Every finding on record at Bridge Hospice, LLC

Based on record review, staff interview, and review of facility policies, it was determined the agency failed to complete an initial comprehensive assessment by the agency Chaplain for one patient (P) (P#10) of 14 patient records reviewed. --- Findings include: Review of undated facility policy titled, ";Assessment – Initial and Comprehensive", reveals the following: Policy (Facility) will conduct and document in writing a patient-specific comprehensive assessment that identifies the patients need for hospice care and services, and the patients need for physical, psychosocial, emotional, and spiritual care. This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. Review of undated facility policy titled ";Assessment Guidelines", reveals the following: Policy: Hospice will utilize and adhere to defined assessment guidelines in order to accurately and consistently assess the patients needs as a basis for planning care. Each assessment will be completed by qualified Hospice staff that have the necessary skills and training and comply with federal and state laws and regulations. Record review for P#10 revealed the initial comprehensive Chaplin assessment identifying patient and family needs for establishing the frequency of Chaplin visits throughout the stay or decline of services with the agency failed to be included in the record. During an interview with the Administrator on 1/17/2024 at 2:30 p.m., the Administrator confirmed P#10 failed to have an initial assessment completed by the agency Chaplain. The Administrator stated, ";that patient was before I became the Administrator."

Based on record reviews, staff interview, and facility policy review, it was determined the agency failed to follow staff frequencies, specifically Certified Nursing Assistant (CNA), as ordered by the Medical Doctor (MD) for five patients (P) (P#2, P#4, P#6, P#7, P#9) of 10 patient records reviewed. --- Findings include: Review of undated facility policy titled, ";Plan of Care", reveals the following: Procedure: 1) Plan of care a. All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by (facility) interdisciplinary group in collaboration with the attending physician (if any), the patient or the representative, and the primary caregiver in accordance with the patients' needs if any of them so desire. 1. Record review revealed P#2 was admitted to hospice services on 12/14/2023 with CNA frequency to include three visits a week for the certification period beginning on 12/14/2023. The facility failed to have CNA visits made during the week of 12/19/2023 through 1/3/2024 and provided no documentation of these missed visits. 2. Record review revealed P#4 was admitted to hospice services on 3/30/2021 with CNA frequency to include three visits a week for the certification period beginning on 11/15/2023 and ending on 1/13/2024. Record review for P#4 revealed two CNA visits were made during the week of 11/19/2021 through 11/25/2021 and the facility provided no documentation of theses missed visits. 3. Record review revealed P#6 was admitted to hospice services on 8/8/2023 and contained orders effective 8/15/2023 for the CNA frequency as three visits a week. Record review for P#6 revealed no CNA visits were made during the week of 12/19/2023 through 1/3/2024 and the facility provided no documentation of theses missed visits. 4. Record review revealed P#7 was admitted to hospice services on 6/29/2022 and contained orders effective 8/9/2022 for the CNA frequency as three visits a week. Record review for P#7 revealed no CNA visits were made during the week of 12/19/2023 through 1/3/2024 and the facility provided no documentation of these missed visits. 5. Record review revealed P#9 was admitted to hospice services on 9/23/2022 and contained orders effective 12/13/2023 for the CNA frequency as three visits a week for the certification period beginning on 12/14/2023. Record review for P#9 revealed no CNA visits were made during the week of 12/19/2023 through 1/3/2024 and the facility provided no documentation of these missed visits. During an interview on 1/17/2024 at 1:00 p.m., the Administrator confirmed the CNA missed visits for P#2, P#4, P#6, P#7, and P#9. The Administrator revealed she was not aware of the missed documentation for CNA visits for P#2, P#4, P#6, P#7, and P#9 stating, ";that was the week our CNA was off work but, we had someone to cover for her. I do not know why the charting did not get completed."

Based on record reviews, observation, staff interview and agency policy review, it was determined the agency failed to follow an individualized written plan of care established by (facility) interdisciplinary group for providing care and services, whether directly or indirectly, for three patients (P) (P#2, P#5, P#7) of 10 patient records reviewed. --- Findings include: Review of undated facility policy titled, ";Plan of Care" reveals the following: All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by (facility) interdisciplinary group in collaboration with the attending physician (if any), the patient or the representative, and the primary caregiver in accordance with the patients needs if any of them so desire. Physician orders are needed to provide any hospice services, including all support services related to patient care, and any services requiring the administration of medications, prescribed treatment(s), or other activities governed by state law. 1. Review of records revealed P#2, with an admission date of 12/14/2023, was admitted with a decubitus ulcer stage four (full thickness skin loss with extensive destruction tissue necrosis) at the sacrum and right mid back decubitus ulcer. Review of the nursing assessment dated 12/17/2023, revealed the skilled nurse (SN) documented a decubitus ulcer to the sacrum. and the right mid back. Wound care orders for P#2 including goals and interventions from a medical doctor or active care plan failed to be included in the interdisciplinary team meeting documentation. 2. Review of records revealed P#5 was admitted to hospice services on 1/3/2023. SN documented on 1/6/24: small skin tear measuring 5 cm on left forearm. Review of Nursing wound care assessment dated 1/3/24 reveals: wound type – skin tear to left arm. The SN documentation reveals wound care treatment as: cleanse site, pat dry, cover with foam dressing daily. Wound care orders for P#5 including goals and interventions from a medical doctor or active care plan failed to be included in the interdisciplinary team meeting documentation. 3. Review of records revealed P#7 was admitted to hospice services on 6/29/22. Review of nursing documentation dated 12/21/23 revealed chronic wound stage 2 (partial thickness skin loss involving epidermis, dermis, or both to the sacral area with wound care treatment: cleanse with wound cleanser, pat dry, cover site with foam dressing. Wound care orders for P#7 including goals and interventions from a medical doctor or active care plan failed to be included in the interdisciplinary team meeting documentation. On 1/17/24 at 10:30 a.m. during a home visit, with the agency CNA, observed P#5 with wounds to the right lateral foot, left lateral foot, right heel, left heel, left arm, and sacral areas. During an interview on 1/17/2024 at 3:00 p.m., the Administrator confirmed that P#2, P#5, and P#7 failed to have wound care orders included in the POC from the hospice MD for P#2, P#5, and P#7 stating ";the facility has been taking care of the patients wound.

Based on review of policies, record review, and staff interview, it was determined the hospice failed to have an infection control program that identifies and plans for infectious disease problems. Specifically, the hospice failed to have an infection control policy that includes up-to-date information for the identification and prevention of COVID-19 (an infectious disease caused by the SARS-CoV-2 virus). --- Findings include: Review of the policy titled, ";Infection Control", Policy INF.10, dated 2016, reveals the following: Procedure: 3) An infection surveillance-risk analysis is formally reviewed at least annually and whenever significant changes occur. Review of the policy titled, ";Infection Control Program", Policy INF.12, dated 2016, reveals the following: Policy: (Facility) will maintain and document an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases. A review of a document titled, ";Emergency Preparedness Plan related to Coronavirus Disease 2019 (Covid-19)", dated March 2020 reveals the following: 2. Action Plan b. All staff will immediately implement the Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings On 1/18/2024 at 10:00 a.m., an interview with the Administrator confirmed that all policies and procedures addressing COVID-19 had been provided.

Based on review of agency policy, and staff interview, it was determined the hospice failed to document cost savings achieved through the use of volunteers. --- Findings include: Review of the facility undated policy titled ";Coordination of Services- Volunteer Coordinator", Policy COC.30, reveals the following: Volunteer Coordinator will ensure that volunteers provide a minimum of 5% of the total patient service hours and that there are demonstrated cost savings. Procedure: 1) The Volunteer Coordinator will: n. Prepare quarterly service reports as required by the director to include: 4. Estimates of the dollar costs which (facility) would have incurred if paid employees occupied the positions held by volunteers. On 1/17/2024 at 12:25 p.m., an interview with the Administrator revealed the hospices Volunteer Coordinator position is currently filled by the Administrator. The Administrator was unfamiliar with volunteer cost savings report requirements or calculations and was unable to provide any cost savings reports.

Based on record reviews, and staff interviews, it was determined the hospice governing body failed to assume responsibility for the management of the hospice and the provision of all hospice services. --- Findings include: A review of clinical records revealed five (P#2, P#4, P#6, P#7, P#9) of ten patients failed to receive Home Health Aide visits as ordered A review of clinical records revealed four of four discharged patients (P#11, P#12, P#13, P#14), failed to have a discharge summary in the clinical record. No volunteer cost savings reports available. Review of the Infection Control Program revealed an outdated infection control policy. On 1/18/2024 at 10:00 a.m., an interview with the Administrator revealed surveyors had received all available documents. Cross-reference L555 as it relates to providing services per the plan of care. Cross-reference L684 as it relates to discharge summary requirements. Cross-reference L646 as it relates to volunteer cost savings reports. Cross-reference L581 as it relates to infection control.

Based on record reviews, staff interview, and agency policy review, it was determined that the hospice agency failed to complete the discharge summary including: a summary of each patient stay with treatments, symptoms and pain management, current plan of care (POC), the latest physician orders, and, if needed, any documentation that would assist in continuity of care for four patients (P) (P#11, P#12, P#13, P#14) of four patient records reviewed. --- Findings include: Review of the agency undated policy titled, ";Discharge", COC.32 reveals the following: Procedure: 9. (Facility) discharge summary must include: a. The date and reason for discharge b. Any instructions or referral information given to the patient and family c. Patient identifying information d. Patients physician e. Hospice diagnosis f. Significant health history g. Discharge orders, instructions, medication profile and allergies if discharge is other than patient death h. A brief description of services provided and ongoing needs that cannot be met i. Status of patient at the time of discharge j. Presence of Advance Directives k. End of life decisions l. Any third party revocation or termination m. A summary of the patients stay, including treatments, symptoms, and pain management n. The patients current plan of care o. The patients latest physician orders p. Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility 12) Discharge records are completed within 30 days of discharge. 1.Record review revealed P#11 discharged from services on 11/23/23 and failed to have a completed discharge summary. 2. Record review revealed P#12 discharged from services on 8/8/23 and failed to have a completed discharge summary. 3. Record review revealed P#13 discharged from services on 9/8/23 and failed to have a completed discharge summary. 4. Record review revealed P#14 discharged from services on 12/9/23 and failed to have a completed discharge summary. On 1/17/24 at 11:00 a.m., during an interview with the Administrator, she admitted she was not aware that the discharge summary had not been completed for P#11, P#12, P#13, and P#14. After reviewing P#11, P#12, P#13, and P#14 charts, the Administrator confirmed the previously stated patient charts did not have a discharge summary.