Every finding on record at Belmont Hospice, Inc.

Observed in Record Review. In 1 of 2 extended prognosis discharged patient records reviewed, During RR# 7's patient record review it was noted the organization had not ensured it respected the patient's right to participate in decisions about their care, treatment, or services. For example: review of RR# 7's patient record revealed the patients were determined ineligible for hospice services due to extended prognosis and were discharged. Review of the patients records failed to reveal a Notice of Medicare Non-Coverage (NMNOC) per regulations. This was reviewed and discussed with the Administrator and Director of Patient Care Services and validated. Observed in Record Review. In 1 of 3 discharged patient records reviewed with revocation, During RR# 4's patient record review it was noted the organization had not ensured it respected the patient's right to elect and revoke hospice care in accordance with Medicare hospice regulations. For example: review RR# 4's patient records revealed documentation the patients had revoked hospice and the revocation statement could not be found. This was reviewed with the Administrator and Director of Patient Care Services and validated.

Observed in Record Review. In 1 of 6 active patient records reviewed, During HV# 1's patient record review it was noted the organization had not ensured the registered nurse (RN) conducted the start of care comprehensive assessment. For example: review of the patient's record revealed documentation the licensed vocational nurse completed the start of care comprehensive assessment in person with the RN on Facetime/telehealth 34 days prior to the surveyor review of the record. This was discussed with the owner who shared the organization was unaware a process for implementing emergency waivers such as telehealth was needed. The owner further shared the Emergency Plan was activated for Covid-19 approximately 2 and 1/2 years ago and deactivated six months prior to the surveyor review of the patient record.

Observed in Record Review. During HV# 1, HV# 3, RR# 8, RR# 9, RR# 10's patient record review it was noted the organization had not ensured the patient's plans of care were based on the patient's goals and the time frames, setting, and services required to meet those goals. For example: review of HV# 1, HV# 3, RR# 8, RR# 9, and RR# 10's patient records revealed MSW and Chaplain frequency of one time a month visit with no goals. Further review of HV# 3's patient record revealed documentation that HV# 3 was hard of hearing with no hearing aides and a communication board was implemented for communication. However, review of HV# 3's plan of care revealed no communication goal or interventions. In addition, HV# 3's plan of care revealed a cardiovascular goal of optimal peripheral circulation with no indication what was optimal for HV# 3. Further review of HV# 1's plan of care revealed a cardiovascular goal of optimal peripheral circulation with no indication what was optimal for HV# 1. This was discussed and validated with the Director of Patient Care Services. Observed in Patient Home. In 6 of 6 Active patient records reviewed, The organization plans the patient’s care based on individual patient needs and goals. As noted in 1 of 1 HV patients with cognitive deficits, the HV#2 Hospice Plan of Care lacked specific plan to meet her communication needs. The surveyor reviewed both the Hospice plan of care and the facility's plan of care. The facility plan of care had clear goals to meet the patients communication needs. This was reviewed with the RN during the home visit, and discussed and validated with the Director of Patient Care Services.

Observed in Record Review. In 5 of 6 active patient records reviewed, During HV# 1, HV# 3, RR# 8, RR# 9, and RR# 10's patient records review it was noted the organization had not included all the services needed for palliation and management of the terminal illness and related conditions to include: For example: review of the patients records revealed the disciplines MSW and Chaplain with the frequency of one time a month visit and prn [as needed] with no indication of as needed. This was reviewed, discussed, and validated by the Director of Patient Care Services.

Observed in Record Review. During HV# 1, HV# 3, RR# 8, RR# 9, and RR# 10's patient records review it was noted the organization had not ensured the plans of care included all the treatments necessary to meet the needs of the patients. For example: review of HV# 1, HV# 3, RR# 8, RR# 9, and RR# 10's patient records revealed MSW and Chaplain frequency of one time a month visits. Review of the patients' plans of care revealed no interventions for the MSW or Chaplain. This was reviewed, discussed, and validated by the Director of Patient Care Services. Observed in Record Review. The patient record contains information that reflects the patient's care, treatment, or services including a list of medications, including dose, strength, frequency, route, date and time of administration. It was observed during HV#2, the patient without oxygen therapy in use or readily available in her room. Upon review of the record for HV#2, it was noted that the order for Oxygen therapy added approximately 9 months prior to survey date did not indicate as needed. This was discussed and validated with the Director of Patient Care Services.

Observed in Patient Home. In 3 of 3 home visits conducted, Accepted standards of practice to prevent the transmission of infections and communicable diseases was not followed during 3 of 3 home visits. Micro-Kill One disinfectant wipes with wet time between one and five minutes per manufacturer instructions was not followed by SN for cleaning equipment post use. It was observed in 3 of 3 home visits that equipment was cleansed post use and returned to equipment bag without consideration of the Manufacturer's recommended wet time This was reviewed and validated with the Director of Patient Care Services. Observed in Patient Home. During HV# 3's home observation it was noted the nurse had not followed the organization's bag technique policy that included having a nurse bag with separated clean and dirty sections and hand sanitizing prior to placing the cleaned equipment back into the bag. For example: the nurse was observed with a back pack with one section where all items were stored except for a side pocket where the hand sanitizer was stored. In addition, the nurse was observed cleaning the vital sign equipment and placing the equipment immediately into the nurse bag without hand sanitizing on several occasions. This was discussed and validated by the Director of Patient Care Services.

Observed in Patient Home. In 2 of 3 home visits conducted, Belmont Hospice Infection Control Policy no 9-014.2, Bag Technique requires a bag with a “clean” and “dirty” compartment, and also requires the nurse to cleanse hands prior to returning clean equipment to the bag. It was observed in 2/2 home visits that an equipment bag had only one main compartment, not the two noted as required in the policy. The nurse completing HV#2 and HV#3 was utilizing a tokidoki backpack as her equipment bag. It was observed that following cleaning the equipment, she also failed to cleanse her hand per HCO Policy no. 9-014.2 prior to returning clean equipment to backpack. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. During HV# 3's home observation it was noted the registered nurse (RN) had not supervised the hospice aide as frequently as every 14 days. For example: review of HV# 3's patient record revealed 21 days between documented hospice aide supervisory visits by the RN. This was discussed and validated with the Director of Patient Care Services. Observed in Record Review. In 2 of 3 patient records reviewed with hospice aide services, For hospices that elect to use The Joint Commission deemed status option: In order to assess the quality of care and services provided by the hospice aide and to ensure that services ordered meet the patient’s needs, the registered nurse supervises the hospice aide during an on-site visit to the patient’s home no less frequently than every 14 days. In Home Visit #2 record review there were two instances of greater than 14 days between hospice aide supervisory visits during the current quarter. This was reviewed and validated with the Director of Patient Care Services.

Observed in Leadership Session. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.100 §418.104, §418.60, and §418.54.

Observed in Record Review. In 1 of 6 active patient records reviewed, During HV# 3's patient record review it was noted the organization had not ensured the patient record was accurately documented. For example: review of HV# 3's patient record revealed Skilled Nurse visit notes by registered nurse (RN) with documentation that HV# 3 had a wound on the back with dressing change completed on multiple visits dating back approximately five weeks prior to the surveyor review of the record and observed on the home visit. Review of the subsequent seven SN visit notes by the licensed vocational nurse (LVN) dated after the identification of the wound by RN, revealed no documentation of a wound on the back or a dressing change. This was reviewed, discussed, and validated by the Director of Patient Care Services.

Observed in Record Review. In 5 of 6 active patient records reviewed, During HV# 1, HV# 3, RR# 8, RR# 9, and RR# 10's patient records review it was noted the organization had not ensured all entries into the patient record were authenticated. For example: review of the patients' Consent and Treatment Authorization forms, revealed staff signature with no date. Review of HV# 3's patient record revealed 18 skilled nurse (SN) visit notes with no signatures dating back three months prior to the surveyor review of the record. Further review of HV# 3's patient record revealed 17 of 18 home health aide visit notes for the current month without signatures. Further review of HV# 3's revealed recertification RN comprehensive assessments dated 13 months, 11 months, nine months, and four months prior to the surveyor review of the record with no signatures. Review of RR# 10's patient record revealed 17 of 18 Skilled Nurse visit notes with no signature and 12 of 15 home health aide visit notes with no signatures dating back two months prior to the surveyor review of the record. Review of RR# 9's patient record revealed 9 of 12 SN visit notes with no signatures. Review of RR# 8's patient record revealed a start of care 20 days prior to the surveyor review of the record with no signature on the RN comprehensive assessment or four of four SN visits notes since start of care. An audit trail was requested and not provided. This was discussed and validated with the Director of Patient Care Services.

Observed in Record Review. In 2 of 6 active patient records reviewed, During HV# 1 and HV# 3's patient records review it was noted the organization had not ensured it maintained the security and integrity of health information. For example: review of HV# 1's paper copy of the plan of care revealed an Endocrine goal with interventions with a created date 19 days prior to the surveyor review. Review of HV# 1's electronic medical record revealed no Endocrine goal or interventions on the plans of care dated 18 days and four days prior to the surveyor review of the record. Review of HV# 3's paper copy of the plan of care revealed no wound care orders. Review of HV# 3's EMR revealed wound care orders dated 37 days prior to surveyor review of the record. Further review of HV# 3's EMR revealed an Integumentary goal and interventions dated 65 days prior to the surveyor review of the record. However, the paper copy of the current plan of care did not have the same documentation. Audit trails were requested and not provided. This was reviewed, discussed, and validated with the Director of Patient Care Services.

Observed in Patient Home. In 2 of 3 home visits conducted, During HV# 1's patient record review it was noted the organization had not ensure the patient record contained information that reflected the patient's care, treatment, or services. For example: review of the medication profile revealed the drug Meclizine with the indication for use as HTN [hypertension]. During the home observation the licensed vocation nurse (LVN) educated the patient that Meclizine was for hypertension and not an antihistamine used at time to control nausea, vomiting, or dizziness. This was discussed and validated with the Director of Patient Care Services.

Observed in Patient Home. Based on the patient’s condition and assessed needs, the organization provides education and training to ensure needs are met. No education related to the use and management of restraints (when applied) was provided to the patient's caregiver. During HV#2 the patient's bed was observed set with full side rails in the up position. Patient lacked ability to utilize side rails for mobility purposes, thus side rails present as a physical restraint. There was no documented provision of education in the record as required by the organization's policy No. 2-083.1. This was reviewed and validated by the Director of Patient Care Services and the Hospice Administrator.

Observed in Record Review. In 1 of 1 patient records reviewed residing in a Skilled Nursing Facility, During HV# 3's home observation it was noted the organization had not ensured the hospice plan of care identified which provider is responsible for performing functions that had been agreed upon and included in the plan of care. For example: HV# 3 resided in a Skilled Nursing Facility (SNF). Review of HV# 3's hospice plan of care included wound care, yet did not indicate which provider was to perform the wound care. This was discussed and validated with the Director of Patient Care Services.