Every finding on record at Amber Hospice LLC

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met, as evidenced by clinical record review and interview. In 1 of 5 (20%) records reviewed, the agency did not ensure that the hospice plan of care included a detailed scope and frequency for disciplines providing care. Clinical Record 1: The hospice election of benefits was dated 03/27/2023. A review of the 06/25/2023 episode hospice plan of care revealed no aide frequency, although the aide documented provision of care 2 x week from 06/27/2023 through 09/19/2023. The nursing frequency read 2 mo 3 as needed for symptom management, while nursing care provision was documented as provided 1 x week from 06/29/2023 through 09/21/2023. During the interview on 09/26/2023, the Administrator reviewed the associated record and stated the nursing and aide frequency order had been obtained but had inadvertently been omitted from the hospice plan of care and had since been corrected.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the drugs and treatment necessary to meet the needs of the patient. This standard was not met, as evidenced by clinical record review and interview. In 1 of 5 (20%) records reviewed, the agency did not ensure the plan of care included complete drug and treatment orders on the hospice plan of care. Clinical Record 2: The hospice election of benefits was dated 08/27/2023. The 08/27/2023 plan of care and the 08/27/2023 registered nurse comprehensive assessment indicated the patient had a peg tube and education to be provided to caregivers on PEG tube care. Peg tub care was not included in the hospice plan of care at the time of the review on 09/26/2023. During the interview on 09/26/2023, the Administrator reviewed the associated record and stated PEG tube care instructions had inadvertently been omitted from the hospice plan of care and had since been added.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over the counter (OTC) drugs. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 3 of 11 (27%) records reviewed, the agency did not ensure that the medication profile included all prescription drugs. Per agency policy PC.17: Medication List and Monitoring, "The Hospice will maintain a current, accurate Medication Profile of all the prescription and over the counter medications taken by the patient. The medication profile will also include dosage frequency and route." Clinical Record 5: The medication profile was not updated to date with the 10/25/2022 Physician's order for Oxygen 2- 6 liters per minute via nasal cannula as needed for dyspnea. Clinical Record 6: The 10/17/2022 start of care assessment and hospice plan of care documented the patient was utilizing oxygen at 2.5 liters per minute via nasal cannula as needed for dyspnea. Oxygen was not included on the medication profile to date. Clinical Record 8: The 10/25/2022 start of care assessment and hospice plan of care documented the patient was using oxygen at 2 liters per minute via nasal cannula. Oxygen was not included on the medication profile to date. During interview 12/14/2022, Director of Clinical Services stated Oxygen had not been included on the medication profile per agency policy.

It is required that the comprehensive assessment includes an initial bereavement assessment of 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. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 11 (9%) records reviewed the agency did not ensure that an initial bereavement assessment was completed.. Clinical Record 9: The patient elected the hospice benefit on 11/12/2022. The RN who completed the start of care assessment did address psychosocial and spiritual needs, however there was no initial bereavement assessment documentation to date. The interview 12/14/2022, Director of Clinical Services stated bereavement assessment was not completed to date.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 2 of 11 (18%) records reviewed the agency did not ensure the hospice plan of care included interventions and goals for disciplines providing care based on problems identified in the initial and updated comprehensive assessments. Agency policy PC.6 Plan of Care Process read 'The plan of care includes but is not limited to interventions to manage identified issues /problems, a detailed statement of the scope and frequency of services." Clinical Record 2: The 09/20/2022 hospice plan of care did not document interventions or goals for the Chaplain services provided to date. Clinical Record 4: The 11/02/2022 hospice plan of care did not include interventions or goals for the Chaplain services provided to date. During interview 12/14/2022, Director of Clinical Services stated the hospice plan of care did not include chaplain interventions and goals per agency policy. .

It is required that each patient’s individualized written plan of care Includes all services necessary for the palliation and management of the terminal illness, including the following: a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 2 of 11 (18%) records reviewed the agency did not ensure that the hospice plan of care included a detailed scope and frequency for disciplines providing care. The agency policy PC.6 Plan of Care Process read 'The plan of care includes but is not limited to interventions to manage identified issues /problems, a detailed statement of the scope and frequency of services." Clinical Record 2: The 09/20/2022 hospice plan of care did not document a visit frequency for the Chaplain who made visits on 09/20/2022, 10/05/2022, 10/13/2022, 10/31/2022, 11/11/2022 and 11/28/2022. Clinical Record 9: The 11/12/2022 hospice plan of care did not document any visit frequency for nursing services provided to date. During interview 12/14/2022, Director of Clinical Services stated the hospice plans of care did not document discipline frequencies per agency policy.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records and interviews. In 3 of 11 (27%) records reviewed the agency did not ensure the plan of care included complete drug and treatment orders on the hospice plan of care.. Clinical Record 2: The 06/22/2022 hospice plan of care read Alphagna P 0.1% ophthalmic solution 1 drop as directed with no specific directive to one or both eyes and frequency of administration. Clinical Record 10: The 09/12/2022 hospice plan of care read 'nurse to educate caregiver on use of suctioning device' with no noted frequency, duration, or description for said treatment. Clinical Record 11: The 11/01/2022 hospice plan of care read 'nurse to change indwelling catheter as needed for blockage/soiling' with no description of type or size of indwelling catheter. During interviews dated 12/13/2022 and 12/14/2022, Director of Clinical Services reviewed the records and stated treatment and medication orders were incomplete.

It is required that each patient’s individualized written plan of care Includes all services necessary for the palliation and management of the terminal illness, including the medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by a review, of clinical records, document reviews and interviews. In 2 of 11 (18%) records reviewed the agency did not ensure that medical equipment was included on the hospice plan of care. The Agency Policy PC.6 Plan of Care Process stated, "the plan of care includes but is not limited to interventions to manage identified issues and problems, a detailed statement of, medical equipment." Clinical Record 1: The 07/21/2022 start of care assessment and the10/09/2022 recertification assessment indicated patient using a walker. The 10/19/2022 hospice plan of care stated no durable medical equipment (DME) in use. Clinical Record 8: The 10/24/2022 physician ordered hospice plan of care did not include DME. The 10/24/22 start of care assessment and hospice plan of care nursing interventions stated the patient was utilizing oxygen. During Interview on 12/13/2022, Director of Clinical Services stated the durable medical equipment was not included on the plan of care per policy and had since been corrected.

It is required that bags used to carry medical equipment (e.g., BP cuff) or supplies into or out of the care environment are transported and used in a manner consistent with organizational policy to prevent the spread of infections and communicable diseases. This standard was not met as evidenced by observations, document review and interviews. In 2 of 3 (67%) home visit observations, the agency did not ensure that supplies were used in a manner to prevent spread of infection. The agency policy C.12 Bag Technique read, 'when the visit is completed reusable equipment is cleaned.... hands are washed, and equipment and supplies are returned to the bag'. Home Visit 1: At the end of the visit, dirty equipment was placed in a separate zip lock bag. Hand hygiene performed and the nurse transported zip lock bag to next visit. Home Visit 2: Hand hygiene performed by nurse and gloves donned. The nurse opened the zip lock bag with prior used and uncleansed equipment, placed on clean barrier and cleansed with wipe. Dirty wipes placed alongside cleansed equipment and clean barrier as nurse completed assessment. During interview on 12/14/2022, Director of Clinical Services stated equipment should have been cleaned at first visit end and not at the beginning of the second visit per agency policy.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. In 5 of 8 (62%) records reviewed, with aide services provided, the agency did not ensure that the aide followed the aide plan of care. Clinical Record 1: The 07/21/2022 aide care plan assigned a task of once per week for linen change. The 10/19/2022 hospice plan of care indicated a frequency of once a week for one week, twice a week for thirteen weeks, effective 10/20/2022. The aide documented linen change at each visit dated 11/01/2022-12/01/2022. The aide documented only one visit made week of 10/27/2022 with no documentation of missed visit. Clinical Record 3: The 10/12/2022 aide care plan assigned a once a week linen change. The 10/11/2022 hospice plan of care (POC) documented an aide visit frequency of five times a week for twelve weeks. For the week of 10/17/2022 only four visits were made and on the week of 10/27/2022 only two visits were made with no documentation for missing visits or notification to MD. Clinical Record 6: The 12/05/2022 aide care plan assigned a task frequency of once a week for nail care, linen change and tidy area. The 12/05/2022 Physician's order documented an aide visit frequency of two times a week for six weeks. Clinical Record 10: The 09/12/2022 aide care plan documented a frequency of three times per week for linen change and one time per week shampoo. The aide documented the completion of assignments every visit 09/14/2022-10/07/2022. Aide visit frequency on the 09/12/2022 hospice plan of care documented four times a week for one week, five times a week for eleven weeks. Clinical Record 11: The 11/01/2022 aide care plan indicated a frequency of once per week for shampoo. The 11/01/2022 hospice plan care aide visit frequency documented three times a week times one week, five times a week for twelve weeks, and the aide documented shampoo at every visit. Interview on 10/15/2022, Director of Clinical Services stated aide had not provided care per aide assigned frequency and at the visit frequency designated on the hospice plan of care.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by a review of personnel records, document reviews and interviews. In 3 of 11 (27%) records reviewed, the agency did not ensure that new employee competency assessments had been completed. The agency policy HR.8 Employee Orientation read, 'The agency will orient each employee to their respective job responsibilities and Agency policies and procedures prior to the employee performing job duties independently. The new employees' knowledge and skill proficiencies/competency will be assessed." Staff 5: The RN was hired on 12/09/2022 and a skills competency is not on file to date. Staff 6: The RN was hired on 11/02/2022 and a skills competency is not on file to date. Staff 11: The NP, RN was hired on 12/12/2022 and a skills competency is not on file to date. During interview 12/15/2022, Administrator and Director of Clinical Services stated competencies had not been completed per agency policy..

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document reviews and interviews. In 2 of 4 (50%) contracts reviewed for provision of direct patient care or access to patient records the agency did not ensure the contract included the requirement of obtaining a criminal background check. The 02/23/2021 Therapy contract did not include the requirement of a criminal background check for all contracted employees that have access to patient records or provide direct patient care. The 02/16/2021 Respite contract did not include the requirement of a criminal background check for all contracted employees that have access to patient records or provide direct patient care. During Interview on 12/14/2022, Administrator reviewed contract and stated criminal background checks are not included in the contracts to date and an addendum had since been made to correct..