Every finding on record at A Better Way Home, LLC

Observed in Record Review. In 3 of 6 patient records reviewed, the written plan of care (POC) was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for RR#1, the goals on the POC were not measurable nor time based. Examples included medications will be managed appropriately as evidenced by steady symptom control. Patient...staff will verbalize appropriate pain management. There was no goal for bowel management despite Colon CA diagnosis, narcotics and orders for bowel management meds. In the chart for RR#2, the plan of care was revised to include a goal for a new problem of 2+edema, yet the goal was not measurable nor time-based and read DECREASE EDEMA AND IMPROVE COMFORT Lasix had been added to the POC. Another new problem INCREASED ANXIETY WITH DECREASED ABILITY TO SWALLOW. The POC changed to liquid Lorazepam Goal IMPROVE PATIENT COMFORT was not measurable nor time-based. The patient had a pressure relief mattress and a history of pressure ulcers. There was no goal on the POC related to pressure ulcer prevention measures. The clinical visit documentation addressed these issues and included assessments regarding progress. In the chart for RR#4, the patient was at risk for falls, was on high risk medications, had a bowel program initiated at the time of admit, yet there were no goals on the POC related to these items. This was discussed with the Administrator and DON.

Observed in Record Review. In 2 of 6 patient records reviewed, the plan of care (POC) did not include all treatments necessary to meet the patient's needs. In the chart for RR#2, the patient has a pressure relief mattress which is identified in the assessments, yet this intervention is not on the hospice POC. In the chart for RR#4, the RN indicated that walker use, and safety measures are in place for falls precautions, yet there were no patient specific interventions on the POC. Additionally, during the admission, the assessment revealed that the caregiver takes the patient's blood sugar as needed, yet this intervention is not on the POC, nor is there any indication that this was discontinued at the time of admission to hospice. The order for oxygen was not added to the POC. This was discussed with the DON and Administrator.

Observed in Record Review. In 1 of 6 patient records reviewed, the patient record did not contain any medications administered, including dose. In the chart for RR#5, during a RN visit, the nurse documented prn Morphine, Lorazepam and Hyoscyamine administered on this visit. This was discussed with the DON and Administrator.

Observed in Record Review. In 5 of 19 patient records reviewed, the hospice’s interdisciplinary group, in consultation with the patient’s attending physician, if any, had not completed the comprehensive assessment no later than five calendar days after the election of hospice care. In the charts for RRHV#2, RRNHV#5, RRNHV#9, RRNHV#10 and RRNHV#11, the Spiritual Care assessment that included all of the required elements, was not completed within first 5 days after election. This was discussed with the Director of Clinical Services.

Observed in Record Review. In 1 of 19 patient records reviewed, the organization had not documented a patient specific comprehensive assessment. In the chart for RRNHV#5, the initial comprehensive assessment did not include survivor risk factors. The initial bereavement risk assessment did not occur within the 5 days after the election of hospice as part of the comprehensive assessment as confirmed with the Director of Clinical Services.

Observed in Record Review. In 1 of 19 patient records reviewed, the hospice’s interdisciplinary group had not updated the comprehensive assessment in collaboration with the patient’s attending physician, if any, as frequently as the patient’s condition requires, but no less than every 15 days. In the chart for RRHV#4, 21 days passed between RN visits between the first and second benefit period. An LVN saw the patient once between the RN visits. This was discussed with the Director of Clinical Services.

Observed in Record Review. In 1 of 19 patient records reviewed, the patient record was not accurately documented. In the chart for RRNHV#8, approximately 2 months prior to the survey, the IDT plan of care (POC) update indicated the patient had refused further spiritual care visits. One month later (and in all subsequent IDT meeting notes) the SC input into the POC update indicated that the patient was being seen monthly with no change needed in the care provided. There was no documentation in the record to indicate any SC visits had been made or attempted since the documented refusal of services. Additionally, the nursing interventions taught included how to self administer insulin. The patient was not on insulin. This was discussed with the Director of Clinical Services.

Observed in Record Review. In 19 of 19 patient records reviewed, the written plan of care (POC) was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. It was verified with the Clinical Supervisor that the organization does not incorporate individualized goals on the POC. The organization had some patient specific goals in the discipline specific care plans, though not time based. There were no patient charts which had goals on the POC which included time frames for anticipated achievement, nor were there individualized goals related to specific symptom problems or safety risks such as falls, high risk medications and/or oxygen use. These findings included the charts for RRHV#1, RRHV#2, RRHV#3, RRHV#4, RRNHV#5, RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#9, RRNHV#10, RRNHV#11, RRNHV#12, RRNHV#13, RRNHV#14, RRDC#1, RRDC#2, RRBR#1, RRBR#2 and RRBR#3. Some examples included, in the chart for RRHV#1, Patient will follow an effective bowel program to prevent or relieve constipation. In a visit note, the RN instructed the patient to notify the hospice office if no BM in 3 days or change in usual This was a patient with history of multiple bowel obstructions needing to maintain soft stools at least daily. Additionally, Patient/caregiver will verbalize/demonstrate appropriate pain management. In the chart for RRNHV#6, examples of a missing time frame were: Patient/caregiver verbalizes/demonstrates use of positive coping mechanisms in dealing with depression and Patient demonstrates adequate use of positive coping mechanisms in dealing with hopelessness. The plan of care was not updated with a goal related to the safe use of oxygen when oxygen was added to the treatment plan. In the chart for RRHV#2, initial. The patient fell out of bed and fall prevention interventions were implemented, yet there was no goal related to fall prevention on the plan of care. In the chart for RRHV#3 goals were not time based and/or measurable including Caregiver will verbalize understanding/demonstrate measures to prevent/manage skin breakdown. Patient will have safety needs met.. In the chart for RRHV#4, the goal Caregiver will verbalize/demonstrate understanding of care required secondary to bowel incontinence lacked when that important safety goal would be anticipated to be met. In the chart for RRNHV#10, the private caregiver was changing the Foley catheter. There was no goal on the POC re: verifying the caregiver’s ability and technique to change the Foley catheter. The patient subsequently developed a UTI. This was discussed with the Director of Clinical Services.

Observed in Record Review. In 1 of 19 patient records reviewed, the plan of care (POC) did not include all services necessary for the palliation and management of the terminal illness and related conditions. In the chart for RRNHV#6, the current POC was updated with need for volunteer companionship and respite, however no frequency of those visits was included. This was discussed with the Director of Clinical Services.

Observed in Record Review. In 15 of 19 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: medications and treatment necessary to meet the patient's needs. In the chart for RRNHV#6, there were three medications all ordered prn for pain, Morphine, Acetaminophen and Tramadol without further clarity on when to use each. The order for Lantus read Inject 14 units subcutaneous daily for blood sugar <80. There was no indication that anyone clarified this order with the physician. The patient has been on service for more than 18 months. Oxygen was added approximately 15 months post admission. The plan of care was not updated with interventions related to instructing on oxygen safety, though the nursing care plan had these interventions added approximately 2 months post-order. In the chart for RRHV#1, oxygen 2lpm prn added to POC approximately 9 months post admission. The POC was not updated with any interventions related to oxygen safety. There was a history of repeated bowel obstructions with hospitalizations and Nausea was a problem for the patient upon admission. There were no interventions on the POC related to nausea other than medication, despite interventions in the nursing care plan. The patient had a fall risk of 5 at admission indicating she is at risk for falls. There were no interventions on POC re: falls and the POC was not updated when the patient transitioned from a walker to wheelchair due to decline for increased fall risk. The RN documented patient specific instruction to keep pathways clear, eliminate clutter, keep phone/items within reach, remove throw rugs, etc. In the chart for RRHV#2, the patient is bedbound with heels in soft boots and with the nursing staff educating the facility staff to turn the patient frequently per SN notes. These interventions are not on the POC. The patient required a hoyer lift for transfers. This is not on the POC. Falls precautions are in place due to patient turning and falling out of bed per SN note documentation, however no individualized fall prevention interventions are on the plan of care. In the chart for RRHV#3, there were no interventions on the POC related to measures to prevent and/or manage skin breakdown despite there being a goal related to this issue. In the chart for RRHV#4, there were no patient specific interventions on the hospice plan of care related to high fall risk simply stated, Hospice Nurse for assessment of patient safety, instruct safety measures as applicable. Patient had neuropathy, used a walker and had a history of falls. In the chart for RRNHV#5, the RN cleansed scalp staples and removed staples. No order was found for this treatment on the POC. The patient was at high risk for falls, had a history of frequent falls with injury yet the plan of care had no individualized fall reduction strategies. In the chart for RRNHV#7, the RN applied a condom catheter. This intervention was not on the POC. In the chart for RRNHV#8, the patient and family were assessed to be at high bereavement risk during the initial comprehensive assessment. There were no interventions on the POC related to this identified risk. In the chart for RRNHV#9, on admission, the patient had diarrhea several times per day, was at risk for falls with wounds related to a recent fall. There were no interventions on the POC for these identified problems nor for the dressing changes provided by the nurse at the first 2 nursing visits. A subsequent assessment indicated the patient wears compression socks to assist with edema, yet this was not part of the POC. In the chart for RRNHV#10, the patient was assessed to have significant anxiety issues. The RN is instructing on numerous interventions/techniques to assist with the problem, yet these interventions are not included on the POC. MSW interventions in the documentation are to assist with advance directives yet this intervention is not on the POC. In the chart for RRNHV#11, the patient had multiple falls with injury during the first benefit period. The interventions the RN implemented with the caregiver were not added to the POC. In the chart for RRNHV#13 Acetaminophen, Ibuprofen and Morphine were all ordered prn for pain without further clarity. Milk of Magnesia, Bisacodyl, Polyethylene Glycose all ordered prn for constipation without further clarity. The patient with history of frequent falls; no patient specific fall reduction interventions on POC. In the chart for RRNHV#14, the patient was getting protein shakes. This treatment was not on the POC. In the chart for RRDC#2, the patient had significant pain issues, requiring positioning per the assessment. There were no interventions except meds on the POC. The Physician noted in a routine visit note that the Aide was using a massage gun on the patient for complaints of pain. This intervention was not on the POC. This was discussed with the Director of Clinical Services.

Observed in Record Review. In 7 of 19 patient records reviewed, the plan of care was not revised based on updates to the comprehensive assessment and did not address progress toward goals. Examples included: In the chart for RRNHV#6, the patient had been on service for approximately 19 months at the time of survey. The current plan of care included goals such as A Medical Social Worker plan of care will be established. Patient/caregiver will verbalize/demonstrate compliance with medication regimen. which were added on the initial hospice plan of care and met in the first benefit period. In the chart for RRHV#1, in all of the multiple recertification plans of care, the goals had not been updated to reflect the attainment of goals including: Patient will follow an effective bowel program to prevent or relieve constipation. Patient/caregiver will verbalize/demonstrate appropriate pain management. In the chart for RRHV#2, the goals of patient/caregiver will verbalize understanding of effects of urinary incontinence. oxygen levels will be monitored as appropriate remain on the plan of care during the current, 5th benefit period POC despite the SN notes indicating that the caregivers had verbalized understanding of the effects of urinary incontinence during the admission visit. In the chart for RRHV#3, the goals of Caregiver will verbalize understanding/demonstrate measures to prevent/manage skin breakdown. Patient will have safety needs met. remain on all of the recertification plans of care with no documentation as to why these goals had not been met. In the chart for RRHV#4, the goal Caregiver will verbalize/demonstrate understanding of care required secondary to bowel incontinence remains on the POC since admission despite the nursing staff having documented the goal had been met early in the care of the patient. In the chart for RRNHV#8, there was no update of the POC at recertification. On the current POC which is for the 4th benefit period, it continued to have patient/caregiver verbalizes/demonstrates understanding of management of diabetes to prevent a diabetic event. which was met during the initial benefit period. In the chart for RRNHV#13, the goals that had been met in the first benefit period remained on the recertification plan of care. This was discussed with the Director of Clinical Services.

Observed in Record Review. In 1 of 19 patient records reviewed, the organization had not provided the patient with care, treatment, or services according to the patient's individualized plan of care. In the chart for RRHV#4, Spiritual Care visits were planned monthly, yet no visits were documented for the months of June or August of the current year. There was no documentation the team was notified, nor any indication why the visits were not made. This was discussed with the Director of Clinical Services.

Observed in Record Review. In 1 of 19 patient records reviewed, the registered nurse had not supervised the hospice aide during an on-site visit to the patient’s home no less frequently than every 14 days. In the chart for RRHV#4, 21 days passed between supervisory visits by the RN in the second benefit period. This was discussed with the Director of Clinical Services.

Observed in Tracer Activities. There was evidence that the governing body and leadership had not established requirements to support patient care treatment and services as evidenced by Condition level observations at 418.56 and 418.54. This was discussed with the Executive Director and leadership team.

Observed in Record Review. In 4 of 11 patient records reviewed, the chaplain and social worker failed to complete their initial assessments within five days after the election of hospice. In HV#1/RR#1 record review, the surveyor noted that the chaplain completed their assessment on Day 10 and the social worker on Day 8. In HV#2/RR#2 record review, the surveyor noted that the social worker completed their assessment on Day 7. In HV#3/RR#3, the surveyor noted that the social worker and the chaplain completed their assessment on Day 6. In RR#5, the surveyor noted that the social worker completed their initial assessment and the pre-bereavement risk assessment on Day 8. In all instances, there was no documentation to support a delay in assessment. This was confirmed by the Clinical Manager and the Administrator.

Observed in Record Review. In 2 of 11 patient records reviewed, the plan of care was not updated to reflect the patient's current identified needs. In RR#4, the surveyor noted that the patient's terminal diagnosis was protein calorie malnutrition; but the plan of care did not address altered nutrition. In RR#11, the surveyor noted that the patient was on 3.5 L of oxygen as per the visit notes, yet there was no order for oxygen. This was confirmed by the Administrator.

Observed in Record Review. In 4 of 10 patient records reviewed, the aide plan of care was not specific, individualized, and updated. During HV#1/RR#1, the surveyor noted that the aide care plan did not document specifically how the Hoyer lift was to be used (i.e. to also give shower). In addition, it did not address other tasks, such as shaving, washing hair, trimming nails, and dressing. In HV#3/RR#3, the patient was on oxygen yet the care plan did not address what to do with the oxygen during bathing and other activities, nor updated to provide wound care instructions for a new wound. In RR#5 and RR#6, the patient was on oxygen yet the care plan did not address what to do with the oxygen during bathing and other activities. This was confirmed by the Administrator.

Based on medical record review, staff interviews, and IDG notes, it was determined the agency failed to ensure care was coordinated and the IDG maintained responsibility for directing, coordinating and supervising care for 1 of 1 patients (#1) whose record was reviewed following a self reported adverse event investigation. This resulted in a failure of team members to notify the agency of ongoing concerns in response to patient needs. Findings include: Patient #1 was a 71 year old female, readmitted to the hospice agency on 6/23/21, with a terminal diagnosis of chronic obstructive pulmonary disease. She received SN, MSW, chaplain, and aide services. Patient #1 died on 9/15/21. 1. The agency's Adverse Event Investigation Report included a written statement from the MSW, written on 9/15/21, at 1:04 PM. The statement included: "[RN] and the POA let me know that they suspected neighbor [sic] might be stealing medications from the patient sometime in late July or early August". The statement also included: "The POA asked for my assistance to set up a camera ... I helped her select a camera and researched internet service and hotspots". Patient #1's IDG notes documented the following: a. IDG on 7/14/21; note signed by SW states: "Visits are moving to twice per month for support and resources. Plan of care reviewed with IDT and continues to meet patient and family goals of care". b. IDG on 7/28/21; note signed by SW states: "Visits one per month for social and emotional support, personal affairs and resources, and support to POA. Plan of care reviewed with IDT and continues to meet patient and family goals of care". It did not include any mention of communication with team members regarding patient #1's medication management or diversion concerns. Scribe note for IDG 7/28/21 states: "There was no more hydocodone[sic] missing. SW-supporting team with med management". c. IDG on 8/11/21; note signed by SW states: "Visits are once per month for social and emotional support and setting up PCS. Frequency changing to twice a month in September, plan of care reviewed with IDT and continues to meet patient and family goals of care". It did not include any mention of communication with team members regarding patient #1's medication management or diversion concerns. d. IDG on 8/25/21; note signed by SW states: "Visits are twice per month for social and emotional support, assitance[sic] with PCS, and other resources. Plan of care reviewed with IDT and continues to meet patient and family goals of care". It did not include any mention of communication with team members regarding patient #1's medication management or diversion concerns. e. IDG on 9/08/21; note signed by SW states: "Visits twice per month for social and emotional support, and support to hospice team with medication issues. Plan of care reviewed with IDT and continues to meet patient and family goals of care". It did not include any mention of communication with team members regarding patient #1's medication management or diversion concerns. f. IDG on 9/15/21; note signed by SW states: "Death reviewed with IDT". The MSW failed to communicate concerns with Patient #1's medication management or suspicions of neighbor involvement to the IDG. 2. The agency's "ABUSE, NEGLECT, AND EXPLOITATION" policy stated, "Any hospice staff member. contractor, or representative will ... Immedicately report an assessment of a patient's condition which might indicate abuse or neglect of a patient or misappropriation of patient property to the Hospice administrator." The agency's Adverse Event Investigation Report included a written statement from the RN, dated and timed at 9/16/21, at 2:03 PM. The RN stated, "Jul. [sic] 2nd is the first time [Patient #1] came up short on her hydrocodone." Additionally, the RN stated she had sent an email to "the team" which included, " WE ARE HAVING AN ISSUE WITH POSSIBLE THEFT OF MEDICATION ... WE ARE INSTALLING A CAMERA ASAP." Patient #1's record did not include the RN's concerns regarding suspicions of medication diversion or the placement of cameras in her home. Patient #1's IDG reports for June thru September 2021 did not include documentation of the RN's concerns. During an interview on 10/18/21 at 8:50 AM, The Administrator, who was the acting DON, stated the RN did not communicate to him or the IDG team her suspicions of Patient #1's missing medication and the installation of the cameras until after Patient #1 died on 9/15/21. He stated the RN came to his office to tell him about the incident and told him, "You are not going to like this. You are probably going to fire me." The agency's Adverse Event Investigation Report documented the agency placed the RN on administrative leave on 9/16/21, pending the investigation. The RN was terminated on 9/17/21. The report documented staff were provided with in-service education regarding the agency's policies and procedures for the reporting of abuse and medication incidents, medication monitoring, and scope of practice for clinical personnel. The agency failed to ensure Patient #1's care was coorinated and surpervised.