Every finding on record at Amerihealth Hospice Provider, Inc.

Observed in HR File Review. In 1 of 1 Volunteer HR files reviewed, During HR# 10's HR record it was noted the organization had not ensured it provided ongoing emergency management education and training to volunteers. For example: review of HR# 10/Volunteer's HR file revealed HR# 10's date of hire approximately 10 days prior to the last survey. Further review of HR# 10's HR file revealed no documentation of emergency management education for the last three years. This was reviewed and discussed with the Volunteer Coordinator and Director of Human Resources and validated.

Observed in Record Review. In 2 of 14 patient records reviewed, During RR# 5's patient record review it was noted the organization had not ensured the comprehensive assessment was completed no later than five calendar days after the election of hospice care. For example: review of RR# 5 revealed an initial Spiritual assessment signed and dated by the Chaplain. According to the audit trail the initial Spiritual assessment was completed and signed 13 days after the election of hospice care. Review of RR# 2's patient record revealed an initial Psychosocial assessment signed and dated by the MSW. According to the audit trail the initial Psychosocial assessment was actually completed 25 days after the election of hospice care. Review of RR# 2's initial Bereavement assessment revealed a signature and date by the MSW. According to the audit trail the initial Bereavement was actually completed 25 days after the election of hospice care. This was reviewed, discussed, and validated with the Administrator, DPCS, and QA.

Observed in Patient Home. In 2 of 3 home visits conducted, During RRHV# 2 and RRHV# 3's home observations it was noted the organization had not ensured staff followed the organization policy Bag Technique that included performing hand hygiene prior to entering the bag. For example: during RRHV# 2's home observation the registered nurse (RN) was observed removing gloves and without performing hand hygiene and place the clean vital sign equipment into the bag. During RRHV# 3's home observation the RN was observed cleaning the vital sign equipment with gloves and with the same gloves placed the vital sign equipment immediately into the bag with out performing hand hygiene prior to entering the bag. This was discussed and validated with the RN and the Administrator. Observed in Patient Home. In 2 of 2 home visits conducted, During RRHV# 1 and RRHV# 2's home observations it was noted the organization had not ensured staff followed the organization policy Hand Hygiene that included hand hygiene be performed after removing gloves and prior to putting on gloves and when moving from a dirty part of the patient body to a clean area. For example: during RRHV# 1's home observation the Hospice Aide (HA) was observed using the same pair of gloves washing the peri-anal area and then washing the legs and feet of RRHV# 1. In addition, the HA was observed removing gloves and putting on new gloves without performing hand hygiene. During RRHV# 2's home observation the Registered Nurse (RN) was observed completing a patient assessment and removed gloves and put on new gloves without performing hand hygiene during multiple glove changes. This was discussed with the RN and Administrator and validated.

Observed in HR File Review. In 7 of 11 HR files reviewed, During HR# 3, HR# 5, HR# 7, HR# 8, HR# 9, HR# 10, and HR# 11's HR file review it was noted the organization had not ensured it provided annual education on blood borne pathogens per Occupational Safety and Health Administration (OSHA) requirement. For example: review of the HR files revealed no documentation of blood borne pathogens education for the last three years. This was reviewed, discussed, and validated with Director of Human Resources and the DPCS.

Observed in Record Review. In 1 of 11 Patient records reviewed with Hospice Aide, During RRHV# 2's patient record review it was noted the organization had not ensured the registered nurse (RN) prepared complete written patient care instructions for the hospice aide. For example: review of RRHV# 2's patient record revealed RRHV# 2 had an indwelling foley catheter and was on aspirin 81mg for blood thinning. Review of RRHV# 2's Hospice Aide written patient care instructions revealed the task of shaving every visit with no documentation on what type of razor to use and no documentation of bleeding precautions, In addition, the Hospice Aide written patient care instructions had the task of a complete bed bath with no documentation that RRHV# 2 had a foley. Observed in Patient Home. In 1 of 1 Home visits conducted with Hospice Aide, During RRHV# 1's home observation it was noted the organization had not ensured the registered nurse (RN) prepared complete written patient care instructions for the hospice aide. For example: RRHV# 1 was observed with a sign above the bed that stated Maintain Head Elevation of 30-45 degrees at all times. The hospice aide was observed performing a bed bath with bed flat. Review of the hospice aide patient written instructions revealed no documentation regarding if the bed could be flat while giving a bed bath. In addition, RRHV# 1 was observed with a colostomy bag in place. Further review of the hospice aide patient written instructions revealed no documentation regarding a colostomy bag and what to do if it got displaced. RRHV# 1 was observed being transferred by Hoyer lift from the chair to the bed by the facility staff. Review of the hospice aide written patient care instructions revealed the task of transfer from chair to bed with no indication on how RRHV# 1 would be transferred, This was reviewed, discussed, and validated with the Administrator.

Observed in Patient Home. In 1 of 1 Home visits conducted with Hospice Aide, During RRHV# 1's home observation it was noted the organization had not ensured the hospice aide followed the patient written care instructions. For example: during RRHV# 1's home observation the hospice aide was observed completing a bed bath. Review of the hospice aide written patient instructions revealed the task of a complete shower. This was observed, discussed, and validated with the Administrator.

Observed in Record Review. There was no evidence that the governing body and leadership had established requirements to maintain the security and integrity of the patient records evidenced by Condition Level Deficiency in the Records of Care 418.104, Medical Director 418.102, and Leadership 418.100.

Observed in Regulatory Review. During Contract review it was noted the organization had not ensured it provided for its planned scope and level of care, treatment, or services. For example: review of the organization contracts revealed no contract for Therapy Services to include physical therapy, occupational therapy, and speech-language pathology services. This was reviewed, discussed, and validated with the Administrator that shared the Therapy Company had gone out of business and had not been able to find a new Therapy Company.

Observed in Record Review. In 3 of 4 patient records reviewed with recertification, During RR# 1, RR# 3, and RR# 6's patient records review it was noted the organization had not ensured the Medical Director or physician designee reviewed the patient's clinical information before the recertification period. For example: review of RR# 3's Written Recertification certification of terminal illness (CTI) electronic medical record (EMR) audit trail revealed the Written Recertification CTI was completed and signed by the Medical Director 28 days after the beginning of the Recertification period. Review of RR# 1's Written Recertification CTI revealed the Written Recertification CTI was completed and signed by the Medical Director 23 days after the beginning of the Recertification period. Review of RR# 6's Written Recertification CTI EMR audit trail revealed the Medical Director completed and signed the Written Recertification CTI 17 days after the beginning of the Recertification period. This was reviewed, discussed, and validated with the DPCS, Administrator, and QA.

Observed in Record Review. In 8 of 14 patient records reviewed, During RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, RR# 6 and RRHV# 3's patient records review revealed the organization had not ensured it maintained accurate patient records. For example: review of RR# 3's patient record revealed a January Written Recertification certification of terminal illness (CTI) signed and dated by the Medical Director dated six days prior to the beginning of the January Recertification. According to the audit trail the January Written Recertification CTI was actually signed by the Medical Director 28 days later than the documented signature and date in the electronic medical record (EMR). In addition, the January Written Recertification CTI was not created in order to be able to be signed until 25 days after the Medical Director signature and date in the EMR. Review of RRHV# 3's patient record revealed a February physician order signed and dated by the Medical Director. According to the audit trail the Medical Director documented a signature date 17 day prior to the Medical Director actually signing the physician order. Review of RR# 2’s patient record revealed an initial Bereavement assessment dated and signed by the MSW two days after RR# 2’s start of care. According to the audit trail the initial Bereavement assessment was actually signed by the MSW 22 days later than the documented signature and date in the EMR. Review of RR# 6’s patient record revealed a June Written Recertification CTI signed and dated by the Medical Director 10 days prior to the beginning of the June Recertification. According to the audit trail the June Written Recertification CTI was actually signed by the Medical Director 17 days later than the documented signature and date in the EMR. Review of RR# 1’s patient record revealed an March Written Recertification CTI signed and dated by the Medical Director 23 days after the beginning of the March Recertification. According to the audit trail the March Written Recertification CTI was actually signed by the Medical Director three days prior than the documented signature and date in the EMR. Review of RR# 5’s patient record revealed an initial Spiritual assessment signed and dated by the Chaplain. According to the audit trail the initial Spiritual assessment was actually signed by the Chaplain eight days later than the documented signature and date in the EMR. In addition, the initial Spiritual assessment was not created in order to be able to be signed until six days after the Chaplain signature and date in the EMR. Review of RR# 4’s patient record revealed an initial Bereavement assessment signed and dated by the MSW. According to the audit trail the initial Bereavement assessment was actually signed by the MSW five days later than the documented signature and date in the EMR. Review of RR# 7’s patient record revealed an initial Written Certification CTI signed and dated by the Medical Director five days after the start of care. According to the audit trail the initial Written Certification was actually signed by the Medical Director five days later than the documented signature and date in the EMR. This was discussed with the Medical Director that shared he manually puts in the date next to his signature when he signs documents. This was reviewed, discussed, and validated with the Administrator, DPCS, and QA.

Observed in Record Review. In 1 of 14 patient records reviewed, During RRHV3 2's patient record review it was noted the organization had not ensured the patient record contained information that reflected the patient's care, treatment, or services. For example: review of RRHV# 2's patient record revealed RRHV# 2 had a foley catheter that was changed by the Urologist once a month. Review of RRHV# 2's plan of care revealed a the goal that the foley catheter would maintain patency and stay in place. Review of RRHV# 2's patient record revealed RRHV# 2's foley catheter was no longer patent and RRHV# 2 was transported to the local Emergency Department (ED) to have the foley catheter changed. However, IDG [Interdisciplinary group] Note dated seven days after the visit to the ED revealed no documentation that RRHV# 2 had been seen in the ED or that the foley catheter had been changed. This was reviewed, discussed and validated with the DPCS. Observed in Patient Home. In 2 of 2 Home visits conducted with medication reconciliation, During RRHV# 2 AND RRHV# 3's home observations it was noted the organization had not ensured the patient record contained information that reflected the patient's care, treatment, or services. For example: during RRHV# 2's home observation the Registered Nurse was observed performing a medication reconciliation that revealed the hospice medication profile with risperidone 0.5 mg daily as needed for agitation, ondansetron 4mg every four hours as needed for nausea and vomiting, and acetaminophen 650mg rectal suppository as needed for mild pain and fever. However, review of the Board and Care medication administration record revealed no documentation of risperidone, ondansetron, or acetaminophen rectal suppository. During RRHV# 3's home observation the RN was observed completing a medication reconciliation. Review of the Board and Care Medication Administration Record (MAR) revealed Tamsulosin 0.4mg one tablet daily with prescription dated approximately 7 weeks prior to the home observation. However, review of the hospice medication profile revealed no documentation of Tamsulosin. This was reviewed, discussed, and validated with the RN and Administrator. listed This was reviewed, discussed, and validated with the RN and the Administrator.

Observed in Record Review. In 8 of 14 patient records reviewed, During RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, RR# 6 and RRHV# 3's patient records review it was noted the organization had not ensured it maintained the security and integrity of health information as staff was able to manipulate the signature date. For example: review of RR# 3's patient record revealed a January Written Recertification certification of terminal illness (CTI) signed and dated by the Medical Director dated six days prior to the beginning of the January Recertification. According to the audit trail the January Written Recertification CTI was actually signed by the Medical Director 28 days later than the documented signature and date in the electronic medical record (EMR). In addition, the January Written Recertification CTI was not created in order to be able to be signed until 25 days after the Medical Director signature and date in the EMR. Review of RRHV# 3's patient record revealed a February physician order signed and dated by the Medical Director. According to the audit trail the Medical Director documented a signature date 17 day prior to the Medical Director actually signing the physician order. Review of RR# 2’s patient record revealed an initial Bereavement assessment dated and signed by the MSW two days after RR# 2’s start of care. According to the audit trail the initial Bereavement assessment was actually signed by the MSW 22 days later than the documented signature and date in the EMR. Review of RR# 6’s patient record revealed a June Written Recertification CTI signed and dated by the Medical Director 10 days prior to the beginning of the June Recertification. According to the audit trail the June Written Recertification CTI was actually signed by the Medical Director 17 days later than the documented signature and date in the EMR. Review of RR# 1’s patient record revealed an March Written Recertification CTI signed and dated by the Medical Director 23 days after the beginning of the March Recertification. According to the audit trail the March Written Recertification CTI was actually signed by the Medical Director three days prior than the documented signature and date in the EMR. Review of RR# 5’s patient record revealed an initial Spiritual assessment signed and dated by the Chaplain. According to the audit trail the initial Spiritual assessment was actually signed by the Chaplain eight days later than the documented signature and date in the EMR. In addition, the initial Spiritual assessment was not created in order to be able to be signed until six days after the Chaplain signature and date in the EMR. Review of RR# 4’s patient record revealed an initial Bereavement assessment signed and dated by the MSW. According to the audit trail the initial Bereavement assessment was actually signed by the MSW five days later than the documented signature and date in the EMR. Review of RR# 7’s patient record revealed an initial Written Certification CTI signed and dated by the Medical Director five days after the start of care. According to the audit trail the initial Written Certification was actually signed by the Medical Director five days later than the documented signature and date in the EMR. This was discussed with the Medical Director that shared he manually puts in the date next to his signature when he signs documents. This was reviewed, discussed, and validated with the Administrator, DPCS, and QA.

Observed in Emergency Management Session. During review of the EOP it was noted the plan lacked documentation that described the patient population served by the organization that included its population's diagnoses, conditions, functional needs, language and cultural needs. This was discussed with the Administrator.

Observed in HR File Review. In 1 of 11 HR files reviewed, During HR#11 file review it was noted lack of initial training in emergency preparedness policies and procedures for individuals providing services under arrangement consistent with their expected roles. This was discussed with the Administrator and DPCS.

Observed in Emergency Management Session. During review of the disaster drills performed, it was noted the organization participated in a state wide earthquake drill in 2021. The drill lacked an identification of a clinically relevant emergency scenario within the organization service area and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. This was discussed with the Administrator.

Observed in Record Review. In 11 of 11 patient records reviewed, During RR#1-8 and HV#1-3, it was noted the consent Election of Benefits (EOB) did not contain the section on the Patient Notification of Hospice Non-Covered Items, Services and Drugs section for the patient/representative to check if they elect to decline or elect to receive the information. This was discussed with the Administrator and DPCS.

Observed in Record Review. In 2 of 11 patient records reviewed, During HV#3 record review it was noted at the recertification RN assessment the end of June 2022, the RN documented under the heading verbally expressed pain that the patient had no pain. The RN did not follow the organization policy, Pain Assessment # 2-032, to use a pain assessment tool that was appropriate for a cognitively impaired person with the terminal diagnosis of Alzheimer's disease. The policy stated the clinician will assess behavioral factors that signal pain or discomfort and include this information in the assessment. During RR#8 it was noted the patient with a dx of Alzheimer's assessment of pain by RN was reported no pain. Per RN assessment pt has confusion verbalizes 1-2 words (which are the same two words, “yes” and “no”) infrequently and is unable to make her needs known. The RN The RN did not follow the organization policy, Pain Assessment # 2-032, to use a pain assessment tool that was appropriate for a cognitively impaired person with the terminal diagnosis of Alzheimer's disease. This was discussed with the Administrator and DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, During RR#5 it was noted lack of a bereavement assessment completed within 5 days of the May 2022 admission. This was discussed with the Administrator and DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, During RR#7 it was noted the patient had a G-tube for feeding purposes. The POC lacked the order, interventions and goals for the G-tube feedings and G-tube wound care. Observed in Record Review. In 1 of 11 patient records reviewed, During HV#1 record review it was noted in the first and second certification periods a frequency for the MSW was 1x/month for the two certification periods. The POC in both certification periods lacked MSW psychosocial, emotional, counseling interventions and goals. This was discussed with the Administrator and DPCS.

Observed in Record Review. In 3 of 11 patient records reviewed, During RR#1 it was noted the frequency of visits on POC for the chaplain was not followed. The frequency of visits for the first certification was 1x/month. The chaplain visited the patient 2x in April 2022 without an order for the extra visit performed. It was also noted on the first certification an order on the POC for PRN visits for the SN without the number of PRN visits to be performed if needed. During HV#2 it was noted the SN frequency of 2x/week was not followed in the first certification period. The SN visited the patient 3x for 2 weeks in December 2021 without an IDG/POC order to change the frequency. During RR#6, it was noted a frequency for the SN for 2x/week + PRN to control symptoms and acute changes without an indication of the number of PRN visits proposed. In addition the MSW provided an extra visit in March 2022 without an IDG order. POC frequency for the MSW was 1x/month per certification. This was discussed with the Administrator and DPCS.

Observed in Record Review. In 2 of 11 patient records reviewed, During RR#5, it was noted lack of documentation of an IDG meeting since the end of May 2022 to date. During RR#7 it was noted lack of documented IDG meetings in June 2022. The last IDG meeting documented was the end of May 2022. This was discussed with the Administrator and DPCS.

Observed in HR File Review. In 1 of 1 HR files reviewed, for a hospice aide. During HR#6 review it was noted lack of documentation of the following required competencies observed by an RN: Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other staff, reading and recording temperature, pulse, and respirations, appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination, safe transfer techniques and ambulation, normal range of motion and positioning. The one observed care was documented as a bed bath.This was discussed with the Administrator and DPCS.

Observed in Individual Tracer. In 1 of 3 home visits conducted, During HV#1 it was noted 3- E tank oxygen cylinders with 1 in a cannister and the other 2 standing upright, not in a crate or cannister. This was corrected on site with the equipment company during the survey. This was discussed with the Administrator and DPCS.