Every finding on record at Affinity Hospice Care, Inc

Observed in Record Review. In 3 of 10 patient records reviewed, the update of the comprehensive assessment did not include specific information about the patient's progress toward desired outcomes and outcomes were not specific and measurable. In review of the medical record for RRHV #3 the care plan included the problem: Integumentary/Skin with the goal; comfort will be promoted as skin integrity changes throughout disease and dying process, minimize risk of bedsores, prevent potential skin problems for comfort. In review of the medical record a communication note 4 weeks following the start of care documented a call from the facility where the patient was residing reporting the patient was experiencing right hand swelling. An LVN visit occurred the next day and the facility staff was instructed to use rest, ice, compression, elevation (RICE) however there was no evidence of physician orders, communication with MD and revisions to the plan of care. This was discussed with and validated by the DPCS/Admin. Observed in Record Review. In 1 of 10 patient records reviewed, the update of the comprehensive assessment did not include specific information about the patient's progress toward desired outcomes and outcomes were not specific and measurable. For RRHV #1 the care plan included a problem of falls risk related to weakness and impaired balance with a goal for facility staff will demonstrate improved knowledge of fall prevention strategies and facility staff will verbalize at least three fall prevention strategies during education sessions.. The communication notes in the medical record documented a patient fall 8 weeks following the start of care where the patient sustained a head wound. The communication notes documentation included; cut/trim hair around wound. Patch him up/apply dressing, he needs neuro checks and although there were orders for wound care there were no orders for neuro checks and the care plan was not updated with patient specific goals and interventions. This was discussed with and validated with the DPCS/Administrator. Observed in Record Review. In 2 of 10 patient records reviewed, the update of the comprehensive assessment did not include specific information about the patient's progress toward desired outcomes and outcomes were not specific and measurable. For RRHV #2 the care plan included the problem: Integumentary/Skin with a goal; Comfort will be promoted as skin integrity changes throughout disease and dying process, minimize risk of bedsores, and prevent potential skin problems for comfort however the care plan remained unchanged with no revisions or updates since the start of care 10 weeks ago. For example the IDG team failed to update the Integumentary/Skin problem and include newly ordered treatments for skin/wound care 4 weeks following the start of care, 6 weeks following start of care and 10 weeks following start of care. This was reviewed and validated with the DPCS/Admin.

Observed in Leadership Session. the organization's quality assessment and performance improvement program (QAPI) did not reflects the complexity of the organization and its services and involves all services provided by the organization, including those provided under contract or arrangement. In review of the organization's QAPI plan there was no evidence that the hospice had included indicators or collected data for contracted services including DME, Pharmacy and Skilled Nursing Facilities providing GIP and Respite Care as well as Volunteer Services and Bereavement Services. This was discussed with and validated by the DPCS/Admin.

Observed in Leadership Session. The organization had not identified indicators for performance improvement or the frequency and detail of the data collection. In review of the organization's quality assessment and performance improvement program (QAPI) there was no evidence that the hospice had identified performance indicators for 2023. This was discussed with and validated by the DPCS/Admin.

Observed in Leadership Session. The organization had not documented what performance improvement projects were being conducted, the reasons for conducting the projects, and the measurable progress achieved on them. In review of the organization's quality assessment and performance improvement program (QAPI) there were no identified performance improvement projects for 2022 or 2023. This was discussed with and validated by the DPCS/Admin.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to use standard precautions. For RRHV #2 the LVN failed to complete hand hygiene after removing his gloves upon completion of the patient assessment. This was validate with the DPCS/Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, the hospice failed to develop a bereavement plan of care that specified the type of bereavement services to be offered and the frequency of service delivery. In review of RRBR #1 the documentation of planned bereavement services failed to specify the type of service to be provided and the frequency. This was discussed with and validated by the DPCS/Admin.

Observed in Record Review. In 3 of 10 patient records reviewed, the registered nurse did not conduct an on-site visit to the patient’s home no less frequently than every 14 days to supervise the hospice aide in accordance with the organization's policy and law and regulation. In review of the medical record the surveyor noted that for RRHV #1 the eighth supervisory visit was conducted at 15 days. Supervisory visits by the RN were also found to be a day late and conducted on day 15 for RRHV # 3, and RRNHV #4. This was discussed with and validated with the DPCS/Administrator.

Observed in Leadership Session. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by the incomplete QAPI program and lack of performance improvement projects to improve patient care, and condition level findings at 418.140 and 418.58.

Observed in Record Review. In 1 of 4 patient records reviewed, for patients who had expired documentation was found to be inaccurate. In review of the medical record for RRDC #1 the surveyor noted that the LVN documentation included pronouncement of the death of the hospice patient as evidenced by the visit note which stated, Pt seen and examined at 0815AM Pt lying on her back. Heart and lung sounds are absent. No spontaneous cardiac or respiratory activity. The patient is nonreactive to verbal or tactile stimuli. No pupillary reflex is present. Pupils fixed and dilated. Absent vital signs Pronounced dead at 0820. The physician was notified at 0830AM.. The DPCS/Admin produced the death certificate signed by the Medical Director which demonstrated that the pronouncement of death was actually 0830AM and the clinical note was not accurate. This was discussed with and validated by the DPCS/Admin.

Observed in HR File Review. In 1 of 10 HR files reviewed, the organization had not verified the credentials of staff at the time of hire. For HR #4 the job description for the Bereavement Coordinator required a bachelors degree or equivalent theological degree from college or university which had not been validated at the time of hire for the Bereavement Coordinator. This was discussed with and verified by the DPCS/Admin.

Observed in Record Review. In 3 of 3 patient records reviewed, nursing plans of care had documented goals based on patients’ assessed needs. However, documentation in the records of patients receiving spiritual and psychosocial services did not have goals identified. In addition, target dates for completion of unresolved goals were either the date of the next interdisciplinary group meeting, or the last day of the benefit period. This was confirmed by the Director of Patient Care Services.

Observed in Tracer Visit. In 2 of 2 patient records reviewed, the update of the comprehensive assessment did not include specific information about the patient's progress toward desired outcomes. Upon review of HV#1, it was noted morphine sulfate was discontinued and documented as an allergy in the record, dexamethasone was added to the patient’s treatment plan, and the nursing visit frequency was decreased to twice a week from three times a week; however, on review of interdisciplinary group (IDG) update documentation, these revisions to the patient’s plan of care and progress towards outcomes were not addressed. Upon review of RR#2, it was noted the patient was started on antibiotics for an upper respiratory infection; an appetite stimulant and anti-depressant were added to the patient’s treatment plan; however, on review of interdisciplinary group (IDG) update documentation, these revisions to the patient’s plan of care and progress towards outcomes were not addressed. This was reviewed and validated with the Administrator/Director Designee.

Observed in Record Review. In 2 of 2 patient records reviewed, the plan of care did not include all goals based on the patient’s needs. Upon review of HV#1, it was noted the patient was on medications for insomnia, anxiety, constipation, acid reflux, and diabetes; however, on review of the plan of care, there were no goals established related to these problems identified on the comprehensive assessment. Upon review of RR#2, it was noted the patient was started on antibiotics for an infection; however, on review of the plan of care, there were no goals established related to the patient’s infection. Upon review of HV#1 and RR#2, it was noted the patients were receiving psychosocial support; however, there were no goals/outcomes established on the plan of care to assist the social worker in determining if the psychosocial needs of the patients were being met. This was reviewed and validated with the Administrator/Director Designee.

Observed in Record Review. In 2 of 2 patient records reviewed, the plan of care did not include all interventions based on the patient’s needs. Upon review of HV#1, it was noted the patient was on medications for insomnia, anxiety, constipation, acid reflux, and diabetes; however, on review of the plan of care, there were no interventions established related to these problems identified on the comprehensive assessment. Upon review of RR#2, it was noted the patient was started on antibiotics for an infection; however, on review of the plan of care, there were no interventions established related to the patient’s infection. On review of HV#1 and RR#2, it was noted the patient's were receiving psychosocial support; however, on review of the plan of care, there were no interventions established related to the patient's psychosocial needs. This was reviewed and validated with the Administrator/Director Designee.

Observed in Record Review. In 1 of 2 patient records reviewed, the plan of care did not include visit frequencies. Upon review of HV#1, social worker documentation indicated monthly visits were being conducted; however, on review of the plan of care, there was no visit frequency established for social services. This was reviewed and validated with the Administrator/Director Designee.

Observed in Record Review. In 2 of 2 patient records reviewed with aide services, complete written patient care instructions were not prepared by the RN. Upon review of HV#1, it was noted the patient had oxygen therapy ordered as needed. Upon interview with the patient during the visit, she stated she becomes very short of breath and requires oxygen to ambulate to the bathroom for her shower and can tolerate being off oxygen only for a few minutes. On review of the aide plan of care, there were no specific instructions provided to the aide regarding oxygen precautions nor whether the patient was to be on oxygen during bathing or while the aide performed other assigned tasks. Upon review of RR#2, it was noted the patient was on Eliquis, had a trach in place, had a PEG tube for feedings, and had a wound to his coccyx; however, on review of the aide plan of care, there were no specific instructions provided to the aide regarding bleeding precautions nor precautions to take when bathing around the trach, PEG tube, and the wound. This was reviewed and validated with the Administrator/Director Designee.

Observed in Record Review. In 2 of 2 patient records reviewed with aide services, the hospice aide did not provide care as ordered. Upon review of HV#1, it was noted the following tasks were not consistently documented as completed as ordered on the aide plan of care: recording bowel movements, peri care, and shampoo. Upon review of RR#2, it was noted the following tasks were not consistently documented as completed as ordered on the aide plan of care: recording bowel movements. This was reviewed and validated with the Administrator/Director Designee.

Observed in Record Review. In 2 of 2 patient records reviewed with aide services, hospice aide supervision did not confirm the aide was following the patient's plan of care as assigned. Upon review of the record for HV#1 and RR#2, it was noted the aide visit documentation reflected the aide was not following the plan of care; however, the supervisory visit documentation completed during the time frame in which those visits were made, reflected the aide was providing services according to the plan of care. This was reviewed and validated with the Administrator/Director Designee.

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: - §418.56, §418.76, and §418.104.

Observed in Record Review. In 1 of 2 patient records reviewed, clinical documentation was not present. Upon review of HV#1, it was noted place holders were present in the record for several nursing notes that indicated the date and time of the visits; however, the clinical documentation for those visits was not completed. A place holder was present in the record for the social worker initial assessment that indicated the date and time of the visit; however, the clinical documentation for the assessment was not completed. This was reviewed and validated with the Administrator/Director Designee. Observed in Record Review. In 1 of 1 home visits in which medication reconciliation was conducted, the medication list in the record was inaccurate. Upon review of the medication profile for HV#1, it was noted trazadone, hydrocortisone acetate, and calcium carbonate/Vitamin D were listed; however, in discussion with the patient and daughter, they stopped trazadone and the Vitamin a while ago and the hydrocortisone acetate was not yet ordered and in the home. The daughter stated the patient takes a daily multi-vitamin; however, on review of the medication profile in the record, this supplement was not included. The medication profile also had duplicate Senna and hydrocodone orders listed. This was reviewed and validated with the Administrator/Director Designee.

Observed in Record Review. In 2 of 2 patient records reviewed, the patient record contained inaccurate information. Upon review of HV#1, it was noted the patient’s terminal diagnosis was documented as rectal cancer; however, on review of nursing documentation and the certification of terminal illness, the documentation indicated renal cancer. On review of the plan of care, spiritual counselor services were documented as declined; however, spiritual counselor documentation on multiple interdisciplinary group notes indicated, “follow up for eval”. On review of RR#2, it was noted social services were declined during the certification period; however, on review of the plan of care, the visit frequency indicated monthly visits. On review of the plan of care, oxygen was ordered at 2-4L/min via nasal cannula; however, the patient was on a trach collar at 10L. This was reviewed and validated with the Administrator/Director Designee.