Every finding on record at Axiom Home Health LLC

Observed in Record Review. In 1 of 5 patient records reviewed, the organization failed to conduct and document a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. On review of HosRRNHV#4 there was documentation of unstageable wounds to bilateral heels yet there was no documentation noted in the record of an ongoing comprehensive wound assessment as required to include wound description such as size, color, drainage, odor, surrounding skin. These observations were reviewed with the Hospice Director.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization failed to conducts and documents a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services to include an initial bereavement risk assessment. On review of HosRRNHV#1 there was no documentation that an initial bereavement risk assessment had been completed. This observation was reviewed with the Hospice Director.

Observed in Record Review. In 3 of 5 patient records reviewed, the organization failed to ensure the plan of care reflect patient and family goals that were individualized, specific, measurable, and time bound. For example: on review of RRNHV#1 there were goals that were no specific and measurable such as Patients pain will remain at a level of comfort. and Patient will have decreased reports of falls. The same non-specific, not measurable goals were noted on RRNHV#4, and RRNHV#5. These observations were reviewed with the Hospice Director.

Observed in Record Review. In 3 of 5 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. For example: on review of HosRRHV#1 the patient was ordered morphine sulfate (concentrate) oral solution 20mg/ml 0.25 ml - 1ml every 2-4 hours as needed, and an order for Lorazepam 0.5 mg 1-2 tabs every 4 hours, however there was no specific instructions to guide the patient/caregiver for when to give which dose for what situation. Morphine with a range of 0.25 to 1ml without specific instructions can also be seen in HosRRNHV#3, along with a range for liquid Hydrocodone without specific instructions. HosRRNHV#4 the documentation noted the patient with bilateral heel wounds yet no wound care treatment orders noted on the record. These observations were reviewed with the Hospice Director.

Observed in Record Review. Upon review of all tracer activities, it was noted that there was a pattern of staff failing to follow established organization policy and the governing body/leadership did not ensure that the Conditions of Participation for 418.56, were met per policy as determined through observations, documentation, and staff interviews.

Observed in Emergency Management Session. The organization failed to provide ongoing education and training to all staff consistent with their roles and responsibilities in an emergency. During emergency management session, the Hospice Director was unable to provide documentation that their staff had been trained on the role and responsibility in the event of an emergency.

Observed in Record Review. In 10 of 10 patient records reviewed, the organization failed to conducts and documents a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services to include the need for volunteer services to offer support or respite to the patient, family, or other caregivers. Throughout all active records reviewed there was no documentation that the need for volunteer services was assessed as part of the comprehensive assessments. This observation was reviewed with the Hospice Director. Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to conduct and document a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. On review of HosRRHV#1 there was documentation of wounds to the sacrum/coccyx and ear yet there was no documentation noted in the record of an ongoing comprehensive wound assessment as required to include wound description such as size, color, drainage, odor, surrounding skin. In review of HosRRNHV#9 there was documentation of a buttocks or sacral wound in the record yet there was no documentation that a wound assessment was conducted. These observations were reviewed with the Hospice Director.

Observed in Record Review. In 2 of 10 patient records reviewed, The organization failed to ensure the initial bereavement assessment was conducted as part of the initial comprehensive assessment. On review of HosRRHV#3 the initial bereavement risk assessment was not documented as conducted until a month after the start of care date. In HosRRNHV#10 there was no documentation that an initial bereavement risk assessment was completed on admission. These observations were reviewed with the Hospice Director.

Observed in Record Review. In 10 of 10 patient records reviewed, the organization failed to ensure the update of the comprehensive assessment was accomplished by the hospice interdisciplinary group that included the patient's progress toward goals. Throughout all records reviewed there was a noted lack of documentation of progress toward goals. There was documentation that interventions such as assessments and education were completed on various visits yet no specific progress toward goals documented. This observation was reviewed with the Hospice Director. Observed in Record Review. In 3 of 10 patient records reviewed, the organization failed to ensure the update of the comprehensive assessment was accomplished by the hospice interdisciplinary group no less frequency that every 15 days. On review of HosRRNHV#4 and HosRRNHV#10 there was a 28 day gap between documented IDG meetings to update the comprehensive assessment between August and September. In HosRRNHV#7 there was a 28 day gap between IDG meetings between June and July. These observations were reviewed with the Hospice Director.

Observed in Record Review. In 10 of 10 patient records reviewed, the organization failed to ensure the plan of care reflect patient and family goals that were individualized, specific, measurable, and time bound. Throughout records reviewed there was a pattern of goals that were not specific, measurable, and time-bound. For example: in HosRRHV#1 an example of a spiritual goals was simply Adjustment, others were caregiver/family will demonstrate understanding of neurological condition and decline - by the time of death/discharge. In HosRRHV#2 and example was Provide active and reflective listening and Pain Control as Patient's Acceptable Level Within 48 Hours of Identification. In HosRRHV#3 an example was Edema will be decreased or managed for patient comfort. By death/discharge. In HosRRNHV#5 an example was patient will have regular bowel movements. Further examples can be found in all active records reviewed. These observations were reviewed with the Hospice Director.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure the patient and/or primary care giver receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care. For example: on review of HosRRNHV#4 there was no order for an antihypertensive with instructions that indicated Hydralazine 50 mg take 1 tab by mouth in afternoon when BP is elevated. There was no documentation noted in the record that the family had been educated on how to properly obtain a blood pressure and the parameter for how and when to give the medication, its indications and side effects. This observation was reviewed with the Hospice Director.

Observed in Record Review. In 7 of 10 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management or the terminal illness and related conditions. For example: on review of HosRRHV#1 the patient was being seen by the MSW yet there was no psychosocial care plan established. There was documentation of medications for upper respiratory infection yet the care was not reflected in the plan of care. In HosRRHV#2 there was documentation that the MSW was working on meals on wheels for the patient yet the issue was not reflected in the plan of care. In HosRRHV#3 there was documentation the patient was admitted to the VA hospital with pneumonia and released on antibiotics yet the plan of care did not reflect the patient change is status, nor was a psychosocial care plan noted on the record. In HosRRNHV#4 there was documentation the patient was using a purewick urinary device but no care plan to guide its care. The MSW documented phone calls to assist the family with psychosocial issues but no care plan to reflect the issues. In HosRRNHV#5 the was documentation of a Left Calf rash with meds, and issues necessitating changes in BP meds yet the was no reflection of the issues in the care plans. In HosRRNHV#7 there was documentation the patient was receiving palliative chemotherapy yet no care plan to guide and collaborate the care. In HosRRNHV#8 there was documentation that the patient was symptomatic because of bottomed out blood pressure yet the plan of care did not reflect the issues. Throughout all active records reviewed there was a noted disconnect between the goals established and interventions to achieve the goals. Most interventions were for assessment. Such as in HosRRNHV#8 the goals for cardiac read Patient/PCG will participate in plan of care to ensure understanding of the dying process and feelings of being supported. yet the interventions to achieve the goals were to assess for signs/symptoms of fluid overload, blood clots, cardiac circulatory function, and assess BP and Pulse. These observations were reviewed with the Hospice Director.

Observed in Record Review. In 7 of 10 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. For example: on review of HosRRHV#1 the patient was ordered morphine sulfate (concentrate) oral solution 20mg/ml 0.25 ml - 1ml every 2 hours as needed, however there was no specific instructions to guide the patient/caregiver for when to give which dose for what situation. Morphine with a range of 0.25 to 1ml without specific instructions can also be seen in HosRRNHV#4, HosRRNHV#5, HosRRNHV#7 and HosRRNHV#10. In HosRRHV#1 there was an order for oxygen 2-4 lts PRN yet there was no indication of a route such as per nasal cannula, nor were there specific instruction to guide on which liter flow to choose. In HosRRNHV#7 the order for oxygen noted 2-10 liters per NC or Non Rebreather continuous as needed. An incomplete or absent oxygen order was also noted in HosRRNHV#5, and HosRRNHV#8. In review of HosRRHV#3 and HosRRNHV#7 the medication profile noted oxygen permeable lens products solution in place of oxygen for inhalation. In HosRRNHV#9 the documentation noted the patient with a wound yet not wound care treatment orders noted on the record. These observations were reviewed with the Hospice Director.

Observed in Record Review. In 7 of 10 patient records reviewed, the organization failed to ensure the care and services were provided in accordance with the plan of care. On review of HosRRHV#2 the spiritual counselor and MSW was noted to be seeing the patient monthly through the second benefit period yet there were no orders for spiritual/psychosocial frequency noted on the plan of care (POC). The Aide was seeing the patient starting in June 2 times a week yet there was no frequency order noted on the plan of care until November. In HosRRHV#3 the MSW frequency per the plan of care was quarterly yet there were multiple social work visits documented each month. In HosRRNHV#4 early in the patient's admission in 2023 the MSW and Spiritual Counselor were to see the patient 1 time a month per the plan of care yet monthly visits were not documented in the record. In HosRRNHV#5 the hospice aide frequency per the plan of care was 1 time weekly yet the documentation showed the aid was caring for the patient 3 times a week. In HosRRNHV#6 the MSW was ordered per the POC 1 time a month, yet there were no visits documented March through May. The aide documentation showed visits being made 5 times a week, yet the POC noted a frequency of 3 times a week. In HosRRNHV#8 the MSW documented visits in July,August, and September yet no frequency was established in the POC until late September. In HosRRNHV#9 the only frequency established per the POC was for spiritual counselor yet SN, Aide had documented visits. There was no documentation in the clinical record to explain these variances from the POC. These observations were reviewed with the Hospice Director.

Observed in Data Session. The surveyor noted the HCO did not analyze and compare data over time to identify levels of performance, patterns, trends and variations as evidenced by when reviewing QAPI with the Hospice Director it was noted that each quarter the QAPI stood alone and there was no evidence that the data was trended over time beyond the quarter being reviewed.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned. On home observation for HosRRHV#1 the MSW was noted to not perform hand hygiene throughout the visit. There was no hand hygiene to begin the visit, after contact with the patient, nor was hand hygiene performed after visit concluded. When asked the MSW about hand hygiene she noted she had hand sanitizer in her backpack in the car. This observation was reviewed with the Hospice Director.

Observed in Record Review. In 3 of 10 patient records reviewed, the organization failed to ensure the hospice aide were provided written patient care instructions. In review of HosRRHV#2 the aide was assigned to provide care where the patient utilized oxygen continuously however there were no specific instructions to the aide on whether the oxygen should stay in place or could be removed for showering. In HosRRNHV#4 there was documentation that the patient was a Purewick device yet there were no specific instruction on how the Aide was to handle the device while providing care. In HosRRNHV#8 the patient was taking Eliquis yet bleeding precautions were not indicated on the aide plan of care. These observations were reviewed with the Hospice Director.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to ensure the RN assess the quality of care and services provided by the hospice aide during an on-site visit to the patient's home no less frequently that every 14 days. In review of HosRRHV#3 the only aide supervisory visit documented was early October yet the aide was seeing the patient 3 times a week leaving a 40 day gap in supervisory visits to date of survey. In HosRRNHV#10 the aide restarted in early April yet the first aide supervisory was documented in May leaving a 23 day gap. These observations were reviewed with the Hospice Director.

Observed in Tracer Activities. the organization failed to ensure documentation of its efforts to recruit and retain volunteers as the documentation was unavailable at the time of survey. This observation was reviewed with the Hospice Director.

Observed in Tracer Activities. The organization failed to ensure documentation of the cost savings achieved through the use of volunteers. Through discussion with the Hospice Director it was acknowledged that the hospice had no active volunteers for any documentation of cost savings reports at the time of survey.

Observed in Tracer Activities. The organization failed to ensure volunteers provided day to day administrative and/or direct patient care services in an amount that, at a minimum, equaled 5% of the total patient care hours of all paid hospice employees and contract staff, as the documentation was not available at time of survey.

Observed in Tracer Activities. Upon review of all tracer activities, it was noted that there was a pattern of staff failing to follow established organization policy and the governing body/leadership did not ensure that the Conditions of Participation for 418.100, 418.54, 418.56, and418.78 were met per policy as determined through observations, documentation, and staff interviews.

Observed in HR File Review. In 3 of 7 HR files reviewed, the organization failed to ensure staff competency was initially assessed and documented as part of orientation. On review of HosHR#1 for the MD, HosHR#6 for volunteer coordinator, and HosHR#7 for the MSW there was no documentation that competency was documented as part of orientation. This observation was reviewed with the Hospice Director and the Peoples Director.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure the medical director provided written certification that the patient's life expectancy is six months or less if the illness runs is normal course considering the primary terminal condition. On review of HosRRHV#2 the Initial Certification of Terminal Illness noted a primary terminal diagnosis of COPD yet the record noted a primary diagnosis of Atherosclerotic Heart Disease. This observation was reviewed with the Hospice Director.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to ensure that before the recertification period the medical director or physician designee review the patient's clinical information. For example: on review of HosRRHV#1 there was no documentation of a certification of terminal illness (CTI) noted in the record for benefit period (BP) #7. In BP #6 the CTI stated a primary terminal diagnosis of Alzheimer's however the admitting terminal diagnosis was listed as Atherosclerotic Heart Disease. In HosRRNHV#4 there was no documentation of a CTI for BP# 8. These observations were reviewed with the Hospice Director.

Observed in Record Review. In 1 of 2 patient records reviewed, for live discharge, the organization failed to ensure the discharge summary included all required elements. On review of HosRRDC#2 the discharge summary noted reason for discharge but did not include a summary of the patient's stay, current plan of care or latest physicians orders. This observation was reviewed with the Hospice Director.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to ensure the patient, as well as the family and/or other caregivers receive instruction in the safe use of durable medical equipment and supplies. For example: on home observation in HosRRHV#1 it was noted that the oxygen concentrator, and e-tank were stored in the closet with clothing and other items stored on top of them. When discussing safe oxygen storage with the caregiver she noted she was not informed that the place oxygen was stored needed to have ventilation. In home observation for HosRRHV#2 there were multiple oxygen tanks noted standing upright, unsecured in the home. The caregiver noted she was unaware of the danger of unsecured upright oxygen tanks. These observations were reviewed with the Hospice Director.

Observed in Environment of Care Session. Following review of the emergency management plan and discussion with the Director of Home Health/Interim Director of Hospice, the surveyor noted that the agency has not been evaluating the response following activation of the emergency management plan. Therefore the agency is not able to identify deficiencies and opportunities for improvement. The Director stated it was fully discussed but not documented. Observed in Emergency Management Session. Following review of the emergency management plan and discussion with the Director of Home Health/Interim Director of Hospice, the surveyor noted that management and staff did not evaluate all responses to actual emergencies. The agency has had actual emergency events the past 3 years that were well documented but the surveyor noted that there was not a full evaluation of the events to assess effectiveness of the plan and identify areas that need improvement.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization did not plan the patient's care by documenting anticipated measurable outcomes from implementing and coordinating the plan of care. In RR#5, it was noted there were no goals/outcomes documented on the patient's plan of care. Patient was on hospice for 2 weeks until death. This was reviewed with the Director of Nursing.

Observed in Patient Home. In 3 of 11 patient records reviewed, the organization did not plan the patient's care. The plan of care did not include all medication-related information/orders to meet the patient's needs. In review of the record for HV#3, the patient's Plan of Care/Medication Profile included Bisacodyl suppository and Miralax by mouth as needed for constipation with no clear indications for use. The patient was also on Norco every 4 hours as needed for pain, Tylenol as needed for mild pain, and Morphine solution as needed for mild pain. No clear indications were documented as to when to take which pain medication. Patient also had orders for Alprazolam 0.25 mg twice a day as needed for anxiety, and Lorazepam 1mg every three hours as needed for agitation/ anxiety. In RR#3, the patient's Plan of Care included orders for multiple prn medications for pain. Orders included: Acetaminophen Rectal Suppository 650 MG insert rectally every 6 hours as needed for mild pain; Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML take by mouth: take 0.25ml for mild pain, take 0.5ml for moderate pain, take 1ml for severe pain; and Tramadol HCl Oral Tablet 50 MG one tablet by mouth every 4 to 6 hours as needed for pain. In RR#4, the patient's Plan of Care included Miralax, Senna, and Bisac-Evac Rectal Suppository as needed for constipation. Patient also has Acetaminophen Rectal Suppository, Morphine Sulfate (Concentrate) Oral Solution, and Tylenol Extra Strength Oral Tablet 500 MG ordered as needed for pain. The patients' Plan of Care orders did not clarify when or how multiple PRN medications ordered for the same symptoms were to be administered. These findings were reviewed with the Director of Nursing.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization did not supervise staff effectively. The registered nurse did not supervise the hospice aide during on-site home visits at least every 14 days. In review of the record for HV#1, it was noted there were no hospice aide supervisory visits completed/documented during the first certification period, as confirmed by the Scheduler. Aide supervisory visits were scheduled out in the hospice electronic record into the new certification period. This was verified by the Director of Nursing.

Observed in HR File Review. In 1 of 14 HR files reviewed, the organization did not initially assess and document staff competence as part of orientation. In HOS HR#4, the initial competence was not documented for the hospice LCSW. This was confirmed by the Director of Nursing.

Observed in Patient Home. In 1 of 3 home visits conducted, the patient record did not contain information that reflects the patient's care and treatment. In HV#1, the record did not include an accurate and clear dosage/flow rate and frequency of use for the patient's home Oxygen. The Oxygen order in the patient's Plan of Care was: Oxygen NC Inhalation 2-5 L per minute. Dose: 3LPM, Frequency: PRN for shortness of breath; Apply 2-4 Liters of Oxygen per NC as needed for shortness of breath. During the home visit, the caregiver confirmed the patient was currently on 2 liters of Oxygen continuous per nasal cannula. This was reviewed with the Director of Nursing.

Observed in Record Review. In 2 of 2 live discharge records reviewed, upon patient discharge/transfer the organization did not give information about the care, treatment, or services provided to the patient to other service providers. In RR#4 and RR#8, there was no documentation that the patient's attending physician was notified of the availability of the Hospice Discharge Summary. This was reviewed with the Director of Nursing.

Observed in HR File Review. In 2 of 14 HR files reviewed, the organization did not define and verify staff qualification by maintaining copies/verification of licenses, registrations, and certifications for personnel who provide care, treatment, or services. In HOS HR#1 and HOS HR#5, there was no documentation of the skilled nurse's CPR certification as required by organization policy. This was verified by the Director of Nursing.