Every finding on record at B & D Hospice Services

Observed in Record Review. In 1 of 3 active patient records reviewed, the IDG is does not have all individuals present. On RRNHV #1, it was noted that the IDG did not have the chaplain and Social worker present for the IDG because they have not signed the note. Agency policy for signature of the IDG note is that it will be signed in 2 days and it has now been 4 days. This finding was reviewed with the administrator and CEO.

Observed in HR File Review. In 6 of 7 employee files reviewed, there was no documentation to validate staff were provided emergency management training at least every 2 years. On review of HR #1, HR#2, HR #3, HR #5, HR #6, HR #7 it was noted that the last time the employees had training for emergency management was in 2022. This was reviewed in discussion with the Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed that were live discharges, the organization did not respect the patient rights to revoke hospice. On review of RRDC #1, the organization did not obtain a revocation, their is documentation in the chart from the nurse stating patient/family were refusing care but there was no signed revocation that could be found in the chart. On RRDC #2, it was noted in the chart that patient was choosing to seek further treatment options but there was no signed revocation in the EMR that patient revoked hospice. This was discussed and reviewed with the Hospice Leadership.

Observed in Record Review. In 2 out of 2 bereaved records reviewed, the organization failed to ensure that bereavement needs were assessed. Agency policy for bereaved services (2-010.1) states that a bereavement risk assessment will be completed on admission and then updated and family needs assessed. On RRBR #1, it was noted that the admission assessment was completed but the post death update was not completed and nothing updated in the medical record for that assessment of the family. On RRBR #2, it was noted that the admission and post death bereavement risk assessment was not completed. This observation was reviewed with the Administrator. Observed in Record Review. In 8 out of 10 active patient records reviewed, the organization failed to ensure that the comprehensive assessment included the patient's need for hospice care and services as related to bereavement. Agency Bereavement assessment policy states the nurse or social worker will complete a bereavement assessment on admission and the assessment will include identification of bereaved and their relationship and potential grief reactions. On RRHV #1, RRHV #2, RRNHV #1, RRNHV #2, RRNHV #3, RRNHV #4, RRNHV #6 and RRHV #7, the initial bereavement risk assessment was not completed on admission to include relationship to patient and survivor needs. This observation was reviewed and discussed with the Administrator.

Observed in Record Review. On 9 of 10 active patient records review, all members of the Interdisciplinary Team did not participate in the IDG. On RRHV #1, RRHV #3, RRNHV #1, RRNHV #2, RRNHV #3, RRNHV #4, RRNHV #5, RRNHV #6 and RRNHV #7, it was noted that the Social worker and Spiritual Counselor was not regularly attending the IDG meetings as evidenced by no signature of attendance to the meeting since admission. This observation was reviewed and discussed with the Administrator.

Observed in Record Review. On 2 of 10 active patient records reviewed, the organization did not have orders on the plan of care for the care provided. On RRHV #1, the home health aide made a visit to the home and this was not ordered on the plan of care and all documentation in the medical record states that service was declined when offered. On RRHV #2, the spiritual counselor made a visit to the home but the plan of care had that spiritual care was decline and there was no ordered frequency for the visit. This finding was reviewed with the administrator.

Observed in Data Session. Upon review of the data management program and QAPI summaries it was noted that the organization was not comparing internal data over time to compare levels of performance, patterns, trends and variations. Each quarter the QAPI summary contained data solely for the quarter reporting and did not compare data over time and there was no summary for the end of year to analyze a trend. This observation was reviewed with the Administrator.

Observed in Data Session. During review of the organization's infection control plan and data it was noted the organization had not collected data on hand hygiene guideline compliance. It was noted in their QAPI plan they would collect and report the hand data yearly but there is nothing in the minutes to report on this data. This was discussed with the Administrator.

Observed in HR File Review. On 1 of 1 CHHA HR files reviewed, the organization had not documented that the aide had completed 12 hours of Inservice education. On HR #3, their was no documented monthly education for the aide in her file. This finding was reviewed with the administrator.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by deficiencies in the electronic medical record. The leadership did not ensure the medical record had technical safeguards in place to ensure an accurate medical record that met federal guidelines. Observed in Data Session. During the Leadership and Data session, it was noted that the organization had not designed in writing who the alternate would be in the absence of the administrator. On review of the organizations governing board minutes it was noted that the an administrator designee was appointed in 2018 but left to organization several years ago and a new designee has not been designated in writing. This finding was reviewed with the administrator.

Observed in Record Review. On review of patient records, it was noted that the organization did not have a technical safeguards in place to ensure accurate secure method for electronic signature. Notes entered into the medical record are pulling the date and time of the event and not the actual date and time the document was signed. This finding was reviewed and discussed in detail with the Administrator and CEO.

Observed in Record Review. In 1 of 10 active patient records reviewed, it was noted that the physician CTI was not signed. Agency policy for documentation (5-006.2) states that documentation will be done on day of work and turned in by end of the day which includes signature of note. On RRNHV #4 it was noted that the recert CTI that began over one month ago has not been authenticated by the medical director in the EMR. This was discussed with the Administrator.

Observed in Record Review. On 1 of 14 patient records reviewed, the organization did not authenticate there notes. Agency policy is that notes will be signed by the end of the day of the visit. On RRBR #2, it was noted that a visit note on day patient passed away 7 months ago was not signed and appropriately authenticated. This finding was reviewed and validated with the administrator who reviewed the note with me.

Observed in Tracer Activities. On review of the DME and Pharmacy contracts, the contract failed to require criminal background checks for both the DME and pharmacy. This finding was reviewed with agency leadership.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to ensure that the patient receive effective pain management and symptom control as related to pain per organization policy. For example: on admission it was documented that the patient in RR#4 was experiencing 10/10 pain to the back. The next day the hospice received a call that the patient was still 10/10, at which time the communication log documentation notes pain medication was started. There was no documentation of follow-up to re-assess per policy the patient's pain until 3 days later for a regularly scheduled visit. Example 2: In review of RR#9 the patient called and per phone a medication was called in for the patient's pain. There was no indication in the record that the patient's pain was re-assessed per policy as no further documentation of a visit or communication was noted in the record. The patient revoked hospice 2 days later seeking additional treatment. This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 7 of 11 patient records reviewed, the organization failed to ensure that the comprehensive assessment included the patient's need for hospice care and services as related to bereavement. For example: upon review of RR#4, RR#6, HV#1, HV#2, HV#3 it was noted that an initial bereavement risk assessment was not completed on admission, nor had one been completed to date. On RR#7 and RR#11 the initial bereavement risk assessment was initiated and signed but was left incomplete. This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 3 of 11 patient records reviewed, the organization failed to ensure that the patient and primary caregiver received education and training to their responsibilities for the care and services identified in the plan of care. For example: in RR#7 and HV#1 the patient had orders for blood glucose monitoring, however there was no documentation that the patient and/or caregiver were educated on safely preforming blood glucose monitoring, nor was there documentation of patient/caregiver proficiency of the task. Example 2: on review of RR#9 the patient called and complained of pain. The communication log stated that a medication was prescribed, however there is no documentation that the patient/caregiver was educated about the medication ordered nor was education provided about their role in managing pain and the potential limitations and side effects of pain treatment, as noted in organization policy. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to ensure that the detailed statement of the scope and frequency of services necessary to meet the patient and family needs was carried out. For example: in review of RR#11 the frequency for the RN was ordered at every 14 days however the RN was seeing the patient every week, yet the frequency was not adjusted to meet the patient's need. This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 5 of 11 patient records reviewed, the organization's plan of care did not specify the care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment. For example: upon review of RR#4 the documentation shows the patient had a foley catheter upon admission, yet there were no orders or plan of care associated with the foley. The catheter was later discontinued and there were no orders associated with the d/c. The issues with urinary elimination were not reflected on the plan of care. Further the patient was diabetic and had orders to obtain blood glucose, yet the orders did not specify who, the hospice staff or the patient/caregiver, was to be responsible for obtaining the blood glucose screenings. The patient had safety issues identified such as high risk for falls with multiple falls documented, however these falls were not addressed on the plan of care. Example 2: upon review of RR#8 it was noted that the patient's plan of care lacked addressing any of the patient's psychosocial, spiritual, and/or bereavement needs. The MSW had seen the patient to assist with IHSS, yet there was no care plan established to address this need. In RR#5, RR#6, and HV#1 there is also a lack of care planning to address the patient's psychosocial, spiritual, and/or bereavement needs. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to ensure that the care and services provided to the patient were in accordance with the plan of care. For example: upon review of RR#5 the aide assignment specified the patient was to receive a shower, however the aide documented in the notes on numerous occasions that a bed bath was provided. There was no indication that this change in task was reported to and approved by the supervising RN. Further, the aide documented that shave was provided on most visits, yet this task was not a part of the aide's plan of care. Example 2: in review of RR#7 the patient was diabetic and there were orders for blood glucose monitoring, however in review of the nursing documentation the blood glucose levels were not documented as ordered per the plan of care. These observations were reviewed with the Administrator/DPCS.

Observed in Data Session. Upon review of the data management program and QAPI summaries it was noted that the organization was not comparing internal data over time to compare levels of performance, patterns, trends and variations. Each quarter the QAPI summary contained data solely for the quarter reporting and did not compare data over time. This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to ensure that the registered nurse who is responsible for hospice aide supervision provide specific written care instructions. For example: upon review of RR#4 the hospice aide current plan of care assigned the task of foley catheter care, however the patient's foley had been removed months prior. This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 8 of 11 patient records reviewed, the organization failed to ensure that the clinical record contained all information to reflect the patient's care, treatment, services. For example: Upon review of HV#1, RR#4, RR#5, RR#6, RR#7, RR#8, RR#10, RR#11the patient/caregiver signed to request the Medicare Notice of Non-Covered Items, yet there was no documentation on the record to show that the patient received the completed Notice of Non-Covered Items. This observation was reviewed with the Administrator/DPCS.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to ensure the medical record contained information to accurately reflect the patient's care, treatment, and services. During the home observation for HV#1 the registered nurse noted that the patient's medication profile listed Tylenol for pain and the patient stated he was taking Advil. The medication profile listed atorvastatin, Calmoseptine, fluticasone, gabapentin, and promethazine yet the RN noted that the patient was no longer taking these medications. During HV#2 the medication profile listed Xarelto as a current medication, yet the patient caregiver noted that the medication had been discontinued per conversation with the hospice staff. These observation were reviewed with the Administrator/DPCS.