Harney County Hospice

“Based on medical record review and interview, it was determined the hospice failed to include individualized measurable outcomes anticipated from implementing and coordinating the plan of care for 8 of 14 patient care plans reviewed (Patients #1, 2, 3, 4, 5, 7, 13, and 14). Findings: 1. Review of the medical record of Patient #1 revealed a document titled, “Plan of Care” dated 05/16/2024. A “Risk for Falls” was identified as a problem with the goal statement, “Pt will not fall.” The care plan lacked individualized and measurable patient goals/outcomes anticipated from implementing and coordinating the plan of care to address the risk for falls and fall prevention. 2. Review of the medical record of Patient #5 revealed a document titled, “Plan of Care” dated 07/28/2023. An “Integumentary” problem was identified with the goal statement, “Pts skin will remain intact.” The care plan lacked individualized and measurable patient goals/outcomes anticipated from implementing and coordinating the plan of care to address skin integrity. 3. Review of the medical record of Patient #7 revealed a document titled, “Plan of Care” dated 10/26/2023. A problem of pain was identified with the goal statement, “Pt will be free from pain.” The care plan lacked individualized and measurable patient goals/outcomes anticipated from implementing and coordinating the plan of care to address pain management. 4. Similar findings were identified for patients #2, 3, 4, 13, and 14 with a problem of pain. During an interview with the Administrator on 06/06/2024 at 3:30 PM, the above findings were presented. The Administrator acknowledged that the goal statements did not have goals that were measurable.”

“Based on employee record review, policy review, and interview, it was determined that the hospice failed to monitor for infectious and communicable diseases among staff. Findings: Review of 8 selected employee records (#1-8) revealed 7 records (#1-4 and #6-8) lacked Hepatitis B vaccination status documentation. Review of the policy titled, “Infection Control Program” dated 06/2009 and last revised 03/2020, states, “... Monitors the health status of all employees and volunteers, ensuring that all personnel receive appropriate testing prior to and during employment in accordance with State and Federal regulations.” During an interview with the Administrator on 06/06/2024 beginning at 3:00 PM, the above findings were presented. The Administrator acknowledged that documentation for Hepatitis B vaccination status were missing from the employee records. Additional time was requested to look for documentation. As of 06/14/2024, no additional documentation was provided for Hepatitis B vaccination status on 7 of the 8 selected employees (#1-4 and #6-8).”

“Based on employee record review and interview, the agency lacked evidence of infection control education to employees and contracted providers. Findings: Review of 8 employee records (#1-8) lacked infection control education for the previous year. Review of policy titled, “Infection Control Program” dated 06/2009 and last revised/review 03/2020 states, “... Ensures that infection control training programs and in-services are provided to employees on a timely basis ... Reviews all written infection control policies, techniques and procedures annually for revisions and/or updates.” During interview with the Administrator on 06/06/2024, beginning at 03:00 PM, they acknowledged the agency did not provide infection control in-services the previous year.”

“Based on volunteer record review, policy and procedures review and staff interview, it was determined the agency failed to maintain, document and provide volunteer orientation and training that is consistent with hospice industry standards for 3 of 3 Volunteer records reviewed. Findings: Review of the Employee files of 3 Volunteers (#6-8) lacked documentation to reflect each volunteer received an initial orientation and education to their role and responsibilities within the agency. Review of Employee #6 file revealed a hire date of 04/06/2023. At the time of the review conducted on 06/05/2024, there lacked documentation of a signed job description, orientation, and annual education to perform as a volunteer for the agency. Review of Employee #7 file revealed a hire date of 06/11/2023. At the time of the review conducted on 06/05/2024, there lacked documentation of orientation and training education to perform as a volunteer for the agency. Review of Employee #8 file revealed a hire date of 05/17/2024. At the time of the review conducted on 06/05/2024, there lacked documentation of orientation and training education to perform as a volunteer for the agency. During an interview with the Administrator on 06/06/2024 beginning at 3:00 PM, the above findings were presented. They stated the agency’s orientation program materials have disappeared and new materials have not been obtained.”

“Based on interview, personnel record review and policy review, it was determined the agency failed to provide annual in-service training and education records for 8 of 8 Employees (#1-8), and a performance evaluation on 7 of 8 employees (Employees #1-6 and #8). Findings: Review of the record for Employee #1 revealed a hire date of 06/12/2023. The record was lacking in-service training, education records, skills and competence review, and a performance evaluation. Review of the record for Employee #2 revealed employee was hired in 2016. The record was lacking in-service training, education records, skills and competence review, and a performance evaluation. Review of the record for Employee #3 revealed a hire date of 12/23/2020. The record was lacking in-service training, education records, skills and competence review, and a performance evaluation. Review of the records for Employees #4-8 revealed similar findings. During an interview with the Administrator on 06/06/2024 at 3:00 PM, they confirmed that in-service trainings, education records, skills and competence reviews, and performance evaluations were not available for each of the employees selected. Administrator states, “I know we didn’t have much education offerings last year, but I’m surprised the rest of the documentation is not there.””