Every finding on record at Best Golden Care Hospice, Inc.

Observed in Record Review. In 1 of 1 patient bereavement records reviewed, the hospice failed to show evidence it conducted and documented patient-specific comprehensive assessment and reassessment related to bereavement. Agency process is for the Bereavement coordinator to complete the initial bereavement within 5 days of start of care. On review of RRBR #1, there was no documentation of an initial bereavement risk assessment completed by the bereavement coordinator within 5 days of SOC per agency process. The patient was only on service for 6 days but it was never completed. This was reviewed with the Administrator/DPCS.

Observed in Record Review. In 2 of 4 patient records reviewed, the organization did not provide care, treatment or services according to the patient's individual plan of care. In RRNHV #1, the surveyor noted the plan of care indicated the HHA was to visit the patient 2 times per week and not had been following that order frequency as evidenced by 1 time a week visits for first two weeks in October then there was a week with no visits in the 3rd week of October and no visits for the first week in November. In addition, the SN is ordered 2 times per week and the 1st week in November there was only one visit made. On review of RRBR #1, it was noted that the Chaplian did not follow the ordered visits schedule and there was no documentation of contact or why order not followed. This was reviewed with the DPCS.

Observed in Record Review. In 3 of 4 patient records reviewed, entries were not appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice. In RRNHV #1, the surveyor noted the nursing notes in October were not authenticated. In addition it was noted that on the IDG notes not all members had signed the IDG notes as well. On review of RRNHV #2, it was noted that notes in October for both the nurses and aides have not been authenticated. On review of RRBR #1, it was noted that the SOC assessment from RN and MSW had not been authenticated and patient is now deceased. This was confirmed with the administrator/DPCS.

Observed in Individual Tracer. In 12 of 14 patient records reviewed, RRHV1, RRHV2, RRHV3, RRNHV1, RNHV1, RRNHV2, RRNHV 3, RRNHV4, RRNHV5, RRNHV 6, RRNHV 7 DCRR1, RRDC2 The organization failed to show evidence it had informed the patient of the patient's rights prior to beginning care, treatment, or services or during the initial evaluation visit before beginning care, treatment, or services. For example, in all records the consent form section regarding charges was blank, and the form for noncovered hospice items was a general statement which did not allow for a list of noncovered items. This was not compliant with the organization policy and validated by the Administrator/DPCS and Accountant.

Observed in Individual Tracer. In 5 of 14 patient records reviewed, RRNHV2, RRNHV3,RRNHV4, RRNHV5, RRNHV6, during record review, the hospice failed to show evidence it conducted and documented patient-specific comprehensive assessment and reassessment related to the spiritual care/concerns or bereavement risk factors. For example, RRNHV2 there was no documentation of an initial spiritual care or bereavement risk assessment; RRNHV3, the spiritual care and bereavement risk assessments were not completed; RRNHV4 the spiritual care and bereavement risk assessments were initiated but not completed as there was no further documentation. RRNHV5 and RRNHV6 there was no evidence of an initial spiritual care or completed bereavement risk assessment. This was validated by the Administrator/DPCS and Accountant.

Observed in Individual Tracer. In 4 of 14 patient records reviewed, RRHV1, RRHV2, RRHV3, RRDC2, during the home visit and subsequent record review, the organization failed to show evidence the registered nurse had conducted and updated the comprehensive assessment in collaboration with the patient’s attending physician, no less than every 15 days. For example. RRHV1 the last assessment was dated five weeks prior to survey; RRHV2, the last assessment was dated seven weeks prior to survey; HV3 the last RN assessment was dated seven weeks prior to survey. RRDC2, there was no RN visit for six weeks. This was not compliant with the organization's Comprehensive Assessment policy and validated by the Administrator/DPCS.

Observed in Individual Tracer. In 2 of 14 patient records reviewed, RRHV1, RRNHV4 during the record review, the organization did not show evidence the written plan of care was based on the patient’s goals and the time frames, settings, and services required to meet those goals. For example, RRHV1, there was no goal related to the patients altered cognitive status and declining condition due to diagnosis of dementia. In addition, goals were not measurable as noted by the a cardiovascular goal upon admission: The Patient will maintain optimum peripheral circulation. The record indicated the goal was updated six months later, but the language remained the same. A second goal was stated: Pain will remain in comfortable level during care. A third goal stated Pt/ Family/PCG will verbalize receiving desired spiritual support . RRNHV4 the social workers goal stated daughter will receive information regarding resources This was not compliant with the organization policy and validated by the Administrator/DPCS.

Observed in Individual Tracer. In 1 of 3 home visits conducted, RRHV3, during the home visit and subsequent record review, the hospice failed to demonstrate the plan of care included all services needed for the palliation and management of the terminal illness and related conditions, including medications and treatment necessary to meet the patient’s needs. For example, no orders were documented in the record for Augmentin 875 twice a day x 10 day and Budesonide 0.5 mg x 10 days. This was validated by the Administrator/DPCS.

Observed in Individual Tracer. In 1 of 3 patient records reviewed, HVRR1, during the home visit and record review, the organization failed to show evidence the interdisciplinary group, in collaboration with the patient’s attending physician, if any, reviewed and revised the plan of care as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. These reviews are documented. For example, HVRR1, there was no documentation of an IDG meeting for 28 days during the previous benefit period . Observed in Individual Tracer. In 1 of 3 home visits conducted, RRHV3, during the home visit and subsequent record review, the organization failed to show evidence the interdisciplinary group had updated and revised the plan of care when a significant change in condition occurred. For example, RRHV3 during the interview with the caregiver, the nurse and the DPCS, the patient developed upper respiratory symptoms however there was no IDG documentation of the change in condition, symptoms, communication with the physician or the caregiver, receipt of physician new medication orders or resumption of the nebulizer treatments in the clinical record. This was validated by the Administrator/DPCS.

Observed in Individual Tracer. In 3 of 14 patient records reviewed, HVRR1, HVRR3, RRNHV4 during the home visit and subsequent record review, the organization failed to show evidence it provided the patient with care, treatment, or services according to the patient's individualized plan of care. For example, HVRR1 the chaplain was ordered as needed, however during the interview and record review provided monthly visits during the previous three months. There was no change order noted or documentation in the record indicating the need for change in frequency of visits. HVRR3 and RRNHV4, the aide services were ordered twice a week, however the aide was providing services three times a week. This was validated by the Administrator/DPCS

Observed in Document Review. During the Data Session with leadership, the organization’s governing body did not ensure the quality assessment and performance improvement program (QAPI) met the following criteria: there was no evidence the data collected and aggregated had been evaluated or subsequent action steps taken to improve performance. This included all service lines. For example, the Bereavement program goals for 2022 and 2023 stated as accurate bereavement information however there was no analysis or evaluation of the of data collected, or results of any actions taken. The Volunteer program had only documented the cost savings which were less than 5%, however there was no evaluation of the results or any action steps documented to address improvement efforts. The contract services reported in the annual program evaluation were targeted for PT/OTL/SLP services which the organization had not utilized. There was no documentation presented that the existing contract services (DME, Pharmacy, GIP/Respite) had been evaluated. There was no documentation of a analysis, evaluation or actions taken to demonstrate the organization’s efforts to improve palliative outcomes. Data was collected and aggregated but not evaluated. During the discussion, the organization was unable to identify or show evidence of indicators that had been either improved, required reevaluation etc., related to improved palliative outcomes. This was discussed at length and validated with the Administrator/DPCS and Accountant.

Observed in Leadership Session. During the Volunteer Program session with the Coordinator, the organization failed to show evidence the quality assessment and performance improvement program demonstrated improvement in the indicators related to improved palliative outcomes and hospice services. For example, the QAPI report indicated volunteer program cost savings of 0.21% in 2023 and 0.65% in 2022. However, there was no evidence of analysis, evaluation of the data, any action steps taken, or a plan to improve the service rates. This was validated by the Coordinator and the Accountant.

Observed in Data Session. During the Leadership and data session the organization did not demonstrate it used the data collected to monitor the effectiveness and safety of services and the quality of care. The organization collected and aggregated the data, however there was no documentation of analysis, monitoring of results/effectiveness of any changes implemented based on results of data collected. This was discussed and validated with the Administrator/DPCS and Accountant.

Observed in Data Session. During the data session, the organization did not document the reasons for conducting performance improvement projects, and the measurable progress achieved on them. The data was collected and aggregated from the electronic medical record system. However there were no analysis or documented reasons why the data was collected. There were no performance improvement goals, evaluation or progress/results documented on the data elements collected. There was no evidence that progress was measured or results achieved. This was validated by the Administrator and Accountant.

Observed in Data Session. During the Data Session with leadership, the organization was unable to identity how it set priorities for data collection, performance improvement activities, and patient health outcomes. The leaders were unable to correlate the general data collected from the electronic medical record system data collection process to high-volume, high-risk, or problem-prone areas for performance improvement activities. Data collected was not evaluated for significance and/or reprioritized to develop performance improvement activities in response to changes or the data results. Documentation just restated the data. The program did not address improvements efforts to the safety and quality of patient care. This was discussed at length and validated by the Administrator/DPCS and Accountant.

Observed in Individual Tracer. In 1 of 3 home visits conducted, HV2, during the home visit, the organization failed to implement its infection prevention and control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection. For example, HV1 the aide used a reusable plastic barrier which she carried from home to home, however she did not clean the barrier prior to returning it to her bag. This was not compliant with the organization's Nurse Bag Policy and validated by the Administrator/DPCS.

Observed in Individual Tracer. In 4 of 8 patient records with hospice aide services, HVRR1, HVRR2, HVRR3, DCRR2 the organization failed to show evidence the registered nurse supervised the hospice aide during an on-site visit to the patient’s home no less frequently than every 14 days. For example, HVRR1 there were no supervisory visits documented in the last six weeks prior to survey; HVRR2 and HVRR3, there were no supervisory visits documented in the last eight weeks prior to survey; DCRR2 there was no aide supervisory visit conducted for six weeks. This was not compliant with policy and validated by the Administrator/DPCS.

Observed in Leadership Session. During the Volunteer Program session with the Coordinator and Accountant, the hospice did not document its efforts to recruit and retain volunteers. For example, there was no evidence documented of recruitment or retention efforts for 2022 or 2023. This was validated by the Coordinator and Accountant.

Observed in Medical Management Session. During the Volunteer Program session with the Volunteer Coordinator, the organization did not show evidence its volunteer program had provided day-to-day administrative or direct patient care in an amount that equaled 5% of the total patient care hours of all paid hospice employees and contract staff. For example, in 2023 the percentage was reported as 0.21%, and in 2022 the percentage was reported as 0.65%. This was discussed with the Volunteer Coordinator and Accountant.

Observed in Leadership Session. There was no evidence the governing body and leadership had established requirements to support patient care, treatment and services as evidenced by findings related to implementation of policies and procedures regarding patient care planning, physician orders, oxygen safety, patient rights, performance improvement and recurrent findings. In addition, condition level deficiencies were identified at 418.54, 418.56, 418.58, 418.100, 418.104 and 418.116.

Observed in Individual Tracer. In 1 of 2 bereavement records, RRBR1 during the record review, the patient record failed to contain the following clinical information: assessments relevant to care, treatment, or services. For example, the record indicated a skilled nursing visit was made at time of patient's death, however the only documentation noted was the date and time of the visit. There was no narrative or summary documented. This was validated by the Administrator/ DPCS. Observed in Individual Tracer. In 1 of 2 discharged live patient records, RRDC2-during record review the organization failed to show evidence it had documentation supporting the discharge for extended prognosis. All documentation indicated the patient remained appropriate for hospice services, there was no IDG /POC notes, clinical notes or discharge summary indicating the reason for discharge. There was no revocation of benefit form signed at time of discharge. This was discussed and validated with the Administrator/DPCS.

Observed in Individual Tracer. In 1 of 3 home visits conducted, RRHV3 during the home visit and subsequent record review, the organization failed to demonstrate the patient record contained the list of medications, including dose, strength, frequency, route, date and time of administration for prescription and nonprescription medications, herbal products, and home remedies that relate to the patient's care, treatment, or services. For example, RRHV3, the patient developed respiratory infection symptoms and medications were ordered, however the medication list did not include Augmentin 875 twice a day x 10 day and Budesonide 0.5 mg x 10 days. The orders were texted to the nurse but were not added to the clinical record. This was not compliant with the organizations policy and validated by the Administrator/DPCS.

Observed in Individual Tracer. In 1 of 8 eligible closed records, RRNHV 6, during the record review, the organization failed to ensure all entries in the patient record were legible, clear, complete, and appropriately authenticated and dated in accordance with the organization’s policy and currently accepted standards of practice. For example, the hospice nurse documented a death visit to pronounce the patient, however, it was not signed, timed or dated. Those was not compliant with the organization's policy and validated by the Administrator/DPCS.

Observed in Individual Tracer. In 2 of 14 patient records reviewed, RRNHV5, RRDC1 during record review the organization failed to show evidence when the patient revoked the election of hospice care or is discharged from hospice care, that the hospice provided the patient’s attending physician with a copy of the hospice discharge summary and, if requested, a copy of the patient’s clinical record. For example RRNHV5 the patient revoked the benefit, however there was no documentation in the record of a discharge summary, order or that the physician had been provided with a summary. RRDC1, the daughter called to transfer patient however there was no evidence a discharge summary or order provided to the physician. The record was incomplete. This was validated by the DPCS.

Observed in Individual Tracer. In 5 of 14 patient records reviewed, RRNHV2, RRNHV 3, RRNHV 6, RRNHV, 7 RRDC1, during record review and discussion with the Accountant and Administrator/DPCS, the organization failed to provide care in accordance with regulations. For example, multiple records had NOMNC (Notice of Medicare Non-Coverage) and the Revocation consent forms signed upon admission. During the discussion with leadership it was validated that the process for accurate completion of the consent forms and auditing of the records was a systemic issue and not in place. This was validated by the Administrator/DPCS and Accountant.