Every finding on record at Butterfly Hospice

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure the patient-specific comprehensive assessment and reassessment identified the patient's need for hospice and services. On review of RRNHV#7 there was documentation of a wound to the patient's back that required treatment yet there was no documentation of a comprehensive wound assessment to describe the wound as required such as size, color, character, drainage, and odor. This observation was reviewed with the DPCS.

Observed in Record Review. In 2 of 10 Active patient records reviewed, the organization failed to ensure the update of the comprehensive assessment was accomplished by the interdisciplinary group (IDG) considering changes that took place since the initial assessment. On review of RRNHV#6 there was documentation of all nursing visits refused since mid June leaving 24 days to date of survey since last RN comprehensive assessment. The IDG meeting in mid June failed to update as it noted No changes since last IDG no new orders or meds, POC effective yet nursing visits had been refused during the time period due to the patient's agitation and refusal of care. The missed visits were not reported in the IDG meeting. In RRNHV#10 there was a 27 day gap in RN visits for comprehensive assessment in May. These observations were reviewed with the DPCS and Administrator.

Observed in Record Review. In 10 of 10 patient records reviewed, the organization failed to ensure the plan of care reflect patient and family goals that were specific, measurable and time-bound. Throughout all records review it was not that goals established were not specific and measurable. In RRNHV#4 an example was Promote rest status for Pt/Family/PCG.. In RRNHV#5 a goal read Increase strength/energy for functional activities.. In RRNHV#6 examples of non-specific not measurable goals were Facilitate bowel elimination and comfort and Pt needs will be met on a day to day basis as communicated. In RRNHV#8 an example was Minimize complications due impaired mobility. Further examples of non-specific, non-measurable goals could be seen throughout all records. These observations were reviewed with the DPCS and Administrator.

Observed in Record Review. In 3 of 10 active patient records, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRNHV#5 the patient was being seen by the social worker yet there was no psychosocial care plan to guide the care. The patient also had orders for sliding scale insulin yet no physicians order to specify when and who to conduct blood glucose monitoring. In RRNHV#9 ther was documentation of the patient with a UTI with antibiotics ordered yet the issue was not reflected on the plan of care. On RRHV#3 the patient had a g-tube with tube feeds and a speech therapy consult yet no nutrition care plan to guide the care. These observations were reviewed with DPCS and Administrator.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. On review of RRNHV#7 there were multiple pain medications ordered to include hydromorphone, fentanyl, and MS Contin routinely, and Percocet for breakthrough pain. There was also morphine ordered as part of the comfort kit for as needed use yet there were no specific instructions to guide when to give morphine versus Percocet for as needed use. Further the hydromorphone was ordered as a scheduled frequency of every 4 hours yet the noted instruction section specified to give as needed. These observations were reviewed with the DPCS.

Observed in Record Review. In 7 of 10 Active patient records reviewed, the organization failed to ensure that care and services were provided in accordance with the plan of care. On review of RRNHV#6 the patient was ordered a frequency of skilled nursing visits 1 time a week per the plan of care. There was documentation of 5 declined weekly visits, 1 in May, 3 in June, and 1 in July. There was no documentation that there was an attempt to make up the visit during the assigned week at a different time or day to ensure the care and services were provided in accordance with the ordered plan of care. In RRNHV#8 the aide was ordered 2 times a week but failed to document any visits the last week of May, and only 1 visit was documented on the 3rd week of June. In RRNHV#4 the aide was ordered 2 times a week yet no visits were documented since mid June leaving the last 3 weeks prior to survey with no documented visits. In RRNHV#9, RRHV#2 and RRHV#1 the aide was ordered 2 x week yet no visits were documented the last week of May. In RRHV#3 the spiritual counselor was ordered monthly yet no visit for February was documented. In March the spiritual care was declined yet a visit was documented for April. These observations were reviewed with the DPCS and Administrator.

Observed in Record Review. In 1 of 10 Active patient records reviewed, the organization failed to ensure the ongoing sharing of information between all disciplines providing care and services. On review of RRNHV#5 there was documentation of 5 skilled nursing visits declined/refused by the patient due to patient agitation yet there was no documentation that the physician was informed of the patient's agitation, yelling and refusal of care at the time the visit was documented as declined. This observation was reviewed with the DPCS and Administrator.

Observed in Data Session. the organization failed to analyze and compare internal data over time to identify levels of performance, patterns, trends, and variations. On review of the organizations QAPI program each quarter stood independently and did not compare over time to identify trends. This observation was reviewed with the DPCS and Office Manager.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure social work services were provided based on the patient's psychosocial assessment and the patient's and family's needs and acceptance of services. On review of RRNHV#10 the initial psychosocial assessment documented that psychosocial services were needed and monthly visits were accepted yet the plan of care order 2 days prior to the assessment noted services were declined. Further, an IDG meeting documentation in June noted that patient experiencing difficulty expressing himself verbally. Social support is needed yet social work services were not provided. This observation was reviewed with the DPCS.

Observed in Record Review. In 1 of 7 patient records reviewed with aide services, the organization failed to ensure the RN supervise the hospice aide during an on-site visit to the patient's home no less frequently than every 14 days. On review of RRHV#2 there was a 41 day gap in documentation of on-site aide supervisory visits from April to June. This observation was reviewed with the DPCS.

Observed in Tracer Activities. In 1 of 7 HR files reviewed, the organization failed to maintain, document and provide volunteer orientation and training that is consistent with hospice industry standards as the documentation for orientation for the volunteer (HR#4) was not available at the time of survey. This observation was reviewed with the Office Manager and DPCS.

Observed in Tracer Activities. the organization failed to ensure that volunteers provided day to day administrative and/or direct patient care services in an amount that, at a minimum, equaled 5% of the total patient care hours of all pain hospice employees and contracted staff. On review of the organization's volunteer program the volunteer percentage was consistently below 5% with average for 2024 at 2.1% and quarter 1 for 2025 at 3.5%. This observation was reviewed with the DPCS and the Office Manager.

Observed in Record Review. In 10 of 10 active patient records reviewed, the organization failed to ensure the medical director, physician member of the interdisciplinary team, or physician designee reviews the clinical information for each hospice patient and provides written certification that the patient’s life expectancy is six months or less if the illness runs its normal course to include all required elements. On review of RRNHV#4, RRNHV#5 the physician narrative on the initial certification stated I certify that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. If the patient`s condition improves, he will be discharged from hospice care. The narrative did not include all required elements such as current subjective and objective medical findings. Similar lack of physician narrative was noted in RRHV#1, RRHV#2, RRHV#3, RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#9, and RRNHV#10. These observations were reviewed with the DPCS and Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to ensure the patient record contain all information to reflect the patient's care, treatment and services. On review of RRHV#1 the facility medication profile contained Narcan, Docusate and Glyolax powder that was not included on the hospice plan of care. These observations were reviewed with the DPCS and Administrator.

Observed in Record Review. In 2 of 2 live discharge records reviewed, the organization filed to ensure that if the patient revokes the election of hospice care or is discharged from hospice care the patient's attending physician was provided a copy of the hospice discharge summary and if requested a copy of the clinical record. In review of RRDC#1 and RRDC#2 there was no documentation that the hospice discharge summary was provided to the attending physician. This observation was reviewed with the DPCS and Office staff.

Observed in Competency Session. In 1 of 1 contracts reviewed, for skilled nursing facility (SNF) the organization failed to ensure the contract with the SNF contained a stipulation that the hospice will report all mistreatment, neglect, or verbal, mental, sexual, and physical abuse to the SNF, NF, or ICF/IID administrator within 24 hours of the hospice becoming aware of the alleged violation, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice, as the verbiage was not found on the SNF contract. This observation was reviewed with the Office Manager.

Observed in Competency Session. In 2 of 4 contracts reviewed, the organization failed to ensure the contractual agreement included all requirements. On review of the Contract for Home Medical Equipment and Skilled Nursing Facility it was noted that they did not contain a stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This observation was reviewed with the Office Manager.

Observed in Individual Tracer. In 1 of 3 home visits conducted, the organization had not ensured the comprehensive assessment included the patient’s and spiritual needs were thoroughly reflected in the initial nursing assessment only noting spiritual care needed. No other elements of the evaluation were addressed at the time of admission. This was confirmed by the Administrator.

Observed in Record Review. In 3 of 11 patient records reviewed, the organization had not ensured the interventions to manage pain and symptoms were clearly written to instruct adequate pain and symptom management. For example, during review of the record associated with HV1 the patient was prescribed Hydrocodone and Ibuprofen without a hierarchy indicating which to use under which pain rating or type of pain. Additionally, during the same record review the plan for managing constipation failed to indicate a patient specific plan and instead reflected a generic, multiple medications options for resolution of this issue. In the second patient example, the patient had been prescribed both an albuterol and duoneb (ipratropium and albuterol) nebulized medications without an indication on which medication to utilize. The third example related to the review of record associated with HV3 the orders for both Ipratropium/ Albuterol and Xopenex respiratory nebulized treatments failed to include instructions for both of these medications. These findings were confirmed by the administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization had not ensured the Registered Nurse who directed Hospice Aide's care included all aspects necessary to provide safe care and environmental safety. For example, in review of HV3 the Hospice Aide had no prompt for oxygen safety as per the organizations policy 9.6.3. The same assignment identified the patient as having restricted ambulation without defining the restriction. This was confirmed by the Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization had not ensured the Hospice Aide had been supervised every 14 days. For example, during RR6 there were two instances that the Hospice Aide supervisory visit was not done in the minimum 14 days time frame as per CMS guidelines. This was confirmed by the DPCS.

Observed in Record Review. In 2 of 3 patient records reviewed, the organization had not ensured the medical record was correct and complete. For example, during the review of record associated with HV1 the Surveyor identified three issues reflecting an incorrect or incomplete medical record. Example one was that the Hospice Aides assignment failed to indicate the frequency of showers or shampoo and the assignment also indicate the patient utilizes a wheel chair and there was none noted in the home at the time of the home visit. The second example was that the Aide assignment also reflected full code status but there was an active Do Not Resuscitate in the home chart. In a second patient example, the record associated with HV2, the medication list reflected several pieces of medical equipment that were no longer in use and had been removed from the home (hospital bed, over bed table and side rails) and reflected a oxygen rate of two and a half liters per minute flow rate and the CNA assignment reflected a four liters per minute rate. These were also confirmed by the Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization had not demonstrated all of the requirements for General Inpatient Level of Care were satisfied. For example during RR7 the patient was identified that the required a higher level of care for symptom management and while the patient was admitted to a contracted facility there was no evidence that the training to the facility staff occurred or that there was a clear picture of the care that was provided. Additionally, there was no Registered Nurse assessment daily to assess the patient's condition or need for continuing this level of care or why to discontinue it. This was confirmed by the Administrator.