Every finding on record at Above and Beyond Home Health and Hospice Care

Observed in Record Review. In 3 of 3 patient records reviewed, for bereavement services it was noted that there had been no post death bereavement risk assessment documented as outlined in agency policy Bereavement Services. This was discussed with the hospice director.

Observed in Record Review. In 2 of 19 patient records reviewed, it was noted that in hospice record review #7 the patient was receiving Warfarin however the hospice plan of care did not contain any problem, interventions or goals related to the management of anticoagulant therapy or monitoring of PT/INR. In another example, in hospice record review #8 it was noted that the medication sheet contained duplicative orders, for example, Miralax daily and Miralax daily PRN. This was confirmed by the staff member assisting with record review.

Observed in Tracer Visit. In 1 of 4 home visits conducted, it was noted that hand hygiene guidelines were not followed. For example, in hospice home visit #3 the hospice aide was observed applying hand sanitizer to his hands and then waving his hands in the air. This was observed by the hospice director present on the visit. Observed in Tracer Visit. In 1 of 4 home visits conducted, it was noted that bag technique was not followed per agency policy which stated that the bag be placed on a clean dry surface in the home. For example, in hospice home visit #2 the nurse was observed placing her backpack containing nursing supplies onto the seat of a chair which was ripped and torn in multiple areas as if slashed with a sharp object. This was observed by the director of hospice present on the visit.

Observed in Record Review. In 1 of 3 patient records reviewed, for bereavement services it was noted that in bereavement record #2 the plan of care did not reflect the needs of the bereaved as it was not individualized to include more frequent calls/visits which were planned by the bereavement coordinator. This was discussed with both the bereavement coordinator and the hospice director.

Observed in Record Review. In 2 of 19 patient records reviewed, it was noted in bereavement record #2 that although phone calls were made with the bereaved, they were not documented in the record. This was confirmed by the bereavement coordinator and discussed with the hospice director. In another example, in hospice record review #6 it was noted that for this patient with ascites at start of care, there was no documentation of baseline abdominal girth. This was confirmed by the staff member assisting with record review.

Observed in Tracer Visit. In 1 of 16 patient records reviewed, in hospice home visit #1 it was noted that the Individualized Emergency Plan in the home had not been completed. This was confirmed by the hospice director present on the visit.

Observed in Document Review. During review of contract for general in-patient care it was noted that the contract did not contain a statement:That the record will include documentation of all inpatient services and events and that a copy of the discharge summary and, if requested, a copy of the record will be provided to the hospice. This was discussed with the hospice director.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the Interdisciplinary Group performed an accurate and complete drug regimen review for 4 of 19 sampled patients (Patients #2, #12, #15, and #18). Failure to ensure the interdisciplinary group (IDG) members involved in the assessment of patient needs identified actual or potential issues when performing the drug regimen review (DRR) with each update to the comprehensive assessment increased the risk of unidentified side effects and actual interactions of medications. --- 3. Patient #12 had a hospice admission date of 2/9/24 and received hospice services while residing in an assisted living facility. Clinical record review revealed: a. The Plans of Care, dated 2/9/24 to 5/8/24 and 5/9/24 to 8/6/24, included physician orders for miralax and senna (bowel medications) and finasteride and myrbetriq (benign prostatic hypertrophy medications). b. The Interdisciplinary Group meeting notes, dated 2/14/24, 4/10/24, 4/24/24 and 5/22/24, included a drug regimen review that identified no duplicate drug therapy. The drug regimen reviews failed to identify the duplicate bowel and benign prostatic hypertrophy medications. 4. Patient #15 had a hospice admission date of 7/19/23, a revocation date of 9/27/23 and received hospice services while residing in a private home. Clinical record review revealed: a. The Plan of Care, dated 7/19/23 to 10/16/23, included physician orders for lunesta and trazodone (sleep medications) and sertraline and seroquel (antidepressant medications). b. The Interdisciplinary Group meeting notes, dated 7/26/23, 8/9/23, 8/22/23, 9/6/23 and 9/20/23, included a drug regimen review that identified no duplicate drug therapy. The drug regimen reviews failed to identify the duplicate sleep and antidepressant medications. The Administrator received the above findings. Hospice staff provided no further information prior to the end of the survey. Findings include: The hospice's policy, titled Hospice - Care Planning Process, dated 4/1/2020, identified upon completion of the initial assessment visit and prior to providing care, the hospice develops the Plan of Care with input from the physician(s) and IDG (interdisciplinary group), in collaboration with patient and family. The IDG completes the Comprehensive Assessment in consultation with the attending physician with five (5) calendar days of the notice of hospice election. The content of the comprehensive assessment includes: a drug profile including over the counter drugs, herbal supplements, and alternative treatments. The drug profile will be reviewed for: effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy and drug therapy currently associated with laboratory monitoring. 1.Patient # 2 had a start of care date 2/26/24, and received hospice services in the home. a. During a home observation visit, 6/3/24 at 12;30 pm with Staff F, RN (Registered Nurse), The patient's caregiver indicated they were using A/D ointment on patient's coccyx on a regular basis, the caregiver also indicated they were using good feet lotion daily on patients feet. b. The Plan of Care, dated 5/26/23-8/23/23, included orders for medications, but lacked orders for the A/D ointment and the good feet lotion. c. The Medication Profile, last updated on 5/6/24, failed to identify the A/D ointment and the good feet lotion. d. During an interview with Staff F on the home observation visit, she acknowledged the Medication Profile failed to include the A/D ointment and the good feet lotion. e. The drug regiment review completed on 5/22/24 failed to include these medications as part of a comprehensive review of all medications. 2. Patient #18 had a start of care date of 6/29/23, a death date of 7/723 and received hospice services in a skilled nursing facility. a. Clinical record review identified the Initial IDG (Interdisciplinary group) conference was held on 7/5/23, The IDG failed to address an initial drug regimen review as part of the initial comprehensive assessment.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to document required hospice aide supervision every 14 days when the patient receives skilled services in conjunction with the hospice aide services for 2 of 5 sampled patients (Patients #13 and #15) with hospice aide services for 14 days or longer. Failure to ensure the supervision of hospice aide by registered nurses completed according to regulation increased the risk of agency staff not meeting the patients' personal care needs. --- Findings include: According to the hospice policy, titled Hospice - Supervision of Hospice Health Aides, dated 10/27/23, supervision is completed by a registered nurse in the patient's care setting at least every 14 days. 1. Patient #13 had a hospice admission date of 2/23/24 and received hospice services while residing in a private home. Clinical record review revealed: a. The Plan of Care, dated 2/23/24 to 5/22/24, included orders for hospice aide and skilled nursing services. b. The skilled nursing visit notes, dated 4/8/24 and 4/23/24, included documentation the nurse supervised the hospice aide, 15 days apart, (1 day late). c. The skilled nursing visit note, dated 4/15/24, failed to include documentation the nurse supervised the hospice aide. The hospice failed to document aide supervision every 14 days. 2. Patient #15 had a hospice admission date of 7/19/23, a revocation date of 9/27/23, and received hospice services while residing in a private home. Clinical record review revealed: a. The Plan of Care, dated 7/19/23 to 10/16/23, included orders for hospice aide and skilled nursing services. b. The skilled nursing visit notes, dated 8/8/23 and 8/23/23, included documentation the nurse supervised the hospice aide, 15 days apart, (1 day late). c. The skilled nursing visit notes, dated 8/11/23, 8/15/23 and 8/18/23, failed to include documentation the nurse supervised the hospice aide. The hospice failed to document aide supervision every 14 days. The Administrator received the above findings.

Based on review of written contracts and staff interview, the hospice failed to ensure the written agreement between hospice and durable medical equipment was complete and accurate for 2 of 4 services under contract. Failure to have complete and accurate contracts for hospice services increases the potential that hospice management and oversight could fail to occur and the patient would not receive services as specified on the plan of care. Findings include: --- Review of the contract between hospice and their pharmacy dated 2/7/24 identified the contract was missing verbiage in the following provisions: Hospice retains administrative management. Hospice retains financial management. Hospice retains oversight of staff and services. All services authorized by the hospice. 2. Review of the contract between hospice and their durable medical equipment provider dated 2/1/23 identified the contract was missing verbiage in the following provisions: Hospice retains administrative management. Hospice retains financial management. Hospice retains oversight of staff and services. All services authorized by the hospice. All services are furnished in a safe and effective manner by qualified personnel. All services delivered in accordance with the patients plan of care. In an interview on 6/3/24 at 8:10 AM, the Administrator reported that the pharmacy contract is used for Home Health mostly but understands the verbiage needs to be here if using for hospice. The above findings were reviewed with the Administrator, Business Office Coordinator, and Hospice Admission Coordinator.

Based on clinical record review, nursing home clinical record review and hospice staff interview, the hospice failed to ensure the hospice medication list matched the nursing home medication administration record for 1 of 1 sampled patients (Patient #1) with home observation visit in nursing homes. Failure to ensure the hospice staff provided the required documentation to the nursing home staff placed the patient at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient. --- Findings include: During an interview on 5/29/24 at 10:00 AM, Staff D, Hospice Admission Coordinator reported the hospice registered nurses try to review the medication administration records every visit for patients in nursing homes. Patient #1 had a hospice admission date of 4/12/24 and received routine hospice services while residing in a nursing home. On 5/28/24 at 11:45 AM, during a home visit observation with Staff E, RN (registered nurse) the surveyor received a copy of the medication administration record. The medication administration record included physician orders for acetaminophen 650 milligrams (mg) by mouth every 4 hours as needed for pain or fever effective 3/21/22 and enema disposable enema insert 1 suppository rectally every 24 hours as needed for constipation effective 6/1/21. Clinical record review revealed: a. the hospice medication list included physician order for acetaminophen 325 mg tablets 2 tablets every 6 hours as needed for pain or fever. b. the hospice medication list lacked documentation of a physician order for enema/rectal suppository. The Administrator received the above findings.