Every finding on record at Traditions Hospice of Arizona III, LLC (Mesa)

Observed in Record Review. In 2 of 16 patient records reviewed, during HV# 1 and HV# 2's patient records review it was noted the organization had not ensured the initial comprehensive assessment was completed within five calendar days of the patient electing the hospice benefit. For example: review of HV# 2's patient record revealed the Initial Bereavement Assessment was completed approximately 125 days after the election of benefit. Review of HV# 1's patient record revealed the Initial Bereavement Assessment was completed approximately 57 days after the election of benefit. This was reviewed, discussed, and validated with the Branch Director.

Observed in Record Review. In 2 of 16 patient records reviewed, during BR# 1 and BR# 2's patient records review it was noted the organization had not completed an Initial Bereavement Assessment. For example: review of BR# 1 and BR# 2's patient record revealed no documentation of an Initial Bereavement Assessment. This was reviewed, discussed, and validated with the Bereavement Coordinator and Branch Director.

Observed in Record Review. In 9 of 9 active patient records reviewed, during HV# 1, HV# 2, HV# 3, RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, RR# 6's patient records review it was noted the organization had not ensured the plan of care included patient measurable goals and the time frames for achieving the goals. For example: review of HV# 1's recertification plan of care revealed the goals “patient/caregiver exhibit improved coping skills” with no indication how to measure improved coping skills and “facility staff is knowledgeable and involved in hospice plan of care for patient by (enter date). Review of HV# 2’s recertification RN comprehensive assessment revealed HV# 2 was on a puree diet with nectar thickened liquids due to dysphagia. Review of HV# 2’s medication profile revealed Thickening powder for nectar thickened liquids. However, review of the plan of care revealed no goal for the dysphagia interventions. Further review of the plan of care revealed the goal “Pain will be managed at a level acceptable to the patient” with no indication what an acceptable level of pain is for the patient or a timeframe. Review of HV# 3’s plan of care revealed the goals “patient/caregiver exhibit improved coping skills” with no indication how to measure improved coping skills or timeframe and “patient/caregiver verbalize understanding of potential causes of skin breakdown” with no timeframe. Review of RR# 1’s patient record revealed a MSW initial evaluation with documentation of a need for funeral arrangements. However, review of the plan of care revealed no goal related to funeral arrangements. Further review of the plan of care revealed the goals “pain is currently managed at a level acceptable to patient” with no indication what an acceptable level is for RR# 1 and “patient/caregiver will verbalize/demonstrate understanding of pain management measures” with no time frame. Review of RR# 2’s plan of care revealed the goals “funeral/final arrangement acknowledged and completed per the patient’s wishes” with no time frame and “pain will be managed at a level acceptable to the patient” with no indication what an acceptable pain level is for the patient. Review of RR# 3’s recertification plan of care revealed the goal “patient/caregiver demonstrates proper wound care”. However, RR# 3’s wound had been healed approximately 15 months prior to the surveyor review of the record. Further review of the recertification plan of care revealed no Chaplain goals with a Chaplain visit frequency of two visits every 4 weeks. Review of RR# 4’s plan of care revealed the goals “patient/caregiver demonstrate the ability to check for proper placement of feeding tube” and “patient/caregiver demonstrates safe administration of tube feedings and/or medication” with no time frames. Review of RR# 5’s recertification plan of care revealed the goal “caregiver will verbalize/demonstrate appropriate safe wound care” with no time frame. In addition, review of RR# 5’s record revealed that all the wounds had heeled approximately 45 days prior to the recertification. Review of RR# 6’s recertification plan of care revealed a Chaplain frequency of one visit a month with no goals. Further review of RR# 6’s comprehensive assessment revealed the goal “hospice RN to evaluate patient and develop a nursing plan of care”. This was reviewed, discussed, and validated with the Branch Director.

Observed in Record Review. In 5 of 9 active patient records reviewed, during HV#1, HV# 2, and RR# 5's patient records review it was noted the organization had not ensured the plan of care included all services needed for the palliation and management for the terminal illness and related conditions to include interventions to manage pain and symptoms. For example: review of HV# 2's recertification RN comprehensive assessment revealed HV# 2 was on a puree diet with nectar thickened liquids due to dysphagia. Review of the recertification plan of care revealed no documentation of aspiration precautions or the puree diet. Review of HV# 1's recertification RN comprehensive assessment revealed HV# 1 had oxygen in the home. Review of HV# 1's recertification plan of care revealed no documentation of oxygen safety precautions. Review of RR# 5's recertification RN comprehensive assessment revealed RR# 5 had a puree diet and on honey thickened liquids. Review of the recertification plan of care revealed no documentation of aspiration precautions or puree diet. This was reviewed, discussed, and validated with the Branch Director.

Observed in Record Review. during RR# 5's patient record review it was noted the organization had not ensured the plan of care included a statement of the scope and frequency of the services necessary to meet the patient's and family's needs. For example: review of RR# 5's patient record revealed RR# 5 had been receiving Volunteer services for approximately three months prior to the surveyor review of the record. Review of the recertification plan of care revealed no Volunteer frequency. This was reviewed, discussed, and validated with the Branch Director

Observed in Record Review. during HV# 3, RR# 3, and RR# 5's patient records review it was noted the organization had not ensured the plan of care included medications and treatments necessary to meet the patient's needs. For example: review of HV# 3's start of care RN comprehensive assessment and plan of care revealed documentation HV# 3 had a wound on the posterior left thigh. Further review of the plan of care and subsequent update to plan of care/Interdisciplinary group (IDG) revealed wound care orders. However, review of the wound assessment revealed the wound had healed four days after the start of care or 69 days prior to the surveyor review of the record. Review of RR# 5's recertification plan of care revealed RR# 5 had wound care orders for the pressure ulcer to the coccyx and left heel that included cleaning with wound cleanser apply calmoseptine and cover with a dressing everyday and as needed. Review of RR# 3's patient record revealed the pressure ulcer to the coccyx had healed approximately 25 days after the start of care and the left heel had healed approximately 45 days prior to the recertification. This was reviewed, discussed, and validated with the Branch Director.

Observed in Record Review. In 1 of 3 bereavement records reviewed, during BR# 2's patient record review it was noted the organization had not ensured the bereavement plan of care was followed. For example: review of BR# 2's patient record revealed BR# 2's day of death was approximately 3.5 months prior to the surveyor review of the record. Review of BR# 2's post death bereavement risk assessment revealed a moderate risk level. Review of the bereavement plan of care revealed Chaplain phone calls every month beginning the first month. However, there was no documentation to indicate the phone calls had been scheduled or completed. This was reviewed, discussed, and validated with the Bereavement Coordinator and Branch Director.

Observed in Record Review. In 1 of 9 active patient records reviewed, Duinrg HV# 1's home observation the patient and family member reported the patient had fallen and sustained a skin tear to the right elbow and was complaining of pain when lifting the right arm. Review of the Skilled Nurse visit note, the fall incident report, and the Interdisciplinary Group/Update to the plan of care, the next day following the fall there was no documentation the RN notified the physician of the fall, the skin tear or the pain the right arm. This was observed, discussed, and validated with the Branch Director.

Observed in Patient Home. In 2 of 2 home visits conducted with vital sign equipment, during HV# 1 and HV# 2's home observations it was noted the organization had not implemented infection prevention and control activities when performing disinfection of medical equipment. For example: organization policy Bag Technique - IC60 that included cleaning the blood pressure cuff in accordance with the manufacturers guidelines or when the cuff had been soiled with blood, other body fluid or spills – soap and water and/or disinfectant wipe. During HV# 1's home observation the RN cleaned the stethoscope, blood pressure cuff, pulse oximetry, thermometer, and measuring tape with an alcohol wipe and immediately placed the items into the bag without allowing the equipment to dry per manufacturer’s guidelines of a minimum of 15 seconds wet time. During HV# 2’s home observation the RN was observed spraying the stethoscope, blood pressure cuff, pulse oximetry, and thermometer with a can of Lysol spray. This was observed with the Clinical Team Lead and discussed and validated with the Branch Director. Observed in Patient Home. In 2 of 3 home visits conducted, during HV# 1 and HV# 3's home observations it was noted the organization had not ensured staff performed hand hygiene consistent with the organization’s policies: Bag Technique - IC60 that included hands are cleaned prior to returning clean equipment to bag and Hand Hygiene – IC15 that included “staff will dry hands and wrists thoroughly with a clean paper towel”. For example: during HV# 1's home observation the RN was observed cleaning the stethoscope, blood pressure cuff, pulse oximetry, thermometer, and measuring tape and placing each item directly into the bag without performing hand hygiene prior to returning the equipment to the bag. During HV# 3’s the two home health aides were observed washing their hands and using the patient’s wash cloth to dry their hands. In addition, the two home health aides were observed washing their hands and not drying their hands. This was observed, discussed, and validated with the Clinical Team Lead.

Observed in Patient Home. In 4 of 8 active patient records reviewed with home health aide services, during HV# 1 and HV# 3's home observations and RR# 2 and RR# 4’s patient record reviews it was noted the organization had not ensured the registered nurse prepared complete written patient care instructions for the home health aide. For example: during HV# 1's home observation HV# 1 was observed with oxygen in use per nasal cannula. Review of HV# 1's home health aide written instructions revealed no documentation HV# 1 used oxygen in the home. During HV# 3's home observation HV# 3's was observed with oxygen in use per nasal cannula and needed two home health aides to transfer patient from bed to chair. Review of HV# 3's home health aide written instructions revealed no documentation of the use of oxygen or the need for two person transfers. Review of RR# 2’s patient record revealed RR# 2 had a Geri chair and a Hoyer lift. Review of RR# 2’s home health aide written instructions revealed no documentation of the Geri chair or Hoyer lift. Review of RR# 4’s patient record revealed RR# 4 had a G-tube in place for feeding. Review of the home health aide written instructions revealed the task of a shower with no documentation regarding a G-tube. This was observed, reviewed, and discussed with the Clinical Team Lead and reviewed, discussed, and validated with the Branch Director.

Observed in Patient Home. In 1 of 1 home visits conducted with the home health aide, During HV# 3's home observation it was noted the organization had not ensured the home health aide followed the patient written instructions. For example: during HV# 3's home observation HV# 3 was using oxygen at 2 Lpm per nasal cannula. The home health aide removed the oxygen while showering. However, review of the written instructions revealed no directions regarding if the oxygen should be removed during the shower. This was observed, reviewed, and validated with the Clinical Team Lead.

Observed in Patient Home. In 3 of 13 patient records reviewed, during HV# 2's home observation and HV# 3 and RR# 2's patient records review it was noted the organization had not ensured the patient records reflected the patient's care, treatment, or services. For example: during HV# 2's home observation the RN was observed completing a medication reconciliation with the Group Home and it was noted HV# 2's medication profile was not accurate as it included Benzonatate 100mg that had been discontinued approximately 30 days prior to the home visit. This was reviewed, discussed, and validated with the RN and the Clinical Team Lead. Review of HV# 3's patient record revealed a Skilled Nurse visit note with documentation that an indwelling catheter was placed and clear yellow drainage was observed and documentation the RN had attempted to insert the catheter and was unable to insert it. Review of RR# 2's patient record revealed an order for Physical Therapy for Hoyer Lift education for the family approximately 16 days prior to the surveyor review of the record. Further review of the patient's record revealed no documentation that the Physical Therapist had provided training to the family regarding the Hoyer Lift. This was reviewed, discussed, and validated with the Branch Director.