| 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 |
| 151575 | A. BUILDING __________ B. WING ______________ |
07/16/2021 | |
| NAME OF PROVIDER OR SUPPLIER | STREET ADDRESS, CITY, STATE, ZIP | ||
| VIAQUEST HOSPICE OF INDIANA, LLC | 724 WEST NAVAJO STREET, WEST LAFAYETTE, IN, 47906 | ||
| 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 |
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| 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) |
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| E0006 | |||
| 42617 Based on record review and interview, the hospice agency failed to evidence its Emergency Preparedness Plan (EPP) included strategies for addressing emergency events identified by the risk assessment or related to the current COVID-19 pandemic, which had the potential to affect all hospice patients and staff. Findings include: An agency policy titled "Emergency Management," policy number B-300 revised 2/2017, stated "Policy ... Viaquest Hospice of Indiana conducts an analysis to identify potential emergencies and the direct and indirect effects these emergencies may have on operations and the demand for services. Viaquest Hospice of Indiana will develop and maintain a written emergency management plan describing the process for disaster readiness and emergency management and implements it as appropriate ... Procedure: 1. Emergency Situations: Situations that would constitute an emergency include, but are not limited to: 1. Adverse weather such as floods, tornadoes, hurricanes, blizzards, and storms. 2. Natural disasters. 3. Internal emergencies such as a communications system or utilities failure due to outages of telephone and/or electricity. 4. Security incidents, bomb threats, or civil disturbances. 5. High rate of discharge from an acute, sub-acute, or residential facility. 6. Chemical spills and bio-hazardous weapons. 7. Accidents involving multiple injuries. Staffing shortages ... 3. Emergency Preparedness Plan: Viaquest Hospice of Indiana will establish an Emergency Preparedness Plan ... Areas addressed in the plan include: ... B. Hazard Vulnerability ... E. All Hazard Emergency Plan ... G. Patient, Family, Staff Emergency Preparedness Plan ...." The agency's Emergency Preparedness binder was reviewed on 7/16/2021. The binder included the agency's Emergency Preparedness Plan, and indicated it was last reviewed on 3/8/21 by QAPI Educator #1. The EPP included a "Hazard Vulnerability Assessment," completed on 3/8/21 by QAPI Educator #1, which indicated the hazards " ... Civil Disturbance ... Mass Causality Event ..." were rated as "High" probability for the agency, the hazards " ... Severe Winter Weather ... Electrical Failure ..." were rated as "High ... Level of Vulnerability/Degree of disruption" for the agency, and the hazards " ... Tornado ... Earthquake ... Hurricane ... Hazardous Material Accident ... Civil Disturbance ... Mass Causality Event ... Terrorist Attack ... Water Failure ... Transportation Interruption ... Environmental/Altered Air Quality Pollution ..." were rated as "Low ... Preparedness" for the agency. The hazard "Pandemic/Infectious Disease" was assessed as "Low" probability, "Moderate" level of vulnerability, and the agency had "Moderate" preparedness for this hazard. The agency's EPP stated " ... This plan uses the term 'all hazard' to address all types of incidents ... Types of incidents include: Fire ... Weather related emergencies ... Hazardous materials accidents. Power outages. Transit and worker strikes. Natural disasters. Terrorist/WMD events. Incidents of naturally occurring disease outbreaks. Planned Public Events, such as political conventions, sports events ...." The agency's EPP failed to evidence strategies for addressing emergency events identified by the risk assessment or related to the current COVID-19 pandemic. An interview was conducted on 7/16/21 at 2:47 PM with the Administrator and Vice President of Hospice (VP #1). During the interview, the VP #1 indicated the agency's Emergency Preparedness Plan should include strategies for addressing emergency events identified by the risk assessment and the agency did not have specific strategies within the EPP related to the COVID-19 pandemic. | |||
| E0016 | |||
| 42617 Based on record review and interview, the hospice agency failed to evidence its Emergency Preparedness Plan (EPP) included a system for contacting state and local officials of any on-duty staff and/or patients the agency had been unable to contact, which had the potential to affect all agency patients and employees. Findings include: An agency policy titled "Emergency Management," policy number B-300 and revised 2/2017, stated "Policy. Viaquest Hospice of Indiana has an identified plan in place to ensure the safety and well-being of patients and employees during periods of an emergency or disaster that disrupts agency services ... Viaquest Hospice of Indiana will develop and maintain a written emergency management plan describing the process for disaster readiness and emergency management and implements it as appropriate ... Procedure: ... 3. Emergency Preparedness Plan: Viaquest Hospice of Indiana will establish an Emergency Preparedness Plan ... Areas addressed in the plan include: ... G. Patient, Family, Staff Emergency Preparedness Plan ...." The agency's Emergency Preparedness binder was reviewed on 7/16/2021. The binder included the agency's Emergency Preparedness Plan, and indicated it was last reviewed on 3/8/21 by QAPI Educator #1. The EPP included an "Organization Assignment Sheet," which indicated positions and responsibilities assigned to agency staff. The Organization Assignment Sheet indicated the "Logistics Officer" was responsible for the duty " ... identify patients and staff affected by the emergency ...," the "Safety and Security Officer" was assigned the duty " ... Establish/maintain communication lines to local/state EMS/authorities ... to disseminate general information to/from agency ...," and the "Emergency Supervisor" was assigned the duty " ... Maintain list of contacted and available staff ...." The EPP stated " ... Incident Command Center ... Patient Care & Planning. On admission, the admitting nurse will assign each patient a priority code, dictating that patient's emergency rating (Disaster Triage) ... Plan Activation. Emergency Call Down Procedure (Telephone Tree) ... Each staff member will notify persons listed below them on the call list. If they are unable to reach an employee on the telephone, they will proceed to the next listed person on the list. The staff member will call the office and list the employees available for assistance ... Upon arrival, every five (5) minutes, a designated staff member will try those employees not found with he first call attempt and notify the Branch Director of any other employees found to be available to be on standby ... Assignments: The [Vice President] of Hospice and/or Branch Director ... will work to assist in pinpointing patients affected by the emergency and assigning clinical staff member to check on those patients by utilizing the Disaster Triage priority classification system ...." The EPP failed to evidence a system for contacting state and local officials of any on-duty staff and/or patients which the agency was unable to contact. An interview was conducted on 7/16/21 at 2:47 PM with the Administrator and Vice President of Hospice (VP #1). During the interview, the VP #1 indicated the agency's Emergency Preparedness Plan should include a system for contacting state and local officials of any on-duty staff and/or patients which the agency was unable to contact. | |||
| E0030 | |||
| 42617 Based on record review and observation, the hospice agency failed to evidence its Emergency Preparedness Plan (EPP) included a communication plan with contact information for entities providing services under arrangement, patient physicians, and other hospices, which had the potential to affect all hospice agency patients and employees. Findings include An agency policy titled "Emergency Management," policy number B-300 and revised 2/2017, stated "Policy ... Viaquest Hospice of Indiana will develop and maintain a written emergency management plan describing the process for disaster readiness and emergency management and implements it as appropriate ... Procedure: ... 3. Emergency Preparedness Plan: Viaquest Hospice of Indiana will establish an Emergency Preparedness Plan ... Areas addressed in the plan include: ... G. Patient, Family, Staff Emergency Preparedness Plan ...." The agency's Emergency Preparedness binder was reviewed on 7/16/2021. The binder included the agency's Emergency Preparedness Plan, and indicated it was last reviewed on 3/8/21 by QAPI Educator #1. The EPP included an "Organization Assignment Sheet," which indicated positions and responsibilities assigned to agency staff. The Organization Assignment Sheet indicated the "Liaison Officer" was responsible for the duty " ... Maintain open lines of communication with other health care facilities to assist with referrals to/from ... Hospice ..." and the "Emergency Supervisor" was responsible for the duty " ... Contact local facilities to determine bed availability for displaced ... hospice patients ...." The EPP stated " ... Incident Command Center ... Planning ... Each office will keep and maintain a current list of contact information for staff, vendors, emergency services, hospitals, and other appropriate community resources ...." The EPP included "Emergency Contacts" sheets for each county serviced by the agency, which contained contact information for the county's "Fire ... EMS ... State Emergency Office ... Local Emergency Office ... Hazmat ... Department of Health [local] ... Terrorism Tip Line ... Hospital ... County Highway Department ... Local Radio Station ...." The EPP failed to evidence its communication plan included contact information for entities providing services under arrangement, patient physicians, and other hospices. An interview was conducted on 7/16/21 at 2:47 PM with the Administrator and Vice President of Hospice (VP #1). During the interview, VP #1 indicated the agency's Emergency Preparedness Plan should include a communication plan with contact information for entities providing services under arrangement, patient physicians, and other hospices. | |||
| L0521 | |||
| 42617 Based on observation, record review, and interview, the hospice agency failed to ensure a thorough comprehensive assessment of the patient's physical, psychosocial, emotional, and spiritual needs were completed and documented which identified the patient's specific needs for hospice for 8 of 8 active patient records reviewed (#1, 2, 3, 4, 5, 18, 19), in a total sample of 20 records reviewed. Findings include: 1. An agency policy titled "Initial Assessment/Comprehensive Assessment," policy number C-145 and revised 4/2017, stated " ... Procedure ... II. Comprehensive Assessment. Each patient admitted will receive a comprehensive assessment. The RN [Registered Nurse] Case Manager along with the Hospice IDG [Interdisciplinary Group] ... must complete the comprehensive assessment ... The comprehensive assessment will identify the patient's need for Hospice care and identify the patient's need for: Physical care. Psychosocial and emotional care. Spiritual care. All areas of Hospice care related to the palliation and management of the terminal illness and related conditions ...." 2. An agency policy titled "Reassessments/Update to the Comprehensive Assessment," policy number C-155 and revised 3/2017, stated " ... Procedure. 1. The update of the comprehensive assessment must be accomplished by the Hospice IDG ... and must consider changes that have taken place since the initial assessment ... The update to the comprehensive assessment will include assessments of changes in physical, psychosocial, emotional, and spiritual needs ...." 3. The clinical record of Patient #1 was reviewed on 7/6/21 and 7/14/21 and indicated a benefit election date of 6/25/21, with the patient's terminal diagnosis indicated as pulmonary fibrosis and related diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease (COPD), intellectual disability, cardiomegaly, anxiety, pressure ulcer to the right ankle, and contractures to the left and right feet. The record included an initial comprehensive assessment completed on 6/25/21 by RN #2. The assessment stated " ... Psychosocial - Cognitive Status ... Level of Consciousness: Alert ... Review of Systems - Emotional/Behavioral ... Alertness: Moderately impaired ... Level of Consciousness: Alert ... Status: Emotional/Behavioral ... Anxiety: Persistent fear of object/situation. Repetitive behaviors or mental acts ... Plan of Care - Other - Mental Status ... Mental Status: ... Lethargic ... Narrative Notes ... Patient has ... Ativan [medication given for anxiety], Buspar [medication given for anxiety], Lexapro [medication given for depression and/or anxiety] for anxiety and behaviors ...." The comprehensive assessment failed to evidence a thorough and complete emotional and behavioral assessment which identified the specific behaviors the patient was exhibiting, if the patient's current medication regimen was appropriate and effective, why the patient's mental status was listed as "lethargic, and the need for hospice care services related to this. The comprehensive assessment also stated " ... Review of Systems - Integumentary ... Bruising ..." and indicated the patient had venous stasis ulcers to the right and left shins. The assessment also stated " ... Plan of Care - Other - Supplies ... Supplies: Wound Care ... 4x4 dressing. ABD Pads. Hydrogel. Kerlix Wrap (roll) ... Narrative Notes ... Patient has bilateral stasis ulcers to shins ... measuring R [right] 5.5cm x 3cm, L [left] 7cm x 4cm with active yellow drainage and surrounding erythema, tender to touch, no warmth noted. Patient has pressure ulcer to R outer ankle ... Patient has skin issue to L hip under abdominal apron, tender, scant amount of drainage at this time ...." The comprehensive assessment failed to evidence a complete and thorough assessment of the patient's wounds (amount of drainage and presence or absence of dressing from stasis ulcers; pressure ulcer measurement, grading, presence or absence of drainage, odor, and dressing; detailed description of skin "issue" to the left hip, color of drainage, presence or absence of odor and dressing, etc). The comprehensive assessment stated " ... Pain - Pain Assessment ... Pain Screening ... Patient able to verbalize: Yes ... Staff Observation Scale Used: FLACC ["Face, Legs, Activity, Cry, Consolability;" type of standardized pain scale used by health professionals when patients are non-verbal, with results ranging from 0 - 10, where 0 is no pain observed and 10 is the worst pain observable] ... Total FLACC Score: 0. Pain Severity ... The patient's pain severity is: None ... Comprehensive Pain Assessment ... Treatment and Follow Up: Patient is comfortable with current treatment? Yes. Treatment initiated/modified: Yes. Following treatment changes made: Medication change: Increase opioids ... Medications - Medications ... Medication Profile Review ... New/changed medications identified, medication profile updated ... Morphine Sulfate [opioid medication given to treat pain] ...." The assessment included a "Medication Profile" which indicated the patient's medications included orders for Morphine Sulfate 20 mg/ml (milligrams per milliliter), administer 0.5 ml every 8 hours and 0.25 ml every 4 hours "PRN" (as needed), and Norco (hydrocodone-acetaminophen, opioid medication given to treat pain) 325 mg - 7.5 mg, 1 tab every 6 hours PRN "for pain." The assessment failed to evidence a thorough and complete pain assessment (was the patient able to complete a self-assessment of their pain such as the 0-10 numeric scale, indication for the patient to be started on Morphine Sulfate when the pain assessment documented failed to evidence an issue with the patient's current pain regimen, etc). 4. The clinical record of Patient #2 was reviewed on 7/8/21 and indicated a benefit election date of 4/17/21, with the patient's terminal diagnosis indicated as hypertensive kidney disease (kidney disease caused by high blood pressure) with heart failure (CHF) and related diagnoses including but not limited to: urinary incontinence (inability to control urination), weakness, and history of falls. The record included a recertification comprehensive assessment completed on 6/30/21 by RN #1. The assessment stated " ... Care Plan Documentation ... Assess activity intolerance. Note: Completed ... Assess endurance. Note: Completed ... Review of Systems - Cardiovascular ... Symptoms/Problems: ... Fatigues easily ... Plan of Care - Other - Activities Permitted ... Activities Permitted: Up as Tolerated ... Narrative Notes ... Patient ambulates with a rolling walker but has an unsteady gait ... Supervision is needed for him to ambulate safely ... Patient's resting SpO2 [oxygen saturation, measurement of the percentage of red blood cells saturated with oxygen] is 94%, dropping to low 80s [%] on exertion with notable SOB [shortness of breath], taking about 5 minutes to recover ...." A home visit observation was conducted on 7/7/21 at 9:56 AM with Patient #2 and RN #1. During the visit, the patient was observed using a rollator walker to ambulate. The comprehensive assessment failed to evidence a thorough and complete assessment of the patient's activity intolerance and endurance status (how much activity is tolerated, does patient experience any other symptoms with activity, etc). The assessment also failed to evidence documentation of the patient's needs regarding activities permitted and what the hospice would do to manage. 5. The clinical record of Patient #3 was reviewed on 7/8/21 and 7/15/21 and indicated a benefit election date of 4/5/21, with the patient's terminal diagnosis indicated as hypertensive heart disease and related diagnoses including but not limited to: COPD, hypothyroid, osteoarthritis, urinary incontinence, insomnia, anxiety, Gastro-esophageal reflux disease (GERD, backflow of stomach acid into esophagus), and history of falls. The record included a recertification comprehensive assessment completed on 6/23/21 by RN #3. The assessment stated " ... Care Plan Documentation ... Intervention: Assess respiratory status including rate, pattern, secretions, and lung sounds. Status: Respiratory. Shortness of Breath ... Upon exertion ... Review of Systems - Respiratory. Status: Respiratory: Please refer to intervention documentation ... Clinical Findings: Respiratory. Clinical Conditions: COPD ...." The assessment failed to evidence a thorough and complete assessment of the patient's respiratory system (lung sounds, breathing pattern, presence or absence of cough and secretions, etc), and what the hospice will do for the palliation of these symptoms. The comprehensive assessment stated " ... Nutrition - Nutritional Status/Risks ... Nutritional Risk Assessment: Not Assessed ... Narrative Notes ... [Patient #3's] weight 4/2021 was 120 # [pounds,] her weight today was 114 # ...." The assessment failed to evidence a complete and thorough assessment of the patient's nutrition status despite the patient's weight loss. 6. The clinical record of Patient #4 was reviewed on 7/9/21 and indicated a benefit election date of 4/21/21 with a terminal diagnosis of hypertensive kidney disease with CHF and related diagnoses including but not limited to: fibromyalgia, chronic pain, osteoarthritis of both knees, epilepsy, and urinary incontinence. The record included a recertification comprehensive assessment completed on 6/28/21 by RN #4. The assessment stated " ... Wound Assessment and Care. Right Posterior Medial Buttocks ... Pressure Ulcer Stage II [wound caused by prolonged pressure]. Assessment: Wound Bed ... CBD [acronym meaning unknown] ... Narrative Notes ... [Patient #4] now has a stage 2 pressure ulcer to coccyx area. Barrier cream with zinc and manuka honey used, as well as butterfly adhesive Kerrafoam placed over wound for protection ...." The assessment failed to evidence a complete and thorough assessment of the patient's wound (color of wound bed, presence or absence of drainage and odor, and frequency of dressing changes). 7. The clinical record of Patient #5 was reviewed on 7/12/21 and indicated a benefit election date of 6/12/2020 with a terminal diagnosis of "senile degeneration of the brain" and related diagnoses including but not limited to: dementia with behavioral disturbances, CHF, depression, anxiety, urinary incontinence, pressure ulcer, and history of prostate cancer. The record included a recertification comprehensive assessment completed on 5/18/21 by RN #5. The assessment stated " ... Review of Systems - Emotional/Behaviors ... Emotional: Depression. Behavioral: Appropriate ... Narrative Notes ... Seroquel [medication given to treat several mental health disorders, including depression and bipolar disorder] was increase[d] to 3 times a day, Ativan [medication given to treat anxiety] has been increased to 0.5 ml from 0.25 ml do [sic] to increased behaviors this recertification ...." The assessment failed to evidence if the medication changes had improved or not improved the patient's "behaviors." The assessment also stated " ... Wound Assessment and Care ... Buttocks/Decubitus/Pressure Ulcer Unstageable: ... Wound Bed: Clean ... Genital-urinary Pubic area/Surgical Incision: Assessment: Wound Bed: Clean ...." The assessment failed to evidence a complete and thorough assessment of the patient's wounds (measurements, color of wound bed and surrounding skin, presence or absence of drainage and odor, wound care or dressing needed, etc), or interventions the hospice was to complete in regard to wounds. 8. The clinical record of Patient #18 was reviewed on 7/15/21 and indicated a benefit election date of 6/3/21 with a terminal diagnosis of lung cancer with metastasis [spread] to bone and related diagnoses including but not limited to: altered mental status, atrial fibrillation (irregular heart rhythm), hypothyroidism, depression, chronic kidney disease, visual hallucinations, fecal incontinence, history of renal (kidney) cancer, and pressure ulcer to left buttock. The record included an initial comprehensive assessment completed on 6/3/21 by RN #2. The assessment stated " ... Wound Assessment and Care. Left Buttocks Gluteal Fold [space between buttocks]/Decubitus/Pressure Ulcer: ... Wound Bed: Clean. Bed Color/Percentage: Red. Peri [perimeter] Wound Skin: WNL [within normal limits]. Drainage: ... None ... Dressing ...: Wound Care Provided by: Clinician ... Narrative Notes: ... Patient has reddened area to sacrum, gluteal cleft, and left glute [buttocks], no open areas however [Patient #18] states entire reddened area is tender to touch. Patient has foam Allevyn [type of dressing used on pressure sores] to L heel, area is red and blanchable at this time. [Skilled Nursing Facility] Staff reports dressing is preventative d/t redness ...." The assessment failed to evidence a complete and thorough assessment of the patient's wounds (presence or absence of dressing or treatment to reddened area on sacrum/left buttock, frequency of dressing change to be performed to wound on left heel). 9. The clinical record of Patient #19 was reviewed on 7/15/21 and indicated a benefit election date of 6/22/21 with a terminal diagnosis of breast cancer and related diagnoses including but not limited to: essential hypertension and open wound to left breast and thorax. The record included an initial comprehensive assessment completed on 6/22/21 by RN #7. The assessment stated " ... Symptom Assessment ... Depression: 3 ... Emotional/Behavioral - Coping Mechanisms ... Depression ... Review of Systems - Emotional/Behavioral ... Depression. Fear ... Depression Evaluation: Depression evaluation due to the following: Patient displays symptoms of depression ... Narrative Notes: ... Signs of depression and fear about her recent prognosis ..." The assessment failed to evidence a complete and thorough assessment of the patient's depression (signs and symptoms of depression, etc). 10. An interview was conducted on 7/15/21 at 3:32 PM with the Vice President of Hospice (VP #1). During the interview, VP #1 indicated the comprehensive assessment should include a current a thorough health and psychosocial status. | |||
| L0524 | |||
| 42617 Based on observation, record review, and interview, the hospice agency failed to ensure the comprehensive assessment identified and addressed the physical, psychosocial, and emotional needs related to the patient's terminal illness for 4 of 8 active records reviewed (#1, 2, 5, 11), in a total sample of 20 records reviewed. Findings include: 1. An agency policy titled "Initial Assessment/Comprehensive Assessment," policy number C-145 and revised 4/2017, stated " ... Procedure ... II. Comprehensive Assessment ... The comprehensive assessment will identify the patient's ... need for: Physical care. Psychosocial and emotional care ... All areas of Hospice care related to the palliation and management of the terminal illness ...." 2. The clinical record of Patient #1 was reviewed on 7/6/21 and 7/14/21 and indicated a benefit election date of 6/25/21, with the patient's terminal diagnosis indicated as pulmonary fibrosis and related diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease (COPD), intellectual disability, cardiomegaly, anxiety, pressure ulcer to the right ankle, and contractures to the left and right feet. The record included an initial comprehensive assessment completed on 6/25/21 by RN #2. The assessment stated " ... Review of Systems - Emotional/Behavioral ... Status: Emotional/Behavioral ... Anxiety ... Persistent fear of object/situation. Repetitive behaviors or mental acts ... Narrative Notes ... Patient has ... Ativan [medication given for anxiety], Buspar [medication given for anxiety], Lexapro [medication given for depression and/or anxiety] for anxiety and behaviors ...." The comprehensive assessment failed to evidence the patient's needs related to their "behaviors" and failed to evidence an evaluation of effectiveness for the patient's current anxiety medication regimen. 3. The clinical record of Patient #2 was reviewed on 7/8/21 and indicated a benefit election date of 4/17/21, with the patient's terminal diagnosis indicated as hypertensive kidney disease (kidney disease caused by high blood pressure) with heart failure (CHF) and related diagnoses including but not limited to: urinary incontinence (inability to control urination), weakness, and history of falls. The record included a recertification comprehensive assessment completed on 6/30/21 by RN #1. The assessment stated " ... Review of Systems - Neurological ... Clinical Findings: ... Fatigue ... Times of Occurrences: Throughout the Day ...." The assessment included a "Medication Profile" which contained the medication "Trazodone [medication given to help treat insomnia] ... 50 mg ... Take 1 tab(s) once ... at bedtime ...." A home visit observation was conducted on 7/7/21 at 9:56 AM with Patient #2 and RN #1. During the visit, Patient #1 reported he was "a lot tired ... I don't get enough sleep," and indicated issues with fatigue and difficulty sleeping. The comprehensive assessment failed to evidence an assessment of the patient's needs related to sleep and fatigue and failed to evidence an evaluation of effectiveness of the patient's current sleep medication. 4. The clinical record of Patient #5 was reviewed on 7/12/21 and indicated a benefit election date of 6/12/2020 with a terminal diagnosis of "senile degeneration of the brain" and related diagnoses including but not limited to: dementia with behavioral disturbances, CHF, depression, anxiety, urinary incontinence, pressure ulcer, and history of prostate cancer. The record included a recertification comprehensive assessment completed on 5/18/21 by RN #5. The assessment stated " ... Review of Systems - Emotional/Behaviors ... Emotional: Depression. Behavioral: Appropriate ... Review of Systems - Gastrointestinal ... Bowel Regimen ... Laxatives or stool softeners ... Narrative Notes ... some issues with constipation d/t [due to] decreased mobility ... Seroquel [medication given to treat several mental health disorders, including depression and bipolar disorder] was increase[d] to 3 times a day, Ativan [medication given to treat anxiety] has been increased to 0.5 ml from 0.25 ml do [sic] to increased behaviors this recertification ...." The assessment failed to evidence a thorough and complete assessment of the patient's anxiety and constipation, and failed to evidence an evaluation of the change in Seroquel and Ativan related to patient "behaviors." 5. The clinical record of Patient #11 was reviewed on 7/15/21 and indicated a benefit election date of 11/22/19 with a terminal diagnosis of Alzheimer's disease and related diagnoses including but not limited to: anxiety, restlessness and agitation, dysuria, stress incontinence, bowel incontinence, GERD, and history of falls. The record included a recertification comprehensive assessment completed on 6/22/21 by RN #6. The assessment stated " ... Review of Systems - Emotional/Behavioral ... Behavioral: Pacing ... Wandering ... Narrative Notes: ... [Patient #11] continues to wander all day throughout the house ... [Patient #11] is easily agitated due to inability to understand and follow directions ... [the patient] is given Depakote [medication given to treat agitation, seizures, and/or migraines] 2 times daily for behaviors, she takes Xanax [medication to treat anxiety] at night to assist with sleep. Patient sleeps about 6 hours at night ...." The assessment failed to evidence a complete and thorough assessment of the patient's needs related to her anxiety and restlessness, including an evaluation of the effectiveness of her current anxiety medication regimen. 6. An interview was conducted on 7/15/21 at 3:32 PM with the Vice President of Hospice (VP #1). During the interview, VP #1 indicated the assessment should reflect a thorough assessment of the patient's symptoms related to their terminal diagnosis. | |||
| L0530 | |||
| 42617 Based on record review and interview, the hospice agency failed to ensure the comprehensive assessment's medication list included indications for all as needed (PRN) medications, detailed instructions on where to apply topical medications, and detailed instructions on when to administer multiple medications used for symptomatic treatment, for 3 of 8 active records reviewed (#1, 5, 11), in a total sample of 20 records reviewed. Findings include: 1. An agency policy titled "Medication Management," policy number C-705 and revised 2/2017, stated " ... Procedure. 1 ... a. A comprehensive patient assessment is performed at start of care and other defined points in time and includes a review of all medications the patient is taking ... Medications in the home are reviewed with the patient/family and a medication profile is created ... 2. Medication orders ... A complete medication order must include ... special instructions for the use of the drug ... parameters for using PRN medications including amount and frequency and any other time limitations ...." 2. The clinical record of Patient #1 was reviewed on 7/6/21 and 7/14/21 and indicated a benefit election date of 6/25/21, with the patient's terminal diagnosis indicated as pulmonary fibrosis and related diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease (COPD), intellectual disability, cardiomegaly, anxiety, pressure ulcer to the right ankle, and contractures to the left and right feet. The record included an initial comprehensive assessment, completed on 6/25/21 by RN #2, which contained a "Medication Profile." The Medication Profile included the medications " ... Morphine Sulfate [opioid medication given to treat pain] 20 mg/ml [milligrams per milliliter] oral concentrate; Administer ... 0.25ml Q4H [every 4 hours] PRN ... Norco [hydrocodone - acetaminophen, opioid medication given to treat pain] 325 - 7.5 mg oral tablet; Take 1 tab(s) orally every 6 hours as needed for pain ... Nystatin [medication given to treat fungal infections] ...100000 units/g [gram] topical [applied to the skin] powder; Apply 1 dose topical once a day ...." The medication list failed to evidence an indication for administration for Morphine Sulfate, failed to evidence clear directions on how to determine which of the two PRN opioid medications (Morphine Sulfate vs Norco) to administer for the patient's pain, and failed to evidence clear directions on where to apply Nystatin. 3. The clinical record of Patient #5 was reviewed on 7/12/21 and indicated a benefit election date of 6/12/2020 with a terminal diagnosis of "senile degeneration of the brain" and related diagnoses including but not limited to: dementia with behavioral disturbances, CHF, depression, anxiety, urinary incontinence, pressure ulcer, and history of prostate cancer. The record included a recertification comprehensive assessment completed on 5/18/21 by RN #5 which contained a "Medication Profile." The Medication Profile stated " ... Milk of magnesia [medication used for constipation] 400mg/5ml concentrate; Take 30 milliliter(s) orally Daily as needed ... Nystatin Topical [medication used to treat fungal infections] 100000 units/gram topical powder ... [Apply] 2 times a day as needed ...." The assessment failed to evidence indications for administration for Milk of Magnesia and Nystatin and failed to evidence directions on where to apply the Nystatin powder. 4. The clinical record of Patient #11 was reviewed on 7/15/21 and indicated a benefit election date of 11/22/19 with a terminal diagnosis of Alzheimer's disease and related diagnoses including but not limited to: anxiety, restlessness and agitation, dysuria, stress incontinence, bowel incontinence, GERD, and history of falls. The record included a recertification comprehensive assessment completed on 6/22/21 by RN #6. The assessment included a "Medication Profile" which contained the medication orders " ... Xanax 0.25 milligrams by mouth ... Take one tablet every 8 hours as needed ... Haloperidol 2 mg/ml oral concentrate; Administer 1 milligrams orally every 6 hours as needed; Agitation ... Lorazepam 2 mg/ml oral concentrate; Administer 0.25 milliliter(s) orally 3 times a day as needed for anxiety ... Lorazepam 0.5 mg oral tablet; Take 1 tab(s) orally every 6 hours as needed; Agitation ...." The medication list failed to evidence indication for administration of Xanax and failed to evidence clear directions on how to determine which of the 4 PRN medications to administer for anxiety. 5. An interview was conducted on 7/15/21 at 3:32 PM with the Vice President of Hospice (VP #1). During the interview, VP #1 indicated a PRN medication order should include the indication for administration, a topical medication order should include directions on where to apply, and the medication orders should evidence clear directions on when to administer multiple PRN medications for the same indication. | |||
| L0533 | |||
| 42617 Based on record review and interview, the hospice agency failed to ensure the comprehensive assessment included the patient's progress towards their goals for 5 of 5 active records with recertification comprehensive assessments reviewed (#2, 3, 4, 5 11), in a total sample of 20 records reviewed. Findings include: 1. An agency policy titled "Reassessments/Update to the Comprehensive Assessment," policy number C-155 and revised 3/2017, stated " ... Procedure: 1. The update of the comprehensive assessment must ... include information on the patient's progress towards desired outcomes ...." 2. The clinical record of Patient #2 was reviewed on 7/8/21 and indicated a benefit election date of 4/17/21, with the patient's terminal diagnosis indicated as hypertensive kidney disease (kidney disease caused by high blood pressure) with heart failure (CHF) and related diagnoses including but not limited to: urinary incontinence (inability to control urination), weakness, and history of falls. The record included a recertification comprehensive assessment completed on 6/30/21 by RN #1. The assessment stated " ... Visit Plan - Status of Goals ... Goals partially met; patient continues to make progress according to plan of care ...." The assessment failed to evidence the patient's progress towards goals, reassessment of the patient's response to care, and whether the patient's goals were to continue or needed to be modified. 3. The clinical record of Patient #3 was reviewed on 7/8/21 and 7/15/21 and indicated a benefit election date of 4/5/21, with the patient's terminal diagnosis indicated as hypertensive heart disease and related diagnoses including but not limited to: COPD, hypothyroid, osteoarthritis, urinary incontinence, insomnia, anxiety, Gastro-esophageal reflux disease (GERD, backflow of stomach acid into esophagus), and history of falls. The record included a recertification comprehensive assessment completed on 6/23/21 by RN #3. The assessment stated " ... Visit Plan - Status of Goals ... Goals partially met; patient continues to make progress according to plan of care ...." The assessment failed to evidence the patient's progress towards goals, reassessment of the patient's response to care, and whether the patient's goals were to continue or needed to be modified. 4. The clinical record of Patient #4 was reviewed on 7/9/21 and indicated a benefit election date of 4/21/21 with a terminal diagnosis of hypertensive kidney disease with CHF and related diagnoses including but not limited to: fibromyalgia, chronic pain, osteoarthritis of both knees, epilepsy, and urinary incontinence. The record included a recertification comprehensive assessment completed on 6/28/21 by RN #4. The assessment stated " ... Visit Plan - Status of Goals ... Goals partially met; patient continues to make progress according to plan of care ...." The assessment failed to evidence the patient's progress towards goals, reassessment of the patient's response to care, and whether the patient's goals were to continue or needed to be modified. 5. The clinical record of Patient #5 was reviewed on 7/12/21 and indicated a benefit election date of 6/12/2020 with a terminal diagnosis of "senile degeneration of the brain" and related diagnoses including but not limited to: dementia with behavioral disturbances, CHF, depression, anxiety, urinary incontinence, pressure ulcer, and history of prostate cancer. The record included a recertification comprehensive assessment completed on 5/18/21 by RN #5. The assessment stated " ... Care Plan Documentation ... Goal: Patient will be maintained in safe environment and oriented as appropriate for stage of disease process. Progress: 80% ... Goal: Red area on coccyx will not open. Progress: 100% ... Visit Plan - Status of Goals. Progress Towards Goals: Goals partially met; patient continues to make progress according to plan of care ...." The assessment failed to evidence the patient's progress towards goals, reassessment of the patient's response to care, and whether the patient's goals were to continue or needed to be modified. 6. The clinical record of Patient #11 was reviewed on 7/15/21 and indicated a benefit election date of 11/22/19 with a terminal diagnosis of Alzheimer's disease and related diagnoses including but not limited to: anxiety, restlessness and agitation, dysuria, stress incontinence, bowel incontinence, GERD, and history of falls. The record included a recertification comprehensive assessment completed on 6/22/21 by RN #6. The assessment stated " ... Visit Plan - Status of Goals. Progress Towards Goals: No progress made ..." The assessment failed to evidence the patient's progress towards goals, reassessment of the patient's response to care, and whether the patient's goals were to continue or needed to be modified. 7. An interview was conducted on 7/15/21 at 3:32 PM with the Vice President of Hospice (VP #1). During the interview, VP #1 indicated the comprehensive assessment should evidence a detailed assessment of the patient and/or caregiver's progress towards their goals. | |||
| L0538 | |||
| 42617 Based on record review and interview, the hospice agency failed to ensure the plan of care (POC) specified the care and services necessary to meet the patients' needs for 4 of 8 active records reviewed (#1, 3, 18, 19), in a total sample of 20 records reviewed. Findings include: 1. An agency policy titled "IDG [Interdisciplinary Group] Care Planning Process," policy number C-580 and revised 10/2020, stated " ... Procedure ... 2. The plan of care specifies the care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions ... 8. An individualized written plan of care is developed for each patient ...." 2. The clinical record of Patient #1 was reviewed on 7/6/21 and 7/14/21 and indicated a benefit election date of 6/25/21, with the patient's terminal diagnosis indicated as pulmonary fibrosis and related diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease (COPD), intellectual disability, cardiomegaly, anxiety, pressure ulcer to the right ankle, and contractures to the left and right feet. The record included a plan of care for the benefit period of 6/25/21 - 8/23/21. The POC stated " ... Activity Level: Up as Tolerated ... Additional Services: Wound treatment to bilateral lower extremity shin stasis ulcers: cleanse area with soap and water, dry, apply barrier cream, apply NA dressing [type of wound dressing typically used on ulcer-type wounds], secure with tubi-grip [tubular dressing often used as a final step in wound care] ... Change catheter drainage bag Q72H [every 72 hours] and PRN [as needed] ...." The record also included an initial comprehensive assessment completed on 6/25/21 by RN #2. The assessment stated " ... Review of Systems - Genitourinary ... Indwelling catheter: Assessment: ... Frequency of Change (specify: q [every] _ days) 3 ... Plan of Care - Other - Supplies ... Supplies: Wound Care ... 4x4 dressing. ABD Pads. Hydrogel. Kerlix Wrap (roll) ... Narrative Notes ... Patient does not ambulate, [two person assist] or mechanical lift assist for transfers ...." The POC failed to evidence patient-specific orders for Patient #1's activity level, failed to evidence orders for dressing change frequency and supplies to the patient's stasis ulcers wounds, and failed to evidence orders for the frequency the patient's urinary catheter system (not just the catheter bag) was to be changed. 3. The clinical record of Patient #4 was reviewed on 7/9/21 and indicated a benefit election date of 4/21/21 with a terminal diagnosis of hypertensive kidney disease with CHF and related diagnoses including but not limited to: fibromyalgia, chronic pain, osteoarthritis of both knees, epilepsy, and urinary incontinence. The record included a plan of care for the initial certification period 4/21/21 - 7/19/21 which contained service orders for skilled nursing visits. The record included an "Interdisciplinary Group Meeting" dated 4/30/21 which stated " ... Prep Notes ... 4/26/21 ... [RN #4] spoke with [Patient #4's family member] ... [Family member] also asked about possibility of PT [physical therapy] to help [patient] gain enough strength back for transfers. [RN #4] will discuss with branch director and MD and get back to her at next visit ...." The POC failed to evidence orders for a physical therapy evaluation and/or treatment were placed per the family's desire to treat the patient's weakness. 4. The clinical record of Patient #18 was reviewed on 7/15/21 and indicated a benefit election date of 6/3/21 with a terminal diagnosis of lung cancer with metastasis [spread] to bone and related diagnoses including but not limited to: altered mental status, atrial fibrillation (irregular heart rhythm), hypothyroidism, depression, chronic kidney disease, visual hallucinations, fecal incontinence, history of renal (kidney) cancer, and pressure ulcer to left buttock. The record included a plan of care for the initial certification period of 6/3/21 - 8/31/21. The POC stated " ... Supplies: ... 4x4 Dressing; Catheters - Foley ...." The record also included an initial comprehensive assessment, completed on 6/3/21 by RN #2, which stated " ... Review of Systems - Genitourinary ... Indwelling Catheter ... Frequency of Change (specify: q_days): 30 ... Narrative Notes: ... Patient has foam Allevyn to L heel ...." The POC failed to evidence orders for frequency of the urinary catheter and heel dressing to be changed, as well as who was responsible for changing. 5. The clinical record of Patient #19 was reviewed on 7/15/21 and indicated a benefit election date of 6/22/21 with a terminal diagnosis of breast cancer and related diagnoses including but not limited to: essential hypertension and open wound to left breast and thorax. The record included a plan of care for the certification period 6/22/21 - 9/19/21. The POC included orders for skilled nursing services with 1 visit per week for 1 week then 2 visits per week for 12 weeks, and stated " ... Supplies: ... 4x4 dressing, Other: Larger border dressing ... Interventions: ... SN: Perform wound care/dressing change ...." The record also included an initial comprehensive assessment completed on 6/22/21 by RN #7. The assessment indicated Patient #19 had wounds to the left lower breast and right upper chest. The nurse indicated the left breast wound was dressed with a "Band-Aid" and the right chest wound was packed with wet gauze and covered with a "Border Dressing." The POC failed to evidence patient-specific dressing care orders (type of dressing, frequency of dressing change, etc). 6. An interview was conducted on 7/15/21 at 3:32 PM with the Vice President of Hospice (VP #1). During the interview, VP #1 indicated the interventions to be provided by the interdisciplinary group listed on the plan of care should be determined based on the patient's comprehensive assessment. | |||
| L0548 | |||
| 42617 Based on record review and interview, the hospice agency failed to ensure the plan of care (POC) contained patient-specific and measurable goals and outcomes for 8 of 8 records reviewed (#1,2,3,4,5,11,18,19), in a total sample of 20 records reviewed. Findings include: 1. An agency policy titled "IDG [Interdisciplinary Group] Care Planning Process," policy number C-580 and revised 10/2020, stated " ... Procedure ... 1. Hospice has designated an interdisciplinary group which, in consultation with the patient's attending physician (if any), prepares a written plan of care for each patient ... 8 ... The plan of care reflects patient and family goals and interventions based on the problems identified in the initial comprehensive and updated comprehensive assessments. The plan of care includes ... Measurable outcomes anticipated from implementing and coordinating the plan of care ...." 2. The clinical record of Patient #1 was reviewed on 7/6/21 and 7/14/21 and indicated a benefit election date of 6/25/21, with the patient's terminal diagnosis indicated as pulmonary fibrosis and related diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease (COPD), intellectual disability, cardiomegaly, anxiety, pressure ulcer to the right ankle, and contractures to the left and right feet. The record included a plan of care for the certification period of 6/25/21 - 8/23/21. The POC stated " ... Goals: Aide: Promote healthful environment ... Aide: Promote skin integrity ... Aide: Maintain clean, safe environment ... Aide: Patient's personal care needs will be met ... IDT [Interdisciplinary Team]: Pt [patient] remains free of s/s [signs and symptoms] of pain and behaviors ... IDT: Anxiety reduced and within manageable level during dyspneic [feeling out of breath] episodes ...." The plan of care failed to evidence patient-specific and measurable goals. 3. The clinical record of Patient #2 was reviewed on 7/8/21 and indicated a benefit election date of 4/17/21, with the patient's terminal diagnosis indicated as hypertensive kidney disease (kidney disease caused by high blood pressure) with heart failure (CHF) and related diagnoses including but not limited to: urinary incontinence (inability to control urination), weakness, and history of falls. The record included a plan of care for the recertification period 4/17/21 - 7/15/21. The POC stated " ... Goals: SN [Skilled Nurse]: Patient/caregiver verbalize understanding of disease process including prognosis, signs/symptoms, complications, effect of disease on body systems and what to report ...." The plan of care failed to evidence patient-specific and measurable goals. 4. The clinical record of Patient #3 was reviewed on 7/8/21 and 7/15/21 and indicated a benefit election date of 4/5/21, with the patient's terminal diagnosis indicated as hypertensive heart disease and related diagnoses including but not limited to: COPD, hypothyroid, osteoarthritis, urinary incontinence, insomnia, anxiety, Gastro-esophageal reflux disease (GERD, backflow of stomach acid into esophagus), and history of falls. The record included a plan of care for the recertification period of 7/4/21 - 9/1/21. The POC stated " ... Goals: Aide: Promote safe personal care and hygiene ... MSW [Medical Social Worker]: Continuity of care will be maintained as appropriate to patient/primary caregiver needs ... SN: Patient's symptoms will be consistent with stage of disease process and problems managed as well as disease process will allow ...." The plan of care failed to evidence patient-specific and measurable goals. 5. The clinical record of Patient #4 was reviewed on 7/9/21 and indicated a benefit election date of 4/21/21 with a terminal diagnosis of hypertensive kidney disease with CHF and related diagnoses including but not limited to: fibromyalgia, chronic pain, osteoarthritis of both knees, epilepsy, and urinary incontinence. The record included a plan of care for the initial certification period 4/21/21 - 7/19/21. The POC stated " ... Goals: IDT: Maintenance of respiratory baselines as evidenced by breathing at optimal level within disease parameters ...." The plan of care failed to evidence patient-specific and measurable goals. 6. The clinical record of Patient #5 was reviewed on 7/12/21 and indicated a benefit election date of 6/12/2020 with a terminal diagnosis of "senile degeneration of the brain" and related diagnoses including but not limited to: dementia with behavioral disturbances, CHF, depression, anxiety, urinary incontinence, pressure ulcer, and history of prostate cancer. The record included a plan of care for the recertification period 6/7/21 - 8/5/21. The POC stated " ... Goals: Aide: Patient's personal care needs will be met ... IDT: Patient will avoid contact with infectious/communicable disease ... SN: Patient will be maintained in safe environment and oriented as appropriate for stage of disease process ... SN: Patient will be able to tolerate appropriate diet without signs/symptoms of aspiration using diet modifications ... SN: Indwelling catheter/drainage system patient and functioning without complications ...." The plan of care failed to evidence patient-specific and measurable goals. 7. The clinical record of Patient #11 was reviewed on 7/15/21 and indicated a benefit election date of 11/22/19 with a terminal diagnosis of Alzheimer's disease and related diagnoses including but not limited to: anxiety, restlessness and agitation, dysuria, stress incontinence, bowel incontinence, GERD, and history of falls. The record included a plan of care for the recertification period of 5/15/21 - 7/13/21. The POC stated " ... Goals: ... Aide: Maintain clean, safe environment ... IDT: Patient will be cared for safely at home ... SN: Patient/caregiver can describe measures-maintain adequate nutrition/hydration, allow pt [patient] time eat [sic] ... SN: Patient will be pain free or verbalize an acceptable pain level with current pain management regimen ... SN: Family/caregiver will demonstrate ability to care for dependent patient ... Patient will maintain optimum level of functioning appropriate for stage of disease process, and provide a safe environment ...." The plan of care failed to evidence patient-specific and measurable goals. 8. The clinical record of Patient #18 was reviewed on 7/15/21 and indicated a benefit election date of 6/3/21 with a terminal diagnosis of lung cancer with metastasis [spread] to bone and related diagnoses including but not limited to: altered mental status, atrial fibrillation (irregular heart rhythm), hypothyroidism, depression, chronic kidney disease, visual hallucinations, fecal incontinence, history of renal (kidney) cancer, and pressure ulcer to left buttock. The record included a plan of care for the initial certification period of 6/3/21 - 8/31/21. The POC stated " ... Goals: Aide: Promote safe personal care and hygiene ... Aide: Patient's personal care needs will be met ... Aide: Promote healthful environment ... Aide: Maintain clean, safe environment ... Aide: Promote skin integrity ... IDT: Patient will be pain free or verbalize an acceptable plan of care level with current pain management regimen ...." The plan of care failed to evidence patient-specific and measurable goals. 9. The clinical record of Patient #19 was reviewed on 7/15/21 and indicated a benefit election date of 6/22/21 with a terminal diagnosis of breast cancer and related diagnoses including but not limited to: essential hypertension and open wound to left breast and thorax. The record included a plan of care for the certification period 6/22/21 - 9/19/21. The POC stated " ... Goals: ... SN: Patient will be pain free or verbalize an acceptable pain level with current pain management regimen ... SN: Patient/caregiver demonstrates ability to cope with limitations ... SN: Patient/caregiver will cope with change in lifestyle ... SN: Complete healing of wound without complications ... Patient/Caregiver demonstrates knowledge of disease process and complications ...." The plan of care failed to evidence patient-specific and measurable goals. 10. An interview was conducted on 7/15/21 at 3:32 PM with the Vice President of Hospice (VP #1). During the interview, VP #1 indicated goals should be patient-specific and measurable. | |||
| L0550 | |||
| 42617 Based on observation, record review, and interview, the hospice agency failed to ensure the plan of care (POC) contained the medical supplies and equipment needed for 1 of 8 active records reviewed (#2), in a total sample of 20 records reviewed. Findings include: An agency policy titled "IDG [Interdisciplinary Group] Care Planning Process," policy number C-580 and revised 10/2020, stated " ... Procedure ... 2. The plan of care specifies the care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment ... 8 ... The plan of care includes ... Medical supplies and appliances necessary to meet the needs of the patient ...." The clinical record of Patient #2 was reviewed on 7/8/21 and indicated a benefit election date of 4/17/21, with the patient's terminal diagnosis indicated as hypertensive kidney disease (kidney disease caused by high blood pressure) with heart failure (CHF) and related diagnoses including but not limited to: urinary incontinence (inability to control urination), weakness, and history of falls. The record included a plan of care for the recertification period 4/17/21 - 7/15/21 and a recertification comprehensive assessment completed on 6/30/21 by RN #1. The assessment stated " ... Review of Systems - Genitourinary ... Incontinence being managed by the following: Incontinence briefs ... DME [Durable Medical Equipment]/Assistive Devices ... 2 wheeled walker ... Narrative Notes ... Patient ambulates with a rolling walker ...." The POC stated " ... Supplies: None ...." The POC failed to evidence all patient supplies and equipment needed. An interview was conducted on 7/15/21 at 3:32 PM with the Vice President of Hospice (VP #1). During the interview, VP #1 indicated the plan of care should include all patient supplies and equipment necessary to meet the patient's needs. | |||
| L0552 | |||
| 42617 Based on observation, record review and interview, the interdisciplinary group (IDG) failed to review, revise, and document the individualized plan of care (POC) at least every 15 days for 1 of 8 active records reviewed (#4), in a total sample of 20 records reviewed, and 1 of 1 IDG meetings observed (parent branch), which had the potential to affect all agency patients. Findings include: 1. An agency policy titled "IDG Care Planning Process," policy number C-580 and revised 10/2020, stated " ... Procedure ... 9. The IDG ... reviews, revises and documents the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days ...." 2. An IDG meeting observation was conducted on 7/9/21 at 8:30 AM. During the meeting, the IDG was observed reviewing the current patient status and plans of care for 11 of 61 active patients assigned to the parent location of the agency (#1, 2, 4, 20, 23, 24, 25, 26, 27, 28, 29). The Administrator then listed off the names of the remaining active patients assigned to the parent branch, and for each patient the assigned RN Case Manager indicated no concerns or issues. No further discussion or review of these patients was conducted by the IDG. The IDG failed to review the plans of care of all patients at least every 15 days. 3. The clinical record of Patient #4 was reviewed on 7/9/21 and indicated a benefit election date of 4/21/21 with a terminal diagnosis of hypertensive kidney disease with CHF and related diagnoses including but not limited to: fibromyalgia, chronic pain, osteoarthritis of both knees, epilepsy, and urinary incontinence. The record included a plan of care for the initial certification period 4/21/21 - 7/19/21 which included a medication order for Ferrous Sulfate (iron supplement) and Vitamin D2 (supplement). The record included an "Interdisciplinary Group Meeting," dated 4/30/21, which stated " ... Additional Notes ... [Medical Director #1] recommended to d/c [discontinue] ... iron and [vitamin D medications] ...." The clinical record indicated the patient's iron and vitamin D supplements were not discontinued until 7/8/21. The IDG failed to ensure the patient's medication orders within the plan of care were kept up-to-date with the most recent orders. 4. An interview was conducted on 7/9/21 at 3:45 PM with the Vice President of Hospice (VP #1). During the interview, VP #1 indicated the IDG should review the plans of care for all patients during the IDG meeting and the plan of care for these patients should be updated with any changes. | |||
| L0553 | |||
| 42617 Based on record review and interview, the hospice agency failed to ensure the revised plan of care (POC) included the patient's progress towards their goals for 4 of 5 active records reviewed with a revised plan of care (#2, 3, 5, 11), in a total sample of 20 records reviewed. Findings include: 1. An agency policy titled "IDG [Interdisciplinary Group] Care Planning Process," policy number C-580 and revised 10/2020, stated " ... Procedure ... 9. The IDG ... reviews, revises and documents the individualized plan ... The revised plan of care ... notes the patient's progress toward and goals specified in the plan of care." 2. The clinical record of Patient #2 was reviewed on 7/8/21 and indicated a benefit election date of 4/17/21, with the patient's terminal diagnosis indicated as hypertensive kidney disease (kidney disease caused by high blood pressure) with heart failure (CHF) and related diagnoses including but not limited to: urinary incontinence (inability to control urination), weakness, and history of falls. The record included a plan of care for the recertification period 4/17/21 - 7/15/21 and a recertification comprehensive assessment completed on 6/30/21 by Registered Nurse (RN) #1. The assessment stated " ... Visit Plan - Status of Goals ... Goals partially met; patient continues to make progress according to plan of care ...." The POC stated " ... Goals: SN [Skilled Nurse]: Patient/caregiver verbalize understanding of disease process including prognosis, signs/symptoms, complications, effect of disease on body systems and what to report ...." The recertification plan of care failed to evidence Patient #2's progress towards their goals. 3. The clinical record of Patient #3 was reviewed on 7/8/21 and 7/15/21 and indicated a benefit election date of 4/5/21, with the patient's terminal diagnosis indicated as hypertensive heart disease and related diagnoses including but not limited to: COPD, hypothyroid, osteoarthritis, urinary incontinence, insomnia, anxiety, Gastro-esophageal reflux disease (GERD, backflow of stomach acid into esophagus), and history of falls. The record included a plan of care for the recertification period of 7/4/21 - 9/1/21 and a recertification comprehensive assessment completed on 6/23/21 by RN #3. The assessment stated " ... Visit Plan - Status of Goals ... Goals partially met; patient continues to make progress according to plan of care ...." The POC stated " ... Goals: Aide: Promote safe personal care and hygiene ... Chaplain: Isolation/loneliness will be decreased per patient/CG [caregiver]/staff ... MSW [Medical Social Worker]: Continuity of care will be maintained as appropriate to patient/primary caregiver needs ... MSW: Patient/caregiver will identify and access care system resources to assist with ADL care ... SN: Patient free of any signs/symptoms of infection of COVID-19 ... SN: Patient's symptoms will be consistent with stage of disease process and problems managed as well as disease process will allow ... SN: Patient/caregiver can describe measures to achieve/maintain appropriate weight ...." The recertification plan of care failed to evidence Patient #3's progress towards their goals. 4. The clinical record of Patient #5 was reviewed on 7/12/21 and indicated a benefit election date of 6/12/2020 with a terminal diagnosis of "senile degeneration of the brain" and related diagnoses including but not limited to: dementia with behavioral disturbances, CHF, depression, anxiety, urinary incontinence, pressure ulcer, and history of prostate cancer. The record included a plan of care for the recertification period 6/7/21 - 8/5/21 and a recertification comprehensive assessment completed on 5/18/21 by RN #5. The assessment stated "" ... Care Plan Documentation ... Goal: Patient will be maintained in safe environment and oriented as appropriate for stage of disease process. Progress: 80% ... Goal: Red area on coccyx will not open. Progress: 100% ... ... Visit Plan - Status of Goals ... Goals partially met; patient continues to make progress according to plan of care ...." The POC stated " ... Goals: Aide: Patient's personal care needs will be met ... Chaplain: Pt will find daily confidence in his Salvation ... Chaplain: Pt will be able to cope with fear and anxiety on a daily basis ... IDT: Patient will avoid contact with infectious/communicable disease ... IDT: Patient and family will verbalize decreased feelings of isolation ... MSW: [Family member of Patient #5] will have adequate mechanisms and support to cope with disease process and pt's declines ... SN: Patient will be maintained in safe environment and oriented as appropriate for stage of disease process ... SN: Patient will be able to tolerate appropriate diet without signs/symptoms of aspiration using diet modifications ... SN: Red area on coccyx will not open ... SN: CG can describe ways to maintain non-threatening environment ... SN: Indwelling catheter/drainage system patent and functioning without complication ... Volunteer: Pt will be able to verbalize he feels more socialized after 6 visits ...." The recertification plan of care failed to evidence Patient #3's progress towards their goals. 5. The clinical record of Patient #11 was reviewed on 7/15/21 and indicated a benefit election date of 11/22/19 with a terminal diagnosis of Alzheimer's disease and related diagnoses including but not limited to: anxiety, restlessness and agitation, dysuria, stress incontinence, bowel incontinence, GERD, and history of falls. The record included a plan of care for the recertification period of 5/15/21 - 7/13/21. The POC stated " ... Goals: ... Aide: Caregiver will be able to leave the home for 3 hours on Tuesday and Thursday to run errands, etc ... Aide: Maintain clean, safe environment ... Chaplain: Isolation/loneliness will be decreased per patient/CG/staff ... Chaplain: Resume face to face visits following the lifting of the COVID-19 restrictions ...IDT: Patient will be cared for safely at home ... IDT: Pt/CG will demonstrate understanding of available community resources ... IDT: Patient/family will acknowledge support and understanding of plan ... IDT: Patient/caregiver/Staff verbalize understanding/demonstrate necessary measures to reduce risk and avoid the spread of CoronaVirus ... MSW: Patient caregiver [sic] will consult with staff as needed for support ... SN: Patient/caregiver can describe measures-maintain adequate nutrition/hydration, allow pt time eat [sic] ... SN: Patient will be pain free or verbalize an acceptable pain level with current pain management regimen ... SN: Family/caregiver will demonstrate ability to care for dependent patient ... SN: Patient will maintain optimum level of functioning appropriate for stage of disease process, and provide a safe environment ... SN: Patient free of any signs/symptoms of infection ... SN: Patient/caregiver will be able to demonstrate safe and effective use of recommended DME [durable medical equipment] and assistive devices. Pt will be maintain [sic] a safe environment and free of falls w/o [without] injuries ...." The clinical record also included a recertification comprehensive assessment completed on 6/22/21 by RN #6, which stated " ... Visit Plan - Status of Goals. Progress Towards Goals: No progress made ..." The recertification plan of care failed to evidence Patient #11's progress towards their goals. 6. An interview was conducted on 7/15/21 at 3:32 PM with the Vice President of Hospice (VP #1). During the interview, VP #1 indicated the plan of care should evidence the patient's progress towards their goals. | |||
| L0579 | |||
| 42617 Based on observation, record review, and interview, the hospice failed to ensure all employees followed standard precautions and agency policies and procedures to prevent the transmission of infections and communicable diseases for 2 of 3 home visit observations (#2, 5). Findings include: 1. An agency policy titled "Hand Hygiene Policy & Compliance Program," policy number B-412 and revised 10/2020, stated " ... Procedure: 1. Indications for hand hygiene are: Before and after direct patient care ... Before re-entering nursing bag ... 2. All employees, volunteers and contract staff are responsible for implementing hand hygiene procedures in an on-going attempt to prevent and/or contain infectious processes and communicable disease. 3. Bacteriostatic foal/gel/liquid [alcohol based hand sanitizer, ABHS] is the preferable hand hygiene method. When using [ABHS], the procedure is [as] follows: ... Using friction, clean between fingers ... until hands are completely dry. 4. The proper procedure for handwashing when using soap and water is as follows: ... Lather hands well with liquid, antimicrobial soap: use friction; wash between fingers, wash area around and under nails ...." 2. Centers for Disease Control and Prevention (CDC, Revised 6/10/21). "When & How to Wash Your Hands." Retrieved 7/27/21 from www.cdc.gov. " ... Five Steps to Wash Your Hands ... 3. Scrub your hands for at least 20 seconds ...." 3. Healthwise Staff (3/17/2021). "Caregiving: How to Give a Bed Bath." Obtained 7/27/21 from www.peacehealth.org. " ... Some things to remember: ... Use a new washcloth when you need one ... 7. Start with the cleanest areas of the body and finish with the areas that are less clean ... Using a new washcloth, clean ... the anal area ...." 4. CDC (Updated 2/23/21). "Infection Control Guidance." Retrieved 7/27/21 from www.cdc.gov. " ... CDC recommends using additional infection prevention and control practices during the COVID-19 pandemic, along with standard practices recommended as part of routine healthcare delivery to all patients. These practices are intended to apply to all patients, not just those suspected or confirmed SARS-CoV-2 infection ... One of the following should be worn by HCP [health care providers] for source control ... and for protection during patient care encounters: ... A well-fitting face mask (e.g., selection of a facemask with a nose wire ... use of a cloth mask over the facemask to help it conform to the wearer's face) ...." 5. CDC (Revised 1/8/21). "Hand Hygiene in Healthcare Settings." Retrieved 7/27/21 from www.cdc.gov. " ... When and How to Perform Hand Hygiene ... After touching a patient or the patient's immediate environment ... Immediately after glove removal ...." 6. McGoldrick (1/2014). "Bag Technique." Retrieved 7/27/21 from www.nursingcenter.com/ce. " ... Bag Technique ... 2. Perform hand hygiene. 3. Remove the supplies from the bag and place them on ... a surface barrier ... 4 ... perform hand hygiene, and then reenter the bag ...." 7. McGoldrick (3/2009). "Cleaning and Disinfection of Patient Care Equipment used in the Home Setting." Retrieved 7/27/21 from www.cdss.ca.gov " ... Disinfection of Patient Care Equipment ... vital sign equipment and supplies be cleaned with a low- or intermediate-level disinfectant in the home after use and prior to placing the equipment back in the nursing back for use on another patient ... Disinfectant Contact Time. Contact time is the amount of time that the item or surface is to be kept 'wet' with the disinfectant up through complete drying of the disinfectant on the surface ... Most EPA-registered hospital disinfectants have a label contact time of 10 minutes ... the hospice staff member must follow the safety precautions and use directions on the labeling of each registered product. If they do not follow the specified ... contact time ... the practice is considered a misuse of the product ...." 8. Missouri Department of Elementary and Secondary Education (2006). "Certified In-Home Aide Student Manual." Retrieved 7/27/21 from http://mcce.org. " ... Procedure for Suprapubic Catheter [drain placed into a surgically created stoma in the lower abdomen to empty the bladder] Care ... 7. Cleanse the skin around the site with mild soap and warm water ...." 9. A home visit observation was conducted on 7/7/21 at 9:56 AM with Patient #2 and Registered Nurse (RN) #1. During the visit, RN #1 was observed placing her tablet on the patient's table without a drape, opened the patient's chart and reviewed, then entered her nursing bag. The RN obtained the patient's temperature, heart rate, and oxygen saturation, retrieved a pair of gloves from her nursing bag, and donned the gloves. After completing the visit, RN #1 wiped her vital sign equipment (thermometer, oxygen saturation monitor, and blood pressure cuff) and stethoscope, then placed the equipment immediately into her nursing bag. The RN failed to keep a barrier between her equipment and the patient's home surface, failed to enter the nursing bag with only clean hands, failed to perform hand hygiene immediately prior to donning gloves, and failed to allow the cleanser used on the equipment to dry prior to placing back in nuring bag. 10. A home visit observation was conducted on 7/13/21 at 09:25 AM with Patient #5 and Hospice Home Aide (HHA) #2. During the visit, HHA #2 was observed washing her hands for 34 seconds then adjusted her surgical face mask and hugged Patient #5's family member immediately prior to donning gloves. The aide then performed a bed bath on Patient #5, and during the bath, HHA #2 changed gloves 4 times with no hand hygiene in between donning and doffing. The aide's mask also sat below the aide's nose for the majority of the bath. During the bath, HHA #2 cleaned around the suprapubic catheter with a washcloth previously used to wash other body areas. The aide cleaned the catheter in downward swiping motions, wiping from farther away from the catheter to closer. The aide assisted the patient in turning on his side, washed the patient's buttocks and rectum, then used the same washcloth to wash the patient's upper leg and hip area. HHA #2 washed her hands with soap and water once during the bath and once afterwards, with a scrub time of 14 seconds and 10 seconds respectively, and the 10 second hand wash was performed under water. HHA #2 failed to perform hand hygiene immediately prior to donning gloves and in between glove changes, failed to ensure her mask was positioned appropriately, failed to perform catheter care appropriately, failed to change out washcloths during the bed bath appropriately, and failed to perform hand washing according to agency policy and best practice. 11. An interview was conducted on 7/14/21 at 9:34 AM with the Vice President of Hospice #1 (VP #1). During the interview, VP #1 indicated all staff supplies should be placed on a drape when in the patient's home, hands should be clean when entering the nursing bag, and cleaned equipment should be allowed to dry prior to placing it back in the nursing bag. The Vice President of Hospice #1 stated the surgical mask should be positioned "over the nose and mouth" of the employee, when washing hands with soap and water, hands should be scrubbed for 60 seconds outside of the running water, and hand hygiene should be performed immediately prior to donning gloves and in between glove changes. VP #1 also indicated catheter care should be performed with a new washcloth, wiping in circular motions from the immediate insertion site of the catheter to the outside. | |||
| L0591 | |||
| 42617 Based on observation, record review, and interview, the Registered Nurse (RN) failed to perform an assessment according to best practice, failed to obtain physician orders prior to adjusting a patient's medication dosage, and failed to notify the patient's medical provider for a change in the patient's condition for 1 of 1 home visit observations of a nurse assessment (#2) and 2 of 8 active records reviewed (#4, 18), in a total sample of 20 records reviewed. Findings include: 1. An agency job description titled "Job Description. Position: RN Case Manager/Registered Nurse," dated 2/1/19, stated " ... Process: Assume primary responsibility for a patient/family caseload that includes the assessing ... phases of the nursing process ...." 2. Sheps, M.D (2/2/2021). "Wrist blood pressure monitors: Are they accurate?" Obtained 7/28/21 from www.mayoclinic.org. " ... To get an accurate reading when taking your blood pressure with a wrist monitor, your arm and wrist must be at heart level ...." 3. A home visit observation was conducted on 7/7/21 at 9:56 AM with Patient #2 (benefit election date 4/17/21) and RN #1. During the visit, RN #1 was observed obtaining the patient's blood pressure using an automated wrist blood pressure monitor. The nurse placed the monitor cuff on the patient's left wrist and had the patient bend his arm at the elbow, resulting in the monitor being above the patient's heart. RN #1 reported the patient's blood pressure reading was "80/65." Later in the visit, the nurse obtained a second blood pressure reading with the patient's wrist still above heart level. The second blood pressure reading was reported by the nurse as "113/45." RN #1 indicated these readings were lower than the patient's baseline blood pressure. During the visit, Patient #2 reported excessive fatigue, stating he was "a lot tired ... I don't get enough sleep," however RN #1 did not ask the patient any follow up questions regarding the patient's concerns. The nurse failed to obtain a blood pressure according to appropriate standards, failed to assess the patient for signs and symptoms of low blood pressure, failed to assess the patient's report of fatigue and difficulty sleeping, and failed to failed to perform an Edmonton Symptom Assessment System (ESAS, a method of symptom assessment which had the patient and/or caregiver rate the degree of distress for the following symptoms: pain, fatigue, nausea and/or vomiting, depression, anxiety, drowsiness, shortness of breath, and appetite. Each symptom was rated from 0-10, with 0 meaning no distress and 10 meaning the most distress possible). 4. The clinical record of Patient #4 was reviewed on 7/9/21 and indicated a benefit election date of 4/21/21 with a terminal diagnosis of hypertensive kidney disease with CHF and related diagnoses including but not limited to: fibromyalgia, chronic pain, osteoarthritis of both knees, epilepsy, and urinary incontinence. The record included a plan of care for the initial certification period 4/21/21 - 7/19/21 which contained service orders for skilled nurse visits 1 visit per week for 1 week, then 2 visits per week for 12 weeks. The plan of care also included orders for the medications: Lasix (Furosemide, diuretic given to decrease excess fluid levels) 40 mg in the morning and 20 mg in the evening, and Norco (Hydrocodone-Acetaminophen, combination of an opioid and Tylenol, given to treat pain) 10-325mg tablet, administer 3 times per day. The record included a "Skilled Nursing Visit Note," documented on 5/12/21 by RN #4, which stated " ... Family and [patient] interested in trying to decrease her pain medicine [Norco] from 10 mg to 7.5mg as she doesn't seem to be [helping] her pain [due to] not moving around as much ...." The record included physician orders, signed by Medical Director #1 and dated 5/13/21, which discontinued the patient's Norco 10-325 mg and started the patient on Norco 7.5-325mg. The clinical record also included a Communication Note dated 5/14/21 which indicated the patient's family called the agency's on-call service to report increased pain and swelling to the patient's lower extremities. The on-call nurse documented she advised Patient #4's family to administer the patient's previous dose of Norco (10-325 mg) and administer a one-time dose of Furosemide 40 mg to aide with the swelling. The clinical record failed to evidence the nurse obtained a physician order for the medication changes. 5. The clinical record of Patient #18 was reviewed on 7/15/21 and indicated a benefit election date of 6/3/21 with a terminal diagnosis of lung cancer with metastasis [spread] to bone and related diagnoses including but not limited to: altered mental status, atrial fibrillation (irregular heart rhythm), hypothyroidism, depression, chronic kidney disease, visual hallucinations, fecal incontinence, history of renal (kidney) cancer, and pressure ulcer to left buttock. The record included a plan of care for the initial certification period of 6/3/21 - 8/31/21 which contained orders for skilled nursing services for 1 visit per week for 13 weeks. The record also included a "Skilled Nursing Visit Note," documented 7/5/21 by RN #6. The nurse visit note stated " ... Wound Assessment and Care ... Right Foot Heel is Reddened, not Open ... Pt declined [dressing], heels elevated ... Narrative Notes ... [RN #6] noted right heel had a small reddened area measuring 0.5cm by 0.5cm. Skin intact. Patient declined having a dressing over the area ...." The clinical record failed to evidence the nurse notified the patient's provider of the new wound. 6. An interview was conducted on 7/14/21 at 9:34 AM with the Vice President of Hospice #1 (VP #1). During the interview, VP #1 indicated when obtaining a patient's blood pressure using a manual wrist monitor, the arm should be positioned "over the [patient's] heart." The vice president reported if a patient's blood pressure was lower than the baseline, the nurse should assess the patient for signs and symptoms of hypotension. VP #1 also indicated if the patient reported excessive fatigue, the nurse should further assess the patient's complaint. 7. An interview was conducted on 7/15/21 at 3:32 PM with the Vice President of Hospice (VP #1). During the interview, VP #1 indicated the nurse should perform an Edmonton Symptom Assessment System during each patient visit, the nurse should notify the patient's medical provider for a change in patient condition, and nurse should obtain a physician order prior to advising the patient to resume a discontinued medication dose or take additional doses of medications. | |||
| L0625 | |||
| 42617 Based on record review and interview, the hospice agency failed to ensure the hospice aide care plan was patient-specific and detailed for 4 of 7 active records reviewed with hospice aide services (#1, 2, 4, 18), in a total sample of 20 records. Findings include: 1. An agency policy titled "Aide Care Plan," policy number C-751 and revised 10/2020, stated " ... Procedure ... 1 ... a plan identifying personal care and supportive care services is prepared by a Registered Nurse [RN] ... 2. The Care Plan shall be developed in plain, non-technical lay terms and identify the duties to be performed such as, but not limited to: Personal care. Ambulation ... 3. ... Aide care plans are developed by the RN with documentation that is clear, complete and addresses the patient's current needs ... identification of the patient's cognitive and functional ability is to be utilized when it is appropriate for the patient to make a choice between multiple types of care, such as a choice between a shower or a sponge bath ...." 2. The clinical record of Patient #1 was reviewed on 7/6/21 and 7/14/21 and indicated a benefit election date of 6/25/21, with the patient's terminal diagnosis indicated as pulmonary fibrosis and related diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease (COPD), intellectual disability, cardiomegaly, anxiety, pressure ulcer to the right ankle, and contractures to the left and right feet. The record included a plan of care for the certification period of 6/25/21 - 8/23/21, which contained an order for hospice aide services for 2 visits per week for 9 weeks. The record also included an "Aide Care Plan" which included the tasks " ... 1. Activity- Assist with positioning, repositioning, alignment ... 11. Hygiene - Bath - Complete ... 12. Hygiene - Bath - Shower ...." The hospice aide care plan failed to evidence patient-specific and detailed tasks related to how the aide was to ambulate the patient and whether the aide was to perform a complete bath or shower for the patient. 3. The clinical record of Patient #2 was reviewed on 7/8/21 and indicated a benefit election date of 4/17/21, with the patient's terminal diagnosis indicated as hypertensive kidney disease (kidney disease caused by high blood pressure) with heart failure (CHF) and related diagnoses including but not limited to: urinary incontinence (inability to control urination), weakness, and history of falls. The record included a plan of care for the recertification period 4/17/21 - 7/15/21, which contained an order for hospice aide services for 2 visits per week for 13 weeks and for the medication "Eliquis [medication used to thin the blood and prevent heart attacks and/or strokes]." The record also included an "Aide Care Plan" which contained the tasks " ... 1. Activity - Assist with transfers ... 5. Safety- Fall precautions ...." The hospice aide care plan failed to evidence patient-specific and detailed tasks related to how the aide was to assist the patient with ambulation and failed to evidence precautions related to the patient's increased risk for bleeding. 4. The clinical record of Patient #4 was reviewed on 7/9/21 and indicated a benefit election date of 4/21/21 with a terminal diagnosis of hypertensive kidney disease with CHF and related diagnoses including but not limited to: fibromyalgia, chronic pain, osteoarthritis of both knees, epilepsy, and urinary incontinence. The record included a plan of care for the initial certification period 4/21/21 - 7/19/21, which included an order for hospice home aide visit for 5 visits per week for 10 weeks, then 1 visit per week for 1 week (family had initially declined aide services, then order was placed on 5/9/21). The record also included an "Aide Care Plan" which contained the tasks " ... Activity- Recognize and report any changes in the patient's skin condition ...." A list of all agency patients with specialized transfer equipment was received on 7/15/21. The list indicated Patient #4 had a "electric lift." The hospice aide care plan failed to evidence patient-specific and detailed description of how the aide was to ambulate the patient. 5. The clinical record of Patient #18 was reviewed on 7/15/21 and indicated a benefit election date of 6/3/21 with a terminal diagnosis of lung cancer with metastasis [spread] to bone and related diagnoses including but not limited to: altered mental status, atrial fibrillation (irregular heart rhythm), hypothyroidism, depression, chronic kidney disease, visual hallucinations, fecal incontinence, history of renal (kidney) cancer, and pressure ulcer to left buttock. The record included a plan of care for the initial certification period of 6/3/21 - 8/31/21. The plan of care included orders for hospice home aide services for 1 visit per week for 1 week, 3 visits per week for 12 weeks, then 1 visit per week for 1 week, and medication orders for " ... Enoxaparin Sodium [Lovenox, medication given to thin blood and decrease the risk for heart attack and/or stroke] 100 mg/ml ... Inject 0.7 milliliter(s) ... every 12 hours ...." The record included an "Aide Care Plan" which contained the tasks " ... Bath - Shower or complete bed bath 1x/week ... Vital Signs - Report patient pain to nurse ... Vital Signs - Weight ...." The aide care plan failed to evidence patient-specific and detailed tasks, including whether the aide was to perform a shower or bed bath, what pain rating the aide was to report to the nurse, what was needing regarding patient weight (obtain weight or something else?). The aide care plan also failed to evidence what tasks the aide was to follow due to due to the patient's increased risk of bleeding. 6. An interview was conducted on 7/15/21 at 3:32 PM with the Vice President of Hospice (VP #1). During the interview, VP #1 indicated the aide care plan should be detailed and patient-specific, and the care plan should include bleeding precautions if the patient was an increased risk for bleeding. | |||
| L0626 | |||
| 42617 Based on observation, record review, and interview, the hospice agency failed to ensure the hospice home aide (HHA) performed tasks only according to the aide care plan and failed to ensure the HHA performed a Hoyer transfer according to the Hoyer's manufacturer's instructions for 1 of 2 home visit observations of a hospice home aide (HHA) performing care (#5) and 4 of 7 active records reviewed with hospice aide services (#1, 3, 4, 5), in a total sample of 20 records. Findings include: 1. An agency policy titled "Aide Services," policy number C-220 and revised 10/2020, stated " ... Policy. 1. Aide Service ... A. Aide Services may include but are not limited to: ... Making observations of the client's condition and reporting the results to the Registered Nurse [RN] ... B. A specific care plan is developed documenting the Aide services to be provided. Aide will not perform that particular task without direct supervision by a RN ... The Aide will follow the care plan and will not initiate new services or discontinue services without contacting the supervising Nurse ...." 2. Bestcare (2017). "Bestlift Full Body Patient Lift. Model: PL500/PL400." Obtained 7/13/21 from www.phc-online.com. " ... During lifting ... always keep the base of the lift in the widest position ... While being lifted in a sling, always keep the user/patient ... facing the caregiver operating the lifter ... Transfer From Bed to Wheelchair ... Once the sling has been positioned centrally, feed the leg sections under the thighs and draw them up between the thighs ...." 3. The clinical record of Patient #1 was reviewed on 7/6/21 and 7/14/21 and indicated a benefit election date of 6/25/21, with the patient's terminal diagnosis indicated as pulmonary fibrosis and related diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease (COPD), intellectual disability, cardiomegaly, anxiety, pressure ulcer to the right ankle, and contractures to the left and right feet. The record included a plan of care for the certification period of 6/25/21 - 8/23/21, which contained an order for hospice aide services for 2 visits per week for 9 weeks. The record included an "Aide Care Plan" which included the tasks " ... 17. Hygiene- Skin care- apply moisturizing lotion ...." The record also included an "Aide Visit Note," documented on 6/28/21 by Hospice Aide (HA) #4, which stated " ... Narrative Note: ... [HA #4] gave [Patient #1] a complete bed bath ... cream applied to her bottom, lotion applied ...." The hospice aide failed to perform tasks only as assigned on the patient's aide care plan. 4. A home visit observation was conducted on 7/8/21 at 11:50 AM with Patient #3 and hospice home aide (HHA) #1. During the visit, HHA #1 asked Patient #3 for the date of her last bowel movement and the patient indicated she had not had a bowel movement (BM) for several days, but could not remember the specific date of her last BM. The aide reported she would notify the patient's RN case manager of the concern. The clinical record of Patient #3 was reviewed on 7/8/21 and 7/15/21, and included an "Aide Visit Note" documented on 7/8/21 by HHA #1. The visit note stated " ... Narrative Notes: ... No BM for a couple days. [Patient #3] did report that to her nurse yesterday ...." The record failed to evidence HHA #1 reported Patient #3 had not had a BM for several days to the patient's nurse consistent with aide training. 5. The clinical record of Patient #4 was reviewed on 7/9/21 and indicated a benefit election date of 4/21/21 with a terminal diagnosis of hypertensive kidney disease with CHF and related diagnoses including but not limited to: fibromyalgia, chronic pain, osteoarthritis of both knees, epilepsy, and urinary incontinence. The record included a plan of care for the initial certification period 4/21/21 - 7/19/21, which included an order for hospice home aide services for 5 visits per week for 10 weeks, then 1 visit per week for 1 week (family had initially declined aide services, then order was placed on 5/9/21). The record included a "Communication Note," documented on 7/12/21 by HHA #3, which stated " ... [HHA #3] put [Patient #4] in wheel chair. When getting pt [patient] sat up pt slide [sic] out of chair. [Aide] assisted pt to ground [HHA #3] also checked pt out no injuries happens [sic] ...." The clinical record failed to evidence HHA #3 notified the patient's nurse of Patient #4's fall consistent with aide training. 6. The clinical record of Patient #5 was reviewed on 7/12/21 and indicated a benefit election date of 6/12/2020 with a terminal diagnosis of "senile degeneration of the brain" and related diagnoses including but not limited to: dementia with behavioral disturbances, CHF, depression, anxiety, urinary incontinence, pressure ulcer, and history of prostate cancer. The record included a plan of care for the recertification period 6/7/21 - 8/5/21, which included an order for hospice home aide services for 2 visits per week for 9 weeks. The record also included an "Aide Care Plan" which indicated the aide tasks to be performed were " ... Empty Foley catheter every visit ... Incontinent Care every visit ... Clean bathroom after patient care every visit ... Clean living area of the patient every visit ... Assist patient with dressing after personal care every visit ... Bath - Bed each visit ...." A home visit observation was conducted on 7/13/21at 09:25 AM with Patient #5 and HHA #2. During the visit, HHA #2 was observed applying calmoseptine lotion (thick lotion used as barrier for moisture) to the patient's rectum, inner buttocks, and scrotum. After completing the patient's bath, HHA #2 was observed shaving Patient #2's face and neck using an electric razor. The aide then transferred the patient using an electric Best Care 500 Hoyer lift. The aide placed the Hoyer sling underneath the patient, connected the sling straps to the lift bar with the leg straps connected to the closest hook, raised the patient up out of the bed with the Hoyer legs closed, and transferred the patient positioned facing to the side of aide. HHA #2 failed to follow the aide care plan by completing tasks not on the care plan and failed to transfer the patient with a Hoyer lift according to the manufacturer's instructions (sling leg straps not placed underneath the patient's thighs or connected to the opposite hook, the lift base was not open when lifting the patient, and the patient was not positioned facing the aide when transferring). 7. An interview was conducted on 7/14/21 at 9:34 AM with the Vice President of Hospice #1 (VP #1). During the interview, VP #1 indicated a patient transfer with a Hoyer lift should be performed according to the specific Hoyer's manufacturer's instructions. 8. An interview was conducted on 7/15/21 at 3:32 PM with the Vice President of Hospice (VP #1). During the interview, VP #1 indicated the aide should perform tasks only included on the aide care plan. | |||