Savior Hospice

“Observed in Record Review. In 2 of 14 patient records, it was noted that the plan of care did not include all required information. For example, a review of the medical record for RRHV#1 revealed that the patient had a history of a ground level fall with head trauma 20 days prior to the start of care date. The Morse falls risk assessment indicated the patient was at high risk for falls. The plan of care did not include a goal statement to evaluate the response to care, treatment and services related to fall prevention interventions. 

Example #2: A review of the medical record for RRNHV#1, revealed that the clinician documented the presence of a stage 2 wound at the Left Shin. The plan of care did not include a goal statement to evaluate the response to care, treatment, and services related to Left Shin wound. 

Example #3: A review of the medical record for RRNHV#3, revealed that the patient’s terminal illness diagnosis was Alzheimer’s Dementia disease. The plan of care did not include a goal statement to evaluate the response to care, treatment, and services related to Alzheimer’s Dementia disease. This observation was reviewed with agency Leadership.
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“Observed in Record Review. In 2 of 14 patient records, it was noted that the plan of care did not include interventions based on the problems identified in the comprehensive assessment. For example, a review of the medical record for RRHV#1 revealed that the patient had a history of a ground level fall with head trauma 20 days prior to the start of care date. The Morse falls risk assessment indicated the patient was at high risk for falls. The plan of care did not include interventions to maintain patient safety, and strategies to prevent injury. 

Example #2: A review of the medical record for RRNHV#1, revealed that the clinician documented the presence of a stage 2 wound at the Left Shin. The plan of care did not include interventions related to the care, and treatment of the Left Shin wound. 

Example #3: A review of the medical record for RRNHV#3, revealed that the patient’s terminal illness diagnosis was Alzheimer’s Dementia disease. The plan of care did not include interventions related to the care, treatment, and services of the patient’s terminal illness diagnosis. This observation was reviewed with agency Leadership.”

“Observed in Individual Tracer. In 1 of 4 Individual Tracers, it was noted that the organization did not implement its infection prevention and control activities to minimize, reduce or eliminate the risk of infection. For example, during the home visit activity for RRHV#1, it was noted that when the clinician moved from assessing the patient’s feet with irritated skin and healing blistered areas the clinician moved to assessing the patient’s right eye without removing gloves and performing hand hygiene. This observation was reviewed with agency leadership. Observed in Individual Tracer. In 1 of 4 Individual Tracers, it was noted that the organization did not ensure its planned infection prevention and control activities to eliminate the risk of infection were implemented. For example, during home visit activity for RRHV#1, it was noted that after equipment cleaning was completed the clinician did not place the equipment on a clean barrier. In addition, the organization’s bag technique policy indicated that a 70% alcohol spray should be used for equipment cleaning. The clinician used Sani-Cloth germicidal disposable wipes for equipment cleaning. This observation was reviewed with agency leadership.”

“Observed in Record Review. In 3 of 4 patient records, for patients receiving Hospice Aide services it was noted that the supervisory visit did not address all requirements: For example, a review of the medical record for RRHV#3, RRHV#4, and RRNHV#3 revealed that the following information was not addressed in the supervisory visit: (a) Creating successful interpersonal relationships with the patient and family, (b) Demonstrating competence with assigned tasks, (c) Complying with infection control policies and procedures, and (d) Reporting changes in the patient’s condition. This observation was reviewed with agency leadershipl”

“Observed in Record Review. In 1 of 2 patient records reviewed, for patients discharged or transferred from the organization, it was noted that the discharge/transfer summary did not include all required information. For example, a review of the discharge/transfer summary for RRDC#2, did not include a summary of the patient’s stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patent’s latest physician orders; and any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving provider. This observation was reviewed with agency leadership.

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