Every finding on record at Timeless Moments Hospice Inc

It is required that each patient’s individualized written plan of care that reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) clinical records reviewed, it was revealed that the agency did not ensure the plan of care addressed the specific needs of the patient, specifically related to falls. Clinical Record 1: The patient elected the hospice benefit on 2/17/23 and had a diagnosis of malignant neoplasm of the colon with comorbidities of anemia, obesity, and hypertensive heart disease. The comprehensive assessment conducted on 2/17/23 by the RN indicated that the patient had a fall risk score of 6, with guidance that "a score greater than 4 is considered at risk for falling." Fall risk or fall prevention was not addressed in the patient's plan of care from 2/17/23 to 4/4/23. Clinical Record 3: The patient elected the hospice benefit on 3/3/23 and had a diagnosis of COPD and comorbidities of hypertensive heart disease and heart failure. The comprehensive assessment completed by the RN on 3/3/23 indicated that the patient had a fall risk score of 6 and with guidance that "a score greater than 4 is considered at risk for falling." Fall risk and fall prevention were not addressed in the patient's plan of care from 3/3/23 to 4/4/23. Clinical Record 4: The patient elected the hospice benefit on 2/18/23 and had diagnosis of cerebral infarction. The comprehensive assessment conducted by the RN on 2/18/23 indicated that the patient had a fall risk score of 9 with guidance that "a score of greater than 4 is considered at risk for falling". In addition, the note on 2/18/23 stated, "The patient experienced a fall two weeks ago and has had a progressive decline since that time". The fall risk or fall prevention was not addressed in the patient's plan of care. Interview: During an interview conducted on 4/4/23, the Alternate Administrator confirmed that fall risk and fall prevention were not included in the patient care plans and should have been.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview and observation. In 2 of 3 (67%) home visit observations, it was revealed that the agency did not ensure that staff adhered to the hand hygiene policy. Document 2: Hand Hygiene Policy No. 7-009 (CHAP Hospice Operations Revised May 2022), which stated in relevant parts, "Procedure: 3) Hand Decontamination using an alcohol-based hand rub should be performed. A. Before having direct contact with patients. C. After contact with a patient's intact skin (when taking a pulse, blood pressure or lifting a patient). F. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. G. After removing gloves." Home Visit 2: During Home Visit 2 on Record 2 conducted by Staff 7 on 4/5/23, it was observed that hand hygiene was performed only upon leaving the home after the visit. Home Visit 3: During Home Visit 3 on Record 3 conducted by Staff 7 on 4/5/23, It was not observed that hand hygiene was performed prior to, during or after the visit. Interview: During an interview conducted on 4/5/23 the Alternate Administrator, it was confirmed that the staff had not followed agency policy regarding hand hygiene.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard is not met as evidenced by document review and interview which revealed that the agency did not ensure they had a plan in place to recruit and retain volunteers. Document 3: Volunteer Services Policy No. 9-024 (CHAP Hospice Operations) Revised May 2022) stated relevant parts, "Procedure: 5. The Volunteer Coordinator will document ongoing efforts to recruit, train, and retain volunteers of all ages and ethnic backgrounds." Interview: During an interview on 4/6/23 the Alternate Administrator said that the agency did not have a documented plan to recruit or retain volunteers. This standard is not met as evidenced by document review and interview which revealed that the agency did not ensure they had a plan in place to recruit and retain volunteers.