Every finding on record at Assured Hospice Care Inc.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 4 of 19 (21%) clinical records reviewed it was revealed that the agency did not ensure the plan of care (POC) included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The date of the election of benefits was 11/17/2022. The primary hospice diagnosis was atherosclerotic heart disease of native coronary artery without angina pectoris. The skilled visit note, completed by the registered nurse (RN) dated 09/06/2024 documented that the patient had an "area on coccyx slightly reddened and no open areas." The skilled nursing SOAP note dated 09/10/2024 documented that the patient had a "small area at coccyx site skin open no drainage pinkish in color." The RN skilled nursing visit note dated 09/13/2024 documented that the patient had a "small wound to coccyx Triad ont and boarder drsg." The RN skilled nursing visit note dated 09/25/2024 documented that the patient had a stage III pressure injury wound to the coccyx with wound treatment of "wash with saline/wound wash pat dry apply Meta Honey into wound bed cover with Boarder drsg. Daily wound care." The RN Skilled Nursing Visit note dated 10/03/2024 documented that the patient had a stage III pressure injury wound to the coccyx with wound treatment of "washed with saline and patted dry. Applied Medihoney into wound bed. Covered with Boarder drsg." The IDG Meeting notes dated 09/11/2024, 09/25/2024, and 10/09/2024 lacked problems, interventions and goals for impaired skin integrity and wound care. Clinical Record 8: The patient's date of election was 08/21/2024. The primary hospice diagnosis was Nutritional Marasmus. The RN Initial Assessment Visit note dated 08/21/2024 documented that the patient had a past medical history of epilepsy, psychotic disorder with delusions, schizoaffective disorder, and depression. The Medication Profile dated 08/28/2024 documented Paxil 40mg daily for depression, Phenytoin Sodium Extended Oral Capsule 300mg daily for epilepsy, and Risperdal 3mg daily for antipsychotics. The Plan of Care Order dated 08/26/2024 and the IDG Meeting notes dated 08/26/2024, 09/11/2024, 09/25/2024, and 10/09/2024 lacked problems, interventions, and goals for risk of seizures and a risk for behavioral changes. Clinical Record 9: The date of the election of benefits was 07/06/2023. The primary hospice diagnosis was Cerebral Infarction, unspecified. The RN Skilled Nursing Visit note dated 07/03/2024 documented that the patient had a right-sided weakness, limited mobility, the right leg contracted upward, was bed and chair bound, and had dominant paralysis. The RN Recertification note dated 08/08/2024 documented that the patient had paralysis of the right upper and lower extremities, a severe contracture of the right leg, and an MAHC-10 fall risk of 7/10. The IDG Meeting notes dated 07/03/2024, 07/17/2024, 07/31/2024, 08/14/2024, and 08/28/2024 lacked, interventions, and goals for safety/fall risk. Clinical Record 10: The date of the election of benefits was 06/15/2023. The primary hospice diagnosis was Atherosclerotic heart disease of native coronary artery without angina pectoris. The RN Recertification note dated 03/21/2024 documented that the patient was a FAST 7D, had a MAHC-10 fall risk of 9/10, was in bed mainly, and had "Bil extremities with increased stiffness and ridged. Increased weakness to bil extremities and increased contractures to bil extremities." The RN Recertification notes dated 05/21/2024 and 07/30/2024 documented that the patient was a FAST 7D, had a MAHC-10 fall risk of 9/10, and was "bedbound no longer gets OOB due to increased pain, stiffness, rigidity and contractures." The IDG Meeting notes dated 04/03/2024, 06/05/2024, and 07/31/2024 lacked interventions, and goals for safety/fall risk. During a joint review of the record and an interview on 10/24/2024, the Executive Director/Registered Nurse confirmed that there was no documented evidence that the plans of care included goals, and interventions for the problems identified in the assessments.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview and observation. In 2 of 4 (50%) home visit observations it was revealed that the organization did not ensure the staff followed the hand hygiene policy. Document 1: Agency Policy: Hand Hygiene, Policy No. C:2-048, not dated, stated in part, "Hand decontamination using an alcohol-based hand rub should be performed after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, if hands are not visibly contaminated; when moving from a contaminated body site to a clean body site during patient care; and after removing gloves. Hand Washing with Soap and Water: Wet hands and apply the soap, and rub hands together vigorously; avoid use of hot water because repeated exposure to hot water may increase risk of dermatitis. Wash hands for at least 15 seconds covering all surfaces of the hands and fingers. Rinse with warm water and dry the hands with a disposable towel from the fingers toward the forearm. Use a dry disposable towel to turn off faucet." Home Visit 1: During the home visit (Clinical Record 4) performed on 10/22/2024 with the Chaplain (Staff 9), the Chaplain was observed washing the hands with soap and water, turning off the faucet with wet hands, and using paper towels to dry the hands. Home Visit 3: During the home visit (Clinical Record 1) performed on 10/22/2024 with the Registered Nurse (RN) (Staff 5), the RN was observed donning gloves and cleaning stool before starting wound care to the coccyx. The RN removed one glove and donned a new glove without decontaminating the hand. After cleaning the patient, the RN removed the gloves and washed the hands with soap and water. The RN turned off the faucet with the forearm/elbow. The RN donned a new pair of gloves and performed wound care. The RN removed the gloves during wound care and donned a new pair without decontaminating the hands. The RN removed the gloves after the wound care, changed the patient's brief, and donned another pair without decontaminating the hands. During a joint document review and interview on 10/23/2024, the Executive Director/Registered Nurse agreed the staff did not follow the hand hygiene policy.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 1 of 16 (6%) clinical records reviewed of patients that had a recertification, it was revealed that the agency did not ensure the hospice medical director or physician-designee provided written and signed recertification of the terminal illness no more than fifteen (15) days before the next benefit period begins. Clinical Record 13: The date of the election of benefits was 06/09/2023. The physician's recertification of the terminal illness for the eighth benefit period effective 10/01/2024 was dated and signed on 09/11/2024, twenty (20) days before the beginning of the next benefit period. During a joint review of the record and an interview on 10/24/2024, the Executive Director/Registered Nurse agreed that the recertification documentation was completed more than fifteen (15) days before the next certification period.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 4 of 19 (21%) clinical records reviewed it was revealed that the agency did not ensure the clinical record included documentation of physician orders for treatments and services provided. Clinical Record 1: The date of the election of benefits was 11/17/2022. The RN skilled nurse visit note dated 09/13/2024 documented that the patient had a "small wound to coccyx Triad ont and boarder drsg." There was no documented evidence of any physician orders for the Triad ointment or wound care orders for 09/13/2024. The medication profile did not list Triad or any wound care orders for 09/13/2024. Clinical Record 5: The date of the election of benefits was 02/06/2024. A volunteer assessment note was entered on 02/16/2024. A volunteer visit note was dated 04/19/2024. The record lacked evidence of a physician's order for the volunteer visit. Clinical Record 6: The date of the election of benefit was 09/08/2023. A volunteer visit note was dated 02/14/2024. A volunteer assessment was entered on 02/23/2024 but was unable to be viewed. The record lacked evidence of a physician's orders for the volunteer visit. Clinical Record 12: The date of the election of benefit was 05/23/2023. Volunteer visit notes dated 11/27/2024, 11/28/2024, 11/29/2024, 11/30/2024, 12/01/2024, 12/04/2024, 12/05/2024, 12/06/2024, 12/07/2024, and 12/08/2024 were entered in the record. The IDG meeting documents dated 11/16/2023 and 11/29/2024 lacked volunteer frequency orders. The record lacked evidence of physician's orders for the volunteer visits. During a joint record review and interview on 10/24/2024, the Executive Director/Registered Nurse confirmed that the records lacked evidence of physician's orders for the services and treatments.

It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) records, the plan of care did not document intervention based on problems identified on the comprehensive assessment. Clinical Record 6: Plan of Care was dated 2/25/23 - 4/25/23, for a patient with a primary diagnosis of Nutritional Marasmus, who was admitted with tube feedings via a PEG (percutaneous endoscopic gastrostomy) tube. The initial comprehensive assessment was on 2/25/23, and documented moderate nutritional risk. The plan of care and all updated plans of care as of 7/12/23, did not document interventions for the tube feeding or the PEG site care. During an interview on 7/18/23, the Case Manager and Executive Director confirmed the finding. The Case Manager stated that she has been updating all plans of care, but had not completed this record yet.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records, the agency did not ensure that patient care instructions were prepared for the hospice aide. Clinical Record 1: The Aide plan of care (POC), updated 6/3/23 for activity, documented: "up as tolerated with walker." The nursing clinical visit notes, beginning 4/26/23, documented no longer ambulating, wheelchair bound. However, the Aide POC was not updated. Additionally, the IDG (interdisciplinary group meeting) meeting on 6/20/23, updated the POC with aspiration precautions. However, the Aide POC was not updated as of 7/18/23. During an interview on 7/18/23, the Executive Director confirmed the finding.

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 clinical record review and interview. In 1 of 6 (17%) records, the agency did not ensure that the hospice aide provided services in the plan of care. Clinical Record 4: The aide plan of care (POC) was dated 3/26/23, and ordered a shower 2 x week. The aide visits documented a full bed bath 2 x week. There was no evidence that the POC was updated, as of death on 4/27/23.. The aide documented that the Director of Nursing, of the facility, was notified. The bed baths were provided for a month. During an interview on 7/18/23, the Executive Director confirmed the finding.