Every finding on record at Valley Crest Hospice, Inc.

Observed in Record Review. In 14 of 14 patient records reviewed, It was noted that the organization failed to ensure that the plan of care includes all necessary services for the palliation and management of the terminal illness and related conditions. For example, in the clinical record reviewed, RRHV#1,RRHV#2,RRHV#3,RR#1,RR#2,RR#3,RR#4,RR#5,RRBR#1.RRBR#2,RRBR#3,RRDC#1,RRDC#2,RRDC#3, the required duration or frequency of visits was not documented. This finding was discussed and validated by the hospice management team.

Observed in Individual Tracer. In 1 out of 7 patient records with hospice aide services, it was noted that the organization failed to assess the quality of care and services provided by the hospice aide at a frequency of no less than every 14 days, as required, and to ensure that services ordered by the hospice interdisciplinary group (IDG) continued to meet the patient’s needs. For example, in RR#2, hospice aide supervisory visits were conducted more than 16 days apart on two separate occasions. This finding was discussed and validated by the hospice management team..

Observed in Record Review. In 7 of 7 patient records reviewed, with hospice aide services, it was noted in records RRHV#1, RRHV#3, RR#2, RR#4, RRBR#1, RRBR#3,RRDC#3, that the supervising nurse failed to assess the hospice aide's ability to demonstrate initial and continued satisfactory performance in creating successful interpersonal relationships with the patient and family. This finding was discussed and validated by the hospice management team.

Observed in Record Review. In 2 of 14 patient records reviewed, it was noted that the organization failed to ensure that the patient's clinical information was reviewed by the medical director or physician designee. For example, in RR#1, RR#4 the certification of terminally ill (CTI) had not been reviewed or signed by the physician prior to recertification. This finding was discussed and validated by the hospice management team.

Observed in Record Review. In 1 of 14 patient records reviewed, It was noted that the organization failed to ensure the clinical record contained complete and accurate information necessary for coordination of care among the hospice team and the attending physician. For example, in the record reviewed RRHV#3, skilled nursing visit notes were found to be blank or incomplete, missing key clinical data such as vital signs, care provided, and clinical narratives. This finding was discussed and validated by the hospice management team.

Observed in Record Review. In 8 of 8 active patient records, it was noted that the organization failed to ensure that all documentation entries were appropriately authenticated and dated. During the review of clinical records, RRHV#1,RRHV#2,RRHV#3,RR#1,RR#2,RR#3,RR#4,RR#5, both paper and electronics, several documents such as clinical visit notes, Hospice Aide Assignments, admission forms, were found to be missing required signatures and/or dates. This finding was discussed and validated by the hospice management team.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization did not plan the patient's care by including all medications and treatments necessary to meet the patient's needs. In review of the record for HV#2, the patient's plan of care included Advil 200mg 1 tab oral every 6 hours as needed for pain and Tylenol 500mg EZ tab 500 mg 1 tab oral every 6 hours as needed for pain. There was no clear indication for use (when to take which prn pain medication). In RR#8, the patient's plan of care included Miralax, Docusate Sodium, and Lactulose ordered prn for constipation with no clear indications for use. This was reveiwed and confirmed with the Director of Patient Care Services-Designee.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not implement planned infection prevention and control activities, including standard precautions. During HV#1, the LVN did use hand gel at various points during the visit. The nurse changed gloves prior to beginning the patient's wound care procedure, but did not perform hand hygiene before donning new gloves. It was also noted the equipment used to perform the patient assessment (BP monitor, pulse oximeter, temporal thermometer) was procured and owned by the LPN. The nurse cleaned the equipment with Lysol wipes, but admitted to not knowing what the manufacturer's recommendations were for cleaning products to be used on the various pieces of equipment. This was reveiwed and confirmed with the Administrator/Director of Patient Care Service-Designee.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization did not ensure entries in the patient record were authenticated. In RR#1, RR#2, RR#3, RR#4, RR#5, RR#6, RR#7, RR#8, HV#1, HV#2, and HV#3, it was noted, that members of the hospice interdisciplinary team (IDT) did sign attendance sheets for IDT meetings. All team members, however, did not authenticate/electronically sign their plan of care updates on the IDT notes in the hospice record as required by organizational policy and standards of practice. This was reveiwed and confirmed with the Director of Patient Care Services-Designee.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization did not maintain and ensure the patient record was complete, promptly and accurately documented, and readily accessible. In review of the record for HV#1, it was noted that several weeks of visit notes for the hospice aide and RN assessments were not found in the electronic patient record. It was reveiwed and verified by the Administrator/Director of Patient Care Services-Designee that the hospice aide and RN visits were made per the plan of care, but documentation had not yet been completed/submitted by the staff members.