Every finding on record at Valencia Hospice Care

Observed in Tracer Activities. there was no evidence that the governing body and leadership had established processes to support patient care, treatment, and services through sustained compliance as evidenced by repeat findings at §418.104. This RFI was reviewed with the Administrator and Director of Nursing.

Observed in Record Review. In 1 of 3 patient records reviewed, the organization did not maintain complete and accurate patient records. In the record of RRNHV#1 many of the assessment sections of the comprehensive nursing assessment were incomplete. This RFI was reviewed with the Administrator and Director of Nursing.

Observed in Patient Home. In 1 of 1 home visits conducted, the medication profile in a patient's home was inaccurate. At HV#1 during an interview with the patient, and with an LVN present the Surveyor observed that Acetaminophen 650 mg suppository was listed on the profile, but 650 mg was crossed out and then re-written. According to the LVN he made the change last month because Acetaminophen 325 mg two tablets by mouth was also ordered and he confused the two entries. The list included Vicks Vapo rub ointment apply twice a day as needed for pain: topical 2x daily as needed. This entry was handwritten. The medication list in the EMR included the same directions for “Baby rub” and was dated six weeks prior to this survey date. This RFI was reviewed with the Administrator and Director of Nursing.

Observed in Record Review. In 3 of 9 patient records reviewed, for active patients, it was noted by the nurse surveyor that the initial bereavement risk assessment had not been completed as required. Per Bereavement Services Policy No. 2-010. The initial bereavement risk assessment was to be completed by the Social worker within five days of admission. For RRHV#3, the initial bereavement risk assessment was completed by the chaplain almost five months after the admission. For RRNHV#1, and RRNHV#2, the initial bereavement risk assessment was not completed within five days of admission as required. Finding was verified by the Director of Nursing.

Observed in Record Review. In 9 of 9 patient records reviewed, for active patients, it was noted by the nurse surveyor that the registered nurse does not routinely make a home visit to conduct an assessment on patients no less than every 15 days. Licensed vocational nurses conduct all patient visits except for the initial comprehensive nursing assessment and the recertification assessment. The registered nurse does make home health aide and licensed vocational supervisory visits, when necessary, but does not document that a physical assessment of the patient has been completed. Finding was verified by the Director of Nursing and the Administrator. Observed in Record Review. In 9 of 9 patient records reviewed, for active patients, it was noted by the nurse surveyor that the IDG meeting notes were signed only by the Registered Nurse and the Medical Director and did not document who else attended the meeting. No other documentation was included in the EMR to indicate who attended each IDG meeting. Finding was verified by the Director of Nursing and the Administrator.

Observed in Record Review. In 2 of 9 patient records reviewed, for active records, it was noted by the nurse surveyor that medication orders were not clear or accurate. In RRHV#2, the order in the medical record for Vicodin was unclear and did not include an indication or symptom for when the medication was to be taken: Vicodin ½ to 1 tablet every 4 to 6 hours, PRN. In RRHV#3, the medication profile contained two separate orders for the treatment of pain but did not distinguish when each should be used: Aleve Capsules 220mg (Naproxen), 2 capsules as need for pain not to exceed 2 per day and Tylenol 325mg oral tablet by mouth every four hours for pain. Findings were verified by the Director of Nursing and the Administrator.

Observed in Record Review. In 5 of 7 patient records reviewed, for active patients with a hospice aide, it was noted by the nurse surveyor that the hospice aide care plans did not contain all the necessary information. For RRHV#3, RRNHV#1, RRNHV#2, RRNHV#5, and RRNHV#6, the care plan included that the hospice aide takes vital signs, but there were no parameters for when the registered nurse should be notified. Findings were verified by the Director of Nursing.

Observed in Tracer Activities. It was noted by the nurse surveyor that the governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: §418.54, §418.54 (d), §418.104, and §418.100(b).

Observed in Record Review. In 1 of 9 patient records reviewed, for active patients, it was noted by the nurse surveyor that documentation was not complete or entered promptly. For RRHV#3, the licensed vocational nurse consistently only documented on page one of the EMR nurses note, leaving page two, three and four blank. Additionally, visit documentation by the licensed vocational nurse was not entered for the last three weeks. Finding was verified by the Director of Nursing.

Observed in Medication Management Tracer. In 1 of 9 patient records reviewed, for active patients, it was noted by the surveyor that the medication profile was inaccurate. During RRHV#1, with the LVN, it was noted during the medication reconciliation that there were several edits to the home medication list that were not reflected on the medication profile in the EMR. The indication for PRN Docusate Sodium 250mg, one capsule orally PRN was not on the printed medication sheet in the home, but was on the bottle in Spanish, the LVN had made the edit on the home medication sheet. Also, the patient was taking Fluoxetine HCL 10mg instead of the 20mg on the medication sheet. This had also been updated on the home medication sheet but not the medication profile in the EMR. Additionally, the family was using Calmoseptine ointment on the patient’s bottom and Vicks VapoRub on his chest, neither of these were on his medication profile. Findings were discussed with the Director of Nursing upon return to the office.

Observed in Tracer Activities. It was noted by the nurse surveyor that the Hospice did not have a process in place to ensure that a Notice of Medicare Non-Coverage (NOMNC) was signed by the patient or patient’s representative at least two days prior to a planned discharge as required. Finding was verified by the Director of Nursing and the Administrator.