DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
131578 A. BUILDING __________
B. WING ______________ 		07/01/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
BRIO IDAHO HOSPICE LLC 556 W SUNNYSIDE RD, IDAHO FALLS, ID, 83402
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0530      
42371 Based on medical record review and staff interview, it was determined the agency failed to ensure a comprehensive review of patient medications was performed for 1 of 13 patients (#3) whose records were reviewed. This had the potential to result in adverse patient outcomes. Findings include: 1. Patient #3 was a 79 year old male admitted to the agency on 4/14/21, with a terminal diagnosis of Parkinson's disease. He received SN, aide, MSW, and chaplain services. His record, including the POC, for the benefit period 4/14/21 to 7/12/21, was reviewed. Patient #3's medical record included an RN initial comprehensive assessment, dated 1/14/21, signed by an RN. The "Respiratory/pulmonary assessment stated that Patient #3 was, "90% room air." In "Summary/comments," the narrative stated education on, "O2 safety and proper storage." Patient #3's medical record included an SN visit note, dated 4/23/21, signed by an RN, which stated, "Patient has oxygen on 24/7." Patient #3's medical record included an SN visit note, dated 5/17/21, signed by an RN, which stated, "Patient has oxygen on 24/7." Patient #3's medical record included an SN visit note, dated 5/24/21, signed by an RN, which stated, "Patient has oxygen on 24/7." Patient #3's medical record included an SN visit note, dated 6/14/21, signed by an RN, which stated, "Patient has oxygen on 24/7." b. Patient #3's medical record included an SN visit note, dated 5/24/21, signed by an RN, which stated, "Pt takes Tylenol as needed if some pain is noted." c. Patient #3's medical record included an SN visit note, dated 6/08/21, signed by an RN, which stated, "Multiple scrapes and scabs pulled off with falls, antibiotic cream and dressing placed..." The Director of Clinical Services and QA RN were interviewed together on 7/01/21, beginning at 9:55 AM, and Patient #3's medical record was reviewed in their presence. They confirmed Patient #3's medication profile did not include oxygen, Tylenol, or antibiotic cream. Patient #3's medication profile was not accurate.
L0533      
37262 Based on observation, medical record review, policy review, and staff interview, it was determined the agency failed to ensure comprehensive assessments were updated for 2 of 13 patients (#6 and #9) whose records were reviewed. This resulted in multiple unreconciled medications and confusion as to what medications patients were taking. Findings include: An agency policy, "Medication Reconciliation," revised June 2019, stated, "Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication." This policy was not followed. 1. Patient #6 was a 74 year old male who was admitted to the agency on 4/25/21, with a terminal diagnosis of ESRD. Additional diagnoses included dementia and agitation. He received SN, MSW, chaplain, and aide services. His record, including the POC, for the benefit periods 4/25/21 to 6/23/21 and 6/24/21 to 8/22/21, was reviewed. An SN visit was observed at Patient #6's ALF on 6/30/21, beginning at 1:54 PM. During the visit, Patient #6's ALF medication profile was requested and reviewed. Patient #6's ALF medication profile listed 13 medications he was currently taking: - Sodium Bicarbonate - Lasix - Theragran-M - Vitamin B-12 - Olanzapine - Amlodipine Besylate - Eliquis - Trazodone - Folic Acid - Melatonin - Biscodyl Suppository - Biscodyl Tablet - Donepezil Patient #6's medical record included an agency medication profile, undated, which listed 10 medications he was currently taking: - Quetiapine - Lexapro - Hemorrhoidal Rectal Suppository - Lorazepam - Calmoseptine External Ointment - Melatonin - Levothyroxine - Lasix - Trazodone - Biscodyl Rectal Suppository Patient #6's ALF and agency medication profiles were not reconciled. It was unclear why both medication lists did not match, and which medication list was accurate. The Director of Clinical Services and QA RN were interviewed together on 6/30/21, beginning at 2:56 PM, and Patient #6's medical record and observations were reviewed in their presence. They confirmed Patient #6's ALF and agency medication profiles were not reconciled. The Director of Clinical Services confirmed Patient #6's comprehensive assessment was not updated to accurately document what medications he was currently taking. Patient #6's comprehensive assessment was not updated. 42371 2. Patient #9 was an 80 year old male admitted to the agency on 1/02/21, with a terminal diagnosis of protein calorie malnutrition. An additional diagnosis was chronic kidney disease. He received SN, aide, MSW, and chaplain services. His record, including the POC, for the benefit periods of 1/02/21 to 3/31/21 and 4/02/21 to 6/30/21, was reviewed. a. Patient #9's medical record included an SN visit note, dated 4/05/21, signed by an RN, which stated, "Pt just takes oxygen from concentrator once in awhile but uses the room air majority of the time ..." b. Patient #9's medical record included an SN visit note, dated 6/21/21, signed by an RN, which stated, "Pt gets occ SOB but not very often. Use oxygen as needed but does fine majority of the time at room air." c. Patient #9's medical record included an SN visit note, dated 6/23/21, signed by an RN, which stated, "Pt gets occ Sob at rest, pt is encouraged ... take oxygen majority of the time to minimize SOB." d. Patient #9's medical record included an SN visit note, dated 6/25/21, signed by an RN, which stated, "Pt gets occ SOB but not that often. Use oxygen as needed but does fine majority of time at room air lately." Oxygen was not listed on Patient #9's medication profile or POC. The Director of Clinical Services and QA RN were interviewed together on 7/01/21, beginning at 9:55 AM, and Patient #9's medical record was reviewed in their presence. They confirmed Patient #9's medication profile did not include oxygen. The Director of Clinical Services confirmed Patient #9's comprehensive assessment was not updated to accurately document what medications he was currently taking. Patient #9's comprehensive assessment was not updated.
L0545      
42371 Based on record review and staff interview, it was determined the agency failed to ensure a comprehensive POC was developed to meet the patients' needs identified in the initial comprehensive assessment for 9 of 13 patients (#1, #2 - #5, and #7 - #10) whose records were reviewed. Failure to develop comprehensive plans of care had the potential to interfere with the ability of hospice staff to meet each patient's current needs. Findings include: 1. Patient #3 was a 79 year old male admitted to the agency on 4/14/21, with a terminal diagnosis of Parkinson's disease. He received SN, aide, MSW, and chaplain services. His record, including the POC, for the benefit period 4/14/21 to 7/12/21, was reviewed. Patient #3's medical record included an SN SOC initial assessment, dated 4/14/21, signed by an RN. The SOC initial comprehensive assessment included assessments and ratings for skin integrity, nutrition and fall risks as follows: - "Braden Scale for Predicting Pressure Score Risk ... Total 14 ... moderate risk" - "Nutrition and Fluid Intake Screening ... Total 8 ... Risk High ... (7 or greater): Multiple factors are impacting on nutrition and fluid intake with implications for comfort and coping. Coordinate with IDG about how to best address individual/family needs. Reassess nutritional status and educate base on Plan of Care." - "Fall Assessment ... Total 10 ... a score of 4 or greater is considered at risk for falling" Patient #3's medical record included a POC, dated 4/19/21, signed by his physician. His POC did not include goals and interventions for his identified pressure sore, nutritional, and fall risks. It could not be determined how the agency addressed Patient #3's identified problems. The Director of Clinical Services and QA RN were interviewed together on 7/01/21, beginning at 9:55 AM, and Patient #3's medical record was reviewed in their presence. They confirmed Patient #3's POC did not include goals and interventions for all his identified problems. Patient #3's POC did not include goals and interventions for all identified problems. 2. Patient #2 was a 78 year old female admitted to the agency on 6/03/21, with a terminal diagnosis of chronic diastolic (congestive) heart failure. She received SN, aide, MSW, and chaplain services. Her record, including the POC, for the benefit period 6/03/21 to 8/31/21, was reviewed. Patient #2's medical record included an SN SOC initial comprehensive assessment, dated 6/03/21, signed by an RN. The SOC initial assessment included assessments and ratings for skin integrity, nutrition and fall risks as follows: - "Braden Scale for Predicting Pressure Score Risk ... Total 14 ... moderate risk" - "Nutrition and Fluid Intake Screening ... Total 4 ... Moderate Risk" - "Fall Assessment ... Total 9 ... a score of 4 or greater is considered at risk for falling." Patient #2's medical record included a POC, dated 6/03/21, signed by her physician. Patient #2's POC did not include goals and interventions for her identified pressure sore, nutritional, and fall risks. It could not be determined how the agency addressed Patient #2's identified problems. The Director of Clinical Services and QA RN were interviewed together on 7/01/21, beginning at 9:55 AM, and Patient #2's medical record was reviewed in their presence. They confirmed Patient #2's POC did not include goals and interventions for all identified problems. Patient #2's POC did not include goals and interventions for all identified problems. 3. Patient #4 was a 100 year old female admitted to the agency on 1/08/21, with a terminal diagnosis of combined systolic and diastolic heart failure. She received SN, aide, MSW, and chaplain services. Her record, including the POC, for the benefit periods of 1/08/21 to 4/07/21 and 4/08/21 to discharge on 5/27/21, was reviewed. Patient #4's medical record included an SN SOC initial assessment, dated 1/08/21, signed by an RN. The SOC initial comprehensive assessment included assessments and ratings for skin integrity, nutrition, fall risk, and urinary tract infections as follows: - "Braden Scale for Predicting Pressure Score Risk ... Total 17 ... at risk" - "Nutrition and Fluid Intake Screening...Total 11...Risk High" - "Fall Assessment ... Total 10 ... a score of 4 or greater is considered at risk for falling." - "GU (Genito-urinary) Incontinence ... has the patient had any recurrent Upper Urinary Tract Infections? Yes" Patient #4's medical record included an IDG meeting notes dated 4/19/21 which stated, "She has had repeated UTI's, some with sepsis, four infections in the past 6 months." Patient #4's medical record included a POC, dated 1/11/21, signed by her physician. Patient #4's POC did not include goals and interventions for her identified pressure sore, nutritional, fall, and UTI risks. It could not be determined how the agency addressed Patient #4's identified problems. The Director of Clinical Services and QA RN were interviewed together on 7/01/21, beginning at 9:55 AM, and Patient #4's medical record was reviewed in their presence. They confirmed Patient #4's POC did not include goals and interventions for all identified problems. Patient #4's POC did not include goals and interventions for all identified problems 4. Patient #9 was an 80 year old male admitted to the agency on 1/02/21, with a terminal diagnosis of protein calorie malnutrition. An additional diagnosis included chronic kidney disease. He received SN, aide, MSW, and chaplain services. His record, including the POC, for the benefit periods of 1/02/21 to 3/31/21 and 4/02/21 to 6/30/21, was reviewed. Patient #9's medical record included an SN SOC recertification comprehensive assessment, dated 6/16/21, signed by an RN. The recertification assessment included assessments and ratings for skin integrity, nutrition, and fall risk as as follows: - "Braden Scale for Predicting Pressure Score Risk ... Total 14 ... moderate risk" - "Nutrition and Fluid Intake Screening ... Total 6 ... Risk Moderate" - "Fall Assessment ... Total 9 ... a score of 4 or greater is considered at risk for falling." Patient #9's medical record included a POC, dated 6/16/21, signed by his physician. His POC did not include goals and interventions for his identified pressure sore, nutritional, and fall risks. It could not be determined how the agency addressed Patient #9's identified problems. The Director of Clinical Services and QA RN were interviewed together on 7/01/21, beginning at 9:55 AM, and Patient #9's medical record was reviewed in their presence. They confirmed Patient #9's POC did not include goals and interventions for all identified problems. Patient #9's POC did not include goals and interventions for all identified problems. 5. Patient #1 was a 67 year old male admitted to the agency on 6/14/21, with a terminal diagnosis of chronic respiratory failure with hypoxia. Additional diagnoses included nontraumatic subdural hemorrhage and pneumonitis due to inhalation of food and vomit. He received SN services. His record, including the POC, for the benefit period 6/14/21 to 9/11/21, was reviewed. Patient #1's medical record included an SN SOC initial comprehensive assessment, dated 6/14/21, signed by an RN. The pintail comprehensive assessment included assessments and ratings for skin integrity and fall risks as as follows: - "Braden Scale for Predicting Pressure Score Risk ... Total 15 ... at risk" - "Fall Assessment ... Total 6 ... a score of 4 or greater is considered at risk for falling." Patient #1's medical record included a POC, dated 6/14/21, signed by his physician. His POC did not include goals and interventions for his identified pressure sore and fall risks. It could not be determined how the agency addressed Patient #1's identified problems. The Director of Clinical Services and QA RN were interviewed together on 7/01/21, beginning at 9:55 AM, and Patient #1's medical record was reviewed in their presence. They confirmed Patient #1's POC did not include goals and interventions for all identified problems. Patient #1's POC did not include goals and interventions for all identified problems. 37262 6. Patient #5 was a 95 year old female who was admitted to the agency on 9/21/20, with a terminal diagnosis of Alzheimer's disease. Additional diagnoses included weight loss and frequent UTI's. She received SN, MSW, chaplain, and aide services. Her record, including the POC, for the benefit period of 9/10/20 to 12/08/20, was reviewed. Patient #5's medical record included an SN SOC comprehensive assessment, dated 9/10/20, signed by her RNCM, which stated: - "Braden Scale for Predicting Pressure Sore Risk ... Total 12 ... 10 - 12: High Risk" - "Nutrition and Fluid Intake Screening ... Total 8 ... Risk: High" - "Fall Assessment ... Total 8 ... A score of 4 or greater is considered risk for falling" Patient #5's medical record included a POC, dated 9/10/20, signed by her physician. Her POC did not include goals and interventions for her identified pressure sore, nutritional, and fall risks. It could not be determined how the agency addressed Patient #5's identified problems. The Director of Clinical Services and QA RN were interviewed together on 6/30/21, beginning at 11:22 AM, and Patient #5's medical record was reviewed in their presence. They confirmed Patient #5's POC did not include goals and interventions for all identified problems. Patient #5's POC did not include goals and interventions for all identified problems. 7. Patient #7 was a 64 year old male who was admitted to the agency on 3/30/21, with a terminal diagnosis of rectal cancer. Additional diagnoses included chronic pain and weight loss. He received SN services. His record, including the POC, for the benefit period 3/30/21 to 6/27/21, was reviewed. Patient #7's medical record included an SN SOC comprehensive assessment, dated 3/30/21, signed by his RNCM, which stated: - "Braden Scale for Predicting Pressure Sore Risk ... Total 17 ... 10 - 12: At Risk" - "Nutrition and Fluid Intake Screening ... Total 5 ... Risk: Moderate" - "Fall Assessment ... Total 10 ... A score of 4 or greater is considered risk for falling." Patient #7's medical record included a POC, dated 3/30/21, signed by his physician. His POC did not include goals and interventions for his identified pressure sore, nutritional, and fall risks. It could not be determined how the agency addressed Patient #7's identified problems. The Director of Clinical Services and QA RN were interviewed together on 6/30/21, beginning at 10:54 AM, and Patient #7's medical record was reviewed in their presence. They confirmed Patient #7's POC did not include goals and interventions for all identified problems. Patient #7's POC did not include goals and interventions for all identified problems. 8. Patient #8 was an 88 year old male who was admitted to the agency on 6/29/20, with a terminal diagnosis of CKD. Additional diagnoses included nutritional deficiency and pain. He received SN, MSW, chaplain, and aide services. His record, including the POC, for the certification period of 6/29/20 to 9/26/20, was reviewed. Patient #8's medical record included an SN SOC comprehensive assessment, dated 6/29/20, signed by his RNCM, which stated: - "Braden Scale for Predicting Pressure Sore Risk ... Total 16 ... 10 - 12: At Risk" - "Nutrition and Fluid Intake Screening ... Total 6 ... Risk: Moderate" - "Fall Assessment ... Total 10 ... A score of 4 or greater is considered risk for falling." Patient #8's medical record included a POC, dated 6/29/20, signed by his physician. His POC did not include goals and interventions for his identified pressure sore, nutritional, and fall risks. It could not be determined how the agency addressed Patient #8's identified problems. The Director of Clinical Services and QA RN were interviewed together on 6/30/21, beginning at 11:09 AM, and Patient #8's medical record was reviewed in their presence. They confirmed Patient #8's POC did not include goals and interventions for all identified problems. Patient #8's POC did not include goals and interventions for all identified problems. 9. Patient #10 was an 88 year old female who was admitted to the agency on 1/29/20, with a terminal diagnosis of CHF. Additional diagnoses included pressure ulcer and pulmonary edema. She received SN, MSW, chaplain, and aide services. Her record, including the POC, for the benefit period 1/29/20 to 4/28/20, was reviewed. Patient #10's medical record included an SN SOC comprehensive assessment, dated 1/29/20, signed by her RNCM, which stated: - "Nutrition and Fluid Intake Screening ... Total 10 ... Risk: High" - "Fall Assessment ... Total 8 ... A score of 4 or greater is considered risk for falling." Patient #10's medical record included a POC, dated 1/29/20, signed by her physician. Her POC did not include goals and interventions for her identified nutritional and fall risks. It could not be determined how the agency addressed Patient #10's identified problems. The Director of Clinical Services and QA RN were interviewed together on 6/30/21, beginning at 11:30 AM, and Patient #10's medical record was reviewed in their presence. They confirmed Patient #10's POC did not include goals and interventions for all identified problems. Patient #10's POC did not include goals and interventions for all identified problems.
L0562      
37262 Based on agency QAPI plan review, QI data review, QAPI meeting minutes review, Governing Body meeting minutes review, and staff interview, it was determined the agency failed to analyze QI data. This directly affected 1 of 3 patients who had documented falls (Patient #3) and whose records were reivewed, and had the potential for missed opportunities to evaluate and improve patient care. Findings include: 1. The agency failed to analyze QI data. The agency's QAPI plan, revised June 2019, stated, "Objectives ... To collect and analyze data to improve identified processes and outcomes of care." This plan was not followed. QI data for 2021 was requested and a "Quarterly Review of Quality Indicators and Adverse Events Tool," dated 4/05/21, was provided. The form included 10 QI's such as patient injuries, patient falls, medication errors, and employee incidents. The form did not include analysis of this QI data. It could not be determined if QI data improved or worsened from previous reporting quarters. Additionally, it could not be determined the methodology of how the QI data was extracted and aggregated. It was unclear if the QI data showed improvement in patient care outcomes due to lack of analysis. QAPI meeting minutes for 2021 were requested and 1 meeting minutes, dated 4/05/21, was provided. The minutes listed an agenda of 3 things to discuss: - "Items to discuss: Quarterly Review of Quality Indicators and Adverse Events Tools ... Covid Policy relating to infection control...HHA [home health aide] Supervisory Visits being completed timely" The meeting minutes did not include what was actually discussed during the meeting, if QI data analysis happened, what conclusions were derived, or how patient care outcomes were improved. Governing Body meeting minutes for 2021 were requested and 3 meeting minutes were provided. The meeting minutes did not include analysis of QI data. The Director of Clinical Services and QA RN were interviewed together on 6/30/21, beginning at 8:54 AM, and the agency's QAPI data was reviewed in their presence. They stated all QAPI data from 2020 was either not kept or not completed by previous leadership; for which they had been cited by their accrediting organization during their most recent recertification survey. The QA RN stated the agency had started over in regard to their QAPI program in 2021. The Director of Clinical Services and QA RN confirmed 2021 QI data had not been analyzed to determine improved patient outcomes. The agency failed to analyze QI data. 42371 An agency policy, "Variance/Incident Reporting," revised March 2013, instructed staff to report fall events, "Witnessed patient falls and Unwitnessed patient falls that require medical intervention." 2. Patient #3 was a 79 year old male admitted to the agency on 4/14/21, with a terminal diagnosis of Parkinson's disease. He received SN, aide, MSW, and chaplain services. His record, including the POC, for the benefit period 4/14/21 to 7/12/21, was reviewed. a. Patient #3's medical record included an SN visit note, dated 4/22/21, signed by an RN, which stated, "Todays fall leads to Skin tear on pts left eyes brows . SN cleaned it and put some breathable dressing." b. Patient #3's medical record included an SN visit note, dated 6/08/21, signed by an RN, which stated, "Multiple scrapes and scabs pulled off with falls, antibiotic cream and dressing placed ..." c. Patient #3's medical record included an SN visit note, dated 6/14/21, signed by an RN, which stated, "Reason for visit pt had a fall ..." The agency's occurrence reports for the last 12 months were requested and reviewed. No variance/incident reports documenting Patient #3's falls were included. The Director of Clinical Services and QA RN were interviewed together on 7/01/21, beginning at 9:55 AM, and Patient #3's medical record was reviewed in their presence. They confirmed Patient #3's falls were not documented and tracked through adverse event reporting. Patient #3's falls were not captured as QI data.
L0565      
37262 Based on QAPI plan review and staff interview, it was determined the Governing Body failed to ensure the frequency and detail of the agency's QI data collection was approved. This resulted in a lack of direction to staff regarding how to implement the QAPI program. Findings include: The agency's QAPI plan, revised June 2019, was reviewed. The plan did not include the frequency and detail of the agency's QI data collection or its approval by the Governing Body. It could not be determined what priorities the Governing Body had set in regard to QI data collection, how often, by whom, or for what duration. The Director of Clinical Services and QA RN were interviewed together on 6/30/21, beginning at 8:54 AM, and the agency's QAPI plan was reviewed in their presence. They confirmed the plan did not include frequency and detail of QI data collection approved by the Governing Body. The Governing Body failed to ensure the frequency and detail of the agency's QI data collection was approved.
L0579      
37262 Based on medical record review, policy review, and staff interview, it was determined the agency failed to ensure COVID-19 screening was documented for 11 of 13 patients (#1 - #9, #12, and #13) who were on service during the COVID-19 PHE and whose records were reviewed. This had the potential for unidentified transmission of COVID-19 from patients to agency staff. Findings include: An agency policy, "COVID-19 Patient Specific Policy," undated, stated, "Patients will be screened for Covid [sic] at the beginning of each visit and documented in the patient's medical record for that visit." The policy did not specify which agency disciplines were responsible for COVID-19 patient screening, how the screening would be documented, or where in the agency's EMR the documentation would be entered. Patient #1 - #9, #12, and #13's medical records were reviewed and did not include COVID-19 patient screening. It could not be determined how COVID-19 patient screening was done for these patients or by whom. The Director of Clinical Services and QA RN were interviewed together on 6/30/21, beginning at 10:21 AM, and the agency's COVID-19 patient screening policy was reviewed in their presence. They confirmed the policy was incomplete. Additionally, the Director of Clinical Services and QA RN confirmed COVID-19 patient screening had not been documented in Patient #1 - #9, #12, and #13's medical records. The agency failed to ensure COVID-19 screening was documented for Patient #1 - #9, #12, and #13.
L0581      
42371 Based on record review, IC log, and staff interview, it was determined the agency failed to ensure a method of identifying infectious and communicable disease problems and a plan for implementing appropriate actions to address those problems was developed. This directly affected 3 of 13 patients who had documented infections ( #4, #9, and #5) whose records were reviewed. This prevented the agency from identifying problems and addressing them. Findings include: 1. Patient #4 was a 100 year old female admitted to the agency on 1/08/21, with a terminal diagnosis of combined systolic and diastolic heart failure. She received SN, aide, MSW, and chaplain services. Her record, including the POC, for the benefit periods of 1/08/21 to 4/07/21 and 4/08/21 to discharge on 5/27/21, was reviewed. Patient #4's medical record included an SN SOC initial assessment, dated 1/08/21, signed by an RN. The SOC initial comprehensive assessment included a genito-urinary assessment that documented incontinence and Patient #4's UTI history as follows: - "Has the patient had any recurrent Upper Urinary Tract Infections? Yes Urinary Tract Infection #1 08/01/2020 Urinary Tract Infection #2 09/04/2020 Urinary Tract Infection #3 09/17/2020 Urinary Tract Infection #4 12/26/2020" Patient #4's medical record included a "Patient Medication Record," listing her current and discontinued medications. Her medication list included an antibiotic, "Macrodantin oral capsule 100 MG capsule daily. Indication: prophylaxis." The Drugs.com website, accessed on 7/12/21, states Macrodantin is an antibiotic that is used to treat urinary tract infections caused by bacteria. Patient #4's "Patient Medication Record," included an antibiotic medication starting on 4/28/21,"Cipro Oral Tablet 500MG: take 1 tab twice a day for 7 days. Indication: UTI." Patient #4's "Patient Medication Record," included an antibiotic medication starting on 3/05/21,"Augmentin Oral Tablet 875-125 MG: take 1 Tab(s) twice per day for 5 days. Indication: Infection." A log of agency reported infections from 1/01/20 to current was requested and reviewed. The infection log did not include Patient #4's infections. It could not be determined why Patient #4's infections were not captured and tracked through the agency's infection control and quality systems. The Director of Clinical Services and QA RN were interviewed together on 7/01/21, beginning at 9:55 AM, and Patient #4's medical record was reviewed in their presence. They confirmed Patient #3's infections were not captured and tracked through the agency's infection control and quality systems. Patient #4's infections were not captured and tracked through the agency's infection control and quality systems. 2. Patient #9 was an 80 year old male admitted to the agency on 1/02/21, with a terminal diagnosis of protein calorie malnutrition. An additional diagnosis included chronic kidney disease. He received SN, aide, MSW, and chaplain services. His record, including the POC, for the benefit periods of 1/02/21 to 3/31/21 and 4/02/21 to 6/30/21, was reviewed. Patient #9's medical record included a "Patient Medication Record," which listed his current and discharged medications. His medication list included an antibiotic, "Bactrim Oral Tablet 400-80 MG take 1 Tab(s) twice daily for 7 days. Indication: UTI." A log of agency reported infections from 1/01/20 to current was requested and reviewed. The infection log did not include Patient #9's infection. It could not be determined why Patient #9's infection was not captured and tracked through the agency's infection control and quality systems. The Director of Clinical Services and QA RN were interviewed together on 7/01/21, beginning at 9:55 AM, and Patient #9's medical record was reviewed in their presence. They confirmed Patient #9's infection was not captured and tracked through the agency's infection control and quality systems. Patient #9's UTI was not captured and tracked through the agency's infection control and quality systems. 37262 3. Patient #5 was a 95 year old female who was admitted to the agency on 9/21/20, with a terminal diagnosis of Alzheimer's disease. Additional diagnoses included weight loss and frequent UTI's. She received SN, MSW, chaplain, and aide services. Her record, including the POC, for the benefit period of 9/10/20 to 12/08/20, was reviewed. Patient #5's medical record included an "RN - Skilled Nursing Visit Addendum Page," dated 10/08/20, signed by her RNCM, which stated, "... family requested to do urinalysis. Pt refused to get up and go to the bathroom so SN did straight cath to get the urine sample. Pt is positive for uti [sic]. Consulted dr [sic] [name] about getting Antibiotics [sic] per family's request. Called dr [sic] [name] about getting antibiotics, dr [sic] [name] responded after an hour saying we can start cephalexin 500 mg liquid tid [sic] for 5 days." A log of agency reported infections from 1/01/20 to current was requested and reviewed. The infection log did not include Patient #5's UTI. It could not be determined why Patient #5's infection was not captured and tracked through the agency's infection control and quality systems. The Director of Clinical Services and QA RN were interviewed together on 6/30/21, beginning at 11:22 AM, and Patient #5's medical record was reviewed in their presence. They confirmed Patient #5's UTI was not captured and tracked through the agency's infection control and quality systems. Patient #5's UTI was not captured and tracked through the agency's infection control and quality systems.
L0648      
37262 Based on medical record review, agreement review, CFR review, CMS SOM review, agency organizational chart review, agency purchase agreement review, and staff interview, it was determined the agency failed to ensure organization and administration of services were executed. This resulted in the inability of the agency to develop and maintain systems necessary for accurate and complete medical record documentation and establish legal authority for the agency's operation. Findings include: 1. Refer to L-651, as it relates to the agency's failure to ensure full legal authority and responsibility for the management of the agency was executed. 2. Refer to L-670, Condition of Participation: Clinical Records and associated standard level deficiencies, as they relate to the agency's failure to ensure medical records were complete, accurate, and included all required information. The cumulative effect of these systemic practices impeded the agency's ability to document effective patient care and administrative services.
L0651      
37262 Based on agency organizational chart review, CMS SOM review, agency purchase agreement review, short-term inpatient care agreement review, and staff interview, it was determined the Governing Body failed to ensure full legal authority and responsibility for the management of the hospice was executed. This resulted in an incomplete agency CHOW process, unclear delineated lines of authority for agency staff, and a lack of a current short-term inpatient care agreement. Findings include: 1. The hospice CHOW process was incomplete. CMS SOM, Chapter 3, Section 3210.1A, states, "To determine ownership of any provider enterprise or organization, the SA determines which party (whether an individual or legal entity such as a partnership or corporation) has immediate authority for making final decisions regarding the operation of the enterprise and bears the legal responsibility for the consequences of the enterprise's operations. CHOW processing is necessary for program participants that have Health Benefit Agreements or Provider Agreements in the Medicare program (hospital, SNF, HHA, hospice, CORF, OPT/SP providers and CMHC) because it must be determined who the responsible party is under the agreement. For the same reason, CHOW processing is necessary for supplier participants that have category-specific agreements with the Secretary (RHC, ASC, and FQHCs) or that must file cost reports (e.g., ESRD facilities). Somewhat less extensive CHOW processing is necessary for the remaining supplier types without agreements or cost report requirements (e.g., PXR) to ensure compliance with the statutory requirement for ownership disclosure and to ensure that the program has current, accurate records regarding participants." This was not followed. CMS SOM, Chapter 3, Section 3210.1B1, states, "Whenever an owner is contemplating or negotiating the sale of a provider, he or she notifies the SA, FI or the RO, as required in 42 CFR 489.18(b). The SA or the RO asks the prospective new owner if he or she intends to participate in the Medicare program, and if so, whether he or she intends to do so by accepting assignment of the previous owner's provider agreement or by applying for a new provider agreement. This will prevent the confusion we have seen in the past and reduce the litigation. The new owner should be made aware that if the agreement is assigned to the new owner, the new owner is responsible for the former owner's liabilities, including any Medicare payments. Also, assignment of the agreement, in some cases, would result n the new owner receiving a Medicare underpayment. If the new owner states that assignment of the former owner's provider agreement is not going to be accepted, but the new owner intends to continue the entity's Medicare participation, inform the provider that there will be a break in the continuity of Medicare payment because CMS requires all new applicants to undergo a survey. If the new owner still does not wish to accept assignment, following a CHOW, the entity must enroll in the Medicare program as a new provider in accordance with the instructions found in §2005, and undergo the survey and certification process." This was not followed. The hospice's "MEMBERSHIP INTERESTS PURCHASE AGREEMENT," dated 10/13/20, stated, "This MEMBERSHIP INTERESTS PURCHASE AGREEMENT (collectively with all schedules and exhibits hereto, this 'Agreement'), effective for all purposes as of October 13, 2020 ...". Additionally, the purchase agreement included signatures of both the agency seller and buyer dated 10/13/20. Further, the purchase agreement stated, "Specifically, Buyer is responsible for all changes of ownership filings required to transfer the Medicare provider numbers (PTAN) and will make such filings within five (5) business days after Closing." These CHOW filings were not completed. The agency Administrator and Director of Clinical Services were interviewed together on 6/30/21, beginning at 2:41 PM. The Director of Clinical Services stated the agency had boxed and shipped agency information to the previous owner who resided in another state. When asked what information was sent, the Director of Clinical Services and Administrator stated quality data and other items they were unsure of. When asked why agency quality information was sent to the previous owner, the Administrator and Director of Clinical Services stated they were unsure. The agency Administrator was interviewed a second time on 7/01/21, beginning at 12:48 PM, and the hospice's purchase agreement was reviewed in his presence. He stated he purchased the agency from the previous owner on 10/13/20. The Administrator stated he was unaware of the required form CMS-855a or the CHOW process; "I want to be up front and transparent, I didn't know about it." He stated he was made aware of the CHOW process by the previous owner on or about 1/13/21, and was requested by him to file the CMS-855a. The Administrator stated he completed his portion of the CMS-855a at that time and forwarded his portion to the previous owner for him to complete. He stated, as of time of survey, the previous owner had not completed his portion of the CMS-855a. The Administrator stated he had retained legal counsel as of May 2021 in regard to the previous owner's noncompliance in completing his portion of the the CMS-855a. He stated his attorney was, as of time of survey, composing a letter to submit to the SA as to the timeline of events and the status of the process. The Administrator stated he had not reached out to the SA regarding the CHOW process prior to survey. The hospice CHOW process was incomplete. 2. Delineated lines of authority were unclear for agency staff. The agency's, "Brio Idaho Hospice Organizational Chart," undated, was reviewed. The chart did not include the following staff: - Medical Director - Associate Medical Directors - Volunteers Additionally, the chart indicated all clinical staff, chaplains, and social workers directly reported to the "Billing Coordinator." The Director of Clinical Services and Administrator were interviewed together on 6/29/21, beginning at 10:18 AM, and the agency's organizational chart was reviewed in their presence. The Director of Clinical Services confirmed all clinical staff, chaplains, and social workers should report to her, not the Billing Coordinator. Additionally, she confirmed the agency's organizational chart was incomplete. Delineated lines of authority were unclear for agency staff. 42371 3. The agency did not have a current short-term inpatient facility agreement. CMS SOM, Subpart D 418.108 the Condition of Participation for Short Term Inpatient Care, states, "If the hospice has an arrangement with a facility to provide for short-term inpatient care, the arrangement is described in a written agreement, coordinated by the hospice ...". This was not followed. The agency provided a copy of their current short-term inpatient care agreement, "Hospice Facility Participation Agreement," dated 1/1/2019. The agreement stated, "Section 9.1, Term of Agreement: The term of this agreement shall by for (2) two years, commencing on the 1st day of Jan. and ending on the 30th day of December 2020." The Administrator was interviewed on 6/29/21, beginning at 10:40 AM, and the agency's short-term inpatient agreement was reviewed in his presence. The Administrator confirmed the agreeement had expired. The agency did not have a current short-term inpatient care agreement.
L0670      
37262 Based on review of medical records, CFRs, and staff interview, it was determined the agency failed to ensure medical records were complete, accurate, and included all required information. This resulted in a lack of information being available on which to base care decisions. Findings include: 1. Refer to L-671, as it relates to the agency's failure to ensure clinical records included current and accurate clinical findings. 2. Refer to L-676, as it relates to the agency's failure to comply with CFR 418.22 of the State Operations Manual as it relates to physician CTI documentation. 3. Refer to L-677, as it relates to the agency's failure to ensure clinical records included a complete copy of advance directives. 4. Refer to L-678, as it relates to the agency's failure to ensure patient records included all physician orders. 5. Refer to L-680, as it relates to the agency's failure to ensure contents of patient clinical records were safeguarded against unauthorized use. The cumulative effect of these systemic practices resulted in the inability of the agency to ensure comprehensive patient information was available and that patient needs were met.
L0671      
37262 Based on medical record review and staff interview, it was determined the agency failed to ensure clinical records included current and accurate clinical findings for 3 of 13 patients (#8, #10, and #11) whose records were reviewed. This resulted in a lack of clarity as to the contents of clinical records. Findings include: 1. Patient #10 was an 88 year old female who was admitted to the agency on 1/29/20, with a terminal diagnosis of CHF. Additional diagnoses included pressure ulcer and pulmonary edema. She received SN, MSW, chaplain, and aide services. Her record, including the POC, for the benefit period 1/29/20 to 4/28/20, was reviewed. a. Patient #10's medical record included a "Discharge - Live" form, dated 3/07/20, signed by his RNCM, which stated, "Reason for Discharge: Discharge for cause (i.e. patient/staff safety). However, Patient #10 revoked hospice services on 3/07/20 for aggressive treatment of his respiratory issues. It was unclear why "discharge for cause" was listed as the reason for Patient #10's agency discharge. b. Patient #10's medical record included a, "NOTICE OF PRIVACY PRACTICES: ACKNOWLEDGEMENT OF RECEIPT" form, dated 1/29/20. The form included a section for Patient #10's signature, date, and time, however, the time portion was blank. It could not be determined if Patient #10 received her privacy practices prior to care being rendered. c. Patient #10's medical record included an "INFORMED CONSENT AND MEDICARE BENEFIT ELECTION FORM," dated 2/20/20, signed by Patient #10. The form included a section titled, "I do not wish to choose an attending physician" with an adjacent check-box. This check box was blank. Underneath the check-box was a section titled, "I acknowledge that my choice for an attending physician is ... Physician Full name ...". This section was also left blank. It could not be determined who Patient #10's attending physician was. The Director of Clinical Services and QA RN were interviewed together on 6/30/21, beginning at 11:19 AM, and Patient #10's medical record was reviewed in their presence. They confirmed Patient #10's medical record was inaccurate and incomplete. Patient #10's medical record was inaccurate and incomplete. 2. Patient #11 was an 88 year old male who was admitted to the agency on 2/20/20, with a terminal diagnosis of Parkinson's disease. Additional diagnoses included weight loss and respiratory distress. He received SN, MSW, and chaplain services. His record, including the POC, for the benefit period of 2/20/20 to 5/19/20, was reviewed. a. Patient #11's medical record included a "Discharge - Live" form, dated 2/04/20, signed by his RNCM, which stated, "Reason for Discharge: Discharge for cause (i.e. patient/staff safety). However, Patient #11 revoked hospice services on 2/04/20 for aggressive treatment of her pressure ulcers. It was unclear why "discharge for cause" was listed as the reason for Patient #11's agency discharge. b. Patient #11's medical record included an "INFORMED CONSENT AND MEDICARE BENEFIT ELECTION FORM," dated 2/20/20, signed by Patient #11. The form included a section titled, "I do not wish to choose an attending physician" with an adjacent check-box. This check box was blank. Underneath the check-box was a section titled, "I acknowledge that my choice for an attending physician is...Physician Full name ...". This section was also left blank. It could not be determined who Patient #11's attending physician was. The Director of Clinical Services and QA RN were interviewed together on 6/30/21, beginning at 11:30 AM, and Patient #11's medical record was reviewed in their presence. They confirmed Patient #11's medical record was inaccurate and incomplete. Patient #11's medical record was inaccurate and incomplete. 3. Patient #8 was an 88 year old male who was admitted to the agency on 6/29/20, with a terminal diagnosis of CKD. Additional diagnoses included nutritional deficiency and pain. He received SN, MSW, chaplain, and aide services. His record, including the POC, for the certification period of 6/29/20 to 9/26/20, was reviewed. a. Patient #8's medical record included an, "INFORMED CONSENT AND MEDICARE BENEFIT ELECTION FORM," dated 6/29/20, signed by Patient #8's spouse. The form included a section titled, "I acknowledge and understand the above, and authorize Medicare hospice coverage to be provided by Brio Hospice beginning on:". This section was blank. It was unclear what date Patient #8's hospice coverage began. b. Patient #8's medical record included a, "NOTICE OF PRIVACY PRACTICES: ACKNOWLEDGEMENT OF RECEIPT" form, dated 6/29/20. The form included a section for Patient #8's signature, date, and time, however, the time portion was blank. It could not be determined if Patient #8 received his privacy practices prior to care being rendered. The Director of Clinical Services and QA RN were interviewed together on 6/30/21, beginning at 11:09 AM, and Patient #8's medical record was reviewed in their presence. They confirmed Patient #8's medical record was incomplete. Patient #8's medical record was incomplete.
L0676      
37262 Based on medical record review, CFR review, and staff interview, it was determined the agency failed to comply with CFR 418.22 of the State Operations Manual as it relates to physician CTI documentation for 13 of 13 patients (#1 - #13) whose records were reviewed. This had the potential for patients to be admitted to the agency without physician verification of their terminal status. Findings include: CFR 418.22(b)(3)(i) states, "(3) The physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms...(i) If the narrative is part of the certification or recertification form, then the narrative must be located immediately prior to the physician's signature." This requirement was not followed. Patient #1 - #13's medical records included a, "Written Certification [CTI]" form. The header of the form included a statement, "I certify that [patient name] is terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course." Underneath this portion was a section titled, "Narrative Statement" which included a copy-paste of an agency RN's SOC initial assessment narrative regarding the patient. Directly beneath this RN narrative was a section titled, "Attestation: I confirm that I composed this narrative based on my review of the patient's medical record and/or examination of the patient." Below this attestation was an agency RN signature, date, and time. Lastly, below the agency RN signature was a section for a physician signature and date. Patient #1 - #13's medical records did not include a physician CTI narrative; CTI narratives were written by RN's. Furthermore, the RN narrative was located immediately prior to the RN's signature, not a physician signature. It was unclear why a physician had not written CTI narratives and signed them accordingly. The Director of Clinical Services and QA RN were interviewed together on 6/30/21, beginning at 10:21 AM, and the agency's CTI forms for Patient #'s 1 - 13 were reviewed in their presence. They confirmed the CTI forms were unclear and did not have physician narratives immediately prior to a physician's signatures. The agency failed to comply with CFR 418.22 of the State Operations Manual as it relates to physician CTI documentation.
L0677      
37262 Based on medical record review and staff interview, it was determined the agency failed to ensure clinical records included a complete copy of advance directives for 7 of 13 patients (#4, #5, #6, #8, #9, #10, and #12) whose records were reviewed. This had the potential to interfere with patients' wishes being honored. Findings include: 1. Patient #8 was an 88 year old male who was admitted to the agency on 6/29/20, with a terminal diagnosis of CKD. Additional diagnoses included nutritional deficiency and pain. He received SN, MSW, chaplain, and aide services. His record, including the POC, for the certification period of 6/29/20 to 9/26/20, was reviewed. Patient #8's medical record included a, "Patient Advance Directives Statement," dated 6/29/20, signed by Patient #8's spouse. The form included a section titled, "I have an advance directive ... Yes". Below this was a section titled, "If Yes: copy obtained". This section was blank. It was unclear if agency staff obtained Patient #8's advance directive. The Director of Clinical Services and QA RN were interviewed together on 6/30/21, beginning at 11:09 AM, and Patient #8's medical record was reviewed in their presence. They confirmed Patient #8's advance directive form was incomplete. Patient #8's advance directive form was incomplete. 2. Patient #10 was an 88 year old female who was admitted to the agency on 1/29/20, with a terminal diagnosis of CHF. Additional diagnoses included pressure ulcer and pulmonary edema. She received SN, MSW, chaplain, and aide services. Her record, including the POC, for the benefit period 1/29/20 to 4/28/20, was reviewed. Patient #10's medical record included a, "Patient Advance Directives Statement," dated 1/29/20, signed by Patient #10. The form was blank. It could not be determined if Patient #10 had an advance directive. The Director of Clinical Services and QA RN were interviewed together on 6/30/21, beginning at 11:30 AM, and Patient #10's medical record was reviewed in their presence. They confirmed Patient #10's advance directive form was incomplete. Patient #10's advance directive form was incomplete. 3. Patient #5 was a 95 year old female who was admitted to the agency on 9/21/20, with a terminal diagnosis of Alzheimer's disease. Additional diagnoses included weight loss and frequent UTI's. She received SN, MSW, chaplain, and aide services. Her record, including the POC, for the benefit period of 9/10/20 to 12/08/20, was reviewed. Patient #5's medical record included a, "Patient Advance Directives Statement," dated 9/10/20, signed by Patient #5's representative. The form was blank. It could not be determined if Patient #5 had an advance directive. The Director of Clinical Services and QA RN were interviewed together on 6/30/21, beginning at 11:22 AM, and Patient #5's medical record was reviewed in their presence. They confirmed Patient #5's advance directive form was incomplete. Patient #5's advance directive form was incomplete. 4. Patient #6 was a 74 year old male who was admitted to the agency on 4/25/21, with a terminal diagnosis of ESRD. Other diagnoses included dementia and agitation. He received SN, MSW, chaplain, and aide services. His record, including the POC, for the benefit periods 4/25/21 to 6/23/21 and 6/24/21 to 8/22/21, was reviewed. Patient #6's medical record included a, "Patient Advance Directives Statement," dated 10/28/20, signed by Patient #6's representative. The form included a section titled, "I have an advance directive ... Yes". Below this was a section titled, "If Yes: copy obtained". This section was blank. It was unclear if agency staff obtained Patient #6's advance directive. The Director of Clinical Services and QA RN were interviewed together on 6/30/21, beginning at 10:21 AM, and Patient #6's medical record was reviewed in their presence. They confirmed Patient #6's advance directive form was incomplete. Patient #6's advance directive form was incomplete. 42371 5. Patient #4 was a 100 year old female admitted to the agency on 1/08/21, with a terminal diagnosis of combined systolic and diastolic heart failure. She received SN, aide, MSW, and chaplain services. Her record, including the POC, for the benefit periods of 1/08/21 to 4/07/21 and 4/08/21 to discharge on 5/27/21, was reviewed. Patient #4's medical record included a, "Patient Advance Directives Statement," dated 1/08/21, signed by Patient #4. The form was blank. It could not be determined if Patient #4 had an advance directive. The Director of Clinical Services and QA RN were interviewed together on 7/01/21, beginning at 9:55 AM, and Patient #4's medical record was reviewed in their presence. They confirmed Patient #4's advance directive form was incomplete. Patient #4's advance directive form was incomplete. 6. Patient #9 was an 80 year old male admitted to the agency on 1/02/21, with a terminal diagnosis of protein calorie malnutrition. An additional diagnosis included chronic kidney disease. He received SN, aide, MSW, and chaplain services. His record, including the POC, for the benefit periods of 1/02/21 to 3/31/21 and 4/02/21 to 6/30/21, was reviewed. Patient #9's medical record included a, "Patient Advance Directives Statement," dated 1/02/21, signed by Patient #9's representative. The form was blank. It could not be determined if Patient #9 had an advance directive. The Director of Clinical Services and QA RN were interviewed together on 7/01/21, beginning at 9:55 AM, and Patient #9's medical record was reviewed in their presence. They confirmed Patient #9's advance directive form was incomplete. Patient #9's advance directive form was incomplete. 7. Patient #12 was a 32 year old male admitted to the agency on 2/10/21, with a terminal diagnosis of alcoholic hepatic failure with coma. Additional diagnoses included alcoholic cirrhosis of the liver with ascites and acute respiratory failure with hypercapnia. He received SN services. His record, including the POC, for the benefit period of 2/11/21 to 3/11/21, was reviewed. Patient #12's medical record included a, "Patient Advance Directives Statement," dated 2/10/21, signed by Patient #12's representative. The form was blank. It could not be determined if Patient #12 had an advance directive.
L0678      
37262 Based on medical record review and staff interview, it was determined the agency failed to ensure patient records included all physician orders for 5 of 13 patients (#1, #3, #8, #9, and #10) whose records were reviewed. This had the potential for inaccuracies as to the course of patient care and unmet patient needs. Findings include: 1. Patient #8 was an 88 year old male who was admitted to the agency on 6/29/20, with a terminal diagnosis of CKD. Additional diagnoses included nutritional deficiency and pain. He received SN, MSW, chaplain, and aide services. His record, including the POC, for the certification period of 6/29/20 to 9/26/20, was reviewed. Patient #8's medical record included an, "RN - Skilled Nursing Visit Addendum Page," dated 7/03/20, signed by his RNCM, which stated, "SN cared for wounds to bilateral feet per current wound care order of cleansing with NS and gauze, patting dry, applying bacitracin, and covering with primapore." Patient #8's medical record did not include wound care orders. The Director of Clinical Services and QA RN were interviewed together on 6/30/21, beginning at 11:09 AM, and Patient #8's medical record was reviewed in their presence. They confirmed Patient #8's medical record did not include wound care orders. Patient #8's medical record did not include all physician orders. 2. Patient #10 was an 88 year old female who was admitted to the agency on 1/29/20, with a terminal diagnosis of CHF. Additional diagnoses included pressure ulcer and pulmonary edema. She received SN, MSW, chaplain, and aide services. Her record, including the POC, for the benefit period 1/29/20 to 4/28/20, was reviewed. Patient #10's medical record included an, "RN - Skilled Nursing Visit," dated 2/04/20, signed by her RNCM, which stated, "Wound 1 ... cleansed with wound wash, covered with dressing as per order" and "Wound 2 ... cleansed with wound wash, and sterile gauze. Applied optifoam absorbant [sic] 6x6" dressing." Patient #10's medical record did not include wound care orders. The Director of Clinical Services and QA RN were interviewed together on 6/30/21, beginning at 11:30 AM, and Patient #10's medical record was reviewed in their presence. They confirmed Patient #10's medical record did not include wound care orders. Patient #10's medical record did not include all physician orders. 42371 3. Patient #3 was a 79 year old male admitted to the agency on 4/14/21, with a terminal diagnosis Parkinson's disease. He received SN, aide, MSW, and chaplain services. His record, including the POC, for the benefit period 4/14/21 to 7/12/21, was reviewed. a. Patient #3's medical record included an SN visit note, dated 4/22/21, signed by an RN, which stated, "Todays fall leads to Skin tear on pts left eyes brows. SN cleaned it and put some breathable dressing." b. Patient #3's medical record included an SN visit note, dated 6/08/21, signed by an RN, which stated, "Multiple scrapes and scabs pulled off with falls, antibiotic cream and dressing placed ..." c. Patient #3's medical record included an SN visit note, dated 6/08/21, signed by an RN, which stated, "Multiple scrapes and scabs pulled off with falls, antibiotic cream and dressing placed ..." Patient #3's medical record did not include wound care orders. The Director of Clinical Services and QA RN were interviewed together on 7/01/21, beginning at 9:55 AM, and Patient #3's medical record was reviewed in their presence. They confirmed Patient #3's medical record did not include wound care orders. Patient #3's medical record did not include all physician orders. 4. Patient #1 was a 67 year old male admitted to the agency on 6/14/21, with a terminal diagnosis of chronic respiratory failure with hypoxia. Additional diagnoses included nontraumatic subdural hemorrhage and pneumonitis due to inhalation of food and vomit. He received SN services. His record, including the POC, for the benefit period 6/14/21 to 9/11/21, was reviewed. a. Patient #1's medical record included an SN visit note, dated 6/15/21, signed by an RN, which stated, "Catheter: Foley. Last changed 06/15/2021." Patient #1's medical record did not include orders to change his foley catheter on 06/15/21. b. Patient #1's medical record included an SN visit note, dated 6/19/21, signed by an RN, which stated, "Catheter: Foley. Last changed 06/15/2021 ... Comments: Family decided to take out foley cath since its hurting the pt. SN took off the cath - Pt tolerated the procedure very well ..." Patient #1's medical record did not include orders to change or discontinue his foley catheter on 06/19/21. The Director of Clinical Services and QA RN were interviewed together on 7/01/21, beginning at 9:55 AM, and Patient #1's medical record was reviewed in their presence. They confirmed Patient #1's medical record did not include catheter change or discontinue orders. Patient #1's medical record did not include all physician orders. 5. Patient #9 was an 80 year old male admitted to the agency on 1/02/21, with a terminal diagnosis of protein calorie malnutrition. An additional diagnosis included chronic kidney disease. He received SN, aide, MSW, and chaplain services. His record, including the POC, for the benefit periods of 1/02/21 to 3/31/21 and 4/02/21 to 6/30/21, was reviewed. Patient #9's medical record included an RN On Call visit note, dated 4/10/21, signed by an RN, which stated, "Catheter occluded, urine leaking around foley. Attempted to flush catheter, unsuccessful. Catheter changed 16 fr [french] 10 cc [cubic centimeters] using sterile technique." Patient #9's medical record did not include orders to change his foley catheter on 04/10/21. The Director of Clinical Services and QA RN were interviewed together on 7/01/21, beginning at 9:55 AM, and Patient #9's medical record was reviewed in their presence. They confirmed Patient #9's medical record did not include catheter change orders for 4/10/21. Patient #9's medical record did not include all physician orders.
L0680      
37262 Based on medical record review and staff interview, it was determined the agency failed to ensure contents of patient clinical records were safeguarded against unauthorized use for 13 of 13 patients (#1 - #13) whose records were reviewed. This had the potential for clinical information being shared with outside parties without patients' knowledge and/or consent. Findings include: 1. Patient #5 was a 95 year old female who was admitted to the agency on 9/21/20, with a terminal diagnosis of Alzheimer's disease. Additional diagnoses included weight loss and frequent UTI's. She received SN, MSW, chaplain, and aide services. Her record, including the POC, for the benefit period of 9/10/20 to 12/08/20, was reviewed. Patient #5's medical record included an, "Authorization for Release of Confidential Information" form, dated 9/10/20, signed by Patient #5's representative. The form did not include what information was being released, to whom, for what purpose, and for what time period. The Director of Clinical Services and QA RN were interviewed together on 6/30/21, beginning at 11:22 AM, and Patient #5's medical record was reviewed in their presence. They confirmed Patient #5's clinical information was not safeguarded against unauthorized use. Patient #5's clinical information was not safeguarded against unauthorized use. 2. Patient #6 was a 74 year old male who was admitted to the agency on 4/25/21, with a terminal diagnosis of ESRD. Other diagnoses included dementia and agitation. He received SN, MSW, chaplain, and aide services. His record, including the POC, for the benefit periods 4/25/21 to 6/23/21 and 6/24/21 to 8/22/21, was reviewed. Patient #6's medical record included an, "Authorization for Release of Confidential Information" form, dated 10/28/20, signed by Patient #6's representative. The form did not include what information was being released, to whom, for what purpose, and for what time period. The Director of Clinical Services and QA RN were interviewed together on 6/30/21, beginning at 10:21 AM, and Patient #6's medical record was reviewed in their presence. They confirmed Patient #6's clinical information was not safeguarded against unauthorized use. Patient #6's clinical information was not safeguarded against unauthorized use. 3. Patient #7 was a 64 year old male who was admitted to the agency on 3/30/21, with a terminal diagnosis of rectal cancer. Additional diagnoses included chronic pain and weight loss. He received SN services. His record, including the POC, for the benefit period of 3/30/21 to 6/27/21, was reviewed. Patient #7's medical record included an, "Authorization for Release of Confidential Information" form, dated 3/30/21, signed by Patient #7's representative. The form did not include what information was being released, to whom, for what purpose, and for what time period. The Director of Clinical Services and QA RN were interviewed together on 6/30/21, beginning at 10:54 AM, and Patient #7's medical record was reviewed in their presence. They confirmed Patient #7's clinical information was not safeguarded against unauthorized use. Patient #7's clinical information was not safeguarded against unauthorized use. 4. Patient #8 was an 88 year old male who was admitted to the agency on 6/29/20, with a terminal diagnosis of CKD. Additional diagnoses included nutritional deficiency and pain. He received SN, MSW, chaplain, and aide services. His record, including the POC, for the certification period of 6/29/20 to 9/26/20, was reviewed. Patient #8's medical record included an, "Authorization for Release of Confidential Information" form. The form was not dated or signed by Patient #8. Additionally, the form did not include what time period the information was being shared for. The Director of Clinical Services and QA RN were interviewed together on 6/30/21, beginning at 11:09 AM, and Patient #8's medical record was reviewed in their presence. They confirmed Patient #8's clinical information was not safeguarded against unauthorized use. Patient #8's clinical information was not safeguarded against unauthorized use. 5. Patient #10 was an 88 year old female who was admitted to the agency on 1/29/20, with a terminal diagnosis of CHF. Additional diagnoses included pressure ulcer and pulmonary edema. She received SN, MSW, chaplain, and aide services. Her record, including the POC, for the benefit period 1/29/20 to 4/28/20, was reviewed. Patient #10's medical record included an, "Authorization for Release of Confidential Information" form, dated 1/29/20, signed by Patient #10's. The form did not include what information was being released, to whom, for what purpose, and for what time period. The Director of Clinical Services and QA RN were interviewed together on 6/30/21, beginning at 11:30 AM, and Patient #10's medical record was reviewed in their presence. They confirmed Patient #10's clinical information was not safeguarded against unauthorized use. Patient #10's clinical information was not safeguarded against unauthorized use. 6. Patient #11 was an 88 year old male who was admitted to the agency on 2/20/20, with a terminal diagnosis of Parkinson's disease. Additional diagnoses included weight loss and respiratory distress. He received SN, MSW, and chaplain services. His record, including the POC, for the benefit period of 2/20/20 to 5/19/20, was reviewed. Patient #11's medical record included an, "Authorization for Release of Confidential Information" form, dated 2/20/20, signed by Patient #11. The form did not include what information was being released, to whom, for what purpose, and for what time period. The Director of Clinical Services and QA RN were interviewed together on 6/30/21, beginning at 11:19 AM, and Patient #11's medical record was reviewed in their presence. They confirmed Patient #11's clinical information was not safeguarded against unauthorized use. Patient #11's clinical information was not safeguarded against unauthorized use. 42371 7. Patient #12 was a 32 year old male admitted to the agency on 2/10/21, with a terminal diagnosis of alcoholic hepatic failure with coma. Additional diagnoses included alcoholic cirrhosis of the liver with ascites and acute respiratory failure with hypercapnia. He received SN services. His record, including the POC, for the benefit period of 2/11/21 to 3/11/21, was reviewed. Patient #12's medical record included an, "Authorization for Release of Confidential Information" form, dated 2/10/21, signed by Patient #12's representative. The form did not include what information was being released, to whom, for what purpose, and for what time period. The Director of Clinical Services and QA RN were interviewed together on 7/01/21, beginning at 9:55 AM, and Patient #12's medical record was reviewed in their presence. They confirmed Patient #12's clinical information was not safeguarded against unauthorized use. Patient #12's clinical information was not safeguarded against unauthorized use. 8. Patient #13 was a 74 year old female admitted to the agency on 2/12/21, with a terminal diagnosis of acute respiratory failure with hypoxia. She received SN services. Her record, including the POC, for the benefit period of 2/12/21 to 3/12/12 was reviewed. Patient #13's medical record included an, "Authorization for Release of Confidential Information" form, dated 2/10/21, signed by Patient #13's representative. The form did not include what information was being released, to whom, for what purpose, and for what time period. The Director of Clinical Services and QA RN were interviewed together on 7/01/21, beginning at 9:55 AM, and Patient #13's medical record was reviewed in their presence. They confirmed Patient #13's clinical information was not safeguarded against unauthorized use. Patient #13's clinical information was not safeguarded against unauthorized use. 9. Patient #1 was a 67 year old male admitted to the agency on 6/14/21, with a terminal diagnosis of chronic respiratory failure with hypoxia. Additional diagnoses included nontraumatic subdural hemorrhage and pneumonitis due to inhalation of food and vomit. He received SN servces. His record, including the POC, for the benefit period 6/14/21 to 9/11/21, was reviewed. Patient #1's medical record included an, "Authorization for Release of Confidential Information" form, dated 6/14/21, signed by Patient #1's representative. The form did not include what information was being released, to whom, for what purpose, and for what time period. The Director of Clinical Services and QA RN were interviewed together on 7/01/21, beginning at 9:55 AM, and Patient #1's medical record was reviewed in their presence. They confirmed Patient #1's clinical information was not safeguarded against unauthorized use. Patient #1's clinical information was not safeguarded against unauthorized use. 10. Patient #9 was an 80 year old male admitted to the agency on 1/02/21, with a terminal diagnosis of protein calorie malnutrition. An additional diagnosis included chronic kidney disease. He received SN, aide, MSW, and chaplain services. His record, including the POC, for the benefit periods of 1/02/21 to 3/31/21 and 4/02/21 to 6/30/21, was reviewed. Patient #9's medical record included an, "Authorization for Release of Confidential Information" form, dated 1/02/21, signed by Patient #9's representative. The form did not include what information was being released, to whom, for what purpose, and for what time period. The Director of Clinical Services and QA RN were interviewed together on 7/01/21, beginning at 9:55 AM, and Patient #9's medical record was reviewed in their presence. They confirmed Patient #9's clinical information was not safeguarded against unauthorized use. Patient #9's clinical information was not safeguarded against unauthorized use. 11. Patient #4 was a 100 year old female admitted to the agency on 1/08/21, with a terminal diagnosis of combined systolic and diastolic heart failure. She received SN, aide, MSW, and chaplain services. Her record, including the POC, for the benefit periods of 1/08/21 to 4/07/21 and 4/08/21 to discharge on 5/27/21, was reviewed. Patient #4's medical record included an, "Authorization for Release of Confidential Information" form, dated 1/08/21, signed by Patient #4's. The form did not include what information was being released, to whom, for what purpose, and for what time period. The Director of Clinical Services and QA RN were interviewed together on 7/01/21, beginning at 9:55 AM, and Patient #4's medical record was reviewed in their presence. They confirmed Patient #4's clinical information was not safeguarded against unauthorized use. Patient #4's clinical information was not safeguarded against unauthorized use. 12. Patient #3 was a 79 year old male admitted to the agency on 4/14/21, with a terminal diagnosis Parkinson's disease. He received SN, aide, MSW, and chaplain services. His record, including the POC, for the benefit period 4/14/21 to 7/12/21, was reviewed. Patient #3's medical record included an, "Authorization for Release of Confidential Information" form, dated 9/19/20, signed by Patient #3's representative. The form did not include what information was being released, to whom, for what purpose, and for what time period. The Director of Clinical Services and QA RN were interviewed together on 7/01/21, beginning at 9:55 AM, and Patient #3's medical record was reviewed in their presence. They confirmed Patient #3's clinical information was not safeguarded against unauthorized use. Patient #3's clinical information was not safeguarded against unauthorized use. 13. Patient #2 was a 78 year old female admitted to the agency on 6/03/21, with a terminal diagnosis of chronic diastolic (congestive) heart failure. She received SN, aide, MSW, and chaplain services. Her record, including the POC, for the benefit period 6/03/21 to 8/31/21, was reviewed. Patient #2's medical record included an, "Authorization for Release of Confidential Information" form, dated 6/03/21, signed by Patient #2's representative. The form did not include what information was being released, to whom, for what purpose, and for what time period. The Director of Clinical Services and QA RN were interviewed together on 7/01/21, beginning at 9:55 AM, and Patient #2's medical record was reviewed in their presence. They confirmed Patient #2's clinical information was not safeguarded against unauthorized use. Patient #2's clinical information was not safeguarded against unauthorized use.