Every finding on record at Traditions Hospice of Overland Park, LLC

Observed in Record Review. In 5 of 10 patient records reviewed, for active patients, the surveyor noted that the initial bereavement risk assessment was not completed as part of the initial assessment as noted for RRHV#3, (4 days late), RRNHV#1 (8 days late), RRNHV#3 (4 days late), RRNHV#4 (not yet completed), and RRNHV#5. Findings were verified by the Administrator and the Clinical Team Lead.

Observed in Record Review. In 10 of 10 patient records reviewed, for active hospice patients the nurse surveyor noted that the goals were not consistently measurable. For example, “Patient exhibits reduction/relief of any cardiopulmonary symptoms,” and “Pain will be managed at a level acceptable to patient”. Additionally, goals were mostly the same from patient to patient with minimal individualization. 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, or safety. There were no time frames for completion. Findings were discussed with the Administrator and Clinical Team Lead.

Observed in Patient Home. In 2 of 3 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”. During RRHV#1 the hospice aide did not perform hand hygiene at any point during the visit to the patient in the nursing facility. She entered the building, signed in at the desk, put updated medication sheets, and plans of care in the patient folder in the facility all without performing hand hygiene. She then went into the linen closet to get clean towels, put them down in the patient room, set up supplies for the bath, went out to the activities room to get the patient and wheeled her into the bathroom, at that point the hospice aide donned gloves, all without ever performing hand hygiene. She then assisted the patient to undress and transferred her to the shower and began to bathe her all with the same gloves on and not performing hand hygiene. During RRHV#2 the chaplain was not observed performing hand hygiene at any point during the visit even though he touched several things in the patient environment, to include his guitar, the patient’s playing cards, and the table. The Administrator was present during the visits and observed the breaks in policy. Observed in Patient Home. In 1 of 3 home visits conducted, it was observed by the nurse surveyor that the nurse did not clean her equipment per agency policy, “Bag Technique - IC60 Policy and Procedure”. For RRHV#2 the nurse cleaned her equipment (BP cuff, stethoscope, thermometer, pulse oximeter) with Super Sani wipes and immediately dropped the items into her bag without allowing them to dry per the recommended product dry time of two minutes. Finding was verified by the Administrator who was present during the home visit.

Observed in Record Review. In 2 of 10 patient records reviewed, for active patients with a hospice aide, the nurse surveyor noted that for RRHV#1, the hospice aide care plan did not have information about the patient's mobility or that she was on PRN oxygen and what to do if she was using it during a visit. Additionally, the care plan listed shampoo every visit, however the hospice aide stated she only washed her hair one time a week. for RRHV#3, the hospice aide care plan did not have any information about the patient's mobility status, she was bed/wheel chair bound. Findings were verified by the Administrator and the Clinical Team Lead.

Observed in Record Review. In 3 of 10 patient records reviewed, For active patients with hospice aides, it was noted by the nurse surveyor that hospice aide supervisory visits were not documented no less frequently than every fourteen days. For RRHV#2, the hospice aide supervisor visit for was done on day fifteen. For RRHV#3, for the last three months, hospice aide supervisory visits were documented every twenty eight days. For RRNHV#3, the last hospice aide supervisory visit was documented on day sixteen. Findings were verified with the Administrator and the Clinical Team Lead.

Observed in Tracer Activities. It was noted by the nurse surveyor that the organization was not able to demonstrate cost savings achieved through the use of volunteers since despite recruitment efforts, they do not have any volunteers. Finding was verified by the Administrator.

Observed in Tracer Activities. It was noted by the nurse surveyor that volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff since despite documented recruitment efforts, the hospice did not have any volunteers. Finding was verified by the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted by the nurse surveyor that for RRHV#2 the patient did not have a completed individualized emergency plan in her home folder, the one in her folder was totally blank. Finding was verified by the Administrator who was present during the home visit.