Every finding on record at Blessed Hope Hospice, Inc.

Observed in Record Review. In 2 of 4 patient records reviewed, During #3 and #4 it was noted although the MSW documented a frequency of visits and identified goals, the POCs lacked interventions to accomplish the goals. This was discussed with Leadership.

Observed in Record Review. In 1 of 2 patient records reviewed, who were discharged alive from hospice. During Live D/C-RR#2 it was noted the patient representative signed and dated a Notice of Non Medicare Coverage (NOMNC) prior to the patient discharge. The date the serivce would end was blank on the form. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 14 patient records reviewed, During RR#1 it was noted orders for dilaudid 4 mg by mouth every 4 hours as needed for pain and morphine sulfate 30 mg q 8 hours by mouth as needed for pain. There was lack of direction on which medication to take when as the orders lacked qualifiers for administration. This was discussed with the organization leadership. Observed in Record Review. In 9 of 14 patient records reviewed, During BR-RR#1 it was noted MSW interventions documented on the POC by the RN. There was lack of documentation of collaboration between the MSW and RN to establish the MSW interventions. During Live D/C RR#2 it was noted spiritual counselor (SC) interventions on the POC were entered by the RN without documentation of collaboration with the SC. During Live D/C-RR#1 it was noted the MSW did not enter interventions for the goals established on the POC. During HV#1 record review it was noted the chaplain services were refused by the patient however spiritual interventions were added to the POC by the RN. During HV#3 record review it was noted and order on the POC to Monitor for pain in the calf, swelling/edema compression stockings as ordered Lovenox SC to be managed by son as ordered -completed Update: Start with Eliquis 2.5mg Tablet daily. The intervention lacked instruction of bleeding precautions with the use of Lovenox and Eliquis. In addition the RN added spiritual interventions on the POC without evidence of collaboration with the chaplain. During RR#2 it was noted the MSW documented in the summary during an IDG meeting the need for monthly visits. The POC lacked psychosocial interventions established by the MSW. During RR#3 it was noted spiritual interventions were added to the POC by the RN without collaboration with the chaplain. The patient refused a spiritual assessment as documented by the chaplain. During RR#5 it was noted MSW and Chaplain interventions were added to the POC by the RN however the patient refused an initial visit from the MSW and the chaplain. During RR#7 it was noted chaplain interventions on the POC documented by the RN, however the patient and family refused a chaplain visit. This was discussed with the organization leadership.

Observed in Record Review. In 3 of 14 patient records reviewed, During Live D/C-RR#1 it was noted the patient had a pleurix catheter to drain and relieve the discomfort of ascites weekly. The following orders were included on the POC Assess puncture site every SN visits for signs of infection (redness, swelling, warmth). Drain fluid at least weekly or as needed observing infection precautions Change dressing every week or as needed. The order lacked the specific dressing change order, the reason to perform the paracentesis as needed, who would perform the wound care and other assessment and interventions related to the pleurix catheter and ascites. During BR-RR#2 it was noted the wound care orders were not added to the POC. The wound care orders were in the hard copy record not in the EMR used to document additions/changes to the POC. During HV#2 record reivew it was noted the hospice aide visited the patient 3x/week to provide personal care however the aide care plan POC assignment initiated by the RN was blank.This was discussed with the organization leadership.

Observed in Record Review. In 1 of 14 patient records reviewed, During Live D/C-RR#1 it was noted an order for a paracentesis weekly performed via a pluerix catheter. There was documentation of one paracentesis performed during the patients hospice admission that spanned more than two weeks. This was discussed with the organization leadership.

Observed in Data Session. During review of the QAPI program it was noted since the organization did not analyze data collected on palliative outcomes and hospice services, the organization could not demonstrate improved outcomes. This as discussed with the organization leadership.

Observed in Data Session. During review of the QAPI program it was noted lack of quality indicators reported at quarterly QAPI meetings. For example patient/family perception of care, patient complaints, results of patient record review were not included in QAPI meetings reviewed for 2022-2024. This was discussed with the organization leadership.

Observed in Data Session. During reivew of the organization QAPI program it was noted, although, data was collected and reported at QAPI meetings, there was lack of documentation of data analysis and therefore the organization was not able to monitor the effectiveness and safety of services and the quality of care. This was discussed with the organization leadership.

Observed in Data Session. During reivew of the QAPI program with the Administrator and DPCS designee it was noted there were performance improvement projects for 2022-2024 that were being conducted, however, progress was not documented or reported at QAPI meetings.

Observed in Patient Home. In 1 of 3 home visits conducted, During HV#2 it was noted the SN used his clean hand to turn off the faucet and then used the patient's cloth towel to dry his hands. This was discussed with the organization leadership.

Observed in Record Review. In 3 of 10 patient records reviewed, who were receiving aide visits. During BR-RR#1 it was noted an order for oxygen therapy, 2L/min PRN shortness of breath documented during the initial RN assessment. This order was not added to the hospice aide POC assignment form. During HV#2 record review it was noted the assignment form was blank and the CHHA has been visiting the patient 3x/week since the beginning of March 2024. During RR#4 it was noted lack of RN direction to the aide on the dressings covering bilat forearm skin tears on the aide assignment form. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 10 patient records reviewed, who were receiving aide services. During review of HR#2 record review it was noted the aide assignment form was blank. The aide notified the RN to ask the type of bath to provide to the patient however the aide did not notify the RN that the instruction form was blank. This was discussed with the DPCS designee.

Observed in Record Review. In 1 of 10 patient records reviewed, who were receiving aide visits. During HV#2 record review it was noted lack of documentation that the hospice aide was supervised no less frequently than every 14 days. There was one supervisory visit documented in 2 months. The hospice aide was visiting the patient without a completed RN assignment from. This was discussed with the organization leadership.

Observed in Document Review. During review of the therapy contract for PT, OT, and ST, it was noted the following was not stipulated in the signed agreement: Identification of the services to be provided, a stipulation that services may be provided only with the authorization of the hospice, the manner in which contracted services will be coordinated, supervised, and evaluated by the hospice, the delineation of the role of the hospice and contractor in the admission process, patient/family assessment, and the interdisciplinary group conferences, requirements for documenting that services are furnished in accordance with the agreement, and the qualifications of the individuals providing the services. This was discussed with the organization leadership.

Observed in Record Review. In 2 of 14 patient records reviewed, During RR#2 it was noted during the IDG meeting, the MSW summary included findings from the initial visit and the need for visits 1x/month however, the frequency of visits on the POC stated the MSW was refused. During RR#4 it was noted on an IDG summary that an MSW visit had been conducted. There was lack of the MSW visit note in the EMR for the date stated. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 14 patient records reviewed, During HV#2 record review it was noted lack of education provided on an individualized disaster/emergency plan. This was discussed with the organization leadership.