Survey Report for 391572

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
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	391572	A. BUILDING __________ B. WING ______________	07/01/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
RESIDENTIAL HEALTHCARE OF NE PA, LLC	50 GLENMAURA NATIONAL BLVD SUITE 202, MOOSIC, PA, 18507
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE		TITLE	(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID PREFIX TAG	SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
L0520
L0520	19122 Based on a review of hospice policies/procedures, clinical records and the National Pressure Ulcer Advisory Panel pressure wound staging guidelines, and based on interview with hospice staff and the administrator, the hospice failed to ensure the hospice failed to ensure wound assessment was completed within 5 days of the election of hospice care (L523) and the hospice failed to ensure the updated comprehensive assessment included an assessment of wound status (L533). This condition was not met based on non-compliance with above standards, and the nature and severity of the deficient practices. The cumulative effects of these deficient practices resulted in the agency's inability to ensure the health and safety of patients and resulted in Immediate Jeopardy. § 484.54(b) TIMEFRAME FOR COMPLETION OF ASSESSMENT (L523) § 484.54(d) UPDATE OF COMPREHENSIVE ASSESSMENT (L533) On June 30, 2020 at 8:13 AM, Immediate Jeopardy was identified. The agency was notified that Immediate Jeopardy was identified on June 30, 2020 at 10:18 AM and the Immediate Jeopardy Templates were provided to entity on June 30, 2010 at 12:21 PM. The hospice submitted a plan to abate Immediate Jeopardy on June 30, 2020 at 4:20 PM which was not accepted. The hospice submitted a plan to abate Immediate Jeopardy on June 30, 2020 at 5:54 PM which was not accepted. The hospice submitted a plan to abate Immediate Jeopardy on July 1, 2020 at 9:59 AM and the plan was accepted on July 1, 2020 at 10:18 AM with implementation of the abatement plan of correction.
L0523
L0523	19122 Based on review of hospice policies/procedures, documentation, clinical records and the National Pressure Ulcer Advisory Panel pressure wound staging guidelines, and based on interview with a hospice registered nurse (employee #9) and the administrator, the hospice failed to ensure wound assessment was completed within 5 days of the election of hospice care for two (2) of four (4) patients for whom wound care orders were included on the initial hospice certification/plan of care. (Patients #1 and #4) Findings include: On June 24, 2020 at approximately 3:10 PM, review of the hospice policy titled "Comprehensive Assessment" revealed the following: "Policy...A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care... Procedure... 2. During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient's clinical record, including at least the following information as relevant...G. A physical assessment, including...skin and other pertinent physical findings... 6. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patient's condition requires but at a minimum of every 15 days...C. If there has been a change in the patient's condition/status, then the comprehensive assessment must be updated..." On June 24, 2020 at approximately 3:16 PM, review of the hospice policy titled "Palliative Wound Care" revealed the following: "Key Points... 2. Symptoms of wounds patients find the most distressing include: a. Odor... b. Bleeding... Procedure...3. Using standard precautions, assess the wound using Wound Assessment procedures... Document According to Agency Policy... 1. Document in the patient's medical record... b. Wound assessment data. c. Plan of Care and its effectiveness of meeting goals. d. Communications with interdisciplinary team. 2. Adjust plan of care as appropriate and communicate changes per agency policy." On June 24, 2020 at approximately 3:24 PM, review of the agency policy titled "Assessment: Wound" revealed the following under "Key Points": 3. Basic wound assessment for all wounds includes... d. Dimensions: 1. Length, width and depth. 2. Presence of tunneling or undermining. (wound area/pocket below the skin). 3. Shape. e. Wound bed tissue: 1. Granulation (new) tissue. 2. Clean, not healing tissue. 3. Slough. (layer of dead tissue) 4. Eschar. (dry, dead tissue) f. Wound edges: 1. Attached. 2. Rolled. 3. Epithelialization. (healing) g. Surrounding skin: 1. Condition. 2. Signs of infection. h. Drainage: 1. Amount. 2. Color. 3. Consistency. 4. Odor. i. Pain: 1. Level of pain. 2. Intermittent or constant... 4. Certain types of wounds require further assessment and documentation: a. Pressure injuries require staging... 5. Wounds and patients change, therefore wounds need to be reassessed regularly and treated according to the changing needs of the patient and the wound: a. In home care, a professional reassessment of most wounds is indicated at least once a week. b. Reassessment and documentation of the wound should include: 1. Wound measurements. 2. Wound bed description. 3. Clinical evaluation of the wound progress: a. Healing. b. No progress. c. Deterioration. c. The wound care plan must be modified as the wound changes. 6. In some patients, notably hospice/palliative care patients, the goal is not wound healing but wound management... Supporting Evidence...National Pressure Ulcer Advisory Panel..." On June 24, 2020 at approximately 3:34 PM, review of the National Pressure Ulcer Advisory Panel pressure wound staging guidelines revealed the following: "Stage 2...Partial-thickness skin loss with exposed dermis (layer of tissue below the skin). The wound bed is viable (healing), pink or red, moist, and may also present as an intact or ruptured serum-filled (fluid) blister... Stage 3...Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue (formation of new tissue/blood vessels during the healing process) and epibole (rolled wound edges) are often present... Unstageable...Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (dead tissue)..." Patient #1: PRE-HOSPICE ADMISSION FINDINGS: On June 9, 2020 at approximately 1:41 PM and June 11, 2020 at approximately 10:48 PM, review of the home health (HH) clinical record revealed HH services were provided by the HH agency which is part of the same limited liability company as the hospice. Skilled nursing (SN) documentation revealed the final home health visit was performed on 04/15/2020 as documented on the discharge "Visit Note Report" dated 04/16/2020. Physician order documentation dated 04/17/2020 revealed the patient was discharged from home health services as the patient was being admitted to hospice services at family request. HH "Visit Note Report" and "Wound Record Report" documentation revealed the following wounds were present during the final HH SN visit which was performed on 04/15/2020: -Wound #2 (left buttock wound): Onset date 02/11/2020. The wound measurement obtained on Monday, 04/13/2020 revealed the wound size was 2.5 cm (centimeters) by (x) 2.5 cm x 1 cm. -Wound #4 (right ankle wound): Onset date 03/18/2020. The wound measurement obtained on Monday, 04/13/2020 revealed the wound size was to 7 cm x 6 cm x 0 cm. -Wound #6 (right buttock): Onset date 03/30/2020. The wound measurement obtained on Monday, 04/13/2020 revealed the wound size was to 6 cm x 3 cm x 0 cm. -Wound #8 (penile wound): Onset date 04/08/2020. Wound measurements were obtained on 04/13/2020 revealed the wound size was 1 cm x 2 cm x 2 cm. -Wound #9 (left ankle), which was the wound referenced in the complaint allegations, had an onset date of 04/13/2020. The wound measurement obtained on Monday, 04/13/2020 revealed the wound size was 4 cm x 6 cm x 0 cm. -During the final HH SN visit performed on 04/15/2020, the HH licensed practical nurse (LPN) documented that the ankle wound (location not specified) had worsened and that tunneling of the sacral (area near the base of spine) wound was noted. HOSPICE RECORD REVIEW FINDINGS: Between June 10, 2020 at approximately 11:15 AM and June 11, 2020 at approximately 1:15 PM, review of the hospice clinical record revealed the hospice benefit election date was April 17, 2020 as documented on the "Medicare Hospice Benefit Election" form. Review of the verbal certification of terminal illness (CTI) physician order dated April 17, 2020 revealed the hospice diagnosis was chronic obstructive pulmonary (lung) disease. Review of the "Hospice Certification and Plan of Care" for the initial certification period of April 17 through July 15, 2020 revealed physician orders included the following: Hospice nurse to perform wound care to unstageable (pressure wound classification) wounds on the sacral area and bilateral (both) ankles...Utilizing clean technique, cleanse with normal saline (salt) solution, apply silver calcium alginate (wound treatment) to wound bed, apply non-sting barrier (skin protectant) to wound edges, cover with dry dressing and change every 3 days and as needed. Goals included on the "Hospice Certification and Plan of Care" revealed the wounds will be managed without infection and pain will be controlled. "Patient Information Report" documentation revealed a registered nurse (RN-employee #3) was the case manager and a licensed practical nurse (LPN-employee #2) were included as a hospice team member. Hospice "Wound Record Report" documentation the following wounds were identified during the 04/17/2020 start of care SN visit: -Wound #2: Left buttock (mid to low); -Wound #3: Coccyx (base of spine); -Wound #4: Right lateral ankle; -Wound #6: Right low buttock; -Wound #8: Penile; and -Wound #9: Left lateral ankle. There was no documentation on the "Wound Record Report" which provided evidence that the above referenced wounds were assessed per the above referenced hospice policies on or after April 17, 2020. Review of "Visit Note Report" and "Medical Record Coordination Notes Report" documentation revealed the following: -April 17, 2020 Start of Care (RN/nursing preceptor-employee #1): Wound care was not provided/performed as wound care was "done earlier in the day, so they (wounds) were not uncovered". -April 18, 2020 (LPN-employee #2): Bilateral ankle wound dressings were changed and that an odor was noted from both wounds. Bilateral buttocks wound dressings were changed. -April 19, 2020 (LPN-employee #2): Bilateral ankle and buttocks dressings changed. -April 20, 2020 (RN-employee #3): Wound care provided to bilateral lower extremities (ankles) and buttocks. -April 23, 2020 (RN-employee #3): Wound care provided as documented under "Interventions Provided". -April 24, 2020 (RN-employee #5): "Triage Note" documentation revealed the hospice admission coordinator documented that the patient's spouse contacted the hospice. The patient's spouse reported that patient's wound dressings needed to be changed due to 'being smelly and leaking'. There was no documentation on the "Visit Note Report" nor the "Medical Record Coordination Notes Report" forms, for the time period of April 17, 2020 (start of care) through April 23, 2020, which provided evidence that the above referenced RN's/LPN's (employees #1, #2 and #3) had assessed the bilateral lower extremity, buttocks/sacral wounds and penile wounds for wound size, appearance and the type of drainage present within 5 days of the election of hospice care. Patient #4: On June 23, 2020 at approximately 2:48 PM and June 24, 2020 at approximately 11:42 AM, review of the hospice clinical record revealed the hospice benefit election date was June 4, 2020 as documented on the "Medicare Hospice Benefit Election" form. Review of the verbal certification of terminal illness (CTI) physician order dated June 4, 2020 revealed the hospice diagnosis was toxic metabolic (metabolism) encephalopathy (disease of the brain) and the secondary diagnosis was Alzheimer's disease. Review of the "Hospice Certification and Plan of Care" for the initial certification period of June 4 through September 1, 2020 revealed physician orders/goals included the following: -Hospice nurse to perform wound care as follows: -Right heel non-stageable decubitus ulcer: Cleanse with betadine, cover with 4X4 (size) gauze and wrap with Kling (gauze wrap) daily and as needed for soilage or dislodgement; -Right forearm decubitus: Cleanse with normal saline, dry, apply thin layer of Hydrogel (wound treatment), cover with Optifoam (foam wound dressing), change every 3rd day and as needed for dislodgement/soilage; -Sacral decubitus: Cleanse with normal saline, dry, apply thin layer of Hydrogel (wound treatment), cover with Optifoam (foam wound dressing), change every 3rd day and as needed for dislodgement/soilage; and -Goals: Goals included on the "Hospice Certification and Plan of Care" revealed the wounds will be managed without infection and pain will be controlled. Review of "Visit Note Report" and "Coordination Notes Report" documentation revealed the following: -June 4, 2020 Start of Care (RN-employee #9): Wound assessment findings were documented as follows: -Right heel decubitus: Necrotic; -Right forearm decubitus: Stage 3; and -Sacral decubitus: Stage 2. -June 5, 2020 (LPN--employee #11): The LPN assisted with patient care after the patient had a bowel movement. -June 9, 2020 (LPN-employee #2): Wound care was provided to the right heel wound and the LPN assisted with/provided instruction regarding application of the sacral wound dressing. Review of email documentation dated June 21, 2020 revealed hospice nursing staff, including the RN (employee #9), were advised to review wound assessment documentation from the start of care to present for patient #4. "Coordination Notes Report" documentation dated June 21, 2020, which was 17 days after the start of care, revealed the following wound assessment findings were documented by the RN (employee #9) -Right heel: Unstageable. Area 4 cm (centimeters) by (x) 4 cm. Necrotic; -Right elbow (forearm): Center of wound bed healing-almost 90%, Pale yellow center measures 2 cm x 2 cm, surrounding skin pink, no drainage; and -Sacral wound: 3 cm x 3 cm. Center of wound bed with yellow slough. Edges distinct. Surrounding perimeter (edges) red with skin intact. Small amount of yellow drainage from center area, no odor. During interview on June 24, 2020 at approximately 9:09 AM, the RN (employee #9) reported that inputting wound assessment findings in the electronic wound tables requires a significant amount of time to complete the documentation. The RN reported that the RN maintains hand-written notes of patient assessment findings until the patient expires. Review of hand-written wound assessment documentation revealed the RN documented that the right heel wound measured 4 cm x 4 cm during the start of care visit but there was no documentation that the RN had obtained measurements of the right forearm, nor the sacral wound, during the start of care visit. There was no documentation on the "Visit Note Report" nor the "Coordination Notes Report", for the time period of June 4, 2020 (start of care) through June 9, 2020, which provided evidence that the above referenced RN's/LPN's (employees #2, #9 and #11) had assessed right foreman, right heel and right sacral wounds for wound size, appearance and type of drainage present within 5 days of the election of hospice care. During a telephone conference conducted on June 25, 2020 at approximately 1:54 PM, the administrator confirmed a complete wound assessment was not documented in the clinical record within 5 days of the hospice benefit election date for patients #1 and #4.
L0533
L0533	19122 Based on review of hospice policies/procedures, clinical records, and the National Pressure Ulcer Advisory Panel pressure wound staging guidelines, and based on interview with the administrator, the hospice failed to ensure the updated comprehensive assessment included an assessment of wound status for three (3) of five (5) patients for whom wound care orders were included on the initial or updated hospice plan of care. (Patients #1, #2 and #4) Findings include: On June 24, 2020 at approximately 3:10 PM, review of the hospice policy titled "Comprehensive Assessment" revealed the following: "Policy...A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care... Procedure... 2. During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient's clinical record, including at least the following information as relevant...G. A physical assessment, including...skin and other pertinent physical findings... 6. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patient's condition requires but at a minimum of every 15 days...C. If there has been a change in the patient's condition/status, then the comprehensive assessment must be updated..." On June 24, 2020 at approximately 3:16 PM, review of the hospice policy titled "Palliative Wound Care" revealed the following: "Key Points... 2. Symptoms of wounds patients find the most distressing include: a. Odor... b. Bleeding... Procedure...3. Using standard precautions, assess the wound using Wound Assessment procedures... Document According to Agency Policy... 1. Document in the patient's medical record... b. Wound assessment data. c. Plan of Care and its effectiveness of meeting goals. d. Communications with interdisciplinary team. 2. Adjust plan of care as appropriate and communicate changes per agency policy." On June 24, 2020 at approximately 3:24 PM, review of the agency policy titled "Assessment: Wound" revealed the following under "Key Points": 3. Basic wound assessment for all wounds includes... d. Dimensions: 1. Length, width and depth. 2. Presence of tunneling or undermining. (wound area/pocket below the skin. 3. Shape. e. Wound bed tissue: 1. Granulation (new) tissue. 2. Clean, not healing tissue. 3. Slough. (layer of dead tissue) 4. Eschar. (dry, dead tissue) f. Wound edges: 1. Attached. 2. Rolled. 3. Epithelialization. (healing) g. Surrounding skin: 1. Condition. 2. Signs of infection. h. Drainage: 1. Amount. 2. Color. 3. Consistency. 4. Odor. i. Pain: 1. Level of pain. 2. Intermittent or constant... 5. Wounds and patients change, therefore wounds need to be reassessed regularly and treated according to the changing needs of the patient and the wound: a. In home care, a professional reassessment of most wounds is indicated at least once a week. b. Reassessment and documentation of the wound should include: 1. Wound measurements. 2. Wound bed description. 3. Clinical evaluation of the wound progress: a. Healing. b. No progress. c. Deterioration. c. The wound care plan must be modified as the wound changes. 6. In some patients, notably hospice/palliative care patients, the goal is not wound healing but wound management... Supporting Evidence...National Pressure Ulcer Advisory Panel..." On June 25, 2020 at approximately 3:34 PM, review of the National Pressure Ulcer Advisory Panel pressure wound staging guidelines revealed the following: "Stage 2...Partial-thickness skin loss with exposed dermis (layer of tissue below the skin). The wound bed is viable (healing), pink or red, moist, and may also present as an intact or ruptured serum-filled (fluid) blister... Stage 3...Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue (formation of new tissue/blood vessels during the healing process) and epibole (rolled wound edges) are often present... Unstageable...Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (dead tissue)..." Patient #1: PRE-HOSPICE ADMISSION FINDINGS: On June 9, 2020 at approximately 1:41 PM and June 11, 2020 at approximately 10:48 PM, review of the home health (HH) clinical record revealed HH services were provided by the HH agency which is part of the same limited liability company as the hospice. Skilled nursing (SN) documentation revealed the final home health visit was performed on 04/15/2020 as documented on the discharge "Visit Note Report" dated 04/16/2020. Physician order documentation dated 04/17/2020 revealed the patient was discharged from home health services as the patient was being admitted to hospice services at family request. HH "Visit Note Report" and "Wound Record Report" documentation revealed wounds present during the final HH SN visit which was performed on 04/15/2020 included, but were not limited, to the following: -Wound #2 (left buttock wound): Onset date 02/11/2020. The wound measurement obtained on Monday, 04/13/2020 revealed the wound size was 2.5 cm (centimeters) by (x) 2.5 cm x 1 cm. -Wound #4 (right ankle wound): Onset date 03/18/2020. The wound measurement obtained on Monday, 04/13/2020 revealed the wound size was to 7 cm x 6 cm x 0 cm. -Wound #6 (right buttock): Onset date 03/30/2020. The wound measurement obtained on Monday, 04/13/2020 revealed the wound size was to 6 cm x 3 cm x 0 cm. -Wound #9 (left ankle), which was the wound referenced in the complaint allegations, had an onset date of 04/13/2020. The wound measurement obtained on Monday, 04/13/2020 revealed the wound size was 4 cm x 6 cm x 0 cm. -During the final HH SN visit performed on 04/15/2020, the HH licensed practical nurse (LPN) documented that the ankle wound (location not specified) had worsened and that tunneling of the sacral (area near the base of spine) wound was noted. HOSPICE RECORD REVIEW FINDINGS: Between June 10, 2020 at approximately 11:15 AM and June 11, 2020 at approximately 1:15 PM, review of the hospice clinical record revealed the hospice benefit election date was April 17, 2020. Review of the verbal certification of terminal illness (CTI) physician order dated April 17, 2020 revealed the hospice diagnosis was chronic obstructive pulmonary (lung) disease. Review of the "Hospice Certification and Plan of Care" for the initial certification period of April 17 through July 15, 2020 revealed physician orders included the following: Hospice nurse to perform wound care to unstageable wounds on the sacral area and bilateral (both) ankles...Utilizing clean technique, cleanse with normal saline (salt) solution, apply silver calcium alginate (wound treatment) to wound bed, apply non-sting barrier (skin protectant) to wound edges, cover with dry dressing and change every 3 days and as needed. Goals included on the "Hospice Certification and Plan of Care" revealed the wounds will be managed without infection and pain will be controlled. "Patient Information Report" documentation revealed a registered nurse (RN-employee #3) was the case manager and a licensed practical nurse (LPN-employee #4) was included as a hospice team member. Hospice "Wound Record Report" documentation revealed the wounds identified during the 04/17/2020 start of care SN visit included, but were not limited to, the following: -Wound #2: Left buttock (mid to low); -Wound #3: Coccyx (base of spine); -Wound #4: Right lateral ankle; -Wound #6: Right low buttock; and -Wound #9: Left lateral ankle. Review of "Visit Note Report" and "Medical Record Coordination Notes Report" documentation revealed the following: -April 24, 2020 (RN-employee #5): "Triage Note" documentation revealed the hospice admission coordinator documented that the patient's spouse contacted the hospice. The patient's spouse reported that patient's wound dressings needed to be changed due to 'being smelly and leaking'. -April 27 and April 29, 2020 (RN-employee #3): Wound care provided to bilateral lower extremities (ankles) and buttocks. Instruction provided to patient/caregiver regarding the signs/symptoms of infection. -May 1, 2020 (RN-employee #6): "Triage Note" documentation revealed the RN documented that the patient's spouse contacted the hospice. The patient's spouse reported that patient's right foot wound dressings had blood soaking through the dressing and that the spouse could not stop the bleeding. -May 1, 2020 (RN-employee #3): Wound care provided to bilateral lower extremities (ankles) and buttocks. Patient tolerated well. -May 2, 2020 (LPN-employee #4): Dressing needed to be changed to left leg/foot. Dressings changed. -May 4, 2020 (RN-employee #3): Wound care provided to bilateral lower extremities (ankles) and buttocks. Re-education provided to patient/caregiver regarding the signs/symptoms of infection. -May 6, 2020 (RN-employee #1): Patient's family expressed concern regarding status of the patient's wounds. Left leg has a "very large", unstageable wound due to the presence of thick, black eschar, the wound was draining purulent (pus)/foul-smelling drainage and "some" bleeding was also noted from the wound. Right ankle/leg wound was covered with black eschar, was draining purulent/foul-smelling drainage and "some" bleeding was noted from the wound. Sacral wound covered with black eschar and had purulent/foul-smelling drainage. Status of wounds explained to family members who agreed to revoke hospice services to seek aggressive wound treatment. The attending physician was notified of the patient and hospice plan of care "changes". The hospice medical director and administrator/clinical manager were provided an update. There was no documentation on the "Visit Note Report", nor on the "Medical Record Coordination Notes Report" and "Wound Record Report" forms, which provided evidence that the above referenced RN's/LPN's (employees #3 and #4) had assessed the bilateral lower extremity and buttocks/sacral wounds for wound size, appearance and the type of drainage present after wound complications were reported on April 24 and May 1, 2020. Patient #2: On June 11, 2020 at approximately 12:49 PM, review of the verbal certification of terminal illness (CTI) physician order dated January 6, 2020 revealed the hospice diagnosis was end-stage COPD. Review of the "Visit Note Report" dated March 20, 2020 revealed the RN (employee #7) documented that the patient had fallen asleep on a heating pad the night before and a "large" reddened area with blistering was noted on the patient's back and left side. Review of the physician order dated March 20, 2020 revealed Silvadene (burn/wound treatment) was to be applied two (2) times a day. Review of the "Visit Note Report" documentation revealed the following: -March 24, 2020 (LPN-employee #4): The patient had suffered a burn on the left side of the back which wrapped around the patient's flank (side of the body between the ribs and hips) to the center of the chest and that blisters were still present. -March 31, 2020 (RN-employee #8): The patient's left axilla (underarm) burns were healing slowly. -April 3, 2020 (LPN-employee #4): The patient's burn was healing well but that the blistered areas were now open. Review of the "Medical Record Coordination Report" dated April 16, 2020 revealed the RN (employee #8) documented that the patient complained of increase discomfort at the left breast burn site and that increased redness/green, crusty drainage was noted at the area. There was no documentation on the "Visit Note Report", nor on the "Medical Record Coordination Notes Report", which provided evidence that the above referenced RN's/LPN's (employees #4, #7 and #8) had assessed the burn injury for size on March 20, 24 and 31, 2020, nor was documentation present which provided evidence that the LPN (employee #4) had assessed the open blisters/wounds for size, appearance and the type of drainage present on April 3, 2020. Patient #4: On June 23, 2020 at approximately 2:48 PM and June 24, 2020 at approximately 11:42 AM, review of the hospice clinical record revealed the hospice benefit election date was June 4, 2020 as documented on the "Medicare Hospice Benefit Election" form. Review of the verbal certification of terminal illness (CTI) physician order dated June 4, 2020 revealed the hospice diagnosis was toxic metabolic (metabolism) encephalopathy (disease of the brain) and the secondary diagnosis was Alzheimer's disease. Review of the "Hospice Certification and Plan of Care" for the initial certification period of June 4 through September 1, 2020 revealed physician orders/goals included, but were not limited to, the following: -Hospice nurse to perform wound care as follows: -Sacral decubitus: Cleanse with normal saline, dry, apply thin layer of Hydrogel (wound treatment), cover with Optifoam (foam wound dressing), change every 3rd day and as needed for dislodgement/soilage; and -Goals: Goals included on the "Hospice Certification and Plan of Care" revealed the wounds will be managed without infection and pain will be controlled. Review of the "Visit Note Report" dated June 4, 2020 (start of care) revealed the RN (employee #9) documented that the sacral decubitus was Stage 2 decubitus. Review of email documentation dated June 21, 2020 revealed hospice nursing staff, including the RN (employee #9), were advised to review wound assessment documentation from the start of care to present for patient #4. "Coordination Notes Report" documentation dated June 21, 2020, which was 17 days after the start of care, revealed wound assessment findings documented by the RN (employee #9) included, but were not limited to, the following: Sacral wound: 3 cm x 3 cm, center of wound bed with yellow slough, edges distinct, surrounding perimeter (edges) red with skin intact and small amount of yellow drainage from center area/no odor. Review of "Visit Note Report" documentation revealed the following: -June 9, 2020 (LPN-employee #2): Wound care was provided to the right heel wound and the LPN assisted with/provided instruction regarding application of the sacral wound dressing; -June 12, 2020 (LPN-employee #11): Sacral dressing was intact. Bandages replaced for padding; -June 15, 2020 (LPN-employee #4): Integumentary (skin) status assessed; and -June 18, 2020 (RN-employee #10): Integumentary status-no problems identified. Review of IPU "Doctor's Notice" documentation revealed the patient was admitted to the hospice inpatient unit (IPU) on June 19, 2020 for respite services. Review of the IPU "Skin Assessment" form dated June 19, 2020 revealed the following assessment findings were documented for the sacral (coccyx) wound: -Stage 3 measuring 2.5 cm x 2 cm by 0.5 cm -Appearance: Wound bed is white/yellow with foul odor. Tunneling at the 2 o'clock point. No granulation tissue visible. There was no documentation on the "Visit Note Report" nor the "Coordination Notes Report", which provided evidence that the above referenced RN/LPN's (employees #2 #4, #10 and #11) had assessed the sacral wound during the home hospice skilled nursing visits performed on June 9 and 12, 2020 nor on June 15 and 18, 2020. During a telephone conference conducted on June 25, 2020 at approximately 1:54 PM, the administrator confirmed that there was no documentation in the clinical record which provided evidence that the updated comprehensive assessment included an assessment of wound status for the above identified patients for whom wound complications were documented in the clinical record.
L0536
L0536	19122 Based on a review of hospice policies/procedures, clinical records and the National Pressure Ulcer Advisory Panel pressure wound staging guidelines, and based on interview with the administrator, the hospice failed to ensure the updated interdisciplinary hospice plan of care included details regarding the progress towards wound goals (L553) and the hospice failed to ensure skin integrity interventions were provided in accordance with the hospice interdisciplinary plan of care for patients for whom wounds were present upon admission to the hospice IPU (inpatient unit). (L555) This condition was not met based on non-compliance with above standards, and the nature and severity of the deficient practices. The cumulative effects of these deficient practices resulted in the agency's inability to ensure the health and safety of patients and resulted in Immediate Jeopardy. § 484.56(d) REVIEW OF THE PLAN OF CARE (L553) § 484.56(e)(2) COORDINATION OF SERVICES (L555) On June 30, 2020 at 8:13 AM, Immediate Jeopardy was identified. The agency was notified that Immediate Jeopardy was identified on June 30, 2020 at 10:18 AM and the Immediate Jeopardy Templates were provided to entity on June 30, 2010 at 12:21 PM. The hospice submitted a plan to abate Immediate Jeopardy on June 30, 2020 at 4:20 PM which was not accepted. The hospice submitted a plan to abate Immediate Jeopardy on June 30, 2020 at 5:54 PM which was not accepted. The hospice submitted a plan to abate Immediate Jeopardy on July 1, 2020 at 9:59 AM and the plan was accepted on July 1, 2020 at 10:18 AM with implementation of the abatement plan of correction.
L0553
L0553	19122 Based on review of hospice policies/procedures, clinical records and the the National Pressure Ulcer Advisory Panel pressure wound staging guidelines, and based on interview with the administrator, the hospice failed to ensure the updated interdisciplinary plan of care included details regarding the progress towards wound goals for one (1) of four (4) patients for whom wounds were present after establishment of the initial hospice plan of care. (Patients #1) Findings include: On June 24, 2020 at approximately 3:02 PM, review of the hospice policy titled "Interdisciplinary Group Plan of Care" revealed the following: "Procedure... 6. Written evidence of care coordination will be found in the plan of care and/or interdisciplinary team meeting forms in the patient's clinical record, and will involve the hospice patient's attending physician... " On June 24, 2020 at approximately 3:07 PM, review of the hospice policy titled "The Plan of Care" revealed the following: "Procedure... 7. Each patient will be monitored for his/he response to care or services provided against established patient goals and patient outcomes to evaluate progress towards goals..." On June 24, 2020 at approximately 3:34 PM, review of the National Pressure Ulcer Advisory Panel pressure wound staging guidelines revealed the following: " Unstageable...Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (dead tissue)..." Patient #1: PRE-HOSPICE ADMISSION FINDINGS: On June 9, 2020 at approximately 1:41 PM and June 11, 2020 at approximately 10:48 PM, review of the home health (HH) clinical record revealed HH services were provided by the HH agency which is part of the same limited liability company as the hospice. Skilled nursing (SN) documentation revealed the final home health visit was performed on 04/15/2020 as documented on the discharge "Visit Note Report" dated 04/16/2020. Physician order documentation dated 04/17/2020 revealed the patient was discharged from home health services as the patient was being admitted to hospice services at family request. HH "Visit Note Report" and "Wound Record Report" documentation revealed wounds present during the final HH SN visit which was performed on 04/15/2020 included, but were not limited, to the following: -Wound #2 (left buttock wound): Onset date 02/11/2020. The wound measurement obtained on Monday, 04/13/2020 revealed the wound size was 2.5 cm (centimeters) by (x) 2.5 cm x 1 cm. -Wound #4 (right ankle wound): Onset date 03/18/2020. The wound measurement obtained on Monday, 04/13/2020 revealed the wound size was to 7 cm x 6 cm x 0 cm. -Wound #6 (right buttock): Onset date 03/30/2020. The wound measurement obtained on Monday, 04/13/2020 revealed the wound size was to 6 cm x 3 cm x 0 cm. -Wound #9 (left ankle), which was the wound referenced in the complaint allegations, had an onset date of 04/13/2020. The wound measurement obtained on Monday, 04/13/2020 revealed the wound size was 4 cm x 6 cm x 0 cm. -During the final HH SN visit performed on 04/15/2020, the HH licensed practical nurse (LPN) documented that the ankle wound had worsened and that tunneling of the sacral (area near the base of spine) wound was noted. HOSPICE RECORD REVIEW FINDINGS: Between June 10, 2020 at approximately 11:15 AM and June 11, 2020 at approximately 1:15 PM, review of the hospice clinical record revealed the hospice benefit election date was April 17, 2020. Review of the verbal certification of terminal illness (CTI) physician order dated April 17, 2020 revealed the hospice diagnosis was chronic obstructive pulmonary (lung) disease. Review of the "Hospice Certification and Plan of Care" for the initial certification period of April 17 through July 15, 2020 revealed physician orders included the following: Hospice nurse to perform wound care to unstageable wounds on the sacral area and bilateral (both) ankles...Utilizing clean technique, cleanse with normal saline (salt) solution, apply silver calcium alginate (wound treatment) to wound bed, apply non-sting barrier (skin protectant) to wound edges, cover with dry dressing and change every 3 days and as needed. Goals included on the "Hospice Certification and Plan of Care" revealed the wounds will be managed without infection and pain will be controlled. "Patient Information Report" documentation revealed a registered nurse (RN-employee #3) was the case manager and a licensed practical nurse (LPN-employee #4) was included as a hospice team member. Hospice "Wound Record Report" documentation revealed the wounds identified during the 04/17/2020 start of care SN visit included, but were not limited to, the following: -Wound #2: Left buttock (mid to low); -Wound #3: Coccyx (base of spine); -Wound #4: Right lateral ankle; -Wound #6: Right low buttock; and -Wound #9: Left lateral ankle. Review of the "Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report" dated April 20, 2020 revealed hospice problems included the "Need for Wound Care-Hospice". Review of "Hospice POC (Plan of Care) Report" documentation revealed goals included under the hospice problem "Need for Wound Care-Hospice" included for wounds to be free of signs/symptoms of infection or complications. Review of "Visit Note Report" and "Medical Record Coordination Notes Report" documentation revealed the following: -April 24, 2020 (RN-employee #5): "Triage Note" documentation revealed the hospice admission coordinator documented that the patient's spouse contacted the hospice. The patient's spouse reported that patient's wound dressings needed to be changed due to 'being smelly and leaking'. -April 27 and April 29, 2020 (RN-employee #3): Wound care provided to bilateral lower extremities (ankles) and buttocks. Instruction provided to patient/caregiver regarding the signs/symptoms of infection. -May 1, 2020 (RN-employee #6): "Triage Note" documentation revealed the RN documented that the patient's spouse contacted the hospice. The patient's spouse reported that patient's right foot wound dressings had blood soaking through the dressing and that the spouse could not stop the bleeding. -May 1, 2020 (RN-employee #3): Wound care provided to bilateral lower extremities (ankles) and buttocks. Patient tolerated well. -May 2, 2020 (LPN-employee #4): Dressing needed to be changed to left leg/foot. Dressings changed. -May 4, 2020 (RN-employee #3): Wound care provided to bilateral lower extremities (ankles) and buttocks. Re-education provided to patient/caregiver regarding the signs/symptoms of infection. -May 6, 2020 (RN-employee #1): Patient's family expressed concern regarding status of the patient's wounds. Left leg has a "very large", unstageable wound due to the presence of thick, black eschar, the wound was draining purulent (pus)/foul-smelling drainage and "some" bleeding was also noted from the wound. Right ankle/leg wound was covered with black eschar, was draining purulent/foul-smelling drainage and "some" bleeding was noted from the wound. Sacral wound covered with black eschar and had purulent/foul-smelling drainage. Status of wounds explained to family members who agreed to revoke hospice services to seek aggressive wound treatment. The attending physician was notified of the patient and hospice plan of care "changes". The hospice medical director and administrator/clinical manager were provided an update. Review of the "Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report" dated May 4, 2020 failed to reveal that the IDG addressed the patient's progress towards the above referenced wound goals included under the hospice problem "Need for Wound Care-Hospice". During a telephone conference conducted on June 25, 2020 at approximately 1:54 PM, the administrator confirmed that there was no documentation in the clinical record which provided evidence that the May 4, 2020 updated plan of care included details regarding the progress towards wound care goals for patient #1.
L0555
L0555	19122 Based on review of hospice policies/procedures, clinical records and the National Pressure Ulcer Advisory Panel pressure wound staging guidelines, and based on interview with the administrator, the hospice failed to ensure skin integrity interventions were provided in accordance with the hospice interdisciplinary plan of care for two (2) of two (2) patients for whom wounds were present upon admission to the hospice inpatient unit (IPU). (Patients #4 and #5) Findings include: On June 24, 2020 at approximately 3:02 PM, review of the hospice policy titled "Interdisciplinary Group Plan of Care" revealed the following: "Policy...The type and scope of service provided by the interdisciplinary group will be based upon comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals and interventions... Procedure...9. All interdisciplinary group members...will have access to the plan of care to ensure coordination and continuity..." On June 24, 2020 at approximately 3:07 PM, review of the hospice policy titled "The Plan of Care" revealed the following: "Policy...The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions... Procedure... 12. The written plan of care will contain, but not be limited to, the following...I. Safety measures to protect against...injury, infection...as appropriate... 13. Care provided to the patient will be in accordance with the plan of care..." On June 25, 2020 at approximately 3:34 PM, review of the National Pressure Ulcer Advisory Panel pressure wound staging guidelines revealed the following: "Stage 3...Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue (formation of new tissue/blood vessels during the healing process) and epibole (rolled wound edges) are often present..." Patient #4: On June 23, 2020 at approximately 2:48 PM and June 24, 2020 at approximately 11:42 AM, review of the hospice clinical record revealed the hospice benefit election date was June 4, 2020 as documented on the "Medicare Hospice Benefit Election" form. Review of the verbal certification of terminal illness (CTI) physician order dated June 4, 2020 revealed the hospice diagnosis was toxic metabolic (metabolism) encephalopathy (disease of the brain) and the secondary diagnosis was Alzheimer's disease. Review of IPU "Doctor's Notice" documentation revealed the patient was transferred from home hospice services to the hospice IPU on June 19, 2020 for respite services (short-term admission to provide relief to family/caregivers). Review of the IPU "Skin Assessment" form dated June 19, 2020 revealed wound assessment included, but was not limited to, the following: -Sacral (area at base of spine) wound: -Wound Type: Stage 3 measuring 2.5 cm x 2 cm by 0.5 cm; and -Appearance: Wound bed is white/yellow with foul odor. Tunneling at the 2 o'clock point. No granulation tissue visible. -Right heel: -Wound Type: Deep tissue injury; and -Appearance: 100% black eschar. Review of IPU "Admitting Orders" dated June 19, 2020 revealed the following wound care was to be provided: -Sacral wound: Cleanse with normal saline solution (NSS), pat dry, apply Hydrogel (wound treatment), cover with Optifoam (foam wound dressing), change every 3 days and as needed; and -Right heel wound: Apply betadine, cover with Telfa (wound dressing), ABD (thick, gauze wound dressing), Kling (gauze wrap), change daily and as needed. Review of IPU "Interdisciplinary Plan of Care" documentation revealed the following interventions were included under the "Impaired Skin Integrity" hospice problem: -06/19/2020: Turn (reposition) every 2 hours. Use pillows to position patient; and -06/21/2020: New wound care order for sacral wound: Cleanse with NSS (normal saline solution), pack loosely with NSS wet to dry dressing, change two (2) times a day and as needed. Review of the IPU "Skin Assessment" form dated June 21, 2020, which was 2 days after admission to the IPU, revealed the following sacral wound assessment findings were documented by IPU nursing staff: -Wound Type: Stage 3 measuring 3.0 cm x 2 cm by 0.6 cm; and -Appearance: Wound bed noted to have increased odor, black necrotic tissue to wound bed (95%) which was surrounded by yellow slough, wound edges thickened, redness noted of the surrounding skin, tunneling remains at the 2 o'clock position. Review of IPU "Hospice Interdisciplinary Note" and "24 Hour Patient Care Flow Sheet" failed to reveal that IPU staff had repositioned the patient every two (2) hours between the following times on the below referenced dates: -June 19, 2020: The patient was documented as being repositioned at 8:00 PM. The patient was then repositioned on June 20, 2020 at 6:00 AM, which was 8 hours after the previous repositioning; -June 20, 2020: The patient was documented as being repositioned at 6:00 AM. The patient was then repositioned on June 20, 2020 at 9:30 AM, which was 3.5 hours after the previous repositioning; -June 20, 2020: The patient was documented as being repositioned at 9:30 AM. The patient was then repositioned on June 20, 2020 at 4:00 PM, which was 6.5 hours after the previous repositioning; -June 20, 2020: The patient was documented as being repositioned at 10:00 PM. The patient was then repositioned on June 21, 2020 at 5:00 AM, which was 7 hours after the previous repositioning; -June 21, 2020: The patient was documented as being repositioned at 5:00 AM. The patient was then repositioned on June 21, 2020 at 9:00 AM, which was 4 hours after the previous repositioning; and -June 22, 2020: The patient was documented as being repositioned at 7:00 AM. The patient was then repositioned on June 22, 2020 at 4:00 PM, which was 9 hours after the previous repositioning. Review of "Hospice Interdisciplinary Note" documentation revealed the patient was transferred home to resume home hospice services on June 22, 2020 at 5:45 PM. Review of IPU "Scheduled Medication..." form documentation failed to reveal that IPU nursing staff had provided wound care to the sacral and right heel wounds on June 22, 2020 at 9:00 AM. Review of home hospice interim physician orders dated June 23, 2020, which was one (1) day after discharge from the hospice IPU, revealed the following medication order was received: Augmentin (antibiotic) was ordered to be administered two (2) times a day for 10 days for wound infection. Patient #5: On June 25, 2020 at approximately 12:55 PM, review of the hospice clinical record revealed the hospice benefit election date was June 4, 2020 as documented on the "Medicare Hospice Benefit Election" form. Review of the verbal certification of terminal illness (CTI) physician order dated June 4, 2020 revealed the hospice diagnosis sepsis (infection of the blood stream) due to pneumonia. Review of the IPU "Skin Assessment" form dated June 4, 2020 revealed wound assessment included, but was not limited to, the following: -Sacral wound: Wound Type-Stage 2 measuring 1 cm x 1 cm with a small open area at the center. Review of IPU "Admitting Orders" dated June 19, 2020 revealed the following wound care was to be provided to the sacral wound: Cleanse with NSS or wound cleanser, use hydrocolloid (wound dressing), change every 3-5 days and as needed. Review of IPU "Interdisciplinary Plan of Care" documentation revealed the following interventions were included under the "Impaired Skin Integrity" hospice problem: 06/19/2020: Turn (reposition) every 2 hours. Use pillows to position patient. Review of IPU "Hospice Interdisciplinary Note" and "24 Hour Patient Care Flow Sheet" failed to reveal that IPU staff had repositioned the patient every two (2) hours between the following times on the below referenced dates: -June 5, 2020: The patient was documented as being repositioned at 7:30 AM. The patient was then repositioned on June 5, 2020 at 5:00 PM, which was 7.5 hours after the previous repositioning; -June 5, 2020: The patient was documented as being repositioned at 11:00 PM. The patient was then repositioned on June 6, 2020 at 5:30 AM, which was 6.5 hours after the previous repositioning; and -June 6, 2020: The patient was documented as being repositioned at 10:00 PM. The patient was then repositioned on June 7, 2020 at 9:00 AM, which was 11 hours after the previous repositioning. During a telephone conference conducted on June 25, 2020 at approximately 1:54 PM, the administrator confirmed that there was no documentation in the clinical records which provided evidence that wound care was provided as per physician orders for patient #4 on June 22, 2020 and that neither patient #4 nor #5 were repositioned every 2 hours on the above referenced dates between the aforementioned times.