Every finding on record at A Plus Hospice Care Inc

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted the organization did not ensure that a thorough and ongoing medication reconciliation process was conducted. It was observed during home visits HOSRRHV#1 medication reconciliation was not completed during this visit. The nurse reported that medication reconciliation had been performed during the prior week's visit. The Hospice Director confirmed that medication reconciliation is conducted on every visit as per policy. This finding was discussed and validated by the Hospice Administrator.

Observed in Record Review. In 6 of 6 active patient records, it was noted the organization failed to ensure that the hospice plan of care plan includes all services needed for the palliation and management of the terminal illness and related conditions, including medications necessary to meet the patient’s needs. Upon review of the records, multiple PRN pain medication ordered to be given for pain without specifying which PRN medication should be administered based on defined parameters. For example, in records of HOSRRHV#1, HOSRRHV#2, HOSRRHV#3, HOSRRNHV#1, HOSRRNHV#2, and HOSRRNHV#3, these patients were taking: Acetaminophen 650 mg 1 suppository every 6 hours as needed for pain and Morphine Sulfate IR 20mg/ml 15 ml SL every 2 hours as needed for pain. This finding was discussed and validated by the Hospice Director

Observed in Record Review. In 2 of 6 active patient records reviewed, it was noted the organization failed to ensure that the care and services are provided in a accordance with the plan of care. For example, in review of record HOSRRHV#1, the hospice nurse was ordered to see patient 2 x per week, however, only one visit completed by LVN during the second week of benefit period #1. Also noted, the hospice aide was ordered to see patient 2 x per week, however, only one visit completed during the first week of benefit period #1. Another example in HOSRRHV#3, the hospice aide was ordered to see patient 2 x per week, however, only one visit completed during the first week of benefit period #1. Also noted, the skilled nurse was ordered to see patient 2 x per week, however, only one visit completed by LVN during the second week of benefit period #1. This finding was discussed and validated by the Hospice Director.

Observed in Record Review. In 4 of 5 active patient records with hospice aide services, it was noted the organization had failed to ensure that the written patient care instructions for a hospice aide must be prepared by a registered nurse who is responsible for the supervision of a hospice aide. For example, in record of HOSRRHV#1, the patient was on oxygen at 3 LPM via nasal cannula and G-tube feeing due to Dysphagia, however, the hospice aide care plan did not include additional instruction such as whether the oxygen could be removed for the bath, and to observe aspiration precaution secondary to g-tube feeding. Another example in HOSRRHV#2, no additional written instruction on the aide care plan such as oxygen precaution and bleeding precaution (patient had been taking Aspirin). HOSRRHV#3, HOSRRNHV#1, no additional instructions written in Aide CP related to home oxygen if aide was allowed to take it off and for how long while bathing/showering. This finding was discussed and validated by the Hospice Director.

Observed in Record Review. In 1 of 6 active patient records with hospice aide services, it was noted the organization failed to ensure that hospice aide supervision was conducted at the patient's home no less than every 14 days as required. During review of record of HOSRRNHV#1, there was no evidence documented that the hospice aide had been supervised by the registered nurse on the 3 week of benefit period #1. This finding was discussed and validated by the Hospice Director.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization did not plan the patient's care for all services needed for the palliation and management of the terminal illness and related conditions, including drugs and treatments necessary to meet the needs of the patient. In RR#2, the patient's plan of care included Bisacodyl Suppository, Docusate Sodium, and Lactulose prn for constipation with no clear indications for use (which prn medication to administer when for constipation). In RR#4, the patient had an indwelling foley catheter with documented complications. The foley catheter order did not indicate the size of catheter/balloon. This was reviewed and verified with QAPI Coordinator.

Observed in Record Review. In 1 of 7 patient records reviewed, services were not provided according to the plan of care. In BR#1, per the Post-Death Bereavement Assessment, the family requested no further bereavement mailings. It was documented in the hospice EMR that three (3) subsequent bereavement mailing had been sent to family after this request. This was reviewed and verified with QAPI Coordinator.

Observed in Patient Home. In 3 of 3 home visits conducted, the hospice did not provide written information to patients and families on their advance directive policy, nor was education about it documented in the patient records. This observation was reviewed with the Administrator and Director of Nursing.

Observed in Proficiency Testing. In 1 of 11 patient records reviewed, the organization failed to document initial bereavement assessments as part of the comprehensive assessment. For example, in the record of RR#3 an initial bereavement assessment was not completed and documented. This observation was reviewed with the Administrator and Director of Nursing.

Observed in Record Review. In 11 of 11 patient records reviewed, revisions to interdisciplinary meeting notes did not include comprehensive assessments that documented decline, revisions to plans of care, and goals. For example, the nursing documentation was the same in most notes. Spiritual care and psychosocial notes stated: “continue plan of care as ordered”. This was found in records where services were provided as well as records where services were declined. This observation was reviewed with the Administrator and Director of Nursing.

Observed in Record Review. In 1 of 11 patient records reviewed, the patient record was inaccurate. For example, in the record of HV#3 a nurse practitioner documented in her telehealth face-to-face notes that the patient had consistently lost weight since admission 11 months earlier. However, documentation in all nursing comprehensive reassessments consistently recorded the patient’s mid arm circumference at 20.5 centimeters during that same time frame. This observation was reviewed with the Administrator and Director of Nursing.

Observed in Record Review. In 11 of 11 patient records reviewed, goals did not have individualized time frames for completion. The surveyor found that all interdisciplinary group meeting notes had goal completion dates for the next meeting. Additionally, spiritual care and psychosocial services did not document goals for any patient. This observation was reviewed with the Administrator and Director of Nursing.

Observed in Record Review. In 7 of 11 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. For example, in the record of RR#1 a nurse wrote that she removed a foley catheter, but there was no order to do so. In the records of HV#2, RR#1, RR#2, RR#3, RR#4, and RR#6 prn visit orders were incomplete because there were no documented reasons for the extra visits. And in the record of RR#7 it was written that the patient was using 3 liters of oxygen via face mask. It was also noted that skilled nurse visits were made daily in the seven days before the patient died. There were no orders for the face mask or the extra visits. These observations were reviewed with the Administrator and Director of Nursing.

Observed in Record Review. In 3 of 11 patient records reviewed, services were not provided according to the plan of care. For example, in the record of HV#1 psychosocial services were declined, however visits were made and documented for two months. In the record of HV#2 a comfort kit was ordered at admission but had not been provided to the patient at the time of the home visit six weeks later. And in the record of RR#8 it was found that to date, all scheduled bereavement letters have been mailed, despite the family requesting not to receive them. These observations were reviewed with the Administrator and Director of Nursing.

Observed in Record Review. In 1 of 11 patient records reviewed, all disciplines that provide services to the patient did not collaborate in the care of the patient and coordinate their efforts. For example, in the record of RR#3 the social worker who was also responsible for completing the initial bereavement assessment documented that the patient declined services. The spiritual counselor did not complete the bereavement risk assessment when he next visited the patient. This observation was reviewed with the Administrator and Director of Nursing.

Observed in Leadership Session. The organization did collect and aggregate data, but could not provide documentation to show that it was analyzed and used to improve services. This observation was reviewed with the Administrator and Director of Nursing.

Observed in Leadership Session. The organization did not have a hospice wide quality assessment and performance improvement program to evaluate. This observation was reviewed with the Administrator and Director of Nursing.

Observed in Competency Session. During the HR competence session, it was learned that competency for the CHHA had not been correctly assessed in more than three years of employment. Documentation did not specify how competence was evaluated. According to the employee’s file, each skill was assessed through demonstration, observation, and verbalization, including those specifically required by Medicare to be demonstrated. This observation was reviewed with the Administrator and Director of Nursing.

Observed in Leadership Session. Leaders did not manage implementation of patient care policies and procedures governing the provision of hospice care. Documentation failures were identified in the following: bereavement risks; required assessments and reassessments; progress towards goals; plan of care revisions; emergency preparedness activities; and performance improvement. These omissions resulted in condition level findings that were reviewed with the Administrator and Director of Nursing.

Observed in Competency Session. During the HR competence session, it was learned that competency for the Bereavement Coordinator was not assessed at hire. This observation was reviewed with the Administrator and Director of Nursing.

Observed in Leadership Session. The organization did not protect health information. During medication reconciliation at HV#2 the surveyor learned that the comfort kit could not be located. Several hours after the survey day had ended a hospice leader sent a text message to the surveyor that the comfort kit had been found. Attached to the message was a picture of the six medications in the comfort kit that showed the patient's name, prescription number, names of the medications and directions for use. This activity was reviewed with the Administrator.

Observed in Patient Home. In 3 of 3 home visits conducted, the organization did not ensure that the patient, patient’s representative, and family were educated on the hospice’s policies and procedures for managing the safe use and disposal of controlled medications. In all three home visits made, the patient handbook had information on narcotic disposal, but did not include a copy of the narcotic use and disposal policy, nor was there documentation of education on the policy having been provided. This observation was reviewed with the Administrator and Director of Nursing.

Observed in Competency Session. During the HR competence session, it was learned that the license of the MSW was not verified at hire. The license was issued two and a half months after she was hired. This observation was reviewed with the Administrator and Director of Nursing.