Every finding on record at Tri Meadows Healthcare, LLC

Observed in Emergency Management Session. The organization’s hazard vulnerability analysis failed to include the following: Emerging infectious diseases (such as Ebola, Zika Virus, SARS-CoV-2, this was observed and validated by the DON

Observed in Record Review. In 10 of 11 patient records reviewed, The organization failed to provide a written plan of care based on the patient’s goals and the time frames as evidenced in RRHV#1: A neurological goal: Patient needs will be met on a day to day basis as communicated and minimize episodes of cognitive symptoms through medications throughout this certification period. RRHV#2: The patient`s s/sx of agitation will be managed and controlled by the use of Quetiapine Fumarate 50 mg 1 tablet in the morning routinely until the end of certification period. RRHV#3: Patient`s pain will remain in comfortable level within certification period. RRNHV#1: patient will verbalize and/or express decreased episodes of SOB during activities during this benefit period. RRNHV#2: pain will remain at a comfortable level during this benefit period. RRNHV#3: achieve and maintain peripheral circulation for patient comfort as evidenced by a normal level of BP and having no edema. RRNHV#5: Goal not specific: patient will have strength and energy for daily activities,. RRNHV#6: Cardiac: patient will maintain optimum peripheral circulation maintaining VS within normal limits during this cert period. RRNHV#7: Achieve and maintain peripheral circulation for Pt comfort by maintaining blood pressure at normal limits and give anti-coagulant. RRNHV#8: Goals not specific: Episodes of confusion will be decreased during this benefit period this was observed and validated by the DON

Observed in Record Review. In 1 of 11 patient records reviewed, The plan of care failed to include all services needed as evidenced in RRNHV#7: POC did not include safety precautions such as bleeding precautions for a patient on anticoagulants, this was observed and validated by the DON

Observed in Record Review. In 5 of 11 patient records reviewed, The organization failed to revise the plan of care based on information from updates to the patient’s comprehensive assessment and address the patient’s progress toward goals and outcome as evidenced in RRHV#1: Psychological goals unchanged since SOC - Establish trusting relationship with Pt/Family/PCG.-Pt and Family to be learned on progression of illness, dying process and grieving.-Pt/Family/PCG will receive emotional support to adequately cope with illness/death and Pt/Family/PCG will verbalize understanding of Pt`s terminal illness. RRHV#2: Pt/Family/PCG will verbalize understanding of functional limitations as part of terminal condition and disease process. -No physical injuries as a result of accidents/fall RRHV#3: Pt/Family/PCG will receive emotional support to adequately cope with illness/death and Pt/Family/PCG will verbalize understanding of Pt`s terminal illness. RRNHV#3: patient and family will freely verbalize spiritual needs and concerns and will verbalize receiving desired spiritual support. RRNHV#6: Cardiac: patient will maintain optimum peripheral circulation maintaining VS within normal limits during this cert period, this was observed and validated by the DON

Observed in Infection Control Tracer. The organization failed to gather data to evaluate hand hygiene compliance, therefore could not establish any goals, this was observed and validated by the DON

Observed in Record Review. In 1 of 2 patient records reviewed, The organization failed to develop a bereavement plan of care that specifies the type of bereavement services to be offered and the frequency of service delivery as evidenced in RRBR#2: there is no bereavement care plan, this was observed and validated by the DON

Observed in HR File Review. In 1 of 1 HR files reviewed, The supervising nurse failed to assess the aide’s ability to demonstrate initial satisfactory performance in the following: - Completing the tasks in the plan of care assigned to the hospice aide by the registered nurse as evidenced that the HHA competency was not completed on orientation, this was observed and validated by the DON

Observed in Record Review. In 6 of 11 patient records reviewed, The RN who prepares written patient care instructions for the hospice aide failed to update the HHA assignment as evidenced in RRNHV#1 & RRNHV#4, RRNHV#6: HHA assignment was not updated when the patient developed the pressure ulcer, RRNHV#2: HHA assignment did not include specific instruction for wound or if O2 can be taken off during bed bath. RRNHV#5: if O2 can be taken off during bed bath. RRNHV# 7: patient was on an anticoagulant and bleeding precautions were not identified in POC, this was observed and validated by the DON

Observed in Patient Home. In 1 of 3 home visits conducted, The organization failed to treat the patient in a dignified and respectful manner as evidenced in RRHV#3: while providing a bed bath to the patient the HHA did not close a door that was open to an outdoor patio area, therefore not providing privacy for the patient, this was observed and validated by the DON

Observed in Emergency Management Session. On review of the written Emergency Management Plan , it was found that the plan, had not addressed in writing, a delegation of authority plan that described the decisions and policies that could be implemented by authorized successors during an emergency and criteria or triggers that would initiate this delegation. There was , however, a list of those who would replace the key leaders during an emergency This was validated by the Alternate DON.

Observed in Individual Tracer. On review of the admission packet it had been identified that the organization had not included in the State Hotline notification that the patient had the right to call the hotline if they had any concerns about the implementation of Advance Directives. This was validated by the DON/Administrator.

Observed in Individual Tracer. On review of the admission packet and the organizations marketing brochure it was found that the patients were given the hotline number, however, the information had not included the hours of operation, that the purpose of the hotline was to receive complaints or questions about home health agencies, and voice concerns about the implementation of Advance Directives. This was validated by the DON/Administrator.

Observed in Individual Tracer. In 3 of 6 patient records reviewed, it was found that the hospice plans of care goals had not been individualized and had not identified measurable time frames for the patient/caregiver. For example, for HV # 2 the goal for self care deficit was Pt will have good assistance with personal care. Pt/cg will verbalize understanding of functional limitations as part of the terminal condition and disease process, and had a target date of the end of the 90 day certification. For HV # 3 for the problem of increase generalized weakness the goal was Pt's ADL needs will be met to an optimum level through assistance with personal care within the certification period. The plan of care goals were picked from a generic electronic medical record system and had not been specific to the individual patients. All goals had measurable time frames of end of certification period or had a date that was actually the end of the certification period. This was validated by the DON/Administrator.

Observed in Infection Control System Tracer. On review of the written Infection Control Plan it was identified that the plan had not identified, in writing ,a measurable goal for limiting the spread of infections associated with procedures. This was validated by the Alternate DON. Observed in Infection Control System Tracer. On review of the written Infection Control Plan it was identified that the plan had not identified, in writing ,a measurable goal for limiting the spread of infections associated with the use of medical equipment, devices, and supplies. This was validated by the Alternate DON. Observed in Infection Control System Tracer. On review of the written Infection Control Plan it was identified that the plan had not identified, in writing, a measurable goal for limiting unprotected exposure to pathogens. This was validated by the Alternate DON.

Observed in HR File Review. On review of the personnel file for the hospice aide, it had been found that an observed skills competency had not been completed with a patient or a pseudo-patient for appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination , and normal range of motion and positioning. The aide had been providing care for over a month to a hospice patient. Competency was documented as observed for transfer and ambulation. This was validated by the Alternate DON.