Every finding on record at Traditions Hospice of Highland Heights, LLC

Observed in Patient Home. There was no written documentation that the patient's rights were communicated to the patient both verbally and in writing. Also the cost for the patient was not listed for the patient's review. This was confirmed by the Nurse Manager accompanying the surveyor.

Observed in HR File Review. In 2 of 16 Human Resource files reviewed, the surveyor noted that ongoing Emergency Management Education had not been documented. This finding was validated by the Hospice Administrator.

Observed in Record Review. In 1 of 13 patient records reviewed, for active patients, the nurse surveyor noted that for RR#8 the RN did not visit the hospice patient every 15 days to conduct an assessment, the LVN conducted the assessment visits for a period of time that was greater than 15 days. Finding was verified by the Branch Manager and Administrator. Observed in Record Review. In 4 of 13 patient records reviewed, for active records it was noted by the nurse surveyor that for the Interdisciplinary group meeting notes did not document decline, revisions to plans of care and goals. For example, for HOSHV#4/RR#4, the IDG notes did not reflect the patient’s response to a new pain medication. RR#5 did not reflect the decline of a wound on the patient’s leg or changes in treatment orders. RR#6 there was no documentation to reflect the patient’s response to multiple medication changes. RR#8, there was no documentation regarding the patient’s foley catheter and the problems that had occurred. All findings were verified by the Branch Director.

Observed in Record Review. In 13 of 13 patient records reviewed, for active patients the nurse surveyor noted that the goals were not measurable. For example, “Pain will be managed at a level acceptable to patient by end of certification period,” and “Patient/caregiver will feel relief form spiritual concerns.” 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 or the timeframe for completion was the end of the certification period . Findings were verified by the Branch Director.

Observed in Record Review. In 1 of 4 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 policy “Hand Hygiene – IC15 Policy and Procedure” and “Bag Technique - IC60 Policy and Procedure”. For example, during HOSHV#1/RR#1 the Social Worker entered the patient’s room and placed a barrier on the floor then put her bag on the barrier. She then went into the bathroom and washed her hands, after washing her hands she could not make the paper towel dispenser work, tuning the dial with her hand, she then left the bathroom, went into her bag, got her own paper towels, dried her hands and turned off the water. She did not re-wash her hands after touching the inanimate objects per policy. The Branch Director was present during the visit and observed the infection control breaches. Observed in Patient Home. In 1 of 4 home visits conducted, it was observed by the nurse surveyor that the nurse did not clean her equipment per agency policy. For HOSHV#2/RR#2 the nurse cleaned her equipment (BP cuff, stethoscope, thermometer, pulse oximeter) with Clorox wipes and immediately dropped the items into her bag without allowing them to dry per the recommended product dry time. Finding was verified by the Branch Director who was present during the home visit.

Observed in Infection Control Tracer. During the infection control tracer, the pharmacist surveyor noted that the organization had not implemented its surveillance program for hand hygiene compliance. The organizations infection control plan and policy states that all staff will be monitored for hand hygiene compliance using a Hand Hygiene Monitoring Tool. The organization had not implemented the tool and was not able to provide documentation that hand washing surveillance had been performed. This finding was discussed with the Administrator.

Observed in Record Review. In 1 of 13 patient records reviewed, for active patients it was noted by the nurse surveyor that Hospice Aide Supervisory visits were not documented the required every fourteen days per regulation. For RR#8, there was no documented Hospice Aide Supervisory visit for a period of 17 days within the current certificaiton period. Findings were verified with the Branch Director.