Every finding on record at Trinity Home Health Services

Observed in Record Review. In 3 of 17 patient records reviewed, the initial comprehensive assessment was not completed within five calendar days of the patient electing the hospice benefit. For example in records RRHV#2 and RRNHV#3 there was no documentation that a Spiritual Counselor had completed an initial assessment and there was no documentation to indicate a refusal or requested postponement of the visit. In record RRNHV#5 the Spiritual Counselor visit was completed day 7 with no documentation to indicate a request for the postponed date. This was confirmed with the Clinical Manager present.

Observed in Record Review. In 2 of 17 patient records reviewed, it was noted that the initial bereavement assessment was not completed. For example, in records RRBR#3 and RRNHV#3 there was no initial bereavement assessment documented. This was confirmed and discussed with the Clinical Manager present.

Observed in Record Review. In 1 of 4 home visits conducted, it was noted in the home binder of RRHV#3 that the patient's representative/POA had signed a blank addendum, Notice of Non-coverage. This was verified with the Clinical Manager present.

Observed in Record Review. In 13 of 17 patient records reviewed, it was noted that the written plan of care was not individualized with goals including time frames. For example, RRHV#1 22 of 22 goals documented had time frames throughout hospice episode and goals were not individualized; Patient/CG verbalizes proper mouth care throughout hospice episode. RRHV#3 14 of 18 goals time frames were throughout hospice episode and goals were not individualized; General hospice care pak will be provided to the patient within 72 hours. RRHV#2 18 of 19 goals and RRHV#4 18 of 20 goals time frames were documented as throughout hospice episode. RRNHV#1 10 of 10 goal's time frames were documented as throughout hospice episode. Also goals for the MSW and Chaplain stated A (MSW or Chaplain) plan of care will be established that meets the patient's needs and no interventions. RRNHV#2 12 of 12 goals time frames were documented as throughout hospice episode. Also, goals for the Volunteer, MSW and Chaplain stated A (volunteer, MSW or Chaplain) hospice plan of care will be established that meets the patient's needs. and no interventions. RRNHV#4, RRNHV#5, RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#9 and RRNHV#10 records with the same time frames and goal quote problems. This was discussed with the Clinical Manager present.

Observed in Record Review. In 2 of 14 patient records reviewed, it was noted that the POC did not include statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs. For example in records RRNHV#5 and RRNHV#9 the POC did not include the frequency of volunteer services. The records did include documentation of visits performed by the volunteer. This was confirmed and discussed with the Clinical Manager present.

Observed in Record Review. In 5 of 17 patient records reviewed, it was noted that care was not provided according to hospice plan of care. For example, in record RRHV#1 the POC required the MSW to visit the patient 1 time a month and following the initial comprehensive visit there was no documentation of a MSW visit for over 7 weeks. In records RRBR#1 and RRBR#2 the bereavement interventions included mailings at 3 and 6 months and there was no documentation of the mailings. In RRBR#1 there was an intervention for a call at 30 days and there was no documentation of the call and the Bereavement Coordinator stated that the call had not been made because there was no volunteer trained to make the call at the time. This was confirmed and discussed with the Clinical Manager present. It was noted that at the start of care RRHV#4 and RRNHV#8 the nursing admission documentation stated that the patient's family had requested volunteer services, but there was no documentation of the patient or family being contacted by the coordinator or visits being completed. The Clinical Manager present did locate documentation that the nurse who completed the admission had contacted the volunteer coordinator to have volunteer services started. This was discussed with the Clinical Manager present.

Observed in Patient Home. In 2 of 4 home visits conducted, staff did not follow the organizations infection control policy. For example during Hospice RRHV #1 and #2 the RNs were observed to wipe the vital sign equipment off using a 70% alcohol wipe, one item at a time, then immediately integrated back into the bag without allowing to dry or performing hand hygiene. The RNs were observed to perform hand hygiene, don gloves and performed the patient visit touching the patient and patient's environment including performing a medication reconciliation picking up each bottle to read the label then look into tablet, touching the tablet. Also, observed entering and exiting the clinical bag multiple times without performing hand hygiene or changing gloves. This was discussed with the manager present.

Observed in Record Review. In 3 of 3 patient records reviewed, for bereavement services it was noted that the hospice had not developed a bereavement plan of care. For example, in records RRBR#1 and RRBR#2 there were identical lists of interventions however there were no goals documented in either record. In record RRBR#3 the post death bereavement risk assessment indicated that the bereaved were at a high risk, yet there was no plan of care documented, no goal or interventions.

Observed in Tracer Activities. During meeting with the Volunteer Coordinator in was noted that the hospice had not documented retention activities for volunteers. This was confirmed with the Regional Quality Nurse.

Observed in HR File Review. In 2 of 9 HR files reviewed, it was noted that staff competency was not assessed as part of orientation. For example, the volunteer record did not include an initial documented competency. For example, the Spiritual Counselor/Bereavement Coordinator record included a competency document that was only partly completed with entire areas blank including the hospice education area and the field joint visit section. This was confirmed with the HR staff and Volunteer Coordinator present.

Observed in Record Review. In 1 of 1 patient records reviewed, for discharge with transfer of hospice care, it was noted that there was no documentation that the new hospice provider was provided with the reason for the patient's transfer, a summary of care, treatment and services it had provided to the patient, or the patient's progress toward goals. This was confirmed with the Clinical Manager present.

Observed in Record Review. A review of 2 of 13 patient records revealed that the organization did not ensure that initial assessments by members of the interdisciplinary group included all required information. For example, during a review of the medical record for HosRR#5, and HosRR#7, it was noted that an initial bereavement risk assessment was not completed. This observation was reviewed with the Hospice Clinical Manager.