Every finding on record at Trinity Home Health Services

Observed in Record Review. In 1 of 14 patient records reviewed, the organization did not complete the comprehensive assessment no later than five calendar days after the election of hospice care. In review of the medical record for RRNHV #10 the psychosocial assessment was completed on the 6th day following the election of hospice care and there was no evidence that the spiritual assessment had been completed or documentation that the patient or family declined spiritual care services until 18 days following the start of care. This was validated with the Quality Director

Observed in Record Review. The organization was not assessing the volunteer needs for hospice patients/families. The Hospice Clinical Manager reported that the organization had been without a Volunteer Coordinator since April and that the volunteer program had been on hold, and during that time volunteer services were not being assessed or offered to hospice patients/families. In review of the medical records for RRNHV #1, RRNHV #2, RRNHV #3, RRNHV #4, RRNHV #5, RRNHV #6, RRNHV #7, RRNHV #8, RRNHV #9 and RRNHV #10 there was no evidence that the need for volunteers had been assessed and/or offered. This was validated with the Quality Director.

Observed in Record Review. In 9 of 14 patient records reviewed, the written plan of care did not have measurable outcomes anticipated from implementing and coordinating the plan of care. For example, in review of the medical record for RRHV #1 the plan of care included a problem for pain with the goal, patient/caregiver will verbalize/demonstrate knowledge of appropriate pain scales, medications and psychosocial/spiritual support to effectively manage pain and pain will be maintained at an acceptable level of comfort however the goal was not patient specific and failed to identify the acceptable level of comfort for the patient ie; pain level 2- 3, etc. Also, in review of the medical record for RRHV #2 with hypertensive heart disease and COPD the plan of care included the goal; patient will maintain optimal cardiovascular status within disease limitations throughout hospice episode however failed to define what optimal cardiovascular status would be or specific measurable outcomes for the patient or time frames to achieve goals. This was also observed in review of the medical records for RRHV #3, RRHV #4, RRNHV #1, RRNHV #2, RRNHV #3, RRNHV #4 and RRNHV #6. This was validated with the Quality Director.

Observed in Patient Home. In 1 of 4 home visits conducted, the organization's infection prevention and control policies were not followed when cleaning and disinfecting medical supplies and devices. In observation of the care for RRHV #1 the RN failed to clean the tablet which had been laid on the table without a barrier prior to leaving the home. This was validated with the RN and the Hospice Clinical Manager. Observed in Patient Home. In 1 of 4 home visits conducted, staff did not use standard precautions consistent with the organization's policy Hand Hygiene. For RRHV #3 the social worker failed to perform hand hygiene upon entering the home, after contact with the patient and upon leaving the home. This was validated with the Hospice Clinical Manager.

Observed in Record Review. In 2 of 3 patient records reviewed, the hospice bereavement plan of care failed to specify the frequency of service delivery. In review of the medical record for RRBR #1, RRBR #2 the documentation on the bereavement plan of care did not include the frequency of interventions/service delivery such as visits or telephone calls by the Bereavement Coordinator. This was validated with the Bereavement Coordinator and Quality Manager.

Observed in HR File Review. In 4 of 4 HR files reviewed, combined home health and hospice, for home health aides, the competency process failed to include CMS requirements. In review of the personnel file for HR #4 and HR #6 of home health aides the competency evaluation conducted at the time of hire did not include evaluation of required elements including; basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor , maintenance of a clean, safe, and healthy environment, recognizing emergencies and initiating necessary emergency procedures, the physical, emotional, and developmental needs of and ways to work with the populations served by the home health aide or hospice aide, including the need to respect the patient and their privacy and property, adequate nutrition and fluid intake. This was validated with the Hospice Clinical Manager. Observed in HR File Review. In 4 of 4 HR files reviewed, combined home health and hospice, for home health aides, the competency process failed to include CMS requirements. In review of the personnel file for HR #4 and HR #6 of home health aides the competency evaluation conducted at the time of hire did not include evaluation of; communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other staff, 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 was validated with the Hospice Clinical Manager.

Observed in Document Review. No evidence that the governing body and leadership had established processes to support patient care treatment and services through sustained compliance as evidenced by non compliance with organizational policies of medical records and CMS deficiencies of 418.104.

Observed in Tracer Activities. the organization did not follow their policy ; Records Management Policy regarding storage and destruction of records. The Bereavement Coordinator reported that for families/survivors who have completed the 13 month Bereavement Program those clinical notes which have been documented on paper had not been scanned into the medical record and have been destroyed. This was validated with the Bereavement Coordinator and the Quality Manager.

Observed in Record Review. the organization did not follow their policy: Record Management Policy regarding record retention. The Bereavement Coordinator reported that the clinical notes for persons served in the Bereavement Program had been destroyed after completion of the program at 13 months and not retained for six years after the death of the patient as required by law and regulation. This was validated with the Bereavement Coordinator and the Quality Manager.

Observed in Record Review. the organization did not follow their policy ; Hospice - The Medical Record regarding documentation in the clinical record and which states that documentation on paper forms are scanned into the electronic medical record and the policy Records Management Policy regarding storage and destruction of records. The Bereavement Coordinator reported that she documents clinical notes on paper for bereaved family members that she visits as part of the Bereavement Program however the clinical notes are not scanned into the electronic medical record (EMR) in accordance with the organization's policy and the medical record is not complete and readily accessible to other team members. For example in review of the electronic medical records for RRBR #1 and RRBR #2 the documentation in the electronic medical record states; See confidential notes however, the clinical notes have not been scanned into the EMR. This was validated with the Bereavement Coordinator and the Quality Manager.

Observed in Patient Home. In 1 of 4 home visits conducted, the organization had not provided the patient with an individualized emergency plan based on the patient's priority level and individualized to the patient's need. In review of the home folder for RRHV #3 the Individualized Emergency was blank and had not been completed. This was validated with the Hospice Clinical Manager.

Observed in Document Review. the organization did not communicate in writing expectations to the provider of the contracted services. For RRHV #2 there was no evidence in the home that the DME had provided back up oxygen for the hospice patient who uses oxygen as needed and in review of the DME contract there was no language regarding the provision of delivery of back up oxygen with the delivery of the oxygen concentrator. This was validated with the Hospice Clinical Manager and the Quality Manager.

Observed in Patient Home. In 1 of 1 home visits conducted, to hospice patients that resided in a skilled nursing facility, the organization had not provided the skilled nursing facility (SNF) with required information. In review of the SNF medical record for RRHV #4 there was no evidence that the hospice had provided the facility with the patient’s hospice election form and the physician certification and recertification of the patient’s terminal illness. The Hospice Clinical Manager stated that the hospice election form is provided to the SNF if they request it. This was validated with the Hospice Clinical Manager and the Quality Director.

Observed in Individual Tracer. In 1 of 3 hospice home visits, The hospice nurse surveyor noted that (HOSV#3), the plan of care indicated that the nurse was to perform wound care to the patient's necrotic toes. The surveyor noted that the care, as noted in both the admission visit and subsequent visit, was not provided as ordered and the documentation did not indicate that the physician was notified. This was confirmed with the quality manager.

Observed in Individual Tracer. The hospice nurse surveyor noted (HOSV#1) that the aide indicated that assistance of another was required to transfer the patient and indicated that the assisted living staff sometimes used a Hoyer lift. Also, the aide indicated that she sometimes shaves the patient with an electric razor. The surveyor noted that the aide care plan did not include information about the need for a two person transfer or assisting the patient to shave. This was confirmed with the quality manager.

Observed in Individual Tracer. The hospice nurse surveyor noted (HOSV#2) the medication profile was not accurate and did not include accurate information based on the physician orders. The surveyor noted that the medication profile included an order for Amlodipine 10 mg/Atorvastatin 10 mg daily as needed for comfort; however the order read Amlodipine 10 mg/Atorvastatin 10 mg daily with instructions to hold if systolic BP <110 or Pulse < 60. This was confirmed with the quality manager.

Observed in Record Review. The hospice nurse surveyor noted (HOSRR#1) that the plan of care for this skilled nursing facility based patient did not include a delineation of which services shall be provided by the hospice and which services would continue to be provided by the facility, as required by the contract. This was confirmed with the quality manager.