves, she did not immediately hand sanitize. The Registered Nurse Supervisor was present during the home visits and also observed the breaks in technique per agency policy.

Observed in Record Review. In three out of three bereavement records reviewed, established goals were not included in the plan of care as required by the organization's policy Hospice Bereavement. This observation was confirmed by the Bereavement Coordinator.

Observed in HR File Review. In two of four volunteer records reviewed, the 4 hours of annual competencies (education/training) required by the volunteer program policy were not met. This observation was confirmed with the Volunteer Coordinator specialist and corrected onsite. Observed in HR File Review. In one out of four volunteer records reviewed, the volunteer coordinator confirmed that a competence assessment had not been performed in the last three years.

Observed in Tracer Activities. Upon review of contracted services, the hospice administrator confirmed that the evaluations of their contracts had not demonstrated whether the contracted organization met or did not meet their expectations on at least an annual basis as stated in the contract Amendment signed in 2021.

Observed in Building Tour. Upon review of the IPU nutrition refrigerator and freezer, the IPU manager confirmed that the freezer was dirty and in need of cleaning. Observed in Building Tour. Upon review of the IPU nutrition refrigerator and freezer temperature logs, the IPU manager confirmed that numerous dates were missing from the logs over the last several months while. The IPU manager and head cook could not speak to who was responsible for logging those temperatures.

Observed in HR File Review. In one of four Volunteer records reviewed, the background check was not found. This observation was confirmed with the Volunteer Coordinator specialist and corrected onsite.