Kind Heart Hospice and Palliative Care Incorporated

“Observed in Record Review. In 5 of 14 active patient records reviewed, the organization did not actively address potential medication related problems. Agency policy for medication reconciliation (8.20.1) states that discrepancies in meds such as duplication of therapy will be reconciled with the physician. On review of RRHV #1 it was noted that the patient had duplicate therapy for agitation of Ativan 1 mg q 6 PRN for agitation and Ativan 1 mg q 4 PRN for agitation with no indication when to use each duplicate therapy. On RRHV #2, it was noted that patient had duplicate PRN medications for constipation of Bisacodyl Supp PRN for constipation and Docusate Sodium PRN for constipation with no indication when to use each duplicate therapy. On review of RRHV #3, it was noted that patient had duplicate PRN pain medications of Tylenol PM extra strength q 6hr PRN for pain, Roxanol every 2 hours for pain, and Tylenol suppository every 6 hours for pain with no indication when to use each duplicate therapy. On RRHV #4, it was noted that patient had duplicate PRN pain therapy of Morphine q 2 hours PRN for pain and Acetaminophen supp q 6 PRN for pain with no indication when to use each duplicate PRN therapy. On RRNHV #2 it was noted patient had duplicate PRN medications for pain of Tylenol supp q 6 hours PRN for pain and acetaminophen/tramadol 1 tabs q 8 hours prn for pain and the duplication was not addressed. This finding was reviewed with the DCPS.”

“Observed in Record Review. In 3 of 14 active patient records reviewed, did not reflect changes that have taken place since initial assessment. On review of RRHV #1, patient had wounds on admission that were never addressed again after the initial assessment to reflect the wounds were now healed and no longer an issue 3 months later. On RRHV #2, per nursing notes the patient was having increased back pain with changes to pain medication and the family seeking ortho input and this change was not discussed in IDG meetings to revise the plan of care. On RRHV #4 IDG notes did not document revisions to the care of a complex wound that required the use of an outside wound company to help manage and care of the wound. This finding was reviewed with the DCPS.”

“Observed in Record Review. In 13 of 14 active patient records reviewed, the Hospice surveyor noted the goals in patient records were not measurable and/or specific to the intervention and care needs of the patient. On review of RRHV #1, the goals for care are not measurable and specific to the care, for example, Pt will maintain optimum peripheral circulation, Prevent physical and emotional stress due to injuries Pt/Family/PCG will verbalize having elimination needs met at an acceptable level thru certification period, Minimize risk of bedsores thru certification period and Minimize complications due impaired mobility which are not measurable or specific for this patient’s unique needs. On review of RRHV #2, the goals are not measurable and specific to the care, for example Prevent discomfort due to increasing edema, Prevent pain and discomfort due to injury, Reduce discomfort with improved bowel elimination status, and Minimize complications due impaired mobility. On review of RRHV #3, the goals were not measurable and specific to care, for example Prevent pain and discomfort due to injury, Pt/Family/PCG will verbalize having urinary elimination needs met at an acceptable level, Minimize complications due impaired mobility. On review of RRHV #4, the goals were not measurable and specific with example of Pt will maintain optimum peripheral circulation, Facilitate bowel elimination and comfort, Minimize risk of urinary tract infection, To heal wound, and Pt will have optimum level of oxygen. In addition, RRNHV #2, RRNHV #3, RRNHV #4, RRNHV #5, RRNHV #6, RRNHV #7, RRNHV #8, RRNHV #9 and RRNHV #10 did not have measurable and specific goals with further examples of: maintain optimum peripheral circulation, facilitate bowel elimination and comfort, verbalize having urinary elimination needs met at an acceptable level and facilitate bowel elimination and comfort.This finding was reviewed with the DPCS.”

“Observed in Record Review. In 5 of 14 active patient records reviewed, the Hospice surveyor noted the chaplain did not have any documentation of participating in the revision or updating the care plan. On RRNHV #3, it was noted that the chaplain had no notes in the IDG meeting since admission 2 months ago and in review of chart the chaplain had documented 2 phone call attempts to call the patient to schedule a visit but was unable to schedule a visit, yet this issue was not brought up in the IDG to address. On RRNHV #7 the chaplain had orders to see patient for initial assessment and documented in a communication note the attempt to see patient with call and stop by house and was never able to reach patient but this was never discussed in IDG so that revision could be made to the plan of care. On RRNHV #8 and RRNHV #9, and RRNHV #10 there is no documentation in IDG to support the spiritual aspects of care are being addressed because the IDG note has no notes or signature on the EMR IDG note from the chaplain, the organization does keep an IDG attendance binder and the chaplain is showing in attendance to those meetings. This finding was reviewed with the DCPS.”

“Observed in Patient Home. In 2 out of 4 home visits conducted, the hospice nurse surveyor noted that the organization had not implemented its infection prevention and control activities. The policy for equipment cleaning (5.4.3) states that thermometers are to be cleaned with alcohol and the stethoscope and blood pressure cuff to be cleaned with approved disinfectant after use and before placing in their bag. On RRHV #1, it was observed that the HHA used vital sign equipment to take patient’s vital signs and returned them to his bag without cleaning the equipment. On RRHV #3, it was noted that the LVN cleaned her vital sign equipment with Lysol and did not observe the 4 minute wet time as indicated per manufacturer instructions for use. This finding was reviewed and validated with the DCPS who was present for the visit.”

“Observed in Record Review. In 1 out of 12 patient records reviewed, that had ordered aide services, the Aide Care Plan did not have specific instructions for the aide. On RRHV #1, the aide care plan did not include specific and individualized task needed for the care of the patient. Patient was being transferred from wheelchair to bath chair during the aide visit but there was not instructions on how to transfer the patient. In addition, the patient is using adult diapers and this was not noted on the aide delegation. This finding was reviewed and validated with the DCPS who was present for the visit. 
”

“Observed in Record Review. In 2 of 14 active patient records reviewed, the patient record did not contain accurate medication information. On RRHV #2, it was noted on the home visit that the medication record was not correct. Patient/ paid caregiver states that Tylenol is taken PRN for discomfort and that she takes multivitamin daily and neither medication on the medication list. It was also noted in a recent nursing visit that the daughter reported she gives her mom Tylenol for discomfort PRN but the medication list had not been updated to reflect these medications. On RRHV #4 it was noted during the home visit that the patient is taking a cranberry supplement daily and this was not reflected on the medication list. This finding was reviewed with the DCPS who was present for the home visits.”

“Observed in Record Review. In 14 of 19 patient record reviews, documentation in the patient record is not entered timely. Agency documentation policy (11.6.1) states that documentation is completed 3 business days. On RRHV #1, it was noted that nursing notes were not authenticated from visits 8 days ago. On RRHV #2 and RRHV #3, it was noted that nursing notes had not been authenticated in the record for multiple notes with the oldest being 12 days ago. On review of RRHV #4 it was noted that nursing notes had not been authenticated in the medical record with some notes over a month old. In RRBR #1, it was noted that there are visit notes that have not been completed in the last 13 days. On RRNHV #2, it was noted that multiple nursing notes from over the last two months had not been authenticated. On RRNHV #3 and RRNHV #4 it was noted that multiple nursing notes over the last month have not been authenticated. On RRNHV #5, it was noted at that nursing notes from 8 days ago had not been authenticated. On RRNHV #6, RRNHV #7, RRNHV #8, RRNHV #9 and RRNHV #10 that nursing notes were not authenticated in the charts per the agency policy. This was reviewed with the DPCS.”

“Observed in Patient Home. On 4 of 4 home visits conducted, the surveyor noted that there was no documentation provided to the patient regarding their policy on controlled substance disposal. Agency Medication Disposal policy (8.10.1) states at time controlled substance is ordered Hospice will provide written copy of the policy and procedures on management and disposal of controlled substances. On review of the admission packet and in the patient packets of all home visits conducted, it was noted the organization provided the FDA Consumer Health Information education on How to Dispose of Unused Medications, but it did not provide a copy of its written policies and procedures on the management and disposal of controlled medications to patients and families/caregivers when controlled medication were ordered. This was reviewed and confirmed with the DPCS who was on all the home visits.”