Every finding on record at Aspirus Comfort Care and Hospice Services

Based on record review, agency staff failed to ensure that measurable outcomes were developed for each patient in 13 of 13 patient records reviewed (Patient's #1-13). Findings include: Review of agency policy and procedure titled "Plan of Care for Aspirus Comfort Care and Hospice Services Patients" last revised 08/2019 revealed in part "Plan of Care, D. Goals are set for each identified problem or need related to the end-stage illness or terminal conditions. The goals are determined based on input from the patient and family. The goals are stated in terms of expected outcomes for the patient and family. Include time frames for accomplishment and are realistic and meaningful. Review of Patients #1-13's goals revealed the following unmeasurable goals: Patient #1 was admitted to hospice on 09/10/2021 with a primary diagnosis of Congestive Heart Failure. Patient #2 was admitted to hospice on 03/11/2021 with a primary diagnosis of Hemiplegia & Hemiparesis. Patient #3 was admitted to hospice on 11/01/2021 with a primary diagnosis of Ovarian cancer. Patient #4 was admitted to hospice on 04/27/2022 with a primary diagnosis of End Stage Dementia. Patient #5 was admitted to hospice on 06/22/2022 with a primary diagnosis of Ischemic Stroke. Patient #6 was admitted to hospice on 05/19/2022 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD) Patient #7 was admitted to hospice on 05/13/2022 with a primary diagnosis of End Stage COPD. Patient #8 was admitted to hospice on 04/18/2022 with a primary diagnosis of Pancreas cancer. Patient #9 was admitted to hospice on 04/19/2022 with a primary diagnosis of End Stage Liver Cirrhosis. Patient #10 was admitted to hospice on 04/28/2022 with a primary diagnosis of Severe Aortic Stenosis with Congestive Heart Failure. Patient #11 was admitted to hospice on 05/18/2022 with a primary diagnosis of Brain Metastasis. Patient #12 was admitted to hospice on 05/09/2022 with a primary diagnosis of Cerebral Vascular Disease. Patient #13 was admitted to hospice on 06/23/2022 with a primary diagnosis of End Stage Renal Disease. "Patient activity needs will be completed by aide as ordered." (Patient #1, #3, #4, #5, #8, #9, #10, #11, and #13) There is no objective criteria to evaluate progress toward the goal. "Patient's environment clean-up will be completed by aide as ordered."(Patient #1, #2, #3, #7, #9, #10, #11, and #13) There is no objective criteria to evaluate progress toward the goal. "Patient's elimination needs will be completed by aide as ordered." (Patient #1, #2, #3, #4, #5, #11, and #13) There is no objective criteria to evaluate progress toward the goal. "Patient's nutritional cares will be completed by aide as ordered." (Patients #1, #2, #3, #4, #5, #10, #11, and #13) There is no objective criteria to evaluate progress toward the goal. "Patient's personal care will be completed by aide as ordered." (Patient #1, #2, #3, #4, #5, #7, #8, #9, #10, #11, and #13) There is no objective criteria to evaluate progress toward the goal. "Ability to cope." (Patient #1) There is no objective criteria to evaluate progress toward the goal. "Patient receives appropriate emotional support." (Patient #1, #2, # 3, #4, #6, #7, #8, #10, and #12) There is no objective criteria to evaluate progress toward the goal. "Patient's quality of life needs are addressed." (Patient #2, #3, and #12) There is no objective criteria to evaluate progress toward the goal. "Patient's personal care needs and safety issues are adequately met." (Patient #1, #4, #5, #6, and #9) There is no objective criteria to evaluate progress toward the goal. "Patient verbalizes understanding of medication regimen." (Patient #1, #2, #4, #5, #7, #8, #9, #10, #12, and #13) There is no objective criteria to evaluate progress toward the goal. "Patient's pain/physical discomfort will be reduced to the level of patient's stated goal." (Patient #1, #4, #6, #7, #9, #10, #11, and #13) There is no objective criteria to evaluate progress toward the goal. "Falls Occurrence." (Patient #1, #2, #4, #7, #8, and #10) There is no objective criteria to evaluate progress toward the goal. "Anxiety Control." (Patient #4) There is no objective criteria to evaluate progress toward the goal. "Nausea & Vomiting Control." (Patient #8) There is no objective criteria to evaluate progress toward the goal. "Patient verbalized/exhibits respiratory ease." (Patient #1, #2, #6, #10, and #11) There is no objective criteria to evaluate progress toward the goal. "Intact skin integrity." (Patient #1, #2, and #4) There is no objective criteria to evaluate progress toward the goal. "Patient's edema is decreased or stabilized." (Patient #6, and #11) There is no objective criteria to evaluate progress toward the goal. These findings were reviewed and confirmed in interview with Hospice Manager A on 06/28/2022 at 10:59 AM. Hospice Manager A stated, "I would expect to see if the goal states as directed or dated, how that is being done."

Based on record review and interview this agency failed to show that one or more persons was appointed to assume responsibility for operation of the QAPI program in 1 of 1 QAPI program reviewed. Findings Include: During Interview with Hospice Manager A on 06/27/2022 at 9:45 AM, Hospice Manager A stated "the previous administrator had resigned 06/03/2022." Hospice Manager A was asked who the Governing Body had appointed as the administrator and alternative administrator. Hospice Manager A stated "(VP (vice president) Post-Acute Care H) would be the interim administrator and (VP Chief Nursing Officer of Home Health and Hospice G) would be the alternative." Hospice Manger A was asked to provide governing body meeting minutes that document the governing body had appointed an administrator and alternative administrator to oversee the hospice program, including QAPI." Review of document titled "Aspirus Board of Directors Meeting" dated 05/16/2022 revealed in part "The Post-Acute Care Transition Plan was reviewed as Administrator I noted Administrator I's last day would be 6/3/2022. The transition and interim coverage plan were explained, and it was noted that three candidates are being considered to fill the Vice President of Post-Acute Care role on an interim basis." During interview with Hospice Manager A on 6/27/2022 at 12:55 PM, Hospice Manager A was asked, as of 6/27/2022 at 12:55 PM has the governing body appointed a hospice administrator and alternative administrator. Hospice Manager A stated "No, the next meeting is scheduled for 7/18/2022." During interview with Hospice Manager A on 6/29/2022 9:35 AM, Hospice Manager A stated "we looked and could not find any documentation of the governing board appointing administrator or alternative administrator, in the governing body minutes dated 1/1/2021 through 05/16/2022. As of exit on 06/29/2022 this agency could not provide documentation that the QAPI program had someone designated by the governing body for operating the program.

Based on record review, observation and interview, the agency failed to adhere to and document infection control practices per the agency's policy and procedure in 13 of 13 (Patient #1-13) record reviews and 1 of 3 (Patient #10) patient observations/home visits conducted. Findings include: Review of policy and procedure titled "Travel Screening" dated 10/27/2021 revealed in part "Travel screening is to be completed during scheduling of all patient visits, prior to entering the patient's home." At the conclusion of an observation on 06/27/2022 at 2:45 PM of a home visit with Patient #10, Registered Nurse (RN) B was asked what the process for prescreening for COVID-19 patients prior to home visits was. RN B stated that upon admitting to hospice the patient is provided with COVID -19 education and that the expectation was that the patient contacts hospice if they (Patients) are experiencing COVID-19 symptoms or if they were positive for COVID-19. When asked if RN B contacted patient #10 prior to visit on 06/27/2022 to screen patient #10 for COVID-19, RN B stated, "No." Review of patient's #1-13 records, revealed under tab titled, "Travel Screening" that all ordered disciplines did not document the completion of COVID-19 pre-screening prior to each ordered visit per agency protocol. During an interview with Hospice Manager A on 06/28/2022 at 11:13 AM , Hospice Manager A was asked what the expectation for pre-screening patients prior to home visits was. Hospice Manager A explained that it's expected that all staff are to contact the patient's prior to each visit and pre-screen for COVID-19. Hospice Manager A confirmed that the documentation was incomplete in the patient records.

Based on record review and interview this agency failed to provide documentation showing that an administrator and alternative administrator were appointed by the Governing Body to be responsible for the day to day operations of the hospice for 1 of 1 Board of Directors Meeting Minutes reviewed. Findings Include: During Interview with Hospice Manager A on 06/27/2022 at 9:45 AM, Hospice Manager A stated "the previous administrator had resigned 06/03/2022." Hospice Manager A was asked who the Governing Body had appointed as the administrator and alternative administrator. Hospice Manager A stated "(VP (vice president) Post-Acute Care H) would be the interim administrator and (VP Chief Nursing Officer of Home Health and Hospice G) would be the alternative." Hospice Manger A was asked to provide governing body meeting minutes that document the governing body had appointed an administrator and alternative administrator to oversee the hospice program." Review of document titled "Aspirus Board of Directors Meeting" dated 05/16/2022 revealed in part "The Post-Acute Care Transition Plan was reviewed as [Administrator I] noted [Administrator I's] last day would be 6/3/2022. The transition and interim coverage plan were explained, and it was noted that three candidates are being considered to fill the Vice President of Post-Acute Care role on an interim basis." During interview with Hospice Manager A on 6/27/2022 at 12:55 PM, Hospice Manager A was asked, as of 6/27/2022 at 12:55 PM has the governing body appointed a hospice administrator and alternative administrator. Hospice Manager A stated "No, the next meeting is scheduled for 7/18/2022." During interview with Hospice Manager A on 6/29/2022 9:35 AM. Hospice Manager A stated "we looked and could not find any documentation of the governing board appointing administrator or alternative administrator, in the governing body minutes dated 1/1/2021 through 05/16/2022. As of exit on 06/29/2022 this agency could not provide documentation that the governing body had appointed an administrator and alternative administrator to be responsible for the day to day operations of the hospice.

Based on record review and interview, the agency administration failed to maintain over-site of contract agencies to ensure the provision and quality of care for hospice patients in 6 of 6 eligible contracts reviewed (Contract J, Contract K, Contract L, Contract M, Contract N, Contract O) in a total of 6 contracts reviewed. Findings Include: Review of agency policy titled "Evaluation of Clinical Contract Services." dated 05/2022 revealed in part "Policy, B. Patient Care Contracts are evaluated on an annual basis or more often as necessary, to ensure quality of services is maintained according to Aspirus patient care and service standards and are in compliance with regulatory requirements." Record review of Contract J file revealed an original contract with this agency dated 02/14/2004. There was no evidence on file to reveal Contract J had been reviewed annually. Contract J's end date was 01/31/2021. Contract J is still providing services. Record review of Contract K revealed an original contract with this agency dated 03/01/2017. There was no evidence on file to reveal Contract K had been revived annually. Contract K is still providing services. Record review of Contract L revealed an original contract with this agency dated 02/12/2016. There was no evidence on file to reveal Contract L had been reviewed annually. Contract L's end date was 02/11/2022. Contract L is still providing services. Record review of Contract M revealed an original contract with this agency dated 11/13/2008. There was no evidence on file to reveal Contract M had been reviewed annually. Contract M's end date was 11/12/2021. Contract M is still providing services. Record review of Contract N revealed an original contract with this agency dated 08/15/2006. There was no evidence on file to reveal Contract N had been reviewed annually. Contract N's end date was 08/14/2021. Contract N is still providing services. Record review of Contract O revealed an original contract with this agency dated 09/29/2019. There was no evidence on file to reveal Contract O had been reviewed annually. Contract O's end date was 09/28/2021. Contract O is still providing services. Interview with VP Post Acute Care H on 6/28/2022 at 3:15 PM. VP Post Acute Care H stated "the contracts are reviewed annually in the OnBase system." On 6/29/2022 at 9:35 AM Hospice Manager A provided OnBase contract reviews for contracts J-O. Contracts J-O have not been reviewed annually. Upon exit conference on 06/29/2022 at 9:35 AM no additional information was provided to show proof that the contract was reviewed annually.

Based on record review and interview, the hospice staff failed to develop plans of care that delineated responsibilities of care and services for performing functions of patients receiving care in assisted living facility or skilled nursing facility the hospice staff and facility staff in 6 of 6 patients that resided in a facility (Patient #1, #4, #5, #6, #9 and #11) in a total of 13 patient records reviewed. Findings include: Review of agency policy and procedure titled "Plan of Care for Aspirus Comfort Care and Hospice Services Patients" last revised 08/2019 revealed in part "Plan of Care, F. Interventions are specified which: 1. Include the actions to be taken by Aspirus staff/and or contracting home or inpatient setting employees." Record review of Patient #1's Plan of Care dated 04/20/2022-06/18/2022 revealed Patient #1 was admitted to hospice with a primary diagnosis of Congestive Heart Failure. Patient #1 resided in a skilled nursing facility. Review of #1's Plan of Care revealed no delineation of which provider was responsible for which interventions on the Plan of Care. Record review of Patient #4's Plan of Care dated 04/27/2022-07/25/2022 revealed Patient #4 was admitted to hospice with a primary diagnosis of End Stage Dementia. Patient #4 resided in an assisted living facility. Review of #4's Plan of Care revealed no delineation of which provider was responsible for which interventions on the Plan of Care. Record review of Patient #5's Plan of Care dated 06/22/2022-09/19/2022 revealed Patient #5 was admitted hospice with a primary diagnosis of Ischemic Stroke. Patient #5 resided in a skilled nursing facility. Review of Patient #5's Plan of Care revealed no delineation of which provider was responsible for which interventions on the Plan of Care. Record review of Patient #6's Plan of Care dated 05/19/2022-08/22/2022 revealed Patient #6 was admitted to hospice with a primary diagnosis of Chronic Obstructive Pulmonary Disease. Patient #6 resided at an assisted living facility. Review of Patient #6's Plan of Care revealed no delineation of which provider was responsible for which interventions on the Plan of Care. Record review of Patient #9's Plan of Care dated 04/19/2022-05/24/2022 revealed Patient #9 was admitted to hospice with a primary diagnosis of End Stage Liver Cirrhosis. Patient #9 resided in a skilled nursing facility. Review of #9's Plan of Care revealed no delineation of which provider was responsible for which interventions on the Plan of Care. Record review of Patient #11's Plan of Care dated 05/18/2022-05/25/20222 revealed Patient #11 was admitted to hospice with a primary diagnosis of Brain Metastasis. Patient #11 resided in a skilled nursing facility. Review of #11's Plan of Care revealed no delineation of which provider was responsible for which interventions on the Plan of Care. These findings were reviewed and confirmed during an interview with Hospice Manager A on 6/28/2022 at 10:59 AM. When the regulatory requirement was explained, Hospice Manager A stated, "you're right, we need to specify who is responsible for what."