Every finding on record at Agape Hospice & Palliative Care NW LLC

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to ensure documentation of a patient specific comprehensive assessment and reassessment that identified the patient's need for hospice care and services. On review of RRNHV#13 the documentation noted a wound to the patient's left heel in May yet there was no documentation of an assessment of the wound to include size, drainage, odor, inflammation, or undermining/tunneling. There was also documentation of a stage 1 pressure injury to the right ankle in February yet no documentation of the size of the wound. These observations were reviewed with the Director of Nursing.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to ensure the pan of care reflect the patient and family goals that were individualized, specific, measurable, and time-bound. On review of RRHV#1 the goals were noted to not be specific and measurable such as Pt/family/primary caregiver will verbalize having elimination needs met at an acceptable level and Promote rest status for pt/family/primary caregiver. An example in RRHV#2 was Pt/family/PCG will verbalize having urinary elimination needs met at an acceptable level to promote comfort and prevent infection or skin breakdown. In RRHV#3 an example was Increase strength/energy for functional activities as clinically appropriate. In RRHV#4 examples were Minimize complications due impaired mobility.-minimize fall/injury. Throughout the records reviewed the target date for goals was not individualized and mostly set to the end of the benefit period. Further examples of goals that were not individualized, specific, measurable, and time-bound could been seen in all records reviewed. These observations were reviewed with the Director of Nursing.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions to include a statement of the scope and frequency of the services necessary to meet the patient and family needs. On review of RRNHV#11 the IDG meeting repeatedly noted the MSW frequency was changed to as needed only yet the frequency order remained at social services one time a month. This observation was reviewed with the Director of Nursing.

Observed in Record Review. In 3 of 14 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRNHV#5 the plan of care included an order for sliding scale insulin however there were no orders for blood glucose monitoring. In RRNHV#8 the patient's foley catheter was discontinued yet the plan of care was not updated to reflect the catheters removal. In Review of RRNHV#14 the patient was being seen by the social worker yet there was no psychosocial care plan open to guide the care. These observations were reviewed with the Director of Nursing.

Observed in Record Review. In 13 of 14 patient records reviewed, the organization failed to ensure the plan of care was revised to include information from the updated comprehensive assessment noting the patient's progress toward goals and outcomes. On review of RRHV#1 there were many goals that were established on admission mid 2024 that remained without progress toward goal for nearly a year. An example of a goal without noted progress toward goal was Bereaved will have knowledge of how to utilize bereavement services upon admission. In RRHV#2 an example was Pt/primary care giver will verbalize/express understanding of medication /treatment orders and side effects The goal was continued IDG to IDG without addressing progress toward goal. IN RRHV#4 an example was PCG/Family will express understanding that increased sleep is expected outcome of disease process the goal continued IDG to IDG since September of last year. Further examples can be seen throughout the records reviewed. These observations were reviewed with the Director of Nursing and the leadership team.

Observed in HR File Review. In 1 of 1 HR files reviewed, for hospice aides, the organization failed to ensure the supervisor evaluate the hospice aide's performance or the required tasks with a patient or pseudo[patient as part of a simulation. On review of HR#6 for the hospice aide the initial competency evaluation there was no documentation that the evaluation was completed by observing the aides performance of the task with a patient or pseudo patient as it was documented as assessed verbally. Further the competency was documented to be assessed by an LPN and not an RN as required. This observation was reviewed with the Director of Nursing, and Administrator.

Observed in Record Review. In 3 of 13 patient records reviewed, with hospice aide services, the organization failed to ensure the registered nurse provide written patient care instructions for the hospice aide. On review of RRHV#4 and RRNHV#5 the patient orders had wound care treatment and dressings and RRNHV#10 had wound care treatment left open to air, yet there were no specific instructions to the hospice aide on how to handle the dressings or treatment area while providing care. These observations were reviewed with the Director of Nursing.

Observed in HR File Review. In 1 of 1 HR files reviewed, for hospice aides, the organization failed to ensure a RN make an annual on-site visit to the location where a patient is receiving care in order to observe and assess the aide while performing care. On review of HR#6 the annual onsite visit was documented as assessed by an LPN and not RN. Further, the visit form did not specify whether or not the visit was on-site with a patient nor how the skills were assessed. This observation was reviewed with the Director of Nursing and the Administrator.

Observed in Record Review. In 2 of 4 patient records reviewed, where care was provided in a skilled nursing facility, the organization failed to identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. In RRHV#5 the patient resided in a skilled nursing facility yet there care and services identified by the plan of care were vague and did not specify who was responsible for the care. The care plan for wound care read skilled nurse/Primary caregiver to provide wound care. The intervention did not specify who was responsible for the care. In RRNHV#10 the patient, who resided in a SNF had a foley and there was no delegation of who was responsible for the foley. These observations were reviewed with the Director of Nursing.

Observed in Tracer Activities. In 1 of 4 contracts reviewed, the organization failed to ensure the written agreement with an outside agency providing contracted services for the hospice contain all required elements. On review of the contract Durable Medical Equipment there was no stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This observation was reviewed with the Director of Nursing.

Observed in Record Review. In 5 of 5 patient records reviewed, The HCO did not ensure patient care plan goals were individualized, measurable, and include appropriate time frames. Examples include the following: Pt needs will be met on a day to day basis as communicated. -Pt will remain free of injury. Pt will have adequate food and fluids as tolerated or desired. -Assess Pt. status for on-going care. Patient will have a bowel movement at least every 3 days when assessed every 14 days (reassessed 5/12/22). Resolve wound status for comfort.-Altered skin will be free of infection. Pt/ Family/PCG will verbalize receiving desired spiritual support. -Patient will be well palliated. These stated goals do not contain specific information that can be accurately measured to assist organizational staff in determining whether the patient is progressing towards achieving their goals. These findings were reviewed, discussed and validated with Administrator, DON, and CCO.

Observed in Patient Home. In 2 of 3 home visits conducted, The HCO’s staff did not follow the organization's bag technique policy. For instance, on home visit #1 the hospice surveyor observed the spiritual care coordinator remove a tablet from the bag and place it on the patient’s bedside table without cleaning the tablet or placing a barrier on the table. The tablet was then placed back in the bag without being cleaned. On home visit #2 the hospice aide placed the bag on a chair without placing a barrier down or cleaning the surface first. The aide went back and forth into the bag, removing and replacing supplies without having identifiable clean and dirty sections. The organization's policy included that the bag should be placed on a clean, dry surface, a clean and dirty section should be identified, and equipment should be cleaned prior to replacement back in the bag. These findings were reviewed, discussed, and confirmed with the Administrator and CCO.