Every finding on record at University of New Mexico Health Sciences Center

Observed in Record Review. In 9 of 10 active hospice patient records reviewed, the organization failed to ensure the plan of care was updated based on the patient's reassessment and progress toward their goals. In HSRRHV #1, HSRRHV #2, HSRRHV #3, HSRRNHV #1, HSRRNHV #2, HSRRNHV #3, HSRRNHV #4, HSRRNHV #6 and HSRRNHV #7, the plans of care had not been updated to reflect the current assessment, achieving goals that had been achieved. For example, teaching goals unaltered from IDT to IDT since the initial assessment with no change or update. THis finding was reviewed with the hospice manager.

Observed in Record Review. In 8 of 10 active hospice records reviewed, Hospice surveyor noted that goals were not measurable and specific to the patient. For example, HSRRHV #2 the patient had a breathing goal that patient would have optimal breathing, and that patient caregiver would have a viable resource that are not measurable goals. On HSRRHV #3 the patient had a goal that cardiac status will be consistent with disease with no detail on how that cardiac status will be measured. HSRRHV #1, HSRRNHV #1, HSRRNHV # 2, HSRRNHV # 3, HSRRNHV # 4, HSRRNHV #6 also had goals that were not measurable with examples that include satisfactory control of pain, stabilization of pulmonary status, optimal level of functioning, adequate nutrition, breathing at optimal level, acceptable pain level and patient will remain comfortable. This finding was reviewed with the Hospice Manager who was present for all chart reviews.

Observed in Record Review. In 4 of 10 active Hospice patient records reviewed, the medication orders were not clear and accurate. Organization Medication policy is that PRN duplicate medications will be handled by the pharmacy to remove duplicate PRN therapy. On HSRRNHV #1, it was noted that the medications orders had duplicate PRN therapy (ondansetron and lorazepam) for nausea and vomiting with no indication when to use each duplicate. On HSRRNHV #3, it was noted that the medications orders had duplicate PRN therapy (Lactulose and glycerin) for constipation and PRN therapy (Lorazepam and midazolam) for agitation with no indication when to use each duplicate therapies. On HSRRNHV #4, it was noted that the medications orders had duplicate PRN therapy (ondansetron and lorazepam) for nausea with no indication when to use each duplicate. On HSRRNHV #5, it was noted that the medications orders had duplicate PRN therapy (acetaminophen and ibuprofen) for pain/fever with no indication when to use each duplicate.

Observed in Data Session. During review of the organization’s Hospice quality program, the governing body had not approved the frequency of the data collection associated to QAPI measures for 2023 and 2024. This was reviewed and validated with the director and hospice manager.

Observed in Data Session. During review of the organizations Hospice data and QAPI plan, it was noted the organization did not collect adverse events as part of their plan. While the organization as a whole is collecting this data it is not being monitored as part of the Hospice QAPI. This was reviewed and validated with the director and hospice manager.

Observed in Record Review. In 1 of 2 Hospice Bereavement records reviewed, the organization did not complete bereavement risk assessment on bereaved. Agency Bereavement policy states that the organization will collect bereavement risk assessment on admission and on death. On HSRRBR #1, it was noted that their was no bereavement risk assessment completed after the death of the patient. This finding was reviewed and validated with the Hospice Manager.

Observed in Record Review. In 4 of 10 active patient records, the hospice nurse surveyor noted that the medical record did not contain medical equipment used by the patient in the home. On review of HSRRHV #1, it was noted during the home visit that patient had a ventilator, tracheostomy, humidifier and feeding pump and these DME items were not documented in the patient's medical record. On HSRRHV #2, it was noted that patient was using a feeding pump and NG tubes and these were not listed on the Plan of Care. On HSRRNHV #2, it was noted that the patient had a BIPAP and Gastric tube and the machine and supplies were not listed on the Plan of Care. On HSRRNHV #3, it was noted that the patient had a feeding pump and the machine was not listed on the Plan of Care. This finding was reviewed and validated with the Hospice Manager.

Observed in Record Review. 1 of 2 Hospice records reviewed, the agency did not send the discharge summary to the receiving provider; it was sent to hospice medical director. Upon record review for HSRRDC #1, the discharge summary was sent to the hospice medical director rather than the receiving provider. This finding was reviewed with the hospice manager.

Observed in Record Review. In review of the clinical record associated with hospice home visit #1, there was no documentation that the registered nurse performing the initial comprehensive assessment had contacted the hospice medical director to discuss the assessment and obtain initial orders. This was discussed with the hospice DPCS.

Observed in Document Review. In 3 of 3 contracts reviewed, there was no documentation stating how the contracted services will be coordinated and evaluated by the organization. This was discussed with the home health DON.