Every finding on record at Victory Compassion Hospice, Inc.

Observed in Individual Tracer. In 3 of 11 patient records reviewed, The hospice nurse surveyor noted (HV#1) that a spiritual assessment was not completed. Also, in (ARR#4) the bereavement risk assessment was not performed until day six (6) and in (DRR#2), the initial bereavement assessment was not completed until day ten (10). The organizational policy required that the assessment be completed within the first five days. This was confirmed with the administrator.

Observed in Record Review. In 2 of 11 patient records reviewed, The hospice nurse surveyor noted (ARR#1) that the interdisciplinary team failed to assess the patient when the patient's condition changed. The surveyor noted in a communication note that the Licensed Vocational Nurse reported to the Registered Nurse that the patient's Foley catheter was leaking and not draining and that the patient had a temperature of 100.5. The nurse obtained an order to initiate Ceftriaxone intramuscular injections daily for 7 days; however the Registered Nurse did not assess the patient until 12 days later. In the mean time the licensed vocational nurse reported that the catheter was clogged and there was evidence of blood clots, another antibiotic was ordered along with Acetic Acid daily irrigations. Also, (ARR#3), the licensed vocational nurse reported that the patient was experiencing vaginal bleeding; however there was no evidence that the interdisciplinary team registered nurse evaluated the vaginal bleeding. The surveyor noted that there was no evidence of discussion or planning for managing the vaginal bleeding in the interdisciplinary team meeting notes. The surveyor confirmed this with the director of clinical services. Observed in Record Review. In 4 of 11 patient records reviewed, The hospice nurse surveyor noted (ARR#1) that there was no evidence of the patient's progress toward goals in either the reassessments or interdisciplinary team meeting notes...………………..Also, (ARR#2), ………………. (ARR#3) since 2020...…………………………….. (ARR#4)…..blood sugar monitoring not completed

Observed in Individual Tracer. In 7 of 11 patient records reviewed, The hospice nurse surveyor noted (HV#1) that the plan of care goals did not reflect the needs of the patient. For example, the assessment indicated that the patient was cachexic and loosing weight and at risk for aspiration; however, the care plan did not include goals or interventions to address her nutritional needs and aspiration risk. Also, there were no time frames or measures for any of the goals listed, for example maintain optimal mobility for this bedbound patient. Also, in (HV#2), the surveyor noted that the patient was hard of hearing and that the son had brought an amplification hearing device to assist. The care plan did not address the patients deficit. Also, in (ARR#4), the goals for urinary care verbalize having urinary needs met at an acceptable level and did not address goals for maintaining and irrigating the Foley catheter or preventing recurrent urinary tract infections. Also, there were no goals to address the patient's pain, hypertension, and agitation. The nursing assessment indicated that the physician suggested monitoring the patient blood glucose levels for one week and reporting in one week; however it was not included in the plan of care and the goal was not measurable and said optimal blood sugar. The surveyor noted that seven records did not include measurable outcomes or time frames for achieving goals. This was confirmed with the administrator.

Observed in Record Review. The hospice nurse surveyor noted (ARR#4), that the nursing assessment indicated that the physician suggested monitoring the patient blood glucose levels for one week and reporting the results in one week; however it was not included in the plan of care and there was no evidence in the record that the blood glucose was monitored, as the patient was on insulin. Also, the HHA was ordered 3 x a week; however, the patient only received one HHA visit week two and week four, and no additional visits in the past two weeks. The surveyor confirmed with the director of clinical services, that there was no evidence in the record that the interdisciplinary team and physician were notified. Observed in Record Review. In 2 of 11 patient records reviewed, The hospice nurse surveyor noted (ARR#1) that the plan of care did not include an oral diet order. The surveyor confirmed that the patient was NPO; however, it was not indicated on the care plan. Also, the enteral feeding orders were incomplete. The order on the plan of care simply stated: Juven powder one packet by mouth daily (patient is NPO) and Novasource and did not include a dilution, amount or frequency or a route for administration. The Juven dilution order was not clarified until five (5) weeks after admission and the Novasource quantity-1/2 can and frequency- four times a day was added eleven (11) days after admission. The surveyor noted that the volume was small and was informed that the patient experienced abdominal distension when the volume was higher; however this was not addressed in the plan of care. This was confirmed with the administrator.

Observed in Record Review. In 3 of 11 patient records reviewed, The hospice nurse surveyor noted (ARR#1) that the plan of care was not updated when the patient condition changed. In discussion with the director, the surveyor confirmed that the patient was ordered only small amounts of enteral feedings because he experience abdominal distension with larger amounts; however, it there was no evidence in the interdisciplinary team discussions or in the care plan and the care plan was not updated with the change. Also, in (ARR#2) the visit notes indicated that the patient was experiencing depression and had a pruritic rash and was ordered Rifampin, Cholestyramine Powder, for the pruritic and mirtazapine for depression. The surveyor noted that the plan of care was not updated to include outcomes for managing the depression or the pruritus or any evidence of progress in managing the symptoms. Also, in (ARR#3), the surveyor noted that the plan of care had not been updated since the patient's admission in 2020, although the patient had been experiencing vaginal bleeding since April. Also, the surveyor noted that the care plan still include Foley catheter and irrigation orders; however the patient did not have a catheter since 2020, when it was discontinued. This was confirmed with the administrator. (ARR#3), the care plan was not updated since the patient was admitted in July of 2020. The visits notes indicated that the patient was experiencing vaginal bleeding.....

Observed in Individual Tracer. The hospice nurse surveyor noted that the organization failed to document the performance improvement projects being conducted, the reasons for conducting these projects, and the measurable progress achieved on them. The surveyor noted that they were collecting data; however there was no evidence that they were conducting any specific projects for the last three years. This was confirmed with the administrator.

Observed in Individual Tracer. In 1 of 3 home visits conducted, The hospice nurse surveyor noted (HV#1) that the nurse failed to follow policy when cleaning supplies and entering the nursing bag. According to the policy .9-015.1 alcohol or soap and water were to be use to clean equipment and before returning them to the bag. The nurse used Clorox wipes to cleanse the equipment before and after use. The policy indicated that all equipment was to be removed after cleansing hands and returned to the bag after cleansing hands; however the nurse removed and replace equipment one piece at a time and wore the same gloves in and out of the bag after examining the patients feet, without sanitizing hands. This was confirmed with the administrator.

Observed in Individual Tracer. In 2 of 11 patient records reviewed, The hospice nurse surveyor noted that (HV#2) the initial bereavement risk assessment was not documented in the record. In discussion with the administrator, it was confirmed that the social worker had completed the assessment in February; however failed to enter the documentation into the electronic medical record, as required by policy. The surveyor noted that this was corrected on site with a late entry of the assessment. In (ARR#2) The surveyor noted that the specific notes on care, treatment, or services were not documented in the record. The surveyor noted that a registered nursing visit/assessment note was not recorded and in the record from twelve (12) days ago. This was confirmed with the director.

Observed in Individual Tracer. In 1 of 11 patient records reviewed, The hospice nurse surveyor noted (HV#1)that the initial plan of care included medication dose orders that were scribbled over and illegible. The surveyor noted that the dose for Remeron was scribbled over and was unclear as to whether it was 30, 40 or 50 mg. The organizational policy 5.00.3 required that incorrect entries be crossed out, initialed and the correct entry written. This was confirmed with the administrator.

Observed in Data Tracer. It was determined that the organization was not in compliance with the CMS COVID-19 staff vaccination requirements as evidenced by vaccination rates reported as (95 % compliance) at the time of survey. CMS requires 100 % compliance. This was confirmed with the administrator.