Every finding on record at Umbrella Hospice, Inc

Observed in Record Review. It was noted by the nurse surveyor that for RRDC#1 the Notice of Medicare Non-coverage (NOMNC) was signed by the patient’s representative on the day of discharge, not in advance of the discharge as required. Finding was verified by the Administrator and Compliance Registered Nurse.

Observed in Record Review. In 10 of 10 patient records reviewed, it was noted by the nurse surveyor that the bereavement risk assessment had not been documented for RRHV#1, RRHV#2, RRHV#3, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6, and RRNHV#7. Per agency policy, the Social Worker/Bereavement Coordinator was the staff member designated to complete the initial bereavement risk assessment. Each of the patients and designated caregivers were telephoned within five days of admission, however all that was documented was that the patient/caregiver refused bereavement services. There was no evidence to support that a bereavement risk assessment had been conducted. Finding was verified by Compliance Registered Nurse and the Quality Assurance Nurse.

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 “Hand Hygiene Policy No. 9-009.01”. For example, during RRHV#1 the hospice nurse donned gloves and then touched the patient's bed controls, turned the patient, and then checked his bottom and back without changing gloves. After removing her gloves and performing hand hygiene, she touched items on the patient’s dresser, documented, and tied up and took out the trash without performing hand hygiene, During RRHV#2 with a skilled nurse, she donned gloves then took the patient’s vital signs, completed a head to toe assessment of the patient to include removing her diaper to assess her bottom, then proceeded to assess her legs and feet all with the same pair of gloves on. Findings were verified by the Administrator Designee who was present during the home visit. 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 “Bag Technique Policy”. For RRHV#2 the nurse cleaned her equipment (BP cuff, stethoscope, thermometer, pulse oximeter) with alcohol wipes and immediately dropped the items into her bag without allowing them to dry per the recommended product dry time of one minute. Finding was verified by the Administrator Designee who was present during the home visit.

Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement, it was noted by the nurse surveyor that for RRBR#1 and RRBR#2 there was not a developed and documented bereavement plan of care. Mailings were set at policy defined intervals which was standard for all families per the Bereavement Coordinator and Administrative Assistant. Finding was verified by the Director of Patient Care Services (DPCS).

Observed in Individual Tracer. In 2 of 2 patient records reviewed, HV1, BR2 the surveyor noted the organization failed to demonstrate the written plan of care was based on the patient’s goals, time frames, settings, and services required to meet those goals. For example, HV1, RR2, the goals were standard or canned language in the electronic medical record, but did not include individualized, measurable outcomes for these goals. For example HV1 goal stated: establish or regaining normal pattern of bowel function with a goal outcome scored as a 2 = goal met with ongoing action. There was no documentation regarding time frame or outcome expected for that patient goal. In addition, the patient had an open pressure ulcer requiring twice weekly dressing changes, however this was not identified on the plan of care. There was no documented individualized goal, time frame or outcome expected to achieve the skin integrity goal on the plan of care. This was discussed and validated by the Administrator/DPCS who stated they had recently transitioned to an electronic format and had a learning curve regarding writing measurable goals.

Observed in Individual Tracer. In 1 of 2 patient records reviewed, HV1, during the record review, the surveyor noted the plan of care revisions did not show evidence it was based on information from updates to the patient’s comprehensive assessment or addressed the patient’s progress toward goals and outcomes. For example, HV 1 the patient was admitted January 2022, however there was no documentation in the clinical record or in the subsequent IDT notes regarding progress toward goals. Multiple goals were only scored using a canned standard number 2 that the legend indicated 50-75% progress. There was no documentation of the patients' individualized progress or status toward achieving the goals as the section goal outcome was left blank. For example, the patient had a pressure ulcer that required twice weekly dressing changes and weekly measurements which were recorded in the clinical note, however there was no documentation regarding the progress toward the goal or outcome on the updated plan of care. This was validated by the Administrator.

Observed in Individual Tracer. In 1 of 1 home visits conducted, HV1, during the home visit with the nurse and Administrator/DPCS, the surveyor noted the organization failed to implement its infection prevention and control activities, to reduce or eliminate the risk of infection. For example, the Administrator/DPCS placed her clinical bag directly on the floor without a barrier; the RN's nurse bag remained open during the entire visit. This was not compliant with the organization's Bag Hygiene Policy which indicated the bag should be placed on the cleanest surface possible and a barrier placed beneath it. Additionally the policy stated: the bag should remain closed when the clinician is not actively obtaining items. This was discussed and validated by the Administrator/DPCS designee/RN and Administrator.

Observed in Individual Tracer. In 1 of 1 bereavement records reviewed, BR 2, during the record review, the surveyor noted the organization failed to implement the bereavement plan of care that specified the type of bereavement services to be offered and the frequency of service delivery. For example BR2, post death phone calls, cards and letters were planned and scheduled in the electronic record (calendar) on a monthly basis, however there was no documentation that the services had been offered to the bereaved or implemented. There was no documentation in the clinical record or in any separate documentation/tracking system. This was validated by the Administrator.

Observed in Individual Tracer. In 1 of 2 patient records reviewed, BR2, during record review, the surveyor noted the organization failed to complete documentation of the initial bereavement risk assessment. For example, the bereavement comprehensive assessment form was incomplete, as several sections were left blank. The addendum bereavement risk tool/form was not in the record for the initial assessment, therefore no bereavement risk evaluation level or score was documented. This was not compliant with the organization documentation policy and validated by the Administrator.

Observed in Individual Tracer. In 1 of 1 home visits conducted, HV1, during home and subsequent record review, the surveyor noted the organization failed to demonstrate there was an accurate list of medications. For example, during the home visit, the nurse noted the patient had a medication bottle dated 3/8/22 for Oyster Shell 500 Vit-D3 200 which the family administered to the patient. This was not listed on the medication profile nor in the plan of care. In addition the patient was admitted three months prior to the survey date and Norco 5/325 mg was listed as ordered. It was discontinued two month later, however the discontinuation date was not listed on the electronic medical record medication profile. This was not compliant with the organization's medication management policy and validated by the Administrator.

Observed in HR File Review. In 1 of 3 HR files reviewed, HR 1, during personnel file review the surveyor noted the organization did not show evidence it verified and documented the credentials of the MSW/Chaplain who is the same individual, at time of hire. This was validated by the Administrator.