Every finding on record at 7 Star Hospice Care, Inc.

Observed in Emergency Management Session. Hospice HVA risk assessment did not include technological hazards. Example HVA assessment did not include technological Hazards. This was confirmed by the DPCS.

Observed in Record Review. In 1 out of 1 wound records, the organization did not reassesses the wound per policy. Example: In RRNHV#3, Stage 2 wound reassessments were not completed weeks 2, 3, 4, 5, 7, 8, 9,10, and 11 of benefit period #2. This was confirmed with the DPCS.

Observed in Record Review. In 8 out of 8 records, hospice did not develop an individualized plan of care for each patient related to Spiritual and Psychosocial needs. Examples: In RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5, RRHV#1, RRHV#2, and RRNHV#3, the Chaplain and MSW each had a planned frequency of Initial evaluation within 5 days and once every recert. This was confirmed by the DPCS. Observed in Record Review. In 7 out of 7 records, the hospice did not develop an individualized plan of care with measurable goals. Examples: In RRNHV#1, the following goals were not measurable: Provide timely, effective pain relief to maintain comfort; For patient/family/PC to remain satisfied with living arrangement it is essential to link patient/family caregiver to have all available resources; Improve sleep quality and promote restful nighttime sleep; In RRNHV#1 there were no individualized goals related to GERD and Hypertension. In RRNHV#2, the following goals were not measurable: Patient will achieve restful sleep and remain comfortable overnight;; Patient/family/PCG to remain satisfied with living arrangement; Maintain patient comfort. In RRHNV#3, patient had a foley catheter but no GU goals. In RRNHV#4, RRNHV#5, and RRNHV#7, patients have medication orders to manage pain but did not have any identified pain goals. In RRNHV#6, patient did not have a skin/integumentary goal and patient had a wound. Patient also had a foley and not have a GU goal. Spiritual goals in RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5, and RRNHV#6 were interventions and not measurable. Examples of the Spiritual goals included: Provide prayer, meditation, scripture reading; Assess spiritual needs and preferences; and Facilitate articulations of spiritual concerns. This was confirmed with the DPCS.

Observed in Record Review. In 2 out 10 charts, the plan of care did not include interventions to manage symptoms and care. Example: In RRNHV#3, the plan of care did not include orders related to the 16F foley catheter identified on admission. The plan of care also did not include wound care orders for the patient's stage 2 wound identified on admission. In RRNHV#6, there were no wound care orders on the initial plan of care for a stage 4 wound identified on admission. There were also no Foley Catheter orders on the plan of care. This was confirmed with the DPCS.

Observed in Record Review. In 4 out of 7 records, multiple PRN medications were ordered to address the same symptom but the orders did not clarify when each medication was to be administered. Examples: In RRHV#1, Acetaminophen and morphine sulfate were ordered to address pain prn but did not state when each was to be given. Lorazepam tablets and Lorazepam concentrate solution were ordered prn for agitation but did not state when each was to be given. In RRNHV#3, Acetaminophen suppositories, Norco, and Diclofenac Sodium gel were ordered prn for pain but did not state when each was to be used. In RRNHV#4, Acetaminophen suppositories and morphine sulfate were ordered prn for pain but did not state when each should be given. . In RRNHV#6, Norco, Acetaminophen suppositories, and Morphine Sulphate was ordered prn for pain but did not state when each should be given. Bisacodyl suppository and Docusate Sodium capsules were ordered prn for constipation but did not state when each should be given. This was confirmed by the DPCS.

Observed in Record Review. In 4 out of 10 records, the organization did not provide services in accordance with the plan of care. Examples: In RRHV#1, there was a missed SN visit in weeks 2, 4, 5, and 6 of benefit period #1. In RRNHV#1, an extra nursing visit was made during weeks 2, 4, 5, and 6 of benefit period 8. In RRNHV#2, an extra nursing visit was made during weeks 3, 4, 6, 7, and 8 of benefit period 17. In RRNHV#5, an extra nursing visit was made during weeks 2 and 3 of admission. In RRBR#2, Bereavement mailings were not sent out per the stated Bereavement POC. This was confirmed with the DPCS.

Observed in Leadership Session. The quality assessment and performance improvement program did not demonstrate improvement in indicators related to improved palliative outcomes and hospice services. As the organization had not identified any performance improvement projects, they were not able to demonstrate improvement. This was discussed with the DPCS.

Observed in Leadership Session. The organization did not analyze and compare internal QAPI data over time to identify levels of performance, patterns, trends, and variations. This was confirmed by the DPCS.

Observed in Record Review. In 1 out of 1 applicable transfer records, the hospice did not provide the receiving facility with a copy of the hospice discharge summary and if requested a copy of the patient's clinical record. This was confirmed by the DPCS.

Observed in Record Review. In 2 out of 2 live discharge records, the hospice did not provide the patient’s attending physician with a copy of the hospice discharge summary and, if requested, a copy of the patient’s clinical records after discharge or transfer. Examples: In RRDC#1, a discharge summary was not sent to the Attending after revocation. In RRDC#2, a discharge summary was not sent to the Attending after a transfer to another agency. This was confirmed with the DPCS.

Observed in Emergency Management Session. During review of the organization emergency operation plan (EOP) it was noted lack of a description of the patient population served by the organization that was documented as part of the EOP. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 5 patient records reviewed, During RR#1 it was noted a history of diabetes type 2 on glipizide with diabetic supplies listed on the POC. The RN initial evaluation lacked an assessment of the patient's diabetic status. The POC lacked interventions and goals related to the patient's diabetes. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 5 patient records reviewed, During HV#1 record review it was noted many goals were not measurable or individualized. For example: Deficit: Potential for altered neurological status r/t; memory loss, goal: Pt needs will be met on a day to day basis as communicated by next IDG. Deficit: Occasional urinary incontinence, goal: Pt/Family/PCG will verbalize having urinary elimination needs met at an acceptable level. Deficit: constipation, goal: Optimal bowel elimination and comfort. -Pt/Family/PCG will verbalize having elimination needs met at an acceptable level, reduce discomfort with improved bowel elimination status. Deficit: self care deficit, goal: ADL needs are met to an optimal level, Pt will have optimum level of independence through assistance with personal care. This was discussed with the organization leadership.

Observed in Record Review. In 3 of 5 patient records reviewed, During RR#1, RR#2, HV#1 it was noted an MSW visit during the first 5 days after the initial RN assessments and a visit in March 2023 as part of the recertification update. The POCs lacked interventions and goals related to psychosocial/emotional issues identified. This was discussed with the organization leadership.

Observed in Infection Control System Tracer. The organization's written infection prevention and control plan did not include a goal limiting the spread of infections associated with the use of medical equipment, devices, and supplies. This was discussed with the organization leadership. Observed in Infection Control Tracer. The organization's written infection prevention and control plan did not include a goal limiting unprotected exposure to pathogens. This was discussed with the organization leadership. Observed in Infection Control System Tracer. The organization's written infection prevention and control plan did not include a goal limiting the spread of infections associated with procedures. This was discussed with the organization leadership.

Observed in HR File Review. In 1 of 7 HR files reviewed, During HR#3 file it was noted lack of orientation that addressed the employee's specific job duties of a Bereavement Coordinator. This was discussed with the organization leadership.

Observed in Record Review. In 3 of 5 patient records reviewed, During RR#1, RR#2, HV#1 it was noted an Emergency Plan form in the patient medical record that consisted of a list of numbers for the patient/caregiver to call in an emergency. The form lacked the patient specific individualized procedures to follow if care, treatment, or services are disrupted by a natural disaster or an emergency. This was discussed with the organization leadership.

Observed in Document Review. During review of the SNF contract it was noted lack of a provision that stated that the hospice will report all mistreatment, neglect, or verbal, mental, sexual, and physical abuse to the SNF, NF, or ICF/MR administrator within 24 hours of the hospice becoming aware of the alleged violation, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice.

Observed in HR File Review. In 1 of 7 HR files reviewed, During HR#3 file it was noted the professional license on file expired in January 2023. There is lack of a current license in the file. This was corrected on site during the survey. This was discussed with the organization leadership.

Observed in Document Review. During review of the pharmacy contract it was noted lack of provision that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. The contract also did not include how the HCO would coordinate, supervise and evaluate their contracted services and the contract did not delineate the role of the hospice and contractor in the admission process, patient/family assessment and the interdisciplinary group conferences. This was discussed with the organization leadership.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization did not assess its patients. Upon review of all records, the surveyor noted that the initial bereavement assessment was not completed. This was confirmed by the Administrator/DPCS Designee.

Observed in Record Review. In 5 of 5 patient records reviewed, organization did not have signed medication and treatment orders. The surveyor noted that physician orders have not been signed by the physician. This was confirmed by the Administrator/DCPS Designee.

Observed in Record Review. In 2 of 2 patient records reviewed, the organization did not make bereavement services available to family. In RR#4 and RR#5, the surveyor noted that there was no post-death bereavement support and follow up after 6 months following EOC. This was confirmed by the Administrator/DCPS Designee.

Observed in Record Review. In 2 of 2 patient records reviewed, hospice aides were not supervised effectively. In RR#4 and RR#5, the surveyor noted that the hospice aide was not supervised during the 3 months patient was on service. According to Policy 4.21.1- Hospice Aide Supervision, All hospice aide supervisory visits will be made at least every 14 days. It further states, that supervisory visits will be completed by the Registered Nurse. This was confirmed by the Administrator/DCPS Designee.

Observed in Record Review. Patient records were not readily accessible. The organization switched from paper records to electronic records, but records were not fully uploaded. No unified clinical record maintained at the organization. Medical Social Worker, Chaplain, and Bereavement Coordinator still scanning and attaching visit notes. This was confirmed by Administrator/DPCS Designee.

Observed in Patient Home. In 2 of 3 home visits conducted, the patient's record did not contain information that reflects the patient's current treatment. In HV#1/RR#1, the surveyor noted that Methocarbamol, Celebrex, and Senna were not listed on the medication list even though patient confirmed that he was taking these medications. In HV#2/RR#2, the surveyor noted that Fludrocortisone Acetate and Carvidopa/Levodopa were not listed on the medication list even though caregiver confirmed that patient is taking these medications. This was confirmed by Administrator/DPCS Designee.

Observed in Record Review. The organization does not maintain the security and integrity of health information. The surveyor noted that the organization does not have a complete medical record on site. Medical Social Worker, Chaplain, and Bereavement Coordinator still maintain visit notes that have not been uploaded to the EMR. This was confirmed by the Administrator/DCPS Designee.

Observed in HR File Review. In 2 of 8 HR files reviewed, organization did not verify staff qualifications. In HR#6 and HR#7, a criminal background check was not conducted or documented per HCO policy. This was confirmed by the Administrator Designee.