Every finding on record at Blue Ridge Hospice, Inc

Based on clinical record review, document review, and interviews, it was determined the agency failed to ensure that medical supplies and appliances to meet the needs of the patient were provided in a timely manner for one (1) of six (6) patients in the clinical records survey sample (Clinical Record for Patient #1). --- The clinical record for Patient #1 was reviewed for the period of May 08, 2024 through May 16, 2024. The clinical record revealed a visit from the admission Skilled Nurse (Staff Member #4) on May 08, 2024. Staff Member #4 documented on the clinical record that supplies were ordered for the patient and consisted of: wipes, chux, briefs and mouth swabs. On September 16, 2024 the complaint log was reviewed and indicated a complaint was placed on May 16, 2024 regarding the above noted supplies from the admission visit took over a week to be delivered. The complaint log revealed the clinical record documented the supplies were ordered but were not entered into the agencys software system for supplies to be ordered. On September 17, 2024 at 9:11 AM, the Medical Facilities Inspector (MFI) spoke to Staff Member #5. Staff Member #5 revealed the patients first Certified Nursing Assistant visit was on May 14, 2024 (6 days after admission), and there were no supplies to bathe the patient. On September 17, 2024 at 10:55 AM, the MFI spoke to Staff Member #1 via teams meeting. Staff Member #1 revealed that Staff Member #4 did not enter the supplies into their software on May 08, 2024,and should have left a bed bound kit. Staff Member #1 revealed the bed bound kits consists of wipes, five (5) large diapers, shampoo, body wash, barrier cream, oral swabs, paper towels and two (2) wash basins that is kept in the nurses trunk of their vehicle. In addition, Staff Member #1 revealed an apology letter was sent to the primary care giver (PCG) regarding late supplies. On September 17, 2024 at 11:30 AM, the MFI spoke to Staff Member #4. Staff Member #4 (who admitted Patient #1) revealed all admission nurses have bed bound kits but unsure if it was given to PCG for Patient #1 during the admission visit. The above interviews revealed supplies for bathing the patient were not ordered on the admission date or delivered in a timely manner.

Based on clinical record review and interview, it was determined the agency failed to ensure care and services were provided in accordance with the patient's plan of care. Specifically, a scheduled Skilled Nurse visit was not performed for one (1) of six (6) patients per the clinical records in the survey sample. (Clinical Record for Patient #1). --- The clinical record for Patient #1 was reviewed for the period of May 08, 2024 through May 16, 2024. The plan of care for the above noted time frame contained orders for Skilled Nursing visit two (2) times weekly beginning the week of May 11, 2024. The clinical record failed to contain documentation of a scheduled Skilled Nursing visit or missed visit for the time frame of May 11, 2024 to May 16, 2024. In addition, the clinical record revealed an on call note whereas, the primary care giver (PCG) is asking for the estimated time of arrival for the scheduled Skilled Nursing (Staff Member #6) visit for May 14, 2024. On September 17, 2024 at 8:50 AM, this Medical Facilities Inspector (MFI) called Staff Member #6 who was scheduled for a visit on May 14, 2024 for Patient #1. Staff Member #6 revealed a visit was scheduled for May 14, 2024 but did not go and the PCG called that day to ask where I was. Staff Member #6 revealed they were 1 hour away from the PCG, and it was late in the evening for a visit. On September 17, 2024 at 10:55 AM, this MFI spoke to Staff Member #1 via Teams Meeting. Staff Member #1 revealed that Staff Member #6 was scheduled to visit Patient #1 on May 14, 2024 and did not visit or notify the PCG of the missed visit.

Based on clinical record review and interview, it was determined the hospice failed to ensure bereavement services to reflect the needs of the bereaved in one (1) of three (3) bereavement records reviewed in the survey sample (Bereavement Record for Patient #1). --- The clinical record for Patient #1 revealed a documented date of death on May 16, 2024. The clinical record also indicated a Medical Social Worker (Staff Member #9) placed a phone call to the bereaved primary care giver (PCG) on May 17, 2024 at 3:41 PM. The documentation revealed the phone call was for condolences offered, and to educate on grief support but the bereaved did not want to talk at this time and to call back in a few days. The clinical record identified the bereaved as having a "moderate" risk score (identified concern for the bereaved who will likely benefit from additional early phone calls and monthly grief support) for bereavement needs. Patient #1s bereavement care plan interventions for the bereaved indicated the first phone call from the agency was on June 11, 2024 (25 days after the first phone call on May 17, 2024) and no phone call a few days later as requested by the bereaved-on May 17, 2024. On September 17, 2024 at 11:20 AM, this Medical Facilities Inspector (MFI) spoke to Staff Member #12 via Teams Meeting. Staff Member #12 revealed the wrong bereavement care plan interventions were generated for Patient #1s bereaved as a low risk instead of a moderate risk, hence the contact to the bereaved was late. The agency staff failed to follow the bereavement care plan for the bereaved with a medium risk score.

Observed in Record Review. The organization did not promote patient's rights. Patients were not provided in writing an approximate dollar amount they will be responsible for, even if that amount is zero. the Hospice did not advise patients related to treatment and services. RR#1 had a commercial payor source and as a result had a deductible and cost per visit for services. There was no documentation in the record that the patient/care giver was advised of the potential cost for hospice services. This observation was based on review of the consent forms and clinical documentation on assessment.

Observed in Individual Tracer. In 2 of 2 patient records reviewed, the Hospice did not advise patients related to treatment and services. RR#1 had a commercial payor source and as a result had a deductible and cost per visit for services. There was no documentation in the record that the patient/care giver was advised of the potential cost for hospice services. This observation was based on review of the consent forms and clinical documentation on assessment. RR#14 had a commercial insurance and documentation from billing reflected that the patient met his deductible and hospice services would be covered. However, the patient consent form, which was signed by the patient, reflected that patient may be charged for services. This observation was discussed with the RN director.

Observed in Record Review. The Hospice did not assess patients per policy. The policy titled - Initial and Comprehensive Assessment indicated that the assessment include a psychosocial assessment that included emotional barriers to treatment. RR#5 had suicidal ideations and there was no psychosocial assessment completed on the RN recertification reassessment. Additionally, this patient had bilateral lower extremity weeping wounds and there was no documented measurement or further description of the wounds. The nursing assessment of RR#13 did not reflect a psychosocial assessment. This patient was elderly with dementia. This observation was discussed with the RN director. Observed in Individual Tracer. The Hospice did not evaluate the need for volunteer service. RR#1-RR#2 , RR#4, and RR#5 did not have documentation in the nursing, social work, or chaplain initial assessment of the need for volunteer services. Additionally, there was no documentation in the initial IDT(s) of the need for this service. This observation was discussed with RN director. Observed in Patient Home. In 8 of 23 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. In RRHV#1, the need for volunteer services not assessed. The surveyor also noted that patient's PEG tube was removed on the day of admission; however, the wound care assessment did not address the wound. This was confirmed by the Director of Nursing.

Observed in Individual Tracer. In 2 of 23 patient records reviewed, the comprehensive assessment was not updated every 15 days. RR#2 resided in a nursing home and had infected wounds that were being managed by the nursing home staff. This patient has had multiple recertifications and there was no description or measurement of the actual wounds detailed on the visit notes and or IDG(s). Similarly, RR#3 had a wound that the family was managing and there was no specific documentation/ description of the wound in the clinical record or the comprehensive assessments. Per the RN director, wound measurements should be documented every 14 days. The need for volunteer services was identified for RR#3 but was not provided. The IDG assessment immediately following this identification, did not reflect the status of volunteer service. These observations were discussed with the RN director.

Observed in Individual Tracer. In 1 of 23 patient records reviewed, the Hospice did not provide a comprehensive initial assessment that was conducted by the core group. RR#2 did not have an assessment completed by a chaplain / the designated spiritual care person. Per the director of compliance, a chaplain was not available for a period of time and the spiritual care assessment was completed by a social worker who had no additional training in chaplaincy.

Observed in Individual Tracer. In 4 of 23 patient records reviewed, the hospice comprehensive care plan did not have individualized target dates related to patient goals. RR#1-RR#4 either had target dates for every 14 days or no target dates to achieve goals. RR#1, RR#2, & RR#3 had complicated wounds and pain issues. Additionally, RR#3 was a fall risk and had a Foley. RR#4 also had pain issues and was oxygen dependent. This observation was discussed with the RN director.

Observed in Individual Tracer. The Hospice comprehensive care plan did not include all interventions required based on the initial assessment. RR#1 was started on multiple new medications to manage her symptoms by the hospice and was tearful during her initial assessment by the RN. The comprehensive care plan did not include interventions/education related to the start of new medications, that were part of the comfort kit, and or interventions to address her emotional distress. In addition to having an infected wound, RR#2 had issues with pain and had bilateral edema. The initial comprehensive care plan did not address these issues. RR#4 was oxygen dependent and had a wound and the initial comprehensive care plan did not address either issue. RR#5 was on suicide precautions and the care plan did not reflect this precautions. The comprehensive care plan of RR#2 reflected that he patient had a Foley however based on record review, this patient did not have a Foley. This observation was discussed with the director.

Observed in Record Review. In 5 of 23 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. In RRHV#1, the surveyor noted that patient's PEG tube was removed on the day of admission; however, the plan of care even though the admission nurse addressed the wound and wound care in the narrative. This was confirmed by the Director of Nursing.

Observed in Tracer Activities. The organization had not included all services provided by the organization in the quality assessment and performance improvement program (QAPI). Contracted services, DME and therapy, were not included in the organization's plan. This finding was discussed with the Vice President of Quality.

Observed in Individual Tracer. The Hospice nurse did not adhere to the policy titled - Hand Hygiene. The RN in the IPU unit was observed preparing and rectally administering a medication to RR#9. During the preparation of the medication the nurse was observed changing her gloves three times without disinfecting or washing her hands between glove changes. After administering the medication, the nurse exited the patient room opened the medication room door and proceeded to wash her hands. The RN did not disinfect and or wash her hands immediately after administering the medication or prior to exiting the patient room. This observation was discussed with the RN Director. Observed in Patient Home. In 2 of 6 home visits conducted, the nurse did not follow the organization's bag technique policy.  In HV#1, the surveyor observed the nurse place her bag on the floor on top of a barrier. In HV#2, the surveyor observed the nurse hang her bag on the bedpost which was low resulting in the bag touching the floor. RN then placed a barrier on the floor. According to the organization's policy, bags are never placed on padded furniture or the floor, even with a barrier. This was confirmed by the Clinical Manager.

Observed in Infection Control System Tracer. The surveyor noted that the organization had not developed a strategy to improve compliance with hand hygiene compliance. The organization had collected data on hand hygiene compliance, but the data had not been analyzed. The organization was not aware of their current compliance rate. The organization did not have a baseline compliance rate. Therefore, the organization could not validate compliance improvement.

Observed in Record Review. In 2 of 8 patient records reviewed, that had aide services, the written patient care instructions was not provided based on the assessed needs. RRNHV#10, the surveyor noted that the aide care plan did not address foley catheter care instructions. RR#13 had seizures and seizure precautions were not included on the aide care plan. This was confirmed by the Director of Nursing.

Observed in Leadership Session. The governing board of the Hospice failed to consistently ensure that policies and procedures were effectively implemented. For example, the Hospice did not comply with standards related to patient informed consent, evaluation of volunteer services, developing and updating the comprehensive care plan, and the comprehensiveness of the QAPI program. This observation was discussed with the director.

Observed in Tracer Activities. The organization was not performing annual supervisory visits to assess competency of the volunteers as required by the organization's policy. In 2 of 3 volunteer records reviewed, the surveyor noted these visits had not occurred. This was finding discussed with the Volunteer Director.

Observed in Individual Tracer. In 1 of 24 patient records reviewed, the Hospice record reflected inconsistent documentation. The fall risk documentation in RR#13 was inconsistent. The initial assessment of RR#13 reflected that the patient was both low risk and at risk for falls. This observation was discussed the RN director.

Observed in Patient Home. In 1 of 4 patient records reviewed, Medication list was discovered to be inaccurate. In RRHV#1, the surveyor noted that the hospice medication list did not include the following medications: Multivitamin, Acetaminophen, and Acyclovir, which was listed on the facility medication list and being administered by facility staff. This was confirmed by the Clinical Manager.

Observed in Record Review. IDG Meeting Note entries in the patient record were not appropriately authenticated and dated in accordance with accepted standards of practice. For example, in RRNHV#11, the signature and date of IDG team members was captured once the Clinical Manager completed a review of the record, which may be completed a day or two later. Organization did not maintain a paper sign-in sheet of IDG team meeting attendance. Based on the discussion with the QA team, this authentication issues will be found in all records because this is their current process.

Observed in Record Review. In 4 of 23 patient records reviewed, the patient's individualized emergency plan was not specific to the patient's needs based on the assessment. RR#1 had a draining wound that required daily dressings and the - Evacuation Plan did not address the wound or the supplies needed. Additionally, RR#3 had a wound and RR#4 had a Foley and was on oxygen and the Evacuation Plan for these patients did not include the required equipment and supplies. RRHV#1 did not have an individualized emergency plan. This observation was discussed with the RN director.

Observed in Patient Home. The organization did not coordinate the patient's care, treatment, or services based on the patient's needs. In RRHV#1, the organization did not provide the facility with the patient's most recent hospice plan of care, physician certification and recertification of patient's terminal illness, information on the hospice medications, or orders from the hospice physician and/or attending physician. This was confirmed by the Clinical Manager.

Observed in Building Tour. The Surveyor observed during the tour of the inpatient unit, an exit door leading to a stairwell and to the outside that did not have an exit sign. This observation was discussed with the facility manager. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.