Every finding on record at All Caring Hospice Cincinnati Dayton, LLC

It is required that the hospice designates a registered nurse member of the IDG to: Provide coordination of care; Ensure continuous assessment of each patient’s and family’s needs; and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 8 (12%) Clinical Records reviewed that included wound care, the agency did not ensure coordination of care with the facility, and wound care was documented. Clinical Record 4: The Patient was identified with a stage 3 pressure ulcer on the right buttock on the initial comprehensive assessment 06/27/2024 and the wound would be measured weekly. No measurements were documented on the initial assessment completed on 6/27/2024. The plan of care interventions was to wash the wound and pat it dry, apply Venelex ointment (this is a protective ointment), and cover it with a border gauzed dressing daily, and the facility would also help with the wound. The plan of care interventions did not document the location of the wound or that the wound would be measured weekly. The nurse visited 06/28/2024 and 06/29/2024, 07/03/2024 and 07/08/2024. No wound measurements were documented as the patient refused wound care each visit. No observation of the wound was documented in two weeks. During the interview, the Program Manager stated that the facility was monitoring but agreed documentation of that was not in the record but was obtained before the end of the site visit. The facility had pictures and measurements of the wound on 07/03/2024 and 07/10/2024. and improvement in measurements and status were documented.

It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 6 of 14 (43%) Clinical Records reviewed, the agency did not ensure that all plans of care included interventions based on the problems identified in the initial comprehensive assessment and follow-up assessments for the care of the patient. Clinical Record 3: The patient was identified with a PEG tube on the initial comprehensive assessment dated 07/08/2024. There were no interventions documented for the care of the PEG tube. Skincare was identified to float heels. Medications were given per the PEG tube which would require irrigation but no care for this was identified on the plan of care as of review 7/10/2024. Clinical Record 4: The initial comprehensive assessment dated 06/27/2024 identified a stage 3 pressure ulcer on the right buttock and the wound would be measured weekly. No measurements were documented on the initial assessment completed on 06/27/2024. The plan of care interventions was to wash the wound and pat it dry, apply Venelex ointment, and cover it with a border gauzed dressing daily, and the facility would also help with the wound. The plan of care intervention did not document the location of the wound or that the wound would be measured weekly as of record review on 07/10/2024. Clinical Record 5: The initial nursing comprehensive assessment dated 01/30/2024 stated that the patient voided with a Foley catheter. The plans of care and updated plans of care did not document interventions for the Foley catheter. The initial and ongoing assessments documented a cachectic patient of 70 pounds using nutrition supplements with updates 01/31/2024 and 02/20/2024 and additional IDG (interdisciplinary group) that the patient consumes these, but the care plan documented no nutrition interventions. Clinical Record 7: The initial nursing comprehensive assessment was dated 06/30/2024 and included a history of CHF (congestive heart failure) and oxygen therapy as well as the primary diagnosis of end-stage renal disease. The patient used oxygen continuously. No interventions were documented related to the respiratory needs of the patient. The patient was deceased on 07/02/2024. Clinical Record 9: The initial nursing comprehensive assessment was dated 06/11/2024 and included a history of diabetes and the patient was using a sliding scale for insulin delivery. The plan of care initially and updated plan of care did not document any interventions related to diabetes management and the patient continued on sliding scale insulin as of the record review on 07/10/2024. Clinical Record 11: A nursing comprehensive assessment dated 02/14/2024 identified anxiety and agitation problems and the physician was notified, and Ativan was ordered with some improvement. The nursing assessment documented 02/22/2024 documented the patient was using protein shakes for nutrition. There were no interventions updated to the plan of care for anxiety/agitation or nutrition. During the interview, the Program Manager stated that the plans of care have been a work in progress and continued needs had been identified in their audit process. During IDG it was observed that staff were instructed on updates to the plan of care as patient needs changed.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions, such as Hand hygiene. This standard was not met as evidenced by interview and observation. In 1 of 3 (33%) Observed visits, the agency did not ensure hand hygiene policy was followed. Document 2: PC.l10 Infection Control- Hand Hygiene and Bag Technique stated in part; "Use of alcohol-based hand sanitizer is preferred (until dry) If antimicrobial hand soap is used, it must be for a period of at least 15 seconds. Before and after caring for patients, or when coming in contact with inanimate objects/equipment in the immediate vicinity of the patient. After removing gloves. " Home Visit 1:A home visit (Home Visit 1) was completed with the registered nurse (RN) (Personnel Record 8) on 07/09/2024. The RN’s hands were sanitized upon entry to the home and entry into the nursing bag. Gloves were donned to provide patient care. The patient had numerous wounds to dress. The initial wounds on the left leg started on the foot. The dressing was removed, gloves were removed, hands were sanitized, supplies were gathered, and new gloves were donned. The wound was cleaned and re-dressed. Gloves were removed and new gloves were donned (no hand hygiene). The knee dressing was removed and cleaning supplies with Dakin's solution were set up, and the wound was cleaned. Gloves were removed and new gloves were donned without performing hand hygiene. The wound was re-dressed. The client was positioned in bed. Gloves were removed, and new gloves were donned without hand hygiene. On the right heel the dressing was removed, and cleaning was set up. Gloves were removed and new gloves were donned without hand hygiene. The heel was re-dressed. Gloves were removed. New gloves were donned without hand hygiene. The dressing was removed from the right knee and cleaning supplies were set up. Gloves were removed and new gloves were donned without hand hygiene. The Right knee was dressed. Gloves were removed hand hygiene was completed. During the interview the Program Manager stated that increased education and observation would be done. An interview with the nurse during the visit stated that she was nervous.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 3 of 13 (23%) Clinical Records reviewed in which the hospice aide was accepted, the agency did not ensure that the registered nurse prepared a hospice aide plan of care that contained clear and specific instructions for all care that the patient required. Clinical Record 3: The aide plan with assigned tasks was dated 07/08/2024. The tasks included the Aide providing a bed bath 2 times a week. The Patient had a PEG tube but that was not identified on the aide plan and what to do as far as washing or any care with this tube in the abdomen. Clinical Record 5: The aide plan with assigned tasks was dated 01/29/2024. The tasks included the Aide providing a bed bath 3 times a week. The patient had a Foley Catheter but that was not identified on the aide plan and what to do with the care and emptying of the catheter. Clinical Record 9: The Aide plan of care with assigned tasks was dated 06/24/2024. The tasks included the aide providing a shower 2 x a week with the 1st and second visits. On 07/02/2024 the tasks were updated with the addition of a bed bath 2 x week with first and second visit. The patient primary diagnosis was cerebral atherosclerosis and the secondary of dementia, and documentation of the patient being confused. The patient would not be able to determine which bath was to be provided and both are currently ordered as of the record review 07/10/2024. During an interview with the Patient care manager, she stated that the nurses were all contacted and that the plans for the aides were corrected.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. This standard was not met as evidenced by document review and interview. The hospice volunteer program has been in a rebuild this last year with recruitment and retention efforts documented. In the first quarter of 2024, cost savings were 3.22%, and in the second quarter 2.83% for a savings currently of 3.05%. This is below the 5% requirement. They are slowly building this program. Interview with the Volunteer Coordinator and the Program Manager who are continuing to work on meeting the 5% mark and hope to accomplish this by the end of the year. The hospice volunteer program has been in a rebuild this last year with recruitment and retention efforts documented. In the first quarter of 2024, cost savings were 3.22%, and in the second quarter 2.83% for a savings currently of 3.05%. This is below the 5% requirement. They are slowly building this program. Interview with the Volunteer Coordinator and the Program Manager who are continuing to work on meeting the 5% mark and hope to accomplish this by the end of the year.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires but no less frequently than every 15 calendar days. A revised plan of care includes Information from the patient's updated comprehensive assessment and record of the patient's progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by a review of clinical records and interview. The agency failed to ensure that the plan of care was updated when the patient's condition changed in 1 out of 5 (20%) clinical records reviewed. THIS IS A CONTINUED PRIOR REQUIRED ACTION. Record #33206: The RN nursing note dated 11/19/2021 documented that the patient stated, "I am having tooth pain and hurts bad" and "she could hardly open her mouth." The RN asked the facility nurse to call the MD. The patient was started on Clindamycin 300 mg by mouth three times a day, and pain medications were put in place. The plan of care was not updated to address the infection. In an observation during a home visit with RN #20089 on 11/23/2021, the facility RN stated that the interventions put in place for the patient were effective, and her tooth pain had been resolved. The Director of Clinical Services was interviewed on 11/23/2021 and confirmed that the plan of care was not updated to address the patient's tooth infection.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by observation during a home visit and interview, which revealed a break in infection control related to hand hygiene in 1 of 1 (100%) of home visits observed. THIS IS A CONTINUED PRIOR REQUIRED ACTION. During a home visit observation on 11/23/2021 at 9:15 am, RN #20089 was observed providing a clinical assessment of patient #33206. The RN was observed to assess the patient's blood pressure and place hands into the visit bag without removing gloves or sanitizing hands. The finding was reviewed and confirmed with the Director of Clinical Services in an interview on 11/23/2021.

It is required that hospice aides must report changes in the patient's medical, nursing, rehabilitative, and/or social needs to a Registered Nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient's needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by record review and interview. The agency failed to ensure the Hospice Aide reported the change in the patient's condition in 1 of 3 (33%) patients reviewed with hospice aide services. Record #93217: The plan of care dated 10/15/2021-1/13/2022 revealed the patient was to receive hospice aide services 1XW effective 10/17/2021. The orders included the hospice aide providing a shave at each hospice aide visit. The hospice aide visit notes were reviewed from 10/17/2021 to 11/13/2021. The hospice aide visit on 11/8/2021 documented that the patient declined a shave. There was no documentation found that the Hospice Aide notified the RN. In a review of nursing notes from 11/8/2021, there was no documentation that the RN received a report that the patient declined a shave. The Director of Clinical Services was interviewed on 11/23/2021 and confirmed that there was no documentation that the hospice aide reported the change in the patient's condition.