Every finding on record at Adoration Hospice Care Texas, LLC

Observed in Emergency Management Session. The Surveyor noted the organization did not conduct a drill in 2024. The last drill in 2023 was a table top exercise. This was confirmed with the Quality Accreditation Coordinator.

Observed in Record Review. In 1 of 10 patient records reviewed, the hospice did not provide a patient-specific comprehensive assessment. In HOSNHVRR #6, the Surveyor noted the patient resided in a facility and wound care was performed by facility staff; however, the wound was not assessed as part of the comprehensive assessment every 15 days. This was confirmed with the Patient Care Manager.

Observed in Record Review. In 10 of 10 patient records reviewed, the plan of care did not include goals based on problems identified in the comprehensive assessment. In all records reviewed, the plan of care goals did not include time frames for achievement. In HOSHVRR#2, the Surveyor noted the comprehensive assessment indicated the patient had a wound on the heel; however, the plan of care goal skin integrity was not measurable. In addition, the goal for anxiety will be decreased was not measurable. This was confirmed with the Director of Clinical Operations /Alternate Administrator. In HOSHVRR#3, the Surveyor noted the following plan of care goals were not measurable: Patient/Caregiver will understand the pain scale and pain medications; Maintain optimal cardiac function within constraints of disease. In addition, there were no time frames for goal achievement. This was confirmed with the Director of Clinical Operations /Alternate Administrator. In HOSNHVRR#1, the Surveyor noted the following plan of care goals were not measurable: patient will verbalize reduction or relief of cardiopulmonary symptoms of SOB/dyspnea while on hospice services. Edema will be optimally managed AEB decreased signs and symptoms of fluid overload while on hospice services. This was confirmed with the Director of Clinical Operations /Alternate Administrator.

Observed in Record Review. In 4 of 10 patient records reviewed, the plan of care did not include interventions to manage pain and symptoms. In HOSHVRR#1, the surveyor noted the patient was identified as risk for falls and had edema; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Director of Clinical Operations /Alternate Administrator. In HOSHVRR #3, the Surveyor noted the plan of care order for wound care did not specify the location related to the shin. In addition, the patient was diabetic and the comprehensive assessment indicated the patient checked their blood glucose daily; however, blood sugar monitoring frequency was not addressed in the plan of care. This was confirmed with the Director of Clinical Operations /Alternate Administrator. In HOSNHVRR #4, the Surveyor noted the patient was identified as having dizziness and edema; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Director of Clinical Operations /Alternate Administrator. In HOSNHVRR #5, the Surveyor noted the patient was identified as having agitation; however, the plan of care did not include interventions to address this identified need. This was confirmed with the Director of Clinical Operations /Alternate Administrator.

Observed in Record Review. In 2 of 10 patient records reviewed, the plan of care did not include a detailed statement of the scope and frequency of services necessary to meet the patient and family needs. In HOSHVRR #1, the Surveyor noted the plan of care visit frequency included prn visit which did not include an individualized need for prn visits. The prn visit indication was change in condition. This was confirmed with the Director of Clinical Operations /Alternate Administrator. In HOSHVRR #2, the Surveyor noted the prn indication for the chaplain was spiritual support and the indication for the prn visit for the social worker was emotional support. This was confirmed with the Director of Clinical Operations /Alternate Administrator.

Observed in Record Review. In 1 of 10 patient records reviewed, the plan of care did not include all treatments necessary to meet the needs of the patient. In HOSNHVRR#6, the Surveyor noted the plan of care did not include the size of the foley catheter or the frequency of the catheter change. This was confirmed with the Patient Care Manager.

Observed in Data Session. During the data management session, the Surveyor noted the organization was not able to demonstrate improved compliance as the organization did not aggregate and analyzed the hand hygiene compliance data. This was confirmed with the Quality Accreditation Coordinator.

Observed in Record Review. In 1 of 9 patient records reviewed, the hospice aide did not provide services according to the aide plan of care. In HOSNHVRR#6 the Surveyor noted the aide plan of care did not include catheter and indicated a shower; however, the aide performed catheter care and provided the patient with a bed bath. This was confirmed with the Patient Care Manager.

Observed in Record Review. In 1 of 10 patient records reviewed, the clinical record did not contain an accurate medication list. In HOSHVRR#2, the Surveyor noted the medication list contained Silvadene; however this was not the current wound care being provided to the patient. This was confirmed with the DON/Alternate Administrator.

Observed in Record Review. In 1 of 2 closed records, In HOSDCRR #2, the Surveyor noted the patient revoked hospice services due to transfer to hospital to receive IV antibiotics; however the organization did not provide the hospital with a copy of the transfer summary. This was discussed with the Patient Care Manager.

Observed in Individual Tracer. In 3 of 11 patient records reviewed, the comprehensive care plan did not reflect all of the interventions required based on the patient assessment. RR#1 had a history of urinary retention and urinary tract infections and the comprehensive care plan did not reflect any interventions to address this problem. Similarly, RR#3 had bilateral leg cellulitis with an active infection that required antibiotics and there was no interventions on the comprehensive care plan that addressed this problem. RR#2 had six allergies based on the history and physical and the nurses assessment, none of these allergies were included on the comprehensive care plan. These observations were discussed with the RN manager.

Observed in Individual Tracer. In 1 of 11 patient records reviewed, the care plan did not accurately reflect the medications the patient was taking. Per the wife of RR#1, the patient has always taken an antidepressant daily. The comprehensive care plan reflected that the patient was taking this medication twice per day. This observation was discussed with the RN manager.

Observed in Individual Tracer. In 1 of 11 patient records reviewed, the hospice did not revise the plan of care based on patient status. On initial comprehensive care plan a hospice aide was ordered. The aide was never placed and the update to the plan of care did not reflect this change. The next update to the care plan (4 weeks after admission) reflected that the patient refused the aide service. This observation was discussed with the RN manager.

Observed in Data Session. The hospice did not utilize data to monitor the quality of services. There was no aggregated/analyzed data related to falls, medication errors, adverse events, and or complaints for 2019, 2020, or 2021. These observations were discussed with QAPI coordinator.

Observed in Individual Tracer. In 2 of 3 home visits conducted, the hospice did not implement activities that would reduce the transmission of infection for reusable equipment. The RN(s) in RR#1 and RR#2 were observed spraying their stethoscopes, blood pressure cuffs, and pulse oximeter with a clear liquid that was contained in an unlabeled bottle. The saturated equipment was than immediately returned to a bag/case. A review of the available policies did not include what solution should be utilized in the cleaning of reusable equipment and or the procedure that should be followed. This observation was discussed with the RN manager. Observed in Individual Tracer. In 2 of 3 home visits conducted, the hospice did not follow its policy related to hand hygiene. The RN in RR#1 was observed removing his gloves after assessing the patient and than donning a new pair of gloves. The RN did not disinfect and or wash his hands prior to donning the clean pair of gloves. The nurse in RR#2 was observed removing her gloves, rolling them up and then proceeded to enter the interior of her nursing bag without first disinfecting and or washing her hands. These observations were not consistent with the policy titled - Hand Hygiene Compliance Program and were discussed with the case manager RN .

Observed in Infection Control System Tracer. Based on a review of the available data and discussions with the QAPI Coordinator, there was no aggregated and or analyzed infection control data for 2021, 2020, or 2019.

Observed in Tracer Activities. In 5 of 7 patient records reviewed, the hospice did not provide bereavement services to patients that died prior to 12/21 per the Bereavement Coordinator. There were five patients identified that died prior to 12/21 and that there was no documentation of bereavement follow up.

Observed in Leadership Session. 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, 418.60, 418.104, 418.64, 418.108, and 418.58.

Observed in HR File Review. In 1 of 9 HR files reviewed, the hospice did not orient staff to their role. HR#3 who was identified as the back up clinical director, had no documentation in the human resource record of orientation to the position. This observation was discussed with the administrator. Observed in HR File Review. In 2 of 9 HR files reviewed, the hospice did not orient staff to key components of the job. HR#1 was the medical director and back up medical director. There was no documentation that these employees were oriented to key components of their job including to the hospice philosophy. This observation was based on a review of the contracts and discussions with the administrator

Observed in Record Review. In 1 of 11 patient records reviewed, the hospice record did not reflect the care that was provided. RR#1 was bed bound and per the wife received his baths in bed. The home health aide documentation of care/activity sheet reflected that the patient received a partial/shower. This observation was discussed with the RN manager.

Observed in Individual Tracer. In 5 of 7 patient records reviewed, the hospice did not have a process in place to document that the transfer/discharge summary form his sent to the next provider. RR#6 and RR#7 were transferred to another hospice and to a nursing home respectively. There was no documentation in the records that the hospice provided the next provider with the transfer/discharge summary form. These observations were discussed with the RN manager.

Observed in Leadership Session. Based on the review of the available data there was no evaluation of the durable medical equipment, nursing home, and or pharmacy services provided under contract for 2019, 2020 or 2021. These observations were discussed with the administrator

Observed in Individual Tracer. In 1 of 11 patient records reviewed, the certification of terminal illness for RR#1 reflected the following- I certified life expectancy of less than 6 months. Items this certification of terminal illness did not include were the current medication and or treatment orders, as well as medical justification for hospice. Additionally, This certification of terminal illness was not completed in its entirety until the IDT meeting which was two weeks after the admission. The policy titled - Certification of Terminal Illness indicated that the hospice will obtain a written CTI from the medical director no more than 15 calendar days prior to the effective election and within 2 calendar days after a period begins. The policy further indicated that the CTI include a narrative and if the narrative is an addendum, the physician is required to sign the addendum. It also indicated that if the hospice is unable to obtain written certification the RN could obtain a verbal certification. Based on discussions with the administrator. the hospice can obtain the CTI up to 15 days after the certification period as long as the RN gets the verbal certification. For record RR#1 neither the verbal or written certification included all of the elements required within two days after the certification period began. This observation was discussed with the RN manager.