Every finding on record at Trilogy Hospice Care LLC

Observed in Patient Home. In 2 of 2 patient visits with nurses, the organization did not ensure that clinicians conducted an effective medication assessment. At visit RRHV#2 the RN did not use the hospice’s current medication list that was in the home folder. Rather, she used a hospital medication list given to the patient at some point in the past. As well, she looked at only three of seven medications in the comfort kit. And at visits RRNHV#2 and RRHV#3 the RN and LPN reviewed the drug name on the label, but not the strength, dosage, frequency, or rationale for prn medications. This RFI was reviewed and discussed with the Administrator and Director of Clinical Services.

Observed in Record Review. In 14 of 14 active patient records reviewed, the organization did not ensure that interdisciplinary notes documented decline and progress towards goals. Most notes did not address patient decline with metrics or comparative statements. Some included that there was “slow and steady decline” without providing specific examples. Additionally, documentation did not indicate progress towards goals. This RFI was reviewed and discussed with the Administrator and Director of Clinical Services.

Observed in Patient Home. In 2 of 2 home visits conducted, where equipment was cleaned, the organization did not implement infection prevention activities when cleaning and disinfecting equipment. At visits RRHV#2 and RRHV#3 nurses cleaned equipment with Sani Wipe disinfecting cloths by applying the solution to all surfaces of each item and placing it on a barrier to dry. The manufacturer’s instructions for use require two minutes of dwell time. The equipment did not remain wet for the required amount of time during at either visit. This RFI was reviewed and discussed with the Administrator and Director of Clinical Services.

Observed in Competency Session. In 1 of 1 HR files reviewed, the organization did not ensure that competence was assessed at hire in compliance with HR policy and law. In personnel file HR#6 HHA registered nurse did not observe the following areas for a home health aide’s performance of the tasks with a patient or pseudo-patient a part of a simulation: 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; safe transfer techniques and ambulation; normal range of motion and positioning. This RFI was reviewed and discussed with the Administrator and Director of Clinical Services.

Observed in Competency Session. In 1 of 8 HR files reviewed, the organization did not ensure that competence was assessed at hire in compliance with HR policy and law. In personnel file HR#4 MD there was no documentation of competence assessment for the medical director. This RFI was reviewed and discussed with the Administrator and Director of Clinical Services.

Observed in Record Review. In 14 of 14 active records reviewed, the organization did not ensure that clinicians conducted an effective medication assessment. At visit RRHV#2 the RN did not use the hospice’s current medication list that was in the home folder. Rather, she used a hospital medication list given to the patient at some point in the past. As well, she looked at only three of seven medications in the comfort kit. And at visits RRNHV#2 and RRHV#3 the RN and LPN reviewed the drug name on the label, but not the strength, dosage, frequency, or rationale for prn medications in compliance with policy. This RFI was reviewed and discussed with the Administrator and Director of Clinical Services.

Observed in Record Review. In 14 of 14 active patient records reviewed, the organization did not ensure that all entries in the patient record were legible and appropriately authenticated in compliance with policy IM.9 entitled Authorization and Authentication of Medical Records entries. For example, in record RRNHV#1 Medical Director signatures on Certificates of Illness, and admission documents signed by clinicians were not legible or authenticated with credentials. This RFI was reviewed with the Administrator, Clinical Specialist, and Branch Director.

Observed in Record Review. In 1 of 14 active patient records reviewed, the organization did not ensure that education and training to the patient included basic physical and structural home safety. In record RRNHV#1 a nurse documented that there were no carbon monoxide or smoke detectors, or fire extinguishers in the home of patient using oxygen. The nurse did not document that the patient or family were educated on the need for these safety devices, or that action was taken to assist the family in obtaining them through the local fire department, corporate foundation, or other avenues. This RFI was reviewed and discussed with the Administrator and Director of Clinical Services.