Equinox Hospice Inc.

“Observed in Emergency Management Session. The organization had not developed a staffing plan for managing all staff and volunteers based on the settings and services provided to meet patient care needs during the duration of an emergency or disaster incident or during a patient surge. The plan did not include the following: Methods for contacting off-duty staff; Use of volunteer staffing, such as staffing agencies, and those deployed as part of the disaster medical assistance teams. This was discussed with the DPCS. Observed in Emergency Management Session. The organization’s staffing plan did not address the management of all staff and volunteers as follows: Integrating staffing agencies, volunteer staffing, or deployed medical assistance teams into assigned roles and responsibilities; Verifying the identity and licensures of volunteer practitioners (such as nurses, respiratory therapists, physical therapists). This was discussed with the DPCS.”

“Observed in Infection Control System Tracer. The organization’s written infection prevention and control goals did not include the following: Limiting unprotected exposure to pathogens. This was discussed with the DPCS. Observed in Infection Control System Tracer. The organization’s written infection prevention and control goals did not include the following: Limiting the spread of infections associated with procedures. This was discussed with the DPCS. Observed in Infection Control System Tracer. The organization’s written infection prevention and control plan lacked a goal addressing its prioritized infection risks. This was discussed with the DPCS. Observed in Infection Control System Tracer. The organization’s written infection prevention and control did not include a goal limiting the spread of infections associated with the use of medical equipment, devices, and supplies. This was discussed with the DPCS.”

“Observed in Emergency Management Session. The organization had not developed a staffing plan for managing all staff and volunteers based on the settings and services provided to meet patient care needs during the duration of an emergency or disaster incident or during a patient surge. The plan did not include the following: Methods for contacting off-duty staff; Use of volunteer staffing, such as staffing agencies, and those deployed as part of the disaster medical assistance teams. This was discussed with the DPCS. Observed in Emergency Management Session. The organization’s staffing plan did not address the management of all staff and volunteers as follows: Integrating staffing agencies, volunteer staffing, or deployed medical assistance teams into assigned roles and responsibilities; Verifying the identity and licensures of volunteer practitioners (such as nurses, respiratory therapists, physical therapists). This was discussed with the DPCS.”

“Observed in Record Review. In 6 of 14 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for RRHV#2, the patient was assessed to be at risk for pressure ulcer development and admitted with a pressure ulcer yet there were no goals on the plan of care related to pressure ulcer prevention or care of the wound. In the chart for RRNHV#4, the pain goal Pain will remain in comfortable level during care was without a measure of what comfortable means for this patient. The patient is on multiple opioids and Senna prn, yet there was no goal on the POC related to bowel management. In the chart for RRHV#1, the mobility goal is not measurable Minimize complications due impaired mobility. In the chart for RRHV#3, the patient was admitted with a history of frequent falls. The plan of care did not have any goals related to this risk. In the chart for RRBR#14, the patient was assessed to be at risk for pressure ulcers at admission. The time frame for potential goal achievement was the last day of the benefit period. Additionally, the goal was not measurable Comfort will be promoted as skin integrity changes throughout disease and dying process. The patient was also assessed to be at risk for altered bowel elimination and assessed to routinely have BM’s 4-5 times per week. The goal on the plan of care was not measurable Facilitate bowel elimination and comfort. -Facilitate bowel movement -Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects (Opioid) and the potential achievement date the last day of the benefit period. In the chart for RRBR#13, the oxygen goal was not measurable, Pt will have optimum level of oxygen., and had a target date of the last day of benefit period. Additionally, the pain goal target date was not appropriate to the problem, Family/PCG will verbalize understanding of non-verbal signs of pain, with the target date last day of the first benefit period.”

“Observed in Record Review. In 3 of 14 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: medications and treatment necessary to meet the patient’s needs. In the chart for RRHV#2, the patient was assessed to be at risk for pressure ulcer development and admitted with a pressure ulcer yet there were no interventions on the plan of care to address prevention. During the second SN visit, wound care was provided. There was no order found for wound care. Additionally, a wound care order obtained eleven days after the admission of the patient was not added to the plan of care. A subsequent wound care order obtained from the hospice MD was incomplete and read Cleanse per protocol.... without detail of the cleansing protocol. In the chart for RRHV#3, the patient was admitted with a history of frequent falls. The plan of care did not have any interventions related to this risk. During the home visit, it was verified with the LVN that fall prevention interventions had been taught and implemented. In the chart for RRNHV#4, the wound care order is incomplete. Cleanse per hospice policy... The oxygen order is 2-5lpm prn SOB with no parameter for when to give 2 lpm, versus 5lpm. This was discussed with the DPCS.
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“Observed in Patient Home. In 1 of 3 home visits conducted, the organization had not safely managed emergency medications. During RRHV#1, the administrator for the group home discussed with the hospice surveyor that the patient’s comfort pack medications which were ordered upon the patients admission to the organization and which the group home staff attempted to use earlier in the day for the patient had expired more than 4 months prior to the survey date. The medications had previously been dispensed to the patient during an earlier admission to this hospice and were still in the group home and were not expired at the time of this admission to the organization. Additionally, DuoNeb had been ordered for the patient both as a routine prn nebulized medication as well as part of the comfort pack and the organization had never received a nebulizer with which to administer the medication. This was discussed with the RN at the visit as well as the DPCS. Observed in Record Review. In 1 of 14 patient records reviewed, the organization had not provided the patient with care, treatment, or services according to the patient’s individualized plan of care. In the chart for RRNHV#7, the Chaplain and MSW are ordered to see the patient monthly via phone calls. In person visits are being provided. This was discussed with the DPCS. No Chaplain contact was documented in the month prior to the survey. This was discussed with the DPCS.”

“Observed in Patient Home. In 2 of 3 home visits conducted, Organizational bag technique policy stated to use alcohol or soap and water or other appropriate solution but did not indicate what that other solution was. Observed in Patient Home. In 2 of 3 home visits conducted, the organization had not implemented infection prevention and control activities when doing the following: Cleaning and performing disinfection of medical supplies and devices. During RRHV#2, the aide indicated that she uses Lysol wipes to cleanse her equipment after patient use. During RRHV#3, the LVN used Sani-wipes to clean his equipment at the end of the visit while the policy stated to use alcohol or soap and water or other appropriate solution. This was discussed with the DPCS.”

“Observed in Data Session. The organization’s written infection prevention and control goals did not include the following: Improving compliance with hand hygiene guidelines. This was discussed with the DPCS. Observed in Data Session. The organization’s written infection prevention and control goals did not include the following: Limiting unprotected exposure to pathogens. This was discussed with the DPCS. Observed in Data Session. The organization’s written infection prevention and control goals did not include the following: Limiting the spread of infections associated with procedures. This was discussed with the DPCS. Observed in Data Session. The organization’s written infection prevention and control goals did not include the following: Addressing its prioritized risks. This was discussed with the DPCS. Observed in Data Session. The organization’s written infection prevention and control goals did not include the following: Limiting the spread of infections associated with the use of medical equipment, devices, and supplies. This was discussed with the DPCS.”

“Observed in Record Review. In 2 of 14 patient records reviewed, the patient record did not contain complete notes about treatments or medications administered, including dose. In the chart for RRBR#13, during a continuous care note, the record indicated the primary caregiver was not wanting the patient to have medications, with discussion occurring about how meds work; one reason that CC nurses present are to give medications. Nurse documented that Ativan was given, however did not include route nor who administered the medication, the PCG or the LVN. Another note medication administered, labored breathing noted, patient cold to touch... Another note Ativan administered, patient laying in bed with labored breathing noted.... In the chart for RRNHV#6, there was incomplete documentation of wound care to skin tears. This was discussed with the DPCS.”

“Observed in Record Review. In 2 of 14 patient records reviewed, the patient record did not include an accurate list of medications. During RRHV#1, it was observed by the surveyor and RN during the home visit that the medication list in the medical record was not accurate. For example, the patient had been on Loperamide the month prior to the survey for two days only, yet it remained on the medication profile. Atropine was duplicated on the list as was DuoNeb. The medication list stated MiraLAX was to be taken daily, yet the label on the medication in the home, refilled after the medication was ordered and entered into the medication profile indicated it was to be taken prn if no BM for 3 days. During RRHV#3, the LVN completed the medication reconciliation with the primary caregivers. None of the medications that are part of the comfort pack, ordered by the hospice, including Morphine, Ativan, Dulcolax suppository, etc. were on the medication list in the home or the hospice EMR. This was discussed with the DPCS.”