Every finding on record at A Care Hospice Inc

Upon patient record review, 3 of 14 (Patients #1,#3,#4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications Patient 1: The medication profile contained A&D and Calmoseptine topical ointments with no area defined for administration, and Miralax oral powder with no instructions for a diluent. Corrected on site. Patient 3: The medication profile contained Miralax oral powder with no instructions for a diluent. Corrected on site. Patient 4: The medication profile contained oxygen with no delivery method.

Upon patient record review, 1 of 14(Patient #5) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 5: The medical record contained RN visits 9/2/23, 10/9/23, and 11/4/23. There was no evidence of continuous oversight and assessment by the RN.

Upon patient record review, 1 of 14 (Patients #4) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 4: The medical record contained documentation identifying an order for nystatin oral medication was received 2/12/22 upon request from the patient's daughter. There was no evidence of an assessment by the RN and no assessment for effectiveness of the medication. The record also contained documentation of IV fluid administration 2/6/22 and 2/7/22. There was no evidence of an assessment by the RN to examine the IV site and patient tolerance of the fluids, and no documentation of IV removal.

Upon patient record review, 5 of 14 (Patients #1,#2,#8,#9,#10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1: The medical record contained nursing documentation 11/5/23 identifying patient requires thickened liquids for aspiration precautions and the patient also was receiving spiritual care visits by the chaplain. There was no evidence of problems, goals, and interventions related to risk for aspiration and spiritual care. Corrected on site. Patient 2: The patient was receiving spiritual care visits. There was no evidence of problems, goals, and interventions related to spiritual care. Corrected Patient 8: The patient was receiving social work and spiritual care visits. There was no evidence of problems, goals, and interventions related to psychosocial and spiritual care. Patient 9: The patient was receiving social work visits. There was no evidence of problems, goals, and interventions related to psychosocial care. Patient 10: The patient was receiving social work and spiritual care visits. There was no evidence of problems, goals, and interventions related to psychosocial and spiritual care.

Upon patient record review, 3 of 14 (Patients #1,#3,#4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: The medical record contained orders for A&D and Calmoseptine topical ointments with no area defined for administration, and an order for Miralax oral powder with no instructions for a diluent. Corrected on site. Patient 3: The medical record contained an order for Miralax oral powder with no instructions for a diluent. Corrected on site. Patient 4: The medical record contained an order for oxygen with no delivery method.

Upon client record review, 5 of 14 (Patients #2,#3,#4,#5,#6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: The medical record contained an ordered social work visit frequency of one visit every recert. There was no evidence of social work visits since 3/31/23. Patient 3: The medical record contained an ordered spiritual care visit frequency of one visit every recert. There was no evidence of a spiritual care visit during benefit period 3. Patient 4: The medical record contained an ordered nursing frequency of once weekly. There were 2 visits completed the weeks of 1/15/22, 1/29/22, and 2/5/22. There was no evidence of an ordered spiritual care frequency. There was one spiritual care visit completed 2/18/23. Patient 5: The medical record contained an ordered spiritual care visit frequency of one visit every recert. There was no evidence of a spiritual care visit between 3.13.23 and 10.11.23 Patient 6: The medical record contained an ordered nursing frequency of once weekly. There were 2 visits completed each week of October 2023.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence the hospice offers bereavement counseling that includes: • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 5: There was no evidence of a bereavement plan of care. Corrected on site.

Upon patient record review 1 of 14 (Patient #1) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 1: There was no evidence of an aide supervisory visit between 11/19/23 and 12/6/23.

Upon client record review, 14 of 14 (Patients #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11,#12,#13,#14) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed.

Upon observation, there was no evidence the hospice provides orientation to personnel of a SNF/NF or ICF/IID regarding the policies and procedures of the provision of care/service including all required content.

Observed in Record Review. In 4 of 4 patient records reviewed, it was noted that the patient goals and interventions were not specific, measurable and with an appropriate time frame for achievement. For example, in record RR#2 and HV#1 there were documented goals and interventions for the medical social worker, however there were no visits after the comprehensive visit and no orders for visits. In record RR#3 there were documented goals and interventions for the MSW and the Spiritual Counselor, however there were no visits after the comprehensive visit and no order for visits. Other examples include; 'Be able to cope with changes of the declining health of patient' 'maintain optimum peripheral circulation' 'Minimize complications due impaired mobility'. This was confirmed with the DON.

Observed in Record Review. In 2 of 4 patient records reviewed, the surveyor noted that hospice aide supervision had not been completed every 14 days. For example in record RR#1 twice 16 days past between supervisory visits and one time 17 days. In record RR#2 one time there was 21 days between supervisory visits and one time 18 days. This was confirmed with the DON.

Observed in Patient Home. In 4 of 4 patient records reviewed, and during 1 of 1 home visits it was noted that the organization had not provided education for individualized DISASTER plan. For example, in HV#1 the home record contained a copy of general disaster education, but not an individualized plan. This was confirmed with the DON present.

Observed in Record Review. In 2 of 11 patient records reviewed, an Initial bereavement assessment had not been completed. During review of Hospice HV #3 and RR #4, the patient had not had an Initial Bereavement Risk assessment completed and no available bereavement documentation identified in the patient record. This was validated with the Hospice Director and the Chaplain.

Observed in Record Review. In 11 of 11 patient records reviewed, the Surveyor noted the patient goals and interventions were not specific, measurable, or with an appropriate time frame for achievement. Examples include, Optimal blood sugar management for pt. comfort. Pt needs will be met on a day to day basis as communicated. Pt will maintain optimum peripheral circulation adequate hydration. Goals for cardiac issues r/t HTN- Pt will verbalize and/or express decreased episodes of chest pain Pt will maintain optimum peripheral circulation. NIDDM- Assess Pt. status for on-going care. Optimal blood sugar management for pt. comfort. This was validated with the Director of Nursing.

Observed in Record Review. In 4 of 11 patient records reviewed, the Surveyor noted patients had multiple medications for same clinical symptom without specific indications for use. For example, during medication review for HV #1, the patient had Norco 10mg-325mg PRN severe pain, and Roxanol 20mg/ml 0.25 ml every 2 hours as needed pain. RR #6, the patient had Gabapentin 300mg Tab, pain for mild to mod; Ibuprofen 800mg prn moderate pain and Norco 10mg-325mg Tab for moderate to severe pain without what constitutes pain, mild, moderate-severe pain. The patient also had Diclofenac 1% cream ordered to 'apply to affected area'. Similar medication orders were also found in RR #8 and RR #9. This was validated with the Director of Nursing. Observed in Patient Home. In 2 of 3 home visits conducted, the patient had medications in the home that had not been included on the medication profile. for example, in HV #1 the patient had been administering insulin 15 units daily, but the hospice had not know of the medication. in HV #3, the patient reported taking Tylenol as needed for back pain, but this medication had not been on the medication list. Putting OTC medications had not been a part of their medication reconciliation process. This was validated with the Director of Nursing. Observed in Record Review. In 2 of 11 patient records reviewed, The Surveyor noted the patient had been prescribed a High Risk medication; however, there had been no interventions related to patient safety and education. For example in HV # 1, the patient had been prescribed insulin, but there had been no documented patient education. HV #2, the patient had been taking Clopidogrel, a blood thinner, and no high risk medication interventions and education had been provided. This had been validated with the Director of Nursing.

Observed in Patient Home. In 3 of 3 home visits conducted, the Surveyor observed clinicians utilize a clip board for documents and had not demonstrated post visit disinfection. In HV #1, HV #2 and HV #3, the clip boards were set on counters or beds without a barrier and utilized through out the visit (to record vital signs or other information). At the end of the visit, clinicians handed the clip board to the patients to obtain signatures. The clip boards had also been touched with the clinician wearing gloves used in patient care. The clip boards had not been disinfected prior to leaving the site of care per the organization policy. One clip board utilized in HV #2 was a porous type. This was validated with the Director of Nursing.

Observed in Tracer Activities. During a review of the Volunteer Program, the Volunteer Coordinator indicated that she had been the only volunteer since 2019. She described talking with others about volunteering; however, there had been no recruitment documentation to validate the activities. The agency also had no marketing flyers for volunteer recruitment. Of note, she created a flyer about volunteer services and was working on a recruitment plan by the end of survey. This was validated with the Volunteer Coordinator.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: - §418.100 and §418.102(b)(3)-(L677) and (L655), §418.100 (L649), §418.100(b)- (L651) and §418.111(798).

Observed in Record Review. In 6 of 11 patient records reviewed, the Surveyor noted the visit frequency had not been followed. For example, in HV #1 the Spiritual Care and Medical Social Work visit orders had been for 1x/month; however, the visits frequently occurred every other month, or skipped multiple consecutive months. The Nursing visits had been ordered for 1x/week, and 1 prn; however, there had been several weeks where the visits occurred 2 times per week. This was also seen in RR #4, RR #6, RR #7, RR #9 and RR #11. This was validated with the Director of Nursing.

Observed in Patient Home. In 3 of 3 home visits conducted, The surveyor noted the patient clinical diagnosis and actual presentation did not match criteria for hospice benefit qualification. The patients in HV #1, HV #2 and HV #3 had not demonstrated the clinical requirements for Hospice. For example, the patient from HV #1 had a diagnosis of Hypertensive Heart Disease, and had been on service for 406 days. The patient presented ambulatory and able to care for himself with minimal support. KPS and PPS scores were > 70%, and he reported no episodes of chest pain or issues with his blood pressure. HV #2, the patient had a primary diagnosis of Alzheimers disease; however the patient had a KPS and PPS score of >70 and a documented FAST score of 7; however, the observed patient FAST score was <6 as the patient had been able to bath, dress and feed herself, as well as managed her own complex medication regimen without support. The patient carried on a full conversation, including recollection of dates and clinician names. HV #3 the patient had a diagnosis of COPD and had been on service for 839 days (11 certification periods), but was fully ambulatory, speaking without any shortness of breath, denied SOB with ambulation and utilized his nebulizer infrequently. His primary concern was his low back pain from multiple injuries and he wanted to see a chiropractor. There is also a noted misuse of the NYHA Heart Failure classifications. Patients who are without a Heart Failure diagnosis are classified as NYHA IV on the CTI. All of the patient CTI's expressed the patient's had a prognosis of six months or less. Discussed this finding with the Medical Director who validated the concerns related to patients qualifying for the hospice benefit. The Medical Director stated the patient's qualified for Palliative Medicine. These findings were validated with the Director of Nursing.

Observed in Patient Home. In 2 of 3 home visits conducted, The patient had a medication in the home that had not been included on the medication profile. During HV #1, the medication Insulin 100u/ml 15u SQ daily was located in the patient refrigerator that had been prescribed and administered to the patient; however, this medication had not been included on the medication profile. When the clinician was questioned, she reported that the medication had been prescribed by a non-hospice physician, so not on the hospice medication profile. During HV #3, the patient reported taking Tylenol for his back pain this morning. This medication had not been included on his medication profile. Discussed with the agency the medication reconciliation policy, and the inclusion of OTC medications had not been a part of their process. This was validated with the Director of Nursing.

Observed in Record Review. In 10 of 11 patient records reviewed, it was observed that clinical documentation had not supported the requirements for coverage under the Medicare Hospice Benefit—which is being billed. In discussion with the Medical Director, he stated that “they qualify for palliative medicine not hospice”. She then noted that the CTIs signed by him stated that the patients had 6 months or less to live to which he again replied that “he practices palliative medicine”. He was then informed that palliative care was not billable under the Medicare Benefit and that there is no where in the documentation that the patient is on palliative care rather than on hospice to which he replied that “it was for the agency to figure out”. Thus, the organization was found not to be in compliance with Law and Regulation.