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
331512 A. BUILDING __________
B. WING ______________
06/25/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HOSPICARE & PALLIATIVE CARE SERVICES 172 EAST KING ROAD, ITHACA, NY, 14850
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0545      
16327 Based on a review of clinical records, and interviews with the Director of Patient Services (DPS) and Associate Director of Patient Services (ADPS), it was determined in 5 out of 7 clinical records (patients #1, 2, 5, 6 and 7) the plans of care were incomplete and failed to reflect all of the patient's needs. Evidence as follows: 1. Patient #1, was admitted to the hospice and hospice residence on 05/05/21, with diagnoses of esophageal cancer and abnormal weight loss. The interdisciplinary plan of care was incomplete as follows: The 05/05/21 Hospice Certification and Plan of Care included: - Glucerna 1.2 cal, infuse 60 ml/hour continuous by gastrostomy tube: Administer 240 milliliters by gastrostomy tube every 4 hours if no feeding pump available. - Assess nutritional status including dietary habits, ability to swallow, knowledge and compliance with diet. On 05/05/21 the residence hospice nurse (RHN) documented the patient stated he takes no food or drink by mouth (NPO). On 05/06/21 at 9:10 a.m. the RHN documented the patient tolerated 150 ml. of Glucerna via g-tube then became restless and did not want to finish, and at 1:05 p.m. the RHN documented the patient tolerated approximately 200 ml. of Glucerna then became uncomfortable. The RHN failed to update the plan of care to include directions for reporting when the patient is unable to tolerate feedings. On 05/07/21 at 6:55 a.m. the RHN documented "coffee started so patient could swish and spit." The Hospice plan of care did not include this intervention, and there was no indication that this was discussed with the IDG or attending physician. On 05/07/21, the RHN offered the patient feedings every 4 hours begining at 1 p.m. Each time the RHN offered the feedings using the pump, the patient refused and by the 8 pm feeding the patient became agitated when the pump was mentioned. On 05/08/21 at 6:25 a.m. the RHN documented the patient asked whether he could eat and swallow, the RHN reminded him he had been swishing and spitting coffee or ginger ale. The HN failed to update the plan of care. Throughout the months of May and June the RHN progress notes document the patient continued to receive bolus feedings via g-tube at his request/acceptance, and food and beverages to swish and spit. On 06/09/21 the surveyor interviewed the RHN present at the residence and inquired about the patient's nutritional intake. The RHN stated that since his admission the patient refused to use the pump and only allowed bolus feeds. The surveyor noted the patient had root beer at bedside, the RHN stated that the patient was unable to swallow but liked to swish and spit beverages. On 06/14/21 at 5:30 p.m. the surveyor interviewed a RHN who stated that the patient 'was in total control of his intake," and dictated when and how much he wanted to be fed. The Hospice plan of care failed to include directions that the patient could swish and spit beverages, or that he was able to limit when he accepted his feedings and failed to indicate that he only accepted bolus feeding not feeding by pump. On 06/18/21 at 9 a.m. the above findings were reviewed with the Administrator and DPS who acknowledged the findings and provided no additional information. 2. Patient #2 was admitted to the agency and hospice residence on 12/11/21 with diagnoses of abnormal weight loss and age-related physical disability. The interdisciplinary plan of care was incomplete as follows: Review of the patient's medical record from 03/01/21 through 06/11/21 revealed that on more than 30 occasions (including 03/12, 03/16, 03/17, 03/20, 03/21, 03/25, 04/03, 04/20, 04/21, 04/23, 04/30, 05/03, 05/04, 05/06, 05/11, 05/12, 05/16, 05/17, 05/19, 05/20, 05/21, 05/28, 05/30, 05/31, 06/03-10/21) warm rice packs were applied by the RHN or HHA to the patients hands, feet, knees, hip, thigh, and/or shoulder. The interdisciplinary care plan failed to include any intervention for applying warm packs. On 06/18/21 at 9 a.m. the above findings were reviewed with the Administrator and DPS who acknowledged the findings and provided no additional information. 3. Patient # 7 was admitted to the hospice on 05/17/21 with a primary diagnosis of lung cancer. The 05/17/21 Hospice Certification and Plan of Care, and ongoing IDT care plan, failed to address all patient needs as follows: Wound Care On 06/09/21 the hospice nurse (HN) visited the patient and documented the patient had a stage I decubitus ulcer to gluteal fold measuring 2 cm x 1.5 cm and the patient was using a protective ointment. The HN failed to update the 05/17/21 plan of care to include the frequency of wound care, person responsible to preform, cleansing agent, type of ointment to apply and type of dressing if needed. Additionally, the HN documented a gel cushion seat was ordered, however, the HN failed to update the plan of care to include a plan for using the gel cushion. Pain Management On 06/09/21 the HN documented in the visit note the patient was using a heat pack to the left torso for pain management. The patient stated it was one of the preferred measures she used to alleviate pain. The HN failed to update the plan of care to include a plan for using a heat pack for pain management. On 06/18/21 at 09:30 AM the record was reviewed with the DPS and ADPS. They acknowledged the findings and provided no additional information. 4. Patient # 6 was admitted to the hospice on 09/28/20 with a primary diagnosis of stage IV gangrenous pressure ulcer to the left medial and outer heel. The 05/26/21 Hospice Certification and Plan of Care, and ongoing IDT care plan, failed to address all patient needs as follows: On 05/21/21 the hospice physician documented in the hospice recertification assessment note the wound to the left foot was fully healed, but now had re-opened, and on 06/03/21 the HN visited the patient and documented the patient's care giver reported the patient was agitated one night and was rubbing his heels on the bed causing the wound to re-open. The plan of care dated 05/26/21 failed to include a plan/intervention for heel protection to prevent re-opening and/or development of pressure ulcer to lower extremities. On 06/18/21 at 09:30 AM the record was reviewed with the DPS and ADPS. They acknowledged the findings and provided no additional information. 5. Patient # 5 was admitted to the hospice on 03/15/19 with diagnoses of chronic obstructive pulmonary disease, congestive heart failure and severe peripheral edema. The hospice plan of care was not updated to include the following: - wound care orders for a new lower abdominal abscess. - On 05/27/21, at 12:15 pm the licensed practical nurse (LPN) visited the patient and identified a "small mass on lower abdomen, area hart to touch, serosangunous drainage foul oder" - On 05/27/21, at 3:00 pm, the hospice nurse visited the patient and documented that the patient's "medial genital-urinary Pubic area abscess measured 3 cm by 2 cm, with purulent exudate and a foul odor" The wound care was described as cleanse with wound cleanser using a gauze. In the narrative section, the wound is described as ping-pong ball size, near his pubic bone, is red raised and draining purulent drainage. The hospice nurse doucmented that the family was able to "squeeze out" some drainage yesterday and have been using warm compress and antibiotic ointment. The hospice nurse also "extracted some exudate" at the visit and recommented they use warm compress more often to keep the abscess open. The HN documented a call to the primary care provider(PCP) to obtain a course of antibiotics. Although the hospice nurse contacted the PCP, there is no evidence the physician ordered wound care, wound cleansing or directed the HN to extract exudate or have the family squeeze the abscess to remove exudate. On 06/02/21 the HN visited the patient and documented instructing the patient in wound care. The record failed to contain an updated wound care plan. The HN documented the abscess was the same size but, more firm, and appears infuriated, and had minimal drainage when the HN "squeezed" the absess. They continue to use warm compress on it for which there is no odor, and no documentaiton of the application of a dressing to contain the drainage. On 06/18/21, the above findings were reviewed with the DPS and ADPS, they acknowledged the finding and provided no additional information. Failure to develop complete and accurate plans of care has the potential for unmet patient needs and negative patient outcomes.
L0547      
16327 Based on a review of clinical records, and interviews with the Director of Patient Services (DPS) and Associate Director of Patient Services (ADPS), it was determined in 7 out of 7 clinical records (patients # 1, 2, 3, 4, 5, 6 and 7) the plan of care failed to appropriately specify the frequency of visits necessary to meet the needs of the patients. Evidence as follows: 1. Patient #1, was admitted to the agency and the hospice residence on 05/05/21 with diagnoses of esophageal cancer and abnormal weight loss. The 05/05/21 Hospice Certification and Plan of Care included: - skilled nursing 3-5 times per month for 3 months, and 7 as needed (PRN) visits for status change. The range of visits was not based on the needs of the patient, was vague does not give the patient a sense of when the hospice nurse will visit. The visit frequency does not take into account that the patient resides in the hospice residence where a registered nurse providing care 24 hours a day. 2. Patient #2 was admitted to the agency and the hospice residence on 12/11/21 with diagnoses of abnormal weight loss and age-related physical disability. The 03/11-06/08/11 Hospice Certification and Plan of Care included: - skilled nursing 2-5 times per month for 4 months, and 15 as needed (PRN) visits, for symptom management, medication management, falls/injury, death. The range of visits was not based on the needs of the patient, was vague does not give the patient a sense of when the hospice nurse will visit. The visit frequency does not take into account that the patient resides in the hospice residence where a registered nurse providing care 24 hours a day. 3. Patient # 6 was admitted to the hospice on 09/28/20 with a primary diagnosis of stage IV gangrenous pressure ulcer to the left medial and outer heel. The plan of care failed to specify the frequency of visits necessary to meet the needs of the patients follows: The 05/26/21-07/24/21 Hospice Certification and Plan of Care included: skilled nursing 2-4 times per month for 3 months, and 5 as needed (PRN) visits, for symptom management, medication management, falls/injury, death. The range of visits was not based on the needs of the patient, was vague does not give the patient a sense of when the hospice nurse will visit. 4. Patient # 7 was admitted to the hospice on 05/17/21 with a primary diagnosis of lung cancer. The plan of care included a wide range of nursing visits per month and failed to specify the frequency of visits necessary to meet the needs of the patient as follows: The 05/17/21-08/14/21 Hospice Certification and Plan of Care included: skilled nursing 2-4 times per month for 4 months, and 6 as needed (PRN) visits, for symptom management, medication management, falls/injury, death. The range of visits was not based on the needs of the patient, was vague does not give the patient a sense of when the hospice nurse will visit. On 06/25/21 this finding was reviewed with the DPS who acknowledged the finding and provided no additional information. 5. Patient #4 was admitted to the hospice on 05/19/21 with primary diagnoses of Chronic Obstructive Pulmonary Disease and age related debility. The 05/19/21 to 08/16/21 Hospice Certification and Plan of Care included SN visits 2 - 5 times per month for 3 months; 1-2 times a month for 1 month and 10 as needed visits (PRN) for changes in condition. The range of visits was not based on the needs of the patient, was vague does not give the patient a sense of when the hospice nurse will visit. 6. Patient # 5 was admitted to the hospice on 03/15/19 with diagnoses of chronic obstructive pulmonary disease, congestive heart failure and severe peripheral edema. The 05/03/21 to 07/01/21 Hospice Certification and Plan of Care contained SN visits 3-5 times a month for 2 months and 7 PRN visits for status change and SN 1 visit a week for 3 months beginning 05/11/21 to 07/03. There was no explanation for the second set of SN visits beginning 05/11/21. The plan had no frequency for LPN visits conducted weekly to pre-pour medications. The range of visits was not based on the patients needs, were vague and failed to give the patient a plan for visits. Additionally this patient had a wound on the buttocks covered with Duoderm to be changed every 7 days and as needed for soiling and dislodging, the plan doesn't specify that the SN will change the Duoderm weekly. 7. Patient # 3 was admitted to the hospice on 10/14/20 with diagnoses of malignant neoplasm of the esophagus, abnormal weight loss and age related physical debility. The 04/12/21 to 06/10/21 Hospice Certification and plan of care included SN visit frequencies that were unclear and failed to identify the patient's needs. Skilled Nursing (SN) 5 visits a week for 3 months beginning week of 04/12/21 to 06/10/21. Skilled Nursing visits 1 to 2 visits per month and 3 as needed visits 4/14/21 to 04/30/21 Skilled nursing visits 2-4 visits per month for 2 months and for PRN visits 04/20/21 to 05/31/21 Aide 5 visits a week for 2 months beginning 04/16/21 to 05/31/21 Medical Social Worker 1-2 visits per month for 3 months and 2 PRN visits for additional emotional support 04/12/21 to 06/10/21. The plan of care and IDT care plan include interventions assigned to the SN, but failed to indicate if the tasks and interventions are the responsible for the Registered Nurse (RN) or the Licensed Practical Nurse (LPN). The interventions include assess the condition of the gastrostomy tube (G-tube) site 2-5 times a month assigned to the SN. Based on the NYS Nurse Practice Act, LPNs are prohibited from conducting assessments. It is unclear if the LPN is visiting 5 days per week or the the RN is visiting 5 days per week, and the plan doesn't specify interventions to be completed by the SN 5 days a week. On 06/25/21, the findings in patient records #3, 4, and 5 were reviewed with the DPS who acknowledged the findings and provided no additional information. Failure to ensure the plans of care include scope and frequency of visits according to the patient's needs has the potential for unmet patient needs and possible negative patient outcomes.
L0552      
16327 Based on a review of clinical records, and interviews with the Director of Patient Services (DPS) and Associate Director of Patient Services (ADPS), it was determined in # 4 out of 7 clinical records (patients # 1, 2, 4 and 5) the interdisciplinary group (IDG) failed to review and revise patient plans of care during IDG meetings and as the patient's condition changed. Evidence as follows: 1. Patient #1 was admitted to the hospice and the hospice residence on 05/05/21 with diagnoses of esophageal cancer and abnormal weight loss. The IDG failed to review and revise the individualized plan of care during IDG meetings and as the patient's condition changed. On 05/05/21 the primary hospice nurse (PHN) visited the patient and documented the patient had difficulty swallowing secondary to esophageal cancer and had a gastrostomy tube (g-tube) for tube feeding, fluids and medication administration. The HN did not document whether the patient was able to take any food or fluids by mouth The 05/05/21 Hospice Certification and Plan of Care included: - Glucerna 1.2 cal, infuse 60 ml/hour continuous by gastrostomy tube: Administer 240 milliliters by gastrostomy tube every 4 hours if no feeding pump available. - Assess nutritional status including dietary habits, ability to swallow, knowledge and compliance with diet. On 05/05/21 the residence hospice nurse (RHN) documented the patient stated he takes no food or drink by mouth (NPO). On 05/06/21 at 9:10 a.m. the RHN documented the patient tolerated 150 ml. of Glucerna via g-tube then became restless and did not want to finish, and at 1:05 p.m. the RHN documented the patient tolerated approximately 200 ml. of Glucerna then became uncomfortable. On 05/07/21 at 6:55 a.m. the RHN documented "coffee started so patient could swish and spit." On 05/07/21 at 1 p.m. the RHN documented the patient would accept tube feeding but did not want pump hooked up, at 5 p.m. the patient declined feeding and stated he did not want it from the pump, at 6 p.m. patient informed the RHN he would accept his feeding at 8 p.m., at 8:15 p.m. he accepted a bolus feeding and became agitated when the RHN mentioned the pump was present and set up. On 05/08/21 at 6:25 a.m. the RHN documented the patient asked whether he could eat and swallow, the RHN reminded him he had been swishing and spitting coffee or ginger ale. On 05/10/21 the primary hospice nurse (PHN) visited the patient and documented the patient had pain / difficulty swallowing and was accepting two to four of his six scheduled feeding tube boluses over the last three days. Throughout the months of May and June the RHN progress notes document the patient continued to receive bolus feedings via g-tube at his request/acceptance, and food and beverages to swish and spit. On 06/14/21 at 5:30 p.m. the surveyor interviewed a RHN who stated that the patient 'was in total control of his intake," and dictated when and how much he wanted to be fed. On 06/16/21 the surveyor requested, received, and reviewed agency policies pertaining to the interdisciplinary group (IDG). Policy Number: PC.I55 stated: The IDG is responsible for: a. establishing, implementing, reviewing and revising the patient's plan of care; b. providing or coordinating care and services in accordance with the patient's plan of care; IDG notes: On 05/06/21 the IDG note documented the patient's current status and admission, medications and plan of care was reviewed. On 05/13/21 the IDG note included the IDG reviewed the patient's status, medications and plan of care. Visit notes from the PHN on 05/05 and 05/10, the MSW on 05/07 and volunteer on 05/06 were duplicated in the IDT notes. On 05/20/21 the IDT note included, "reviewed patient's current status and any changes of medications and Plan of Care, if any." The same visit notes from the 05/13 IDT meeting (the PHN on 05/10 and, the MSW on 05/07/21 and volunteer on 05/06/21) were duplicated in the 05/20 IDT notes. On 05/27/21 the IDG note documented the patient's current status and admission, medications and plan of care was reviewed. "Patient has moved to Hospicare residence and seems to be adapting well. PN plans to remove staples in his head tomorrow." It does not seem this note is applicable to the patient. This IDT note included duplicated visit notes from the chaplain on 05/21, PHN on 05/17 and MSW on 05/20. During each IDG meeting noted above, the team failed to sufficiently review the plan of care to: - determine the patient's tube feedings were not consistent with the plan of care - did not include interventions to accommodate the patient's difficulty tolerating full feedings or pleasure feed at patient's request - did not include whether the patient was able to have food and beverages by mouth, was NPO, or could chew/swish and spit food and beverages On 06/18/21 at 9 a.m. the above findings were reviewed with the Administrator and DPS who acknowledged the findings and provided no additional information. 2. Patient #2 was admitted to the hospice and the hospice residence on 12/11/21 with diagnoses of abnormal weight loss and age-related physical disability. The IDG failed to review and revise the individualized plan of care during IDG meetings and as the patient's condition changed. The 03/11-06/08/11 Hospice Certification and Plan of Care included: - skin breakdown prevention - bag balm topical ointment, apply topically 2 times per day as needed for skin redness/breakdown (location unspecified). On 03/18/21 at 10:45 a.m. the hospice residence nurse (HRN) documented the patient had a red area on left buttock with small fluid filled blister, bag balm applied. On 03/19/21 the HRN documented buttocks were red and blanchable with a stage 2 (pressure ulcer) located on patient's left buttock approximately 0.5 cm in circular diameter. On 03/19/21 the primary hospice nurse (PHN) documented receiving report from HRN regarding new wound on left buttock. A verbal order was obtained from the hospice medical director for: "Wound care: left buttock blister. Cleanse with soap/water. Rinse. Pat dry. Apply Optifoam. Change dressing every 3 days and as needed if soiled/removed." On 03/23/21 at 2 p.m. the PHN documented receiving update on wound from RHN that wound was improved and open to air, would like order for bag balm. Order received and profile updated. A verbal order was obtained from the hospice medical director to discontinue above stated wound care to left buttock blister. On 06/09/21 the surveyor reviewed the IDG care plan and noted the above wound care intervention added to the plan on 03/19/21 remained on the plan. From 03/23/21, when the hospice medical director ordered wound care to be discontinued, through 06/09/21, the IDG failed to review the plan of care to determine the interventions were not consistent with the current orders. On 06/18/21 at 9 a.m. the above findings were reviewed with the Administrator and DPS who acknowledged the findings and provided no additional information. 3. Patient # 5 was admitted to the hospice on 03/15/19 with diagnoses of chronic obstructive pulmonary disease, congestive heart failure and severe peripheral edema. There was no evidence the hospice plan of care (including interventions) was reviewed at IDG meetings despite changes in patient's condition identified during comprehensive and as needed visits: - On 05/27/21, at 3:00 pm, the hospice nurse visited the patient and documented that the patient's "medial genital-urinary Pubic area abscess measured 3 cm by 2 cm, with purulent exudate and a foul odor" The wound care was described as cleanse with wound cleanser using a gauze. In the narrative section, the wound is described as ping-pong ball size, near his pubic bone, is red raised and draining purulent drainage. The hospice nurse documented that the family was able to "squeeze out" some drainage yesterday and have been using warm compress and antibiotic ointment. The hospice nurse also "extracted some exudate" at the visit and recommenced they use warm compress more often to keep the abscess open. The HN documented a call to the primary care provider(PCP) to obtain a course of antibiotics. Although the hospice nurse contacted the PCP, there is no evidence the physician ordered wound care, wound cleansing or directed the HN to extract exudate or have the family squeeze the abscess to remove exudate. On 06/02/21 the HN visited the patient and documented instructing the patient in wound care. The record failed to contain an updated wound care plan. The HN documented the abscess was the same size but, more firm, and appears infuriated, and had minimal drainage when the HN "squeezed" the abscess. They continue to use warm compress on it for which there is no odor, and no documentation of the application of a dressing to contain the drainage. On 06/03/21, the IDG met and documented in the IDG Conference Communication note, the presence of the abscess, and described the wound as red, raised, draining purulent drainage, and that antibiotics were prescribed. The documentation failed to include any discussion of the current interventions for the abscess, including the hospice nurse squeezing the abscess to remove exudate as documented in the narrative note dated 06/02/21, or direction for the family to use warm compresses and a frequency for use or if there was a dressing in place to collect the "purulent drainage". The IDG Conference Communication note included narrative notes from the hospice nurse dated 05/28/21 and 06/03/21 and social worker dated 05/24/21. The narrative notes included issues regarding the abscess and the patient's 4+ lower extremity edema not responding to Lasix. There was no discussion regarding the patient's buttocks would that requires Duoderm dressing changes weekly, or interventions regarding the severe lower extremity edema. In fact that was no documentation of whether the current interventions were effective or ineffective. On 06/18/21 the above findings were reviewed with the DPS and ADPS, they acknowledged the finding but provided no additional information was provided. 4. Patient #4 was admitted to the hospice on 05/19/21 with primary diagnoses of Chronic Obstructive Pulmonary Disease and age related debility. The 05/19/21 to 08/16/21 Hospice Certification and Plan of Care included SN visits 2 - 5 times per month for 3 months; 1-2 times a month for 1 month and 10 as needed visits (PRN) for changes in condition. The initial IDG meeting completed on 05/27/21 failed to include a review of all interventions and patient needs. On 05/19/21, the hospice nurse documented that the patient requested a home health aide in the morning to assist with personal care and activities of daily living. The HN documented there was no aide available. There was no evidence that the need for a home health aide was reviewed during the IDG meeting or that the patient required assistance with ADLs. On 06/10/21, the IDG team met and although the documented that there would need to be a meeting with the family to discuss increased caregiving needs, there was no discussion or review of interventions related to personal care or HHA services. On 06/18/21 the findings were reviewed with the DPS and ADPS. The acknowledged the findings and provided no additional information. Failure to ensure that the IDG reviews and revises the plan of care has the potential for unmet patient needs and negative patient outcomes.
L0555      
41478 Based on a review of clinical records, and interviews with the Director of Patient Services (DPS) and Associate Director of Patient Services (ADPS), it was determined in # 2 out of 7 clinical records (patients # 1, and 6) the hospice failed coordinate care and services to ensure review and revision of the IDG care plan was completed and documented to ensure that care and services were provided in accordance with the interventions in the IDG plan of care. Evidence as follows: 1. Patient #1, was admitted to the hospice and the hospice residence on 05/05/21 with diagnoses of esophageal cancer and abnormal weight loss. The interdisciplinary team (IDT) failed to coordinate the patient's care as follows: The 05/05/21 Hospice Certification and Plan of Care included: - Glucerna 1.2 cal, infuse 60 ml/hour continuous by gastrostomy tube: Administer 240 milliliters by gastrostomy tube every 4 hours if no feeding pump available. - Assess nutritional status including dietary habits, ability to swallow, knowledge and compliance with diet. From 05/05/21 to 06/09/21 the residence hospice nurses (RHN) documented the patient refused to use the pump for feeding, received bolus feedings via g-tube at his request/acceptance, and food and beverages to swish and spit. There was no documentation of care coordination, or communication between the hospice residence nurse and the IDG to ensure services are provided as outlined in the plan of care or the plan of care is reviewed and revised with changes (see L545 and L 552 for details). There was no evidence of communication between the residence hospice nurse and the IDG regarding the patient's tube feedings or food and beverages by mouth. On 06/18/21 at 9 a.m. the above findings were reviewed with the Administrator and DPS who acknowledged the findings and provided no additional information. 2. Patient # 6 was admitted to the hospice on 09/28/20 with a primary diagnosis of stage IV gangrenous pressure ulcer to the left medial and outer heel. The interdisciplinary group (IDG) failed to coordinate the patient's care as follows: On 04/25/21 the HN documented in the communication notes a late entry for 04/19/21. The note included the patient's wound to the left heel was closed, but dressing remains in place for protection. On 05/22/21 the hospice physician documented the patients wound had re-opened. On 06/03/21 the HN visited the patient and documented the care giver reported the wound re-opened following an episode of agitation, due to the patient rubbing heels on the bed. The patient record included IDG meeting notes held on 04/07/21, 04/21/21, 05/05/21, 05/19/21 and 06/02/21. Although the notes included a report of the wound healing and re-opening as documented above; there was no evidence the IDG discussed and coordinated an individualized plan of care with interventions, including the application of a dressing to provide protection to vulnerable areas such as the closed heel wound and prevent development of new pressure ulcers/skin integrity breakdown. On 06/18/21 at 09:30 AM the record was reviewed with the DPS and ADPS. They acknowledged the findings and provided no additional information. Failure to ensure IDG coordination and appropriate implementation of the plan of care has the potential for unmet patient needs.
L0625      
16327 Based on review of clinical records for patients receiving hospice aide (HHA) services and interviews with the Director of Patient Services (DPS) and Associate Director of Patient Services (ADPS), it was determined in 3 of 4 records (patients # 1, 2, and 6) of patients receiving aide services (patients 1, 2, 6, and 7), that aide written instructions were incomplete and/or inaccurate. Evidence as follows: 1. Patient # 6 was admitted to the hospice on 09/28/20 with a primary diagnosis of stage IV gangrenous pressure ulcer to the left medial and outer heel. The 05/26/21 plan of care included Home Health Aide (HHA)/Licensed Practical Nurse (LPN) service for personal care 3 days per week for 1 hour per visit. The aide plan of care was incomplete or inaccurate as follows: Skin Care The Aide Care Plan instructed the HHA/LPN to change adult brief and perform incontinence care daily as needed. The HN failed to specify the type of care to be provided including cleansing agents and/or topical skin care products for skin protection. Additionally, there were no special instructions for signs and symptoms of skin breakdown the HHA/LPN was to observe for and report to the HN. Wound Care The 05/26/21-07/24/21 Hospice Certification and Plan of Care included the following wound care order: cleanse left heel wound with wound cleanser or sterile water, apply Neosporin and Vaseline gauze gently and evenly, cover with gauze, wrap with rolled gauze, adhere with tape. To be changed by Hospice LPN on Thursday and Tuesday. Changed by PCG every other day and as needed for excess drainage. The HHA/LPN 05/26/21 care plan included the following wound care order: Cleanse left heel wound with wound cleanser or sterile water, apply Santyl gently and evenly, cover with Telfa, apply heel cup, wrap with cling. May also be wrapped loosely with ace wrap. To be changed daily. The HN failed to update or clarify the aide care plan with the current wound care order as per the 05/26/21 Hospice Certification and Plan of Care. Additionally, the HN failed to specify in the aide care plan that wound care was to be provided by LPN or patient care giver as complex wound care is beyond the scope of practice for the HHA as identified in the Home Health Aide Scope of Tasks Guide to Home Health Aide Training and Competency and Permissible and Non-Permissible Activities Home Health Aide Services 2006. On 06/18/21 at 09:30 AM the record was reviewed with the DPS and ADPS who acknowledged the findings and provided no additional information. 2. Patient #1 was admitted to the agency and hospice residence on on 05/05/21 with diagnoses of esophageal cancer and abnormal weight loss. The aide written instruction were incomplete or inaccurate as follows: The 05/05/21 plan of care included residence staff responsible for all patient care needs 24/7, and that the patient received nourishment through a gastrostomy tube (g-tube). Bathing: The aide care plan included instructions for a shower/complete bed bath at least every 7 days but as often as daily per patient preference. The aide care plan failed to include instructions for partial bath when full bath was not complete and did not include special instructions for bathing around the g-tube site. Diet The aide care plan failed to include whether or not the patient was able to have any food or beverage by mouth. On 06/18/21 at 9 a.m. the record was reviewed with the DPS and ADPS who acknowledged the findings and provided no additional information. 3. Patient #2 was admitted to the agency and hospice residence on 12/11/21 with diagnoses of abnormal weight loss and age-related physical disability. The Hospice Nurse (HN) failed to provide the HHA with complete and/or accurate written instructions as follows: The 05/05/21 plan of care included residence staff responsible for all patient care needs 24/7. Bathing: The aide care plan included instructions for a complete bath and failed to specify type of bath (e.g. tub, shower, bed). Application of Heat: Review of visit notes from 03/01/21 - 06/01/21 revealed that on at least 13 occasions (03/12, 03/15, 03/16, 03/20, 03/25, 04/20, 04/23, 04/29, 05/17, 05/21, 05/28, 05/31 and 06/01/21) the aide documented application of warm rice packs. The aide care plan failed to include any instruction related to application of heat. On 06/18/21 at 9 a.m. the record was reviewed with the DPS and ADPS who acknowledged the findings and provided no additional information. Failure of the hospice to ensure aide plans of care include specific assignments and instructions necessary to provide care has the potential for unmet patient needs and possible negative patient outcomes.