Every finding on record at Appalachian Hospice LLC

Observed in Record Review. In 1 of 1 patient records reviewed, with hospice revocation, the organization failed to respect the patient's right to exercise his or her rights as a patient of hospice. On review of RRDC#2 the documentation noted the patient revoked the hospice benefit yet the signed revocation was not found on the record. This observation was reviewed with the Assistant Administrator. Observed in Record Review. In 1 of 1 patient records reviewed, with live discharge for extended prognosis, the organization failed to respect the patient's right to participate in decisions about their care, treatment or services. On Review of RRDC#1 the patient was discharged live with documentation that condition had stabilized however there was no signed Notice of Medicare Non-Coverage noted on the record. There was an ABN signed but was the incorrect CMS form and did not give the patient information of how to appeal the discharge. This observation was reviewed with the Assistant Administrator.

Observed in Record Review. In 2 of 14 patient records reviewed, the organization failed to conduct and document a patient-specific comprehensive assessment and reassessment that identified the patient's need for hospice care and services. On review of RRNHV#5 the patient had documentation of a stage 1 sacral pressure wound yet there was no documentation of a wound assessment as required such as size, color, and surrounding skin. The patient also had cancerous wounds to the scalp. there was no documentation of comprehensive wound assessment as required every 15 days or less noted in the record. In RRNHV#7 there were multiple wounds documented, a sacral wound that was present on admission there was no documentation of a comprehensive wound assessment after April. There were 3 additional wounds documented, yet no comprehensive wound assessment documented as required. These observations were reviewed with the Administrator, Assistant Administrator, and Clinical Manager.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to conduct and document a patient-specific comprehensive assessment and reassessment that identified the patient's need for hospice care and services. On review of RRNHV#11 the documentation noted the patient/family was interested in volunteer services yet there was no documentation that an assessment for volunteer needs was conducted. This observation was reviewed with the Administrator, Assistant Administrator, and Clinical Manager.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to ensure the clinical record was complete, promptly and accurately documented. On review of RRNHV#8 there was documentation of an LVN supervisory visit every RN visit yet there was no LVN seeing the patient per the record. This observation was reviewed with the Administrator, Assistant Administrator, and Clinical Manager.

Observed in Record Review. In 12 of 14 patient records reviewed, the organization failed to ensure the individualized written plan of care reflect patient and family goals that were specific, measurable, and time-bound. On review of all of the clinical records there were goals that were not individualized, specific, measurable and time-bound. An example in RRHV#1 was Patient/caregiver will feel more comfortable and Promote optimal patient orientation and communication skills. In RRHV#2 and example was provide patient with resources to assist him in funding a medical necessity. In RRHV#3 a goal was Nutritional intake to be consistent during this cert period, and in RRHV#4 Patient will maintain optimal swallowing this certification period. In RRNHV#5 an example was Social worker will provide supportive listening, validation, and counseling throughout plan of care. Examples of goals that were not specific, measurable, and time-bound can be seen throughout the clinical records. Similar examples of goals that were not specific, measurable, and time-bound were noted in RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#11, RRNHV#12, RRNHV#14. These observations were reviewed with the Administrator, Assistant Administrator, and Clinical Manager.

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 condition. On review of RRNHV#5 there was documentation of constipation with the addition of Milk of Magnesia and skin infection with pain of the patient's scalp wound requiring topical medications yet the issues were not reflected in the care plans. On review of RRNHV#6 the patent had diabetes type 2 with insulin. There was documentation of issues with hypoglycemia and monitoring of blood glucose by the family yet there was no endocrine care plan to guide the care. There was also documentation of a UTI with antibiotics but no care plan for the infection. In RRNHV#12 there was documentation of a Upper respiratory infection with antibiotics yet the issue was not reflected on the care plan. These observations were reviewed with the Administrator, Assistant Administrator, and Clinical Manager.

Observed in Record Review. In 12 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 RRHV#1, RRHV#3, RRNHV#6, RRNHV#9, and RRNHV#14 there were medication orders with ranges with no specific instructions to guide the user in choosing the correct dosage. For example: Morphine concentrate 100mg/5ml (20 mg/mL) oral solution 0.25 ml – 1 ml every 2 hours as needed - pain or shortness of breath. Lorazepam 1 mg tablet ½ - 2 tablets every 2 hours as needed - anxiety or agitation. Similar range orders were noted in RRHV#4, RRNHV#5, RRNHV#6, RRNHV#9, and RRNHV#14. In RRHV#2, RRNHV#7, RRNHV#10, RRNHV#11, and RRNHV#13 the Morphine order for the e-Kit was noted to not have a specific dosage for administration as the dosage section stated 100 mg/5ml (20mg/ml) only and not how much to give. In RRNHV#11 there were multiple 4 as needed medications for pain (Tylenol, Tylenol with Codeine, Ibuprofen, and Tramadol) but there were no specific instruction to guide the user to know when to choose which medication. These observations were reviewed with the Assistant Administrator, Administrator, and Clinical Manager.

Observed in Patient Home. In 1 of 4 home visits conducted, the organization failed to ensure staff follow accepted standards of practice to prevent the transmission of infections and communicable diseases. On home observation for RRHV#1 the LPN was observed to wash hand in the home sink and dried hands using a bath towel hanging in the patient's bathroom. Further, there was no observation of performing hand hygiene throughout the visit such as after vital signs and patient assessment, cleansing the equipment, and returning the equipment to the nurse's bag. This observation was reviewed with the LPN, Clinical Manager, and Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to conduct and document a patient-specific comprehensive assessment that identified the patient's need for hospice care and services. On review of RRNHV#14 there was documentation from the spiritual counselor that they were unable to contact the patient/caregiver and no spiritual assessment had been documented from admission in late July to date of survey. This observation was reviewed with the Administrator, Assistant Administrator, and Clinical Manager.

Observed in Record Review. In 2 of 11 patient records reviewed, with aide services provided, the organization failed to ensure written patient care instructions for the hospice aide were prepared by the Registered Nurse. On review of RRNHV#5 the patient had multiple cancerous scalp lesions. There were no specific instructions to the aide on how to handle the cancerous lesions while providing care. In RRNHV#7 there were multiple wounds that required wound dressings yet there were no specific instructions on how to handle the dressings while performing tasks. These observations were reviewed with the Administrator, Assistant Administrator, and Clinical Manager.

Observed in HR File Review. In 1 of 10 HR files reviewed, the organization failed to ensure staff competence was initially assessed and documented as part of orientation. On review of HR#5 for the volunteer coordinator there was no documentation that competency was assessed as part of orientation. This observation was reviewed with the Assistant Administrator and Clinical Manager.

Observed in Patient Home. In 1 of 4 home visits conducted, the organization failed to ensure the patient record contain all information that reflects the patient's care, treatment, and services. On home observation of medication reconciliation at RRHV#1 the was Fluticasone Prop 50 mcg nasal spray 2 sprays each nostril daily was noted in the patient home and the caregiver stated he given it to the patient daily over the past year however the medication was not included on the medication profile for the patient. This observation was reviewed with the LPN, Administrator, and Clinical Manager.

Observed in Record Review. In 1 of 2 patient records reviewed, for live discharge, the organization failed to ensure the hospice provide the receiving facility with a copy of the discharge summary and copy of patient clinical record if requested within 2 days as required. On review of RRDC#2 where documentation showed the patient revoked and was sent to a hospital yet there was no documentation that the discharge summary was sent to the receiving facility. This observation was reviewed with the Assistant Administrator, and Clinical Manager.

Observed in Record Review. In 2 of 2 patient records reviewed, the organization failed to ensure when a patient was discharged or transferred the hospice provides the attending physician with a copy of the hospice discharge summary. On review of RRDC#1 and RRDC#2 there was no documentation that the completed discharge summary was provided to the attending physician within 5 days as required. This observation was reviewed with the Assistant Administrator.

Observed in Record Review. In 4 of 11 patient records reviewed, it was observed that the organization did not inform the patient of their financial obligation and of covered and non-covered services prior to beginning services. This section of the Consent For Election of Medicare Hospice Benefit form was blank. This was confirmed by the Clinical Manager.

Observed in Record Review. In 2 of 11 patient records reviewed, chaplain failed to complete their initial assessment within five days after the election of hospice. In RR#8, the surveyor noted that the spiritual assessment was completed on Day 13. In RR#6, the surveyor noted that the spiritual assessment was completed on Day 6. In both instances, there was no documentation on file stating that the attempt was made and that the visit was declined or scheduled for a later date. This was confirmed with the Clinical Manager.

Observed in Record Review. In 5 of 11 patient records reviewed, no evidence that the bereavement risk assessment was completed. In HV#3/RR#3, RR#5, RR#7, and RR#8, the initial bereavement risk assessment was not completed. In RR#9, the post bereavement risk assessment was not completed. This was confirmed by the Bereavement Coordinator and the Clinical Manager.

Observed in Record Review. In 11 of 11 patient records reviewed, the surveyor noted goals developed in the plan of care were not measurable and individualized and did not have time frames for achieving goals. Upon review of all records, goals were not measurable and specific and lacked a time frame to achieve desired outcome. This was confirmed by the Clinical Manager.

Observed in Record Review. In 2 of 4 contracts reviewed, the organization had a signed contractual agreement that did not include all of the required elements. Specifically, the DME and pharmacy contract failed to require criminal background checks. This was confirmed with the Administrator.