Every finding on record at Bartlett Home Health and Hospice

Based on record review, interview, and observation, the hospice failed to ensure all hospice care furnished to patients and their families followed an individualized written plan of care (POC) established by the hospice interdisciplinary group (IDG), the patient or representative, the primary caregiver, and attending physician (if any) in accordance with the patient's needs in 3 of 6 active records reviewed (Records #s 1, 2, and 4). This failed practice placed all patients at risk for not having optimal, individualized care. Findings: --- Record #1 Review of Record #1 revealed a Start of Care (SOC), dated 8/16/23, with a primary diagnosis of Malignant neoplasm of prostate (cancer of the prostate). Review of the Hospice Plan of Care (POC), for the Certification Period of 8/16/23 - 11/13/23, revealed a physician's signature dated 8/16/23 and Clinical Manager signature dated 8/31/23. Further review revealed no care planned for a urinary catheter change with the frequency of the catheter change, and the bulb and French size on this POC. Additionally, this POC failed to document the pain score per patient/family preference, on a scale of 0-10. Review of Record #1 revealed a "Hospice Initial Order Set," dated 8/10/23, with an order for "Foley Catheter PRN for signs and/or symptoms of retention or patient/family request." Further review revealed this order did not specify how often the Foley would be changed or the size of the catheter bulb and French tubing to be used. During an interview on 10/26/23 at 11:00 AM, Licensed Nurse (LN) #1 stated that the Foley was to be changed every 4 weeks with 16 French and 5 cc bulb. LN #1 further stated these specifics of the catheter were not on the plan of care or in the Hospice Initial Order Set. During an interview on 10/26/23 at 11:57 AM, the Clinical Manager agreed that the pain level specifics were not on the plan of care. Record #2 Review of Record #2 revealed a SOC, dated 9/26/23, with a primary diagnosis of Malignant neoplasm of rectosigmoid junction (cancer of the rectal area near the colon). Review of the Hospice POC, for the Certification Period of 9/26/23 - 12/24/23, revealed a physician's signature dated 10/4/23 and alternate Clinical Manager signature dated 10/4/23. There were orders for pain management and comfort measures to Teach pain management and comfort measures including the following: Medication regimen for pain which included hydrocodone - acetaminophen 5 - 325 mg tablet: Administer 1 tablet orally as needed for pain; Morphine 20 mg / ml oral concentrate, administer 0.25 mg - 1 milliliter orally every hour as needed for moderate pain, shortness of breath. Titrate for comfort; and Oxycodone with acetaminophen 5 - 325 mg, take 1 tablet orally 3 times a day as needed for mild pain. Further review of the Hospice POC revealed no goals for pain management despite the pain medication regime and pain management teaching. During an interview on 10/26/23 at 12:12 PM, LN #2 stated the pain score desired for this patient was level 0 – 2 and that this level was the goal the patient desired. Record #4 Review of Record #4 revealed a SOC, dated 9/19/23, with a primary diagnosis of aphasia following cerebral infarction (Difficulty speaking after a stroke). Review of the Hospice POC, for the Certification Period of 9/19/23 - 12/17/23, revealed a physician signature dated 10/23/23 and alternate clinical manager dated 10/11/23. Review of the IDG meeting sign in sheets and notes revealed meetings were held on 9/28/23 and 10/12/23. The IDG note, dated 9/28/23, revealed, "Recently experiencing increased fatigue, decreased appetite. Patient has peg tube in place from previous illness, however not currently in use." During a home visit observation on 10/24/23 at 2:30 PM, Licensed Nurse (LN) #2 was observed to change the peg tube dressing site on the patients abdomen by taking the old gauze off around the peg tube dressing site, discarding soiled gloved, donning clean gloves, and applying clean gauze around the PEG tube site. This need for peg tube site care was not noted on the POC or a POC update. During an interview on 10/24/23 at 4:00 PM, when asked if the plan of care was completed and individualized for Record #4, the Clinical Manager stated that there were no orders for the Peg tube dressing change and care for the peg tube. Review of the Hospice policy ";Hospice IDG Care Planning Process," dated 12/8/22, revealed: ";The care of plan specifies the care and services necessary to meet the patient and family – specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions ... The RN ensures that the plan of care is individualized, updated and relevant to the needs of patient / family by monitoring for successful implementation of the plan of care ... 6. All care and services furnished to patients and their families follows an individualized written plan of care established by the IDG in collaboration with the attending physician [if any], the patient or representative and the primary caregiver in accordance with the patients needs ... 8. An individualized written plan of care is developed for each patient ... the Plan of care is written to include all services necessary for the palliation and management of the terminal illness and related conditions ... standing orders or routine orders will be individualized to address the specific patients needs and signed by the patients physician." Review of the Hospice policy ";Home Health Pain Assessment and Reassessment," dated 12/14/22, revealed: ";Home Health will develop a pain treatment plan based on evidence – based practices, patients condition, past medical history and pain management goals for each patient whose assessed needs indicate the need for a pain treatment plan. The patient is involved in the plan, including developing realistic expectations and measurable goals that are understood by the patient for the degree, duration and reduction of pain."

Based on record review, interview, and observation, the hospice failed to ensure the interdisciplinary group (IDG) members reviewed, revised, and documented the plan of care (POC) at least every 15 days for 7 of 7 records reviewed (Records #s 1, 2, 3, 4, 5, 6, and 9 ), of patients who had been on services at least 15 days. This failed practice placed all patients at risk for not receiving optimal, quality care. Findings: --- Record #1 Review of Clinical Record #1 revealed a Start of Care (SOC), dated 8/16/23, with a primary diagnosis of malignant neoplasm of prostate (cancer of the prostate). Review of the hospice Plan of Care (POC), for the Certification Period of 8/16/23 - 11/13/23, revealed a physicians signature dated 8/16/23 and Clinical Manager signature dated 8/31/23. Review of IDG meeting sign in sheets revealed meetings were held on 8/17/23, 8/31/23, 9/14/23, 9/28/23, 10/12/23, and 10/26/23. The IDG met to discuss needs of the patients and their families every 14 days. There were no POC updates found in the clinical record. Review of an Interdisciplinary Group (IDG) Conference Communication note, dated 9/28/22, revealed, "Patient experiencing increased fatigue and reduced activity tolerance. Experiencing some complications r/t indwelling Foley catheter, reports leaking, blood - tinged urine in drainage bag. RN received verbal order from primary MD [medical doctor] for PRN [as needed] Foley changes." These changes were not on the POC update. Further review also included a hospice order document, dated 9/28/23, which revealed, "Flush indwelling catheter as needed." This order was not included on a POC update after being discussed with the IDG. Record #2 Review of Clinical Record #2 revealed a SOC, dated 9/26/23, with a primary diagnosis of Malignant neoplasm of rectosigmoid junction (area between the rectum and sigmoid colon). Review of the hospice POC, for the Certification Period of 9/26/23 – 12/24/23, revealed a physicians signature dated 10/4/23 and alternate Clinical Manager signature dated 10/4/23. Review of IDG meeting sign in sheets revealed meetings were held on 9/28/23, 10/12/23, and 10/26/23. There were no POC updates found in the record. During an interview on 10/25/23 at 1:21 PM, the Clinical Manager stated the POC updates had not been completed after the IDG meetings. Record #3 Review of Clinical Record #3 revealed a SOC, dated 8/15/23, with a primary diagnosis of secondary malignant neoplasm of the bladder. Review of the Hospice POC, for the Certification Period of 8/15/23 - 11/12/13, revealed a physician's signature dated 8/17/23 and Clinical Manager signature dated 8/31/23. Review of IDG meeting sign in sheets and notes revealed meetings were held on 8/17/23, 8/31/23, 9/14/23, 9/28/23,10/12/23 and 10/26/23.There were no POC updates found in the record. Record #4 Review of Clinical Record #4 revealed a SOC, dated 9/19/23, with a primary diagnosis of aphasia following cerebral infarction (Difficulty speaking after a stroke). Review of the Hospice POC, for the Certification Period of 9/19/23 - 12/17/23, revealed a physician signature dated 10/23/23 and alternate clinical manager dated 10/11/23. Review of IDG meeting sign in sheets and notes revealed meeting were held on 9/28/23 and 10/12/23. Further review of an IDG note, dated 9/28/23, revealed: "Recently experiencing increased fatigue, decreased appetite. Patient has peg tube in place from previous illness, however not currently in use." There were no updates to the POC concerning the care of the PEG tube and site (This is a surgically procedure with a tube inserted through the abdomen for feedings and hydration into the stomach). During a home visit observation on 10/24/23 at 2:30 PM, Licensed Nurse (LN) #2 was observed to change the peg tube dressing site on the patients abdomen by taking the old gauze off around the peg tube dressing site, discarding soiled gloves, donning clean gloves, and applying clean gauze around the PEG tube site. This need for peg tube site care was not noted on the POC or a POC update. Record #5 Review of Clinical Record #5 revealed a SOC, dated 8/23/23, with a primary diagnosis of Malignant Neoplasm of the occipital lobe (cancer in the visual processing area of the brain). Review of the Hospice POC, for the Certification Period of 8/23/23 – 11/20/23, revealed a physician signature dated 9/1/23 and Clinical Manager signature dated 8/31/23. Review of IDG meeting sign in sheets revealed meetings were held on 8/31/23, 9/14/23, 9/28/23, 10/12/23, and 10/26/23. There were no POC updates found in the record. Record #6 Review of Clinical Record #6 revealed a SOC, dated 8/10/23. with a primary diagnosis of Neurocognitive Disorder with Lewy Bodies (progressive dementia). Review of the Hospice POC, for the Certification Period of 8/10/23 – 10/8/23, revealed a physician signature on 8/17/23 and signed by the Clinical Manager on 8/31/23. The review of the second POC for the Certification Period of 10/9/23 – 12/7/23 had the signature of the alternate clinical manager dated 10/11/23. Review of IDG meeting sign in sheets revealed meetings were held on 8/17/23, 9/14/23, 9/28/23, 10/12/23, and 10/26/23. There were no POC updates found in the record. Record #9 Review of closed Record #9 revealed a SOC, dated 9/7/23, with a primary diagnosis of hemiplegia following cerebral infarction on left nondominant side (paralysis on left side after a stroke). Review of the Hospice POC, for the Certification Period of 9/7/23 – 12/5/23, revealed an alternate Clinical Manager signature on 10/8/23 and a physician signature on 10/11/23. The patient was admitted to the hospital on 10/8/23 under the hospice benefit for general inpatient care. The patient passed on 10/8/23. Review of IDG meeting sign in sheets revealed meetings were held on 9/14/23 and 9/28/23. During an interview on 10/26/23 at 11:57 AM, the Clinical Manager stated, when asked if the IDT had updated the POC every 15 days, that the POC had not received updates. During an interview on 10/27/23 at 11:30 AM, the Clinical Manager revealed that all hospice IDG notes and sign in sheets had been given to the writer. Review of the Hospices policy ";IDG Care Planning Process," dated 12/8/22. revealed: ";The IDG [in collaboration with the Patients attending physician, if any] reviews, revises and documents the individualized plan as frequently as the patients condition requires but no less frequently than every 15 calendar days." .

Based on record review and interview, the hospice failed to ensure the Registered Nurse (RN) completed and documented an accurate hospice aide on-site supervisory visit every 14 days for 1 of 4 records reviewed (Record #4) with aide services. This failed practice had the potential to affect the personal care and services of all the hospice's patients with hospice aide services. Findings: --- L 629 lack of aide supervision – Ingrid, Bartlett Hospice . Based on record review and interview, the hospice failed to ensure the Registered Nurse (RN) completed and documented an accurate hospice aide on-site supervisory visit every 14 days for 1 of 4 records reviewed (Record #4) with aide services. This failed practice had the potential to affect the personal care and services of all the hospice's patients with hospice aide services. Findings: Record # 4 Review of the Clinical Record #4 revealed a Start of Care, dated 9/19/23, with a primary diagnosis of dysphagia following cerebral infarction (difficulty swallowing after a stroke). Review of the Hospice Plan of Care for the certification period of 9/19/23 - 12/17/23, revealed the aide was to visit 2 times a week for 2 months. The aide visited 9/28/23, 10/10/23, 10/11/23, 10/17/23, 10/18/23, 10/25/23, and 10/26/23. There were missing aide visits documented on 10/4/23, 10/19/23, and 10/23/23. There were no supervisory nursing visits documented. During an interview on 10/26/23 at 12:19 PM, RN # 1, when asked if supervisory visits for the aide services had occurred, stated there had been no supervisory visits made. Review of the document titled "Position Description Hospice RN I," dated 6/23/23, revealed: "Primary Duties, Essential Functions ... Direct Patient Care under general supervision of the Clinical Manager ... prepares CNA [Certified Nursing Aide] plans of care and provides in - home clinical supervision visits of assigned CNAs at least every 14 days ... documents observations of in - home supervision visits and reports out to Clinical Manager." .

Based on record review and interview, the hospice failed to meet the Condition of Participation: 42 CFR 418.78 Volunteer Services. This deficient practice had the potential to affect all patients and their representatives who needed and desired Volunteer Services. --- The hospice failed to ensure volunteers were available and had been used in day-to-day administrative and/or direct patient care roles (Refer to L644). The hospice failed to ensure cost saving achieved through the use of volunteers had occurred (Refer to L646). The hospice failed to ensure volunteers were available and had been used in day-to-day administrative and/or direct patient care roles, and records were maintained on the use of volunteers (Refer to L647).

Based on interview and record review, the hospice failed to ensure volunteers were available and had been used in day-to-day administrative and/or direct patient care roles. This failed practice had the potential to affect all patients' and their caregivers' individualized needs and desire for volunteer services. --- During an interview on 10/23/23 at 11:15 AM, the Clinical Manager stated, "The Volunteer Program is just starting." During a joint interview on 10/25/23 at 9:35 AM, Patient #1 revealed he/she would be interested in a volunteer but had not had one offered at this time. Licensed Nurse (LN) #1 revealed that volunteer services were not available yet, but LN #1 offered that when volunteer services were available that this could be available to the patient. During an interview on 10/25/23 at 1:40 PM, when asked about the availability of the volunteer program, the Clinical Manager stated the lack of volunteer services was a concern and volunteers had not been offered to the patients yet. During an interview on 10/26/23 at 2:30 PM, the Volunteer Coordinator that the volunteer program was "a work in progress." Two volunteers were now fully cleared but have not started with the hospice yet. There had not been any volunteer services offered yet. Review of a tri-fold pamphlet titled "Bartlett Hospice" found in the admission packet given to patients upon admission found that the pamphlet stated, "Hospice services include ... Volunteer Services." Review of an email letter, dated 10/24/23, to the Volunteer Coordinator from the Human Resources Technician revealed, "Good Morning Everyone. I wanted to touch base and ensure that I had all the volunteers on my radar for Hospice. Here is what I currently have." This letter went on to inform the Volunteer Coordinator that 2 future volunteers had completed new employee orientation and needed photos for badges; 4 future volunteers were ready for new employee orientation and needed completion of forms; and 2 future volunteers were not cleared yet. Review of the hospice policy "Volunteer Services," undated, revealed: "Hospice uses volunteers in administrative or direct patient roles under the supervision of Volunteer Coordinator. Volunteers are considered Hospice employees to facilitate compliance with core services."

Based on record review and interview, the hospice failed to ensure cost-saving achieved through the use of volunteers had occurred. This failed practice had the potential to affect the cost-savings potential of the hospice. Findings: --- During an interview on 10/23/23 at 11:15 AM, the Clinical Manager stated, "The Volunteer Program is just starting." During an interview on 10/26/23 at 2:30 PM, the Volunteer Coordinator that the volunteer program was "a work in progress." Two volunteers were now fully cleared but have not started with the hospice yet. There had not been any volunteer services offered yet. Review of the hospice policy "Volunteer Services," undated, revealed: "Hospice uses volunteers in administrative or direct patient roles under the supervision of Volunteer Coordinator. Volunteers are considered Hospice employees to facilitate compliance with core services ... Hospice will document the cost savings through the use of volunteers."

Based on record review and interview, the hospice failed to ensure day-to-day administrative and/or direct patient care services equaled total patient care hours of all paid staff had occurred and volunteer records were maintained. This failed practice had the potential to affect the cost savings that occurred with the addition of volunteer services. Findings: --- During an interview on 10/23/23 at 11:15 AM, the Clinical Manager stated, "The Volunteer Program is just starting." During an interview on 10/26/23 at 2:30 PM, the Volunteer Coordinator that the volunteer program was "a work in progress." Two volunteers were now fully cleared but have not started with the hospice yet. There had not been any volunteer services offered yet. Review of the hospice policy "Volunteer Services," undated, revealed: "Hospice uses volunteers in administrative or direct patient roles under the supervision of Volunteer Coordinator. Volunteers are considered Hospice employees to facilitate compliance with core services ... Hospice will document the cost savings through the use of volunteers."