Every finding on record at Absolute Palliative Care LLC

Condition of Participation: Emergency Preparedness

Upon observation, there was no evidence the hospice has developed and maintained an emergency preparedness plan that must be reviewed, and updated at least every two years. The emergency preparedness plan was last reviewed May 23,2020.

Upon review of policy and procedure, Emergency Operations Plan did not include that the hospice must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in standard HSP7-4B and the communication plan in standard HSP7-4C The policies and procedures must be reviewed and updated every two years. The agency has an Emergency Operations Plan though it was last revised May 23,2020.

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon observation, there was no evidence of emergency preparedness training and testing program that is based on the emergency plan, policies and procedures and the communication plan. There is no evidence the training and testing of the program every 2 years, last performed in 2020.

Upon personnel record review, 8 of 10 (Personnel #1,2,3,4,5,6,7,9,10 ) did not have evidence Emergency Preparedness training including: Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years, last performed in 2020.

Upon patient record review, 2 of 14 (Patient #1,2) did not have evidence of the appropriate documentation for release of confidential information. Patients 1,2: The nursing administrator was providing surveyor with evidence of a visit by showing text messages that included PHI of patients. There is no evidence the cellular phones text messages are secure.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 1 of 14 (Patient #7) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Patient 7: The comprehensive assessment contains the head to toe assessment and the following assessment areas were left blank: cardiac, immunological/infection, neurological/mental, nutrition, endocrine, GU, Sleep rest,musculoskeletal, personal care/support needs, teaching needs.

Upon patient record review 1 of 14 (Patient 7) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 7: The comprehensive assessment did not contain evidence of psychosocial evaluation within 5 days of SOC. The RN did not complete an assessment of the patients psychosocial needs during the comprehensive assessment either.

Upon patient record review, 1 of 14 (Patient 7) did not have evidence in the patient record that the comprehensive assessment takes into consideration the patient's functional status including patient's ability to understand and participate in their own care. Patient 7: The comprehensive assessment does not contain evidence the RN considered patient's functional status including patient's ability to understand and participate in their own care.

Upon patient record review, 13 of 14 (Patient 1,2,3,4,5,6,7,8,9,10,11,12,13) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Upon patient record review, 1 of 14 (Patient 3) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: Patient 3:The medication profile contains Polyethylene Glycol with no diluent.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 7: The comprehensive assessment did not include a bereavement assessment.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 1 of 14 (Patient 8) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient 8: The nurse documents on 07/18/22 "Pt states she has trouble breathing". There is no evidence the nurse educated pt or family on interventions to relieve dyspnea.

Upon patient record review, 1 of 14 (Patient #1) 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 RN documents pt is dependent on walker and cane in comprehensive assessment 04/16/23 and has weakness there is no evidence of a fall care plan.

Upon patient record review, 2 of 14 (Patient 3 and 7) 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 3: The POC contains Polyethylene Glycol with no diluent. Patient 7: The RN documents on 07/29/22 "Supplemental O2 at pt bedside if needed". There is no evidence of an order for O2 on the POC.

Upon patient record review, 1 of 14 (Patient #5) 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 equipment and supply needs. Patient 5: The nurse documents pt has a Hoyer lift on 01/27/23, and a w/c on 05/30/23 and there is no evidence these DME items are on the POC.

Upon client record review, 10 of 14 (Patient 3,5,6,7,8,9,10,12,13,14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: The POC contains an order for a PT eval on 4/12/23. There is no evidence the PT eval was completed. PT entered note late during survey. Patient 5: The POC contains an order for PT starting 02/08/23 every other month. The eval took place 01/10/23, there is evidence the PT saw the pt on 02/08/23,02/27/23,03/06/23, 03/15/23 and then stopped coming and there was no evidence of an order to increase the visits or an order to discontinue PT visits. The POC does not contain nursing visit orders and there is evidence in the medical record of the nurse visiting the patient weekly since SOC (corrected on site). The RN documents MSW declined on comprehensive assessment and POC, there is evidence the MSW saw pt on 02/08/23 there is no evidence of an order for this visit. Patient 6: The POC contains an order for MSW 1 time a month for 3 months beginning 12/29/22. There is evidence MSW saw pt on 12/29/22 and 01/13/23. There is no evidence the MSW saw pt after the 01/13/23 visit and there was no discharge order or refusal of visit documented. Patient 7: The POC contains an order for MSW 1 time a month for 3 months beginning 9/15/22. There is evidence the MSW saw pt on 10/11/22,11/29/22,12/15/22,01/10/23. There is no evidence of an order for the fourth month visit. Patient 8: The POC does not contain orders for nursing visits, nursing visits were performed on 6-28-22, 7-21-22, 9-10-22, 9-18-22. Patient 9: The POC contains an order for nursing every other week. The medical record contains evidence the nurse saw the pt: twice on 08/18/22,08/25/22,09/01/22,09/08/22,09/15/22. There is no evidence the visits were PRN and there are no PRN orders. Patient 10: The POC contains order for RN weekly starting 11/21/22. The medical record contains evidence the nurse saw the pt 11/25/22, 12/15/22,12/16/22,01/10/23,01/13/23,02/21/23 and 02/24/23. There is no evidence for an order to increase those visits to twice weekly those weeks and no evidence of a PRN order or that the visits were PRN. Patient 12: The POC contains order for RN weekly starting 11-07-22. The RN made visits 11-07-22 and 11-11-22 with no order for increased visits or evidence of visit being PRN and there are no orders for a PRN visit. Patient 13: RN saw pt 01/09/23,01/12/23,01/13/23,01/18/23 three times,01/19/23. The POC does not contain orders for nursing visits. Patient 14: The POC contains order for RN once a week. The RN saw the pt twice on 07/29/22 and twice on 07/30/22. There is no evidence of an order for increased or PRN visits.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patients 1 & 2: The RN did not follow bag technique policy of keeping bag zipped when not in use and after cleansing equipment placing equipment on clean surface prior to placing back in to bag. Patient 6: The agency has a policy Exposure Control/Infection Control Plan Appendix C, Bag Technique that states "Never place a bag on a patient's bed or upholstered furniture". The RN placed her bag on patients upholstered sofa with no barrier. The policy also states "bag must be closed when not in use". The RN did not close bag while not in use and the bag the RN is using does not zip shut completely. The RN cleansed equipment and did not "place on a clean surface" prior to placing back in the bag. The RN laid the cleaning cloth container on the upholstered sofa and after use did not cleanse the container prior to placing back in the nursing bag. The nursing bag does not have a clean and dirty side it was a grocery store freezer bag with one opening.

Upon patient record review, 2 of 14 (Patient 13,14) did not have evidence the hospice offers bereavement counseling that includes: Patients 13 and 14: The medical record does not contain evidence of the hospice making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Ensuring that bereavement services reflect the needs of the bereaved. The BC documented on 06/07/23 "Post death MSW support not provided due to no identified need". There was no evidence of any phone calls or mailings completed through out the year. There was a Bereavement POC for the agency but it was not initiated for either client's bereaved.

Upon patient record review, 1 of 14 (Patient 13) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 13: The POC contains an order for aide 3-4 times per week.

Upon patient record review 2 of 14 (Patient #9 and 13) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 9: The POC contains aide orders for 2 times a week starting 08/20/22 and the medical record contains evidence the patient was seen by the aide on 08/20/22,09/03/22,09/10/22. There was no missed visit documentation or refusal documentation. Patient 13: The POC contains an order for the aide to make visits 3-4 times per week starting 01/18/23. The medical record only contains evidence the aide visited the patient on 01/13/23,01/17/23, 01/18/23. There is no evidence of missed visit or refusal documented. There is no evidence of an order for the aide to visit on 01/13 and 01/17.

Upon patient record review 2 of 14 (Patient 3,5) 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 3: The medical record contains evidence of aide visits on 05/11/22,05/18/23,05/25/23. There is no evidence of a supervisory visit being done. Patient 5: The medical record contains evidence of aide visits on 05/16/23,05/23/23,05/30/23. There is no evidence of a supervisory visit being done.

Upon patient client record review, 10 of 14 (Patient 1,2,3,4,5,7,8,11,12,14) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patients 1,2,3,4,5,7,8,12,14: The RN documents on comprehensive assessment "AOXO2". There is no evidence this is an approved abbreviation. Patient 3: The POC contains an order for aide visits starting 10/19/22 and DME orders start date are 11/15/22, the pt was not admitted until 11/17/22. Patient 4: The Hospice Election statement is signed/witnessed by RN and dated "02/24/24". Patient 11: The nurse documents on discharge summary 04/25/23 "AXOX2". There is no evidence this is an approved abbreviation.

Upon client record review, 1 of 14 (Patient #12) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: Patient 12: The medical record does not contain evidence a copy of the hospice discharge summary was sent to the client's attending physician.

Upon client record review, 2 of 14 (Patient 8,12) did not have evidence that the discharge summary includes all required information. Patient 8: The discharge summary does not contain the patients current plan of care, latest physician orders. Patient 12: The discharge summary does not contain patient's current plan of care, latest physician orders, any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility.

Upon SNF/NF contract review, 1 of 3 (Royal Springs) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation. Corrected on site.