Every finding on record at Anchor of Hope Hospice, LLC

Observed in Record Review. In 4 of 14 active patient records reviewed,, the organization failed to conduct and document a patient specific comprehensive assessment. in record RRNHV #9 there was no initial spiritual assessment documented. This was reviewed with the Administrator and the Director of Patient Services. Observed in Record Review. In 4 of 14 active patient records reviewed, the organization failed to conduct and document a patient specific comprehensive assessment. In record RRNHV#1 there was no initial spiritual assessment documented. And in records RRNHV#4 and RRNHV#5 there were no initial bereavement assessments documented. This RFI was reviewed with the Administrator, and Director of Patient Services.

Observed in Record Review. In 14 of 14 patient records reviewed, plan of care goals were not specific and measurable. Here are some examples: Patient will awaken rested and not be fatigued during day most of the time; patient/caregiver will verbalize or demonstrate feeling supported by hospice team, family, and/or friends and will adapt to changes, challenges and crises throughout hospice admission; patient/caregiver will verbalize understanding of oxygen safety and use of equipment; patient/caregiver will demonstrate how to care for catheter effectively. Additionally, goals were assigned a completion date of either 7, 15, or 30 days. However, most were not completed within those time frames, many had dates moved forward, and some were discontinued and re-written for the next 30 days. The Administrator said that this was done to keep them fresh in the minds of staff. Observed in Record Review. In review of the patient record 1 of 2, the record does not have plan of care goals that are specific and measurable. For example, the documentation of the goals are as follows: the patient will exhibit a decrease in pain related behaviors in 30 days, incontinence of bowel/bladder will be managed by the caregivers for 30 days, patient will receive coordinated care from hospice Interdisciplinary group (IDG) and facility staff ongoing, patient will have acute confusion/agitated behaviors reduced to manage able levels within the limits of the disease in 30 days, and caregiver will verbalize anxiety is absent or reduced to an acceptable level. This was reviewed with the Administrator and the Director of Patient Services.

Observed in Record Review. In 1 of 14 active patient records reviewed,, it was noted in RRHV#3 that the Registered Nurse on call visit documentation did not reflect an evaluation of all fall reduction activities including assessment and intervention, education, and an update to the plan of care based on the patient's changes. For example, three incident reports attached in the patient's record indicated the patient sustained falls within three days resulting in multiple injuries to include, bruising to bilateral upper extremities, a skin tear to the left forearm and elbow, a possible dislocation of the left thumb, and a wound on the corner of the tongue. Despite these events, the plan of care was not updated to reflect the change in condition. This was reviewed with the Administrator of hospice services.

Observed in Record Review. In 14 of 14 active patient records reviewed, interdisciplinary group meeting notes did not document patient decline, progress towards desired outcomes and goals, and plans for the following two weeks. Notes did not include what was discussed. This RFI was reviewed with the Administrator, and Director of Patient Services. Observed in Record Review. In 1 of 2 patient records reviewed the Interdisciplinary group (IDG) documented notes did not identify the patient's status of decline, goals were not well defined to give a clear indication of the desired outcomes and plans of care for the upcoming two weeks. The record also did not contain documentation as to the discussion of the patient's status at IDG. This was discussed with the Administrator of hospice and the Director of patient services.

Observed in Record Review. In 8 of 14 active patient records reviewed, the organization failed to ensure that the plan of care was current. In record RRHV#1, RRHV#2, RRNHV#2, RRNHV#3, and RRNHV#5 scheduled home health aide visits were missed. And in record RRHV#2 a scheduled spiritual care visit was also missed. There were no orders for these missed visits obtained from the Medical Director. This RFI was reviewed with the Administrator, and Director of Patient Services. Observed in Record Review. In 8 of 14 active patient records reviewed,, the organization failed to ensure that the plan of care was current. In record RRNHV#9 scheduled Registered Nurse and Hospice Aide visits were missed. Also, in record RRNHV #10 a scheduled Registered Nurse visit was also missed. There were no orders for these missed visits obtained from the Medical Director. This was reviewed with the Administrator and the Director of Patient Services.

Observed in Competency Session. In 1 of 10 HR files reviewed, the organization did not evaluate staff competence as required. There was no documented competency found in the personnel file HR#8 HHA for reinforcing or replacing a dressing that was soiled or damaged. These directions were found in the aide plan of care. This was reviewed with the Administrator and the Director of Patient Services.

Observed in Record Review. In 1 of 14 active patient record reviewed,, the Registered Nurse did not revise the care plan when there was a change in condition. In RRHV #3 it was noted, that there was no documentation to support a hospice aide care plan update for safety, the implementation of safety measures, and or additional fall risk precautions following three falls by a patient in three days. This was reviewed with the Administrator of hospice services.

Observed in Record Review. In 2 of 14 active patient records reviewed, hospice aide supervision was not documented every 14 days. Over the past three weeks, 16 days elapsed between supervisory visits by a registered nurse in the records of RRNHV#1 and RRNHV#5. This RFI was reviewed with the Administrator, and Director of Patient Services.

Observed in Tracer Activities. Documented volunteer hours equaled 2.2% of the total patient care hours for the previous year, which was well below the required 5%. This RFI was reviewed with the Administrator, and Director of Patient Services.

Observed in Record Review. While conducting a review of the patient's record RRHV #3 it was noted on the hospice aide plan of care, the Registered Nurse delegated wound care tasks to the hospice aide but failed to follow the organization's policy in delegating tasks to the hospice aide to include documentation of teaching, ensuring supervision, and reevaluation of the delegated task. For example, on the hospice aide plan of care, the Registered Nurse documented instructions on the hospice aide care plan to replace the dressing under the chin if it becomes damaged or soiled and in an updated hospice aide care plan, additional instructions instructed the hospice aide to replace the patient's wound dressings underneath the chin, left elbow, and left heel should either dressing become damaged or soiled and apply medihoney to the sacrum. This was reviewed with the Administrator of hospice services.

Observed in Patient Home. In 1 of 2 home visits conducted, with nursing staff the organization had not assessed medication related problems. For HOS 2 the hospice nurse conducted a medication assessment however several errors were identified for the patient who had been on hospice services for more than 12 weeks. For HOS 2 the hospice medication profile included Promethazine 1ml prn q4hr every 4 hours as needed for nausea/vomiting but did not include the dose which was 25mg/ml and was printed on the prescription label. Additionally, when the hospice medication profile was compared to the facility medication list the surveyor noted that the facility list included two medications that had been discontinued on the hospice medication profile including Neosporin Topical Ointment and Lidocaine 5% Topical Cream. This was validated by the Director of Nursing.

Observed in Record Review. In 11 of 13 patient records reviewed, goals on the written plan of care were not measurable or did not have time frames for achieving goals or were documented as on-going. For example for HOS 1 the problem of impaired skin integrity had a goal of: wound will have pain, odor, and drainage managed, but did not include objective measurements for decreasing pain or drainage or the size of the wound. The patient also had a problem for a fall prevention plan related to weakness with a goal: patient/caregiver will verbalize fall safety instructions, but failed to include specific measurable goals related to patient specific equipment provided by the hospice including a Broda-chair and Hoyer lift and the goal was documented as on-going. Additionally, in review of the care plan for HOS 2 hospice staff had documented a problem of alteration in neurological status with a goal: Patient will have acute confusion/agitated behaviors reduced to manageable level within the limits of the disease, however failed to include measurable goals that would identify or define manageable levels such as agitation will reduce to 1-3 x day with pharmacological and non-pharmacological interventions including reduction in stimuli, aromatherapy, etc. Time frames for achieving goals were documented as ongoing. This was also observed in review of the medical records for HOS 3, RR 1, RR 2, RR 3, RR 4, RR 5, RR 6, RR 9 and RR 10. This was validated with the Administrator. Observed in Record Review. In 1 of 13 patient records reviewed, the interdisciplinary group did not comply with the organization's policy Bereavement PC. 27 when preparing the written plan of care which states information gathered from the initial bereavement risk assessment will be incorporated into the IDT plan of care. In review of the medical record for HOS 1 there was no evidence that information from the bereavement risk assessment was incorporated into the plan of care. This was also observed in review of the medical records for HOS 2, HOS 3, RR 1, RR 2, RR 3, RR 4, RR 5, RR 6, RR 9 and RR 10. This was validated by the Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization did not provide care according to the care plan and comply with their policy PC. 6 Plan of Care Process which states that the agency will ensure that each patient and primary caregiver receive education and training as appropriate to their responsibilities for the care and services identified in the plan of care. In observation of the home visit for HOS 1 the RN and Nurse Practitioner had not provided care according to hospice plan of care. For example, the care plan included conduct and document a comprehensive pain assessment which was not completed during the home visit. The care plan also included educate patient/caregivers on use of DME and have them complete return demonstration of safe use, educate patient/caregiver on signs of infection to wound, increased pain, increased drainage, change in character of drainage, fever, induration around wound, erythema around wound which was not addressed during the home visit. The care plan also included perform wound care to left buttocks once a week, cleanse/irrigate with wound cleanser, apply heart shape Meplix, cover and secure with tape, using aseptic technique however the RN also applied triple antibiotic solution which was not on the care plan. Additionally, in observation of the home visit for HOS 2 care was not provided in accordance with the hospice plan of care which included education of facility staff on; setting priorities for treatment of acute dehydration and infections based on prognosis, instruct on realistic expectations, provide education on effective communication, home safety, fall prevention, engagement in meaningful activities and ways to manage cognitive and behavioral changes, educate on techniques for management of dyspnea, educate on oxygen safety, educate on progression patterns of hypertension and peripheral vascular disease associated with symptoms and when to call hospice agency. Education was not completed during the home visit. Also, in review of the medical record for HOS 3 the care plan included educate patient/caregiver regarding oxygen safety measures, educate patient/caregiver how to reposition patient with care to protect against the adverse effects of external mechanical forces, teach conversation techniques however in review of 3 of 3 nursing visit notes there was no evidence in the documentation that teaching had occurred according to the plan of care.

Observed in Patient Home. In 2 of 2 home visits conducted, with nursing staff, the organization did not implement their infection control and prevention activities. For example for HOS 1 the nurse did not follow the organization's Bag Technique Policy IC. 12 which states that bags should never be placed on the floor.  The hospice bag remained on the patient's floor throughout the visit.  The hospice staff also failed to complete the COVID 19 screening questions with the patient and family prior to the home visit as required by the hospice organization. When questioned the daughter who is the primary caregiver reported that she has not been contacted prior to hospice staff visits and questioned about COVID 19. Additionally, the surveyor noted for HOS 2 that the hospice bag was on the patient's floor throughout the visit. This was validated by the Director of Nursing. Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not implement standard precautions in accordance with their policy Hand Hygiene IC. 3 which states decontamination of hands is done after removing gloves. For HOS 1 the nurse practitioner removed her gloves following examination of the patient's sacral wound however failed to decontaminate her hands until several minutes later when she was leaving the patients bedroom and then used the patient's bathroom to wash her hands using the patient's soap and handwashing supplies. This was validated by the Director of Nursing.

Observed in Record Review. In 2 of 3 patient records reviewed, documentation in the clinical record was not accurate. For example in review of 1 of 7 Hospice Aide Visit notes for RR 1 the hospice aide documented that the caregiver reported the patient had already been washed was asleep and the husband stated that the Hospice Aide should let the patient sleep and come back on Wednesday however the Hospice Aide checked all the tasks completed on the Hospice Aide Visit note. Additionally, in review of the medical record for HOS 1 the Hospice Aide Care Plan included a shower with chair on M, W, F and in review of 1 of 1 visits note the Hospice Aide documented and checked bed bath, chair bath, tub bath, shower and shower with chair. This was validated with the Administrator. This was verified by the Administrator.