Every finding on record at Ziba Hospice, LLC

Observed in Record Review. In 8 of 10 patient records reviewed, the organization failed to ensure the plan of care reflect patient and family goals that were specific, measurable and time-bound. Throughout the active records reviewed there were goals established that were not specific, not measurable or not time-bound. In RRHV#1 an example of a non-specific goal was Family/caregiver will express satisfactory control of symptoms.. In RRHV#2 a not measurable goal was Husband/caregiver will demonstrate the ability to cope with limitations. In RRNHV#4 the goals were more measurable yet the goals were not time bound as target dates were not individualized and did not correlate with the goal. In RRNHV#5 examples of goals that were not measurable were Anxiety/agitation controlled through course of care and Patient will be free of preventable complications. In RRNHV#6, RRNHV#8, RRNHV#9, and RRNHV#10 goals target dates were not individualized as they all had the same target dates. An example of an goal that was not measurable in RRNHV#6 was Anxiety reduced and within manageable level during dyspneic episodes and an example in RRNHV#9 was Patient will experience optimal comfort with minimized anemia-related symptoms. These observations were reviewed with the DPCS.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure the plan of care includes all services needed for the palliation and management of the terminal illness and related conditions. On review of RRNHV#8 there was documentation of an initial evaluation for the Medical Social Worker (MSW) that indicated that follow up was needed yet there was no order for a MSW frequency for follow up patient visits. This observation was reviewed with the DPCS.

Observed in Record Review. In 4 of 10 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRHV#3 the documentation noted a wound/non-blanchable redness to the buttocks with orders for treatment yet the care was not reflected in the care plan as the care plan had been resolved. Most care plans were noted to be closed yet the issues were ongoing. On home observation there was a dressing observed to the buttocks area and the caregiver noted it was for protection yet there was no order and the care was not reflected on the care plans. In RRNHV#6 there was documentation of the patient with a URI that required antibiotics yet the infection was not reflected in the care plan. In RRNHV#9 the wound care treatment was discontinued yet the plan of care was not updated as order remained as an intervention on the plan of care. In RRNHV#10 there was documentation of wounds yet the skin integrity care plan was not specific to the wound on the coccyx or the lateral malleolus. Further there was oxygen in the home with orders for use as needed yet there was no respiratory or oxygen safety care plan established. These observations were reviewed with the DPCS.

Observed in HR File Review. In 1 of 1 HR files reviewed, for hospice aide, the organization failed to ensure the registered nurse supervisor evaluate the required areas of: Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other staff - Reading and recording temperature, pulse, and respirations - Appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination - Safe transfer techniques and ambulation and Normal range of motion and positioning, by observing the hospice aide's performance of the tasks with a patient or pseudo-patient as part of a simulation. On review of HR#7 for the Aide the initial competency was documented as being conducted only verbally with the required skills not being observed. This observation was reviewed with the DPCS.

Observed in HR File Review. In 1 of 1 HR files reviewed, the organization failed to ensure a registered nurse make an annual on-site visit to the location where a patient is receiving care in order to observe and assess the aide while preforming care. On review of HR#7 for the Hospice Aide there was no documentation that competencies were observed as part of an annual on-site visit as required. This observation was reviewed with the DPCS.

Observed in Tracer Activities. On review of the volunteer program, there was no documentation of the cost savings achieved through the use of volunteers. This observation was reviewed with the DPCS.

Observed in Tracer Activities. on review of the volunteer program there was no documentation that volunteers had provided administrative and/or direct patient care services in an amount that, at a minimum, equaled 5% of the total patient care hours of all paid hospice employees and contract staff. The organization had documentation of volunteer hours yet there was calculation of the volunteer percentage of total patient care hours. This observation was reviewed with the DPCS.

Observed in Record Review. In 3 of 10 patient records reviewed, the organization failed to ensure the patient was accurately documented. On review of RRHV#1 the LVN documentation noted the patient continued to take Breyna inhaler for shortness of breath yet the plan of care orders noted that the medication was discontinued in December of last year. In RRNHV#5 there was a note from the LVN that was specified as a post-mortem visit yet the documentation in the note was for a skilled nursing visit on a live patient. In RRNHV#9 the psychosocial care plan noted plan to provide volunteer services to assist with home management yet volunteer services had been declined on admission. These observations were reviewed with the DPCS.

Observed in Tracer Activities. In 1 of 4 contracts reviewed, the organization failed to ensure the written agreement for the Skilled Nursing Facility (SNF) contained all required elements. On review of the contract for the SNF there was no provision stating that the hospice will report all mistreatment, neglect, or verbal, mental, sexual, and physical abuse to the SNF, NF, or ICF/IID administrator within 24 hours of the hospice becoming aware of the alleged violation, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice. This observation was reviewed with the DPCS.

Observed in Tracer Activities. In 1 of 4 contracts reviewed, the organization failed to ensure the written agreement with an outside agency providing contracted services for the hospice included all required elements. On review of the contract reviewed for the Skilled Nursing Facility there was no stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This observation was reviewed with the DPCS.

Observed in Emergency Management Session. During review of the volunteer program, it was noted the organization had not ensured all staff were initially trained on their emergency management roles. Volunteers did not have emergency management as part of their training curriculum. This was discussed with the Volunteer Coordinator and Director of Nursing.

Observed in Record Review. In 6 of 11 patient records reviewed the organization failed to complete initial assessment. On HSHV/RR #1, the chaplain and social worker failed to complete an initial assessments within five days after the election of hospice and there was no documentation that refusal of the service took place. On HSHV/RR #2, there chaplain assessment was not completed and no documentation as to why assessment not done. On HSRR #4, the chaplain assessment occurred 7days after SOC and there was no documentation to support this not being done in the 5 day window for the spiritual assessment. On review of HSRR #7, the chaplain assessment did not occur and there was no documentation to support this not being done. On HSRR #8 and HSRR #9, the MSW assessment was not completed and documentation why not done and the chaplain assessment was completed greater than 5 days after start of care. This finding was reviewed with the DON.

Observed in Record Review. On 10 of 11 patient records reviewed, the Hospice surveyor noted individualized goals for the plan of care were not specific to the care being provided and/or not measurable. On review of HSHV/RR #1, all goals had target dates at the end of the cert period with goals that were not measurable such as management of pain without a patient specific measure. On review of HSHV/RR #2 and HSRR #5 patient on antibiotic therapy with no goals for the therapy being provided. On review of HSRR #4, patient on second certification period with the majority of goals started on the first cert period that are carried over to end date of second certification period. Goals that are not measurable such as patient will verbalize optimal bowel function. During review of HSHV/RR #3, HSRR #5, HSRR #6, HSRR #7, HSRR #8, HSRR #9, and HSRR #10 the goals were not measurable and specific to the care needs and all dated at end of certification period. Some examples include: Patient complies with lifestyle changes, Optimal level of functioning appropriate for disease process, Pt will have optimal ability within limits of disease, Patient's symptoms consistent with stage of disease, Patient's nutritional needs met per conditions and Cardiovascular status stable as disease allows. This finding was reviewed and validated with the Director of Nursing.

Observed in Infection Control Tracer. During review of the infection control plan it was noted the agency had not set any goals for minimizing the possibility of spreading infections. This was discussed with the Director of Nursing and validated. Observed in Infection Control Tracer. During review of the infection control plan it was noted the agency had not set any goals for limiting spread of infection for medical equipment and supplies. This was discussed and validated with the Director of Nursing. Observed in Infection Control Tracer. During review of the infection control plan it was noted the agency had not set any goals for limiting unexpected exposures to pathogens. This was discussed with the Director of Nursing and validated Observed in Infection Control Tracer. During review of the infection control plan it was noted the agency had not set any goals for minimizing the spread of infections associated with procedures. This was discussed and validated with the Director of Nursing.

Observed in Record Review. In 3 of 3 patient records where the patient had passed away on service, the bereavement plan of care did not specify the level of care to be provided. Agency policy for bereavement services is a combination of phone calls and mailings for all patients and then the high level has an additional service of referral to counseling. On review of BR #1, BR #2 and BR #3, the patient had passed away and final bereavement assessment was completed but did not identify a risk level so the appropriate plan could be initiated. Agency has in the last few month implemented a new EMR program that identifies 3 risk levels but the policy only has standard and high level for the defined plans. This finding was reviewed with the DON and the Bereavement Coordinator.

Observed in Record Review. In 1 out of 1 patient records reviewed, that had ordered aide services, the Aide Care Plan did not have specific instructions for the aide. On review of HSRR #4, patient is bed bound and has had history of falls and the assigned task was to perform transfer, ambulate and exercise program with no instruction on specifics on how this is to be done. This finding was reviewed and validated with the DON.

Observed in Individual Tracer. Staff failed to perform hand hygiene consistent with policy #4006 Hand Hygiene which stated staff to perform hand hygiene always after removing gloves.... During the joint home visit with the RN the surveyor noted that the RN did not sanitize her hands between multiple glove changes.