Every finding on record at Wvuhs Home Care , LLC

Observed in Individual Tracer. In 3 of 18 patient records reviewed, it was noted that the organization did not ensure that patient specific comprehensive assessments included all required information. For example, during a review of the medical record for HosRRHV#2, the clinician documented the presence of a wound at the patient’s right buttocks. The wound assessment did not include the condition of the wound bed, and surrounding tissue. Example #2: During a review of the medical record(s) for RRNHV#3, and RRNHV#4, it was noted that the comprehensive assessment did not include the initial bereavement risk assessment. This observation was reviewed with the Quality Director – Home Health and Hospice.

Observed in Individual Tracer. In 1 of 6 patient records reviewed it was noted that the organization did not ensure patient education and training was provided based on the patient’s assessed needs. For example, during a review of the medical record for HosRRHV#2, it was noted that a clinician documented that the patient’s caregiver performed wound care treatment in the start of care assessment. However, there was no documented evidence that the patient’s caregiver received education and training related to wound care treatment. This observation was reviewed with the Quality Director - Home Health and Hospice.

Observed in Record Review. In 5 of 18 patient records reviewed, it was noted that the organization did not ensure that the plan of care goals included outcome measures for specific care activities. For example, during a review of the medical record for HosRRHV#1, the following goal statement(s) were noted: “Patient/caregiver/family will demonstrate understanding of and ability to manage respiratory symptoms at end of life” and “Patient/caregiver will verbalize understanding of fall risk areas in the home and strategies to prevent future falls”. The goal statement(s) were not individualized to the patients specific needs and did not include a method to measure the effectiveness of problem interventions. In addition, the stated timeframe of “…at end of life” is not a realistic measurement to assess the implementation of problem interventions. Example #2: During a review of the medical record for HosRRHV#2, it was noted that the patient’s terminal illness diagnosis was Hepatic failure. The plan of care did not include a goal statement to evaluate the response, to care, treatment, and services related to Hepatic failure. In addition, the following goal statement was noted: “Patients incisions, wounds, or drain site will show healing”. The goal statement was not individualized to the patient’s specific needs and did not include a method to measure the effectiveness of problem interventions. Example #3: During a review of the medical record for HosRRHV#3, the following goal statements were noted: “The patient/caregiver family will verbalize and demonstrate ability to manage the patient's anxiety throughout hospice care” and “The patient/caregiver will verbalize understanding of fall risk areas in the home and strategies to prevent future falls”. The goal statement(s) were not individualized to the patient’s specific needs and did not include a method to measure the effectiveness of problem interventions. The stated timeframe of “…throughout hospice care” is not a realistic measurement to assess the implementation of problem interventions. Example #4: During a review of the medical record for HosRRHV#4, it was noted that the patient’s terminal illness diagnosis was Cerebral Atherosclerosis Dementia, unspecified Dementia severity. The plan of care did not include a goal statement to evaluate the response, to care, treatment, and services related to Cerebral Atherosclerosis Dementia, unspecified Dementia severity. In addition, the following goal statement was noted: “Patient/caregiver will verbalize understanding of fall risk areas in the home and strategies to prevent future falls”. The goal statement was not individualized to the patient’s specific needs and did not include a method to measure the effectiveness of problem interventions. Example #5: During a review of the medical record for HosRRNHV#2, the following goal statement was noted: “Patients incisions, wounds, or drain site will show healing”. The goal statement was not individualized to the patient’s specific needs and did not include a method to measure the effectiveness of problem interventions. This observation was reviewed with the Quality Director - Home Health and Hospice.

Observed in Record Review. In 3 of 18 patent records reviewed, it was noted that the organization did not ensure that the plan of care was revised when the patient’s condition changed. For example, during a review of the medical record for HosRRHV#3, it was noted that the patient experienced a fall with injury during week 3 and week 4 of the 1st benefit period. The plan of care was not updated with interventions to maintain patient safety, and strategies to prevent injury. Example #2: During a review of the medical record for HosRRNHV#2, during week 4 of the 1st benefit period, the following treatment orders were noted: “Family member/Caregiver to perform dressing change to coccyx Other Daily, and PRN for soiled/non-adherent dressing, Dressing change to consist of: remove old dressing (May soak with saline prior to removing as needed. Cleanse wound.” The treatment order did not specify if this wound was to be covered with some type of dressing material or left open to air. Example #3: A review of the medical record for HosRRNHV#4, revealed that during the comprehensive assessment update a clinician documented the patient had 2 falls with no injury. The plan of care was not updated with interventions to maintain patient safety, and strategies to prevent injury. This observation was reviewed with the Quality Director – Home Health and Hospice.

Observed in Record Review. In 2 of 2 discharge records reviewed, it was noted that a discharge/transfer summary that included all required information was not completed. For example, a review of the medical records for HosRRDC#1 and HosRRDC#2, revealed no evidence that a discharge summary including the following information was documented: 1) A summary of the patient’s stay, including treatments, symptoms, and pain management, 2) The patient’s current plan of care, and 3) The patient’s latest physician orders. This observation was reviewed with the Quality Director - Home Health and Hospice.

Observed in Individual Tracer. In 1 of 6 patient records reviewed it was noted that the organization did not ensure that an evaluation of patient education and training was provided when required. For example, during a review of the medical record for HosRRHV#2, it was noted that a clinician documented that the patient’s caregiver performed wound care treatment in the start of care assessment. However, there was no documented evidence that an evaluation of the patient’s caregiver to perform the wound care treatment was performed. This observation was reviewed with the Quality Director – Home Health and Hospice.

Observed in Record Review. There was no documentation of bereavement screening or assessment of an 55 day- old infant who was admitted to the organization's GIP with multiple cardiac anomalies on a Friday evening and passed away on just after mid- night the following Sunday. One out sixteen hospice records reviewed had a bereavement documentation issue.

Observed in Record Review. In one hospice record, it was noted that wound dressing order was the same order written once for two different wounds. Both the chest tube dressing and the sacral wound were listed, but only one order was documented. The order did not specify which wound needed to be treated per that order. Hospice orders were not clarified in one out of sixteen records reviewed.

Observed in Patient Home. The Hospice RN did not follow the organizations bag technique, the nurse's bag handle fell into the nurse's clean area of the unzipped nurse's bag where all supplies are kept that has been cleaned before being placed in that clean compartment. Observed in Patient Home. The Hospice RN cleaned the equipment used in patient care ( stethoscope, pulse oximeter) but placed it on the dirty surface before returning this equipment to the nurse's clean compartment of the nursing bag. Two out of four hospice had a bag technique issue.

Observed in Record Review. In one nurse's note the medication of guaifenesin was listed on a nurses note but not on the medication profile. Documentation issues were noted in three of sixteen records reviewed for hospice.