Every finding on record at Caldwell Hospice and Palliative Care, Inc

It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code fire drills at varied times on all shifts. The hospice inpatient facility has evacuation diagrams posted and visible to all staff, patients, and family members or visitors. This standard was not met as evidenced by document review, interview, and observation. National Fire Protection Association (NFPA) 101 "19.7.1.6" stated in part, "Drills shall be conducted quarterly on each shift to familiarize personnel with the signals and emergency action required." K712 The hospice inpatient facility did not ensure that Life Safety Drills at varied times on all shifts were documented on dated written reports. A review of the hospice inpatient units' quarterly (Q) fire drills reports revealed fire drills were not documented on all shifts quarterly. During the inpatient unit (IPU) observation on 10/30/2024(location 1), the required documentation for night shift quarterly fire drills for Quarter 1 in 2022, Quarters 1, 3, and 4 in 2023, and Quarters 1, 2, and 3 for 2024 were missing. During the IPU observation on 10/31/2024 (location 2), the required documentation for night shift quarterly fire drills was missing for Quarters 1 and 3 in 2023 and Quarters 1 and 3 in 2024. Both locations 1 and 2 utilized two 12-hour shifts per day. During interviews on 10/30/2024 and 10/31/2024, the facilities' manager confirmed that documentation for the second shift fire drills was missing for both locations. Quarterly (Q) fire drills were not documented on all shifts quarterly. During IPU observation on 10/30/2024, at location 1, the required documentation for night shift quarterly fire drills for Q 1 in 2022 was missing. Q 1, Q 3, and Q 4 in 2023, and Q1, Q2, and Q3 for 2024. During IPU observation on 10/31/2024, at location 2, the required documentation for night shift quarterly fire drills was missing for Q1 and Q3 in 2023, and Q1 and Q3 in 2024. Both locations 1 and 2 utilize two 12-hour shifts per day. Interview: Interview with facilities manager who stated that documentation for 2nd shift fire drills was missing at both locations. NFPA 101 19.7.1.6 states that "drills shall be conducted quarterly on each shift to familiarize personnel with the signals and emergency action required." K712

It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 5 of 22 (23%) clinical records of patients that received Hospice Aide (HA) services, the agency did not ensure that the HA provided services included in the HA care plan. Clinical Record 1: The patient elected hospice care on 06/25/2024 with a diagnosis of cerebral infarction. The plan of care (POC) ordered HA services three times a week. The Hospice Aide (HA) care plan assigned the HA the tasks of bed bath, hair care, skin care, back care, and incontinence care every visit. The HA visit note dated 07/04/2024 was blank for bed bath, hair care, skin care, back care, and incontinence care, and the HA documented "nothing unusual to report." There was no reason documented for the care not being provided. Clinical Record 2: The patient elected hospice care on 06/04/2024 with a diagnosis of cerebral infarction with embolism. Hospice Aide services were accepted, and care began on 06/07/2024 with a two (2) times a week frequency. The HA care plan dated 06/07/2024 assigned the HA the relevant tasks of showering, transferring with a geri-chair, and skin care each visit. The HA visit note dated 06/21/2024 documented, "unable to shower- gave bath in a chair." The HA care plan was updated on 07/01/2024 with a change in the assigned bath to a bed bath. The HA visit note dated 07/02/2024 documented, "patient requested to shower, patient was stable to get in the shower, shower provided." The HA visit note dated 07/16/2024 stated that a shower was provided. The HA visit note dated 07/26/2024 documented that no bath was provided. There was no reason documented for the care not being provided. Clinical Record 7: The patient elected hospice care on 09/12/2024 with a diagnosis of rectal cancer. The POC ordered HA services two (2) times a week. The HA care plan dated 09/17/2024 assigned the HA the relevant task of a bed bath. The HA visit notes dated 09/18/20224,10/03/2024, and 10/11/2024 documented that a shower was provided. Clinical Record 21: The patient elected hospice care on 9/13/2024 with a diagnosis of protein-calorie malnutrition. The POC ordered HA services two (2) times a week. The HA care plan dated 09/13/2024 assigned the HA the bathing task as "assist shower chair." The HA visit note dated 09/26/2024 documented that a tub bath was provided. On 10/02/2024, the HA care plan was updated for bathing to "assist bed bath." The HA visit notes dated 10/10/2024 and 10/15/2024 documented that the patient got in the tub. The patient was alert and oriented to make decisions. The patient was capable of getting in the tub with assistance. Clinical Record 22: The patient elected hospice care on 05/06/2024 with a diagnosis of senile degeneration brain. The POC ordered HA services one (1) time a week. The HA care plan dated 05/06/2024, with no updates, assigned the HA the tasks: assisting with bed bath and peri care each visit. The HA visit notes dated 08/20/2024 and 09/12/2024 documented "result unknown" for bathing and peri care. The HA visit note dated 08/29/2024 documented there was no care provided. There was no reason documented for the care not being provided. During an interview and a joint record review on 10/31/2024, the Compliance Officer and the Chief Regulatory and Experience Officer confirmed the findings, stating that the space available to document that the nurse was notified was not completed, and the care was not documented in the plan of care.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 4 of 22 (18%) clinical records reviewed of patients who received Hospice Aide services, the agency did not ensure that the HA notified the Registered Nurse of changes related to the patient's needs and plan of care. Clinical Record 1: The patient elected hospice care on 06/25/2024 with a diagnosis of cerebral infarction. The plan of care (POC) ordered HA services three times a week. The Hospice Aide (HA) care plan assigned the HA the tasks of bed bath, hair care, skin care, back care, and incontinence care every visit. The HA visit note dated 07/04/2024 was blank for bed bath, hair care, skin care, back care, and incontinence care and documented "nothing unusual to report." There was no evidence that the change in the patient's care plan and needs were reported to the RN, and no reason was documented for the care not being provided. On 07/09/2024, all assigned tasks were documented as declined. There was no evidence that the change in the patient's care plan and needs were reported to the RN, and no reason was documented for the care not being provided. Clinical Record 2: The patient elected hospice care on 06/04/2024 with a diagnosis of cerebral infarction with embolism. Hospice Aide services were accepted, and care began on 06/07/2024 with two (2) times a week frequency. The HA care plan dated 06/07/2024 assigned the HA the relevant tasks of showering, transferring with a geri-chair, and skin care each visit. The HA visit note dated 06/21/2024 documented, "unable to shower- gave bath in a chair." There was no evidence that the change in the patient's care plan and needs were reported to the RN. The HA care plan was updated on 07/01/2024 with a change in the assigned bath to a bed bath. The HA visit note dated 07/02/2024 documented, "patient requested to shower, the patient was stable to get in the shower, shower provided." The HA visit note dated 07/16/2024 stated that a shower was provided. There was no evidence that the change in the patient's care plan and bath type were reported to the RN. The HA visit note dated 07/26/2024 documented that no bath was provided. There was no reason documented for the care not being provided. There was no evidence that the change in the patient's care plan and needs were reported to the RN. Clinical Record 7: The patient elected hospice care on 09/12/2024 with a diagnosis of rectal cancer. The plan of care (POC) ordered HA services two (2) times a week. The HA care plan dated 09/17/2024 assigned the HA the relevant task of a bed bath. The HA visit notes dated 09/18/20224,10/03/2024, and 10/11/2024 documented that a shower was provided. There was no evidence that the change in the patient's care plan and needs were reported to the RN. Clinical Record 21: The patient elected hospice care on 9/13/2024 with a diagnosis of protein-calorie malnutrition. The POC ordered HA services two (2) times a week. The HA care plan dated 09/13/2024 assigned the HA the bathing task as "assist shower chair." The HA visit note dated 09/26/2024 documented that a tub bath was provided. On 10/02/2024, the HA care plan was updated for bathing to "assist bed bath." The HA visit notes dated 10/10/2024 and 10/15/2024 documented that the patient got in the tub. The patient was alert and oriented to make decisions. The patient was capable of getting in the tub with assistance. The change in the type of bath was not documented as reported to the RN. During an interview and a joint record review on 10/31/2024, the Compliance Officer and the Chief Regulatory and Experience Officer confirmed the findings, stating that a space was available to document that the nurse was notified of tasks not completed.

Based on clinical record review and staff interviews the skilled nurse failed to communicate with the physician related to a positive urinalysis/signs of a urinary tract infection for 1 of 1 patient with a positive urinalysis [#1]. The findings included: --- Patient # 1 had a Start of Care date of 6/24/22 and a terminal diagnosis of COPD [chronic obstructive pulmonary disease-lung condition]. Review of the Plan of Care [POC] for the certification period 12/16/23-2/13/24 included orders for SN [skilled nursing] 1 x a week for 9 weeks with 6 PRN [as needed] for symptom management. Review of the clinical record revealed the patient resided at _______ [name of the assisted living facility]. Review of the SN visit notes revealed the following information: On 2/7/24 at 9:30 am, RN # 1 made a routine visit and documented the following information... " Facility staff reported ";dark amber color urine...dark sediment and ";old blood odor" ...Dr. _______ [name of physician] informed UA [urinalysis] C and S [culture and sensitivity ordered] ...Suspected UTI-urinary sediment with strong odor..." LPN # 2 obtained a clean catch urinalysis on 2/7/24 at approximately 14:40 pm On 2/7/24 at approximately 4:49 pm the physician was notified of the urinalysis results. 2/7/24 5:16 pm the physician responded and stated, ";Very suggestive of an infection. Is she symptomatic? Can we wait until the culture report has arrived?" On 2/7/24 RN # 3 made a PRN [as needed] visit at approximately 19:55 pm. RN # 3 documented the patient had a fever of 100.4 aux [sic] axillary [under the arm], the patient complained of deep back pain which was a 3/10, and foul odor to urine. RN # 3 documented, ";...UA results back with many bacteria, culture and sensitivity pending. Encouraged facility staff to continue to monitor patient and call with any needs, changes or concerns overnight." 2/7/24 at 11:14 pm RN # 1 responded back to the physician and stated ";She reported right sided back pain and abdominal pain last night..." On 2/8/24 at approximately 14:05 pm, RN # 1 documented, ";Med tech calls RN to update on pt status...reporting pt [patient] slightly confused..." On 2/8/24 approximately 22:15 pm, RN # 3 documented she made a visit with the patient at _____ [name of the emergency department]. RN # 3 documented, ";...patient reports ";butt" pain and states the patient states she just ";does not feel well..." On 2/9/24 at 6:30 am, RN # 3 documented a comprehensive assessment completed at ____ [name of the hospital]. RN # 3 documented the patient had a diagnosis of sepsis [infection in blood] related to a UTI. The clinical record revealed no evidence a nursing visit was made after the results of the urinalysis was obtained until after the patient was sent to _____ [name] of emergency department on 2/8/24. Further review of the clinical record revealed no follow up with the physician after 2/7/24 at 11:14 pm to inform him of the patients confusion reported on 2/8/24. During an interview with employee # 5 on 3/18/24 at approximately 3:30 pm, employee # 5 stated, ";The information should have been given to the on-call nurse or the triage nurse so the physician could have been informed of her symptoms before 11:14 pm on 2/7/24." Employee # 4 also confirmed the physician should have been informed of the new onset of confusion reported to RN # 3 on 2/8/24.

Upon patient record review, 5 of 5 (Patient #1, 2, 3, 4, and 5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1, #2, #3, #4, and #5 initial plan of care included order for enemas/laxatives of choice, stool softener/suppositories of choice.

Upon client record review, 3 of 5 (Patient #2, #4 and #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2 initial plan of care included RN frequency of 1w10 and 3prn. RN made prn visits on the following dates 4/8/22, 4/9/22, 4/10/22, 4/15/22, 4/16/22, 4/22/22, 4/23/22, and 4/24/22. Initial plan of care included wound care orders with a frequency of CNA provide 2xweek, RN 1x week, Neighbor 1xweek, Wound clinic 1xweek, and RN Saturday and Sunday for daily wound care. RN provided wound care on schedule visit on 4/12/22 and prn visit on 4/15/22. RN provided wound care on scheduled visit 4/21/22 and prn visit on 4/22/22. Patient #4 initial plan of care ordered social work frequency of 1m8 and 2 prn. SW visits made on 4/11/22 and 4/26/22, no evidence either of these are prn visits. Patient #5 initial plan of care ordered social work frequency of 2xweek10 to start 4/15/22. SW visit made on 4/15/22, no evidence of a second visit or refusal of visit this week.

Upon client record review, 1 of 20 (Patient #6) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Patient #6 The 2/10/22 plan of care was created by the admitting RN was not reviewed and discussed on admission per IDG notes however was discussed on subsequent visit 2/15/22

Upon patient record review, 1 of 20 (Patient #13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #13 2/23/22 physician order for NS and Heparin flushes via implanted port are not on the med profile.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 2 of 20 (Patient #5,11) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. Patient #5 DM was noted diagnosis and patient on medication with no intervention or goals related to DM to date. Patient #11 Patient has aide services. There is missing evidence of interventions and goals related to the identified need for personal care assistance.

Upon patient record review, 9 of 20 (Patient #1,2,5,6,7,9,14,17,20) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Patient #1 The 3/2/22 plan of care reads Nursing 1xshift and prn, MSW 2xweek and prn, Aide 1xshift and prn with no prn quantifiers Patient #2 The 1/3/22 plan of care reads MSW 1-2x/month and prn with no prn quantifiers Patient #5 The 1/8/22 plan of care reads MSW 1-4x/month 2xweek and prn with no prn quantifiers Patient #6 The 2/10/22 plan of care reads MSW 1-2x/month and prn with no prn quantifiers and SC frequency reads initial visit. Patient #7 The 2/14/22 plan of care reads MSW 1-2x/month and prn with no prn quantifiers and SC frequency reads initial visit. Patient #9 The 1/11/22 plan of care reads Nursing 1-3xprn/week. Patient #14 The 1/3/22 plan of care reads MSW 1-2x/month and prn with no prn quantifiers Patient #17 The 12/2/21 plan of care reads Nursing 1-2xweek and prn, MSW 1-2xweek and prn and SC 1-2xmonth and prn with no prn quantifiers Patient #20 The 1/27/22 plan of care reads MSW 1-2month and prn and SC 1-2xmonth and prn with no prn quantifiers. The aide frequency reads 'other'.

Upon patient record review, 20 of 20 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patients 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20 with standing orders that contain medications with prn frequency with no reasons for the PRNs. Patient #1 The 3/2/22 plan of care reads foley insert/connect to BSD prn and may irrigate with NS prn and change q30days and prn without reason for the PRN; Additionally, the same plan of care with orders bowel regimen per standing order and IV per standing order without specific details. Patient #3 The 1/21/22 plan of care reads insert foley cath prn without a reason for the PRN. Patient #5 The 1/8/22 plan of care reads foley insert/connect to BSD prn, may irrigate with NS prn and change q30days and prn without reasons for the PRN. Also the POC included bowel regimen per standing order without specific instructions. Patient #13 The 1/13/22 plan of care reads NS pre flush 5cc and post flush 5cc with 50 units of Heparin via implanted. The order did not include the frequency for the port flush nor did it include the Heparin dosage. Patient #16 The 2/1/22 SOC assessment indicates patient has a PICC line, foley and O2 with no associated orders/interventions on the plan of care. Patient #20 The 2/8/22 nursing note indicates skin tears identified and the application of Neosporin and a telfa dressing however there are no physician orders to date on file related to skin tear care.

Upon client record review, 7 of 20 (Patient #1,2,5,6,7,8,11) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Patient #1,2,5,6,7,8,11 There is no evidence shown in the IDG documentation that patient's or families are in agreement with the plan of care.

Upon client record review, 3 of 20 (Patient #2,4,6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2 The 1/3/22 plan of care reads insert foley, however, 1/3/22 start of care shows no evidence of foley and catheter was not inserted until 1/28/22. Patient #4 The 1/11/22 plan of care reads obtain UA & C&S, however, the order was originally written and completed on 1/4/22 and should not have been included on the 1/11/22 plan of care per VP of Quality. Patient #6 The SC visit ordered on 2/10/22 has not been not performed to date.

Upon personnel record review, 1 of 1 (Personnel # 7) did not have evidence in the personnel file of a complete/clear competency assessment was performed by the aide with a patient. Personnel #7- The Aide competency reads bed bath, sponge, tub or shower and shampoo in sink, tub, or bed. Not clear on which competency was completed on 5/17/21.

Upon patient record review, 14 of 14 applicable (Patient #1,2,3,5,8,9,10,11,12,14,15,18,19,20) did not have evidence in the patient record that hospice aide assignments and duties include the tasks to be provided and the frequency of those tasks. Patient #1,2,3,5,8,9,10,11,12,14,15,18,19,20: The Aide care plan does not define task frequency for all tasks assigned to date.

Upon patient record review, 1 of 14 applicable (Patient #10) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the POC. Patient #10 The 2/22/22 aide visit reads bed bath provided however the 1/28/22 aide assignment sheet reads shower to be provided.

Upon client record review, 3 of 3 applicable (Patient #16,17,18) did not have evidence that the discharge summary includes all required information. Patient #16, 17, & 18 does not include MD orders/plan of care

Upon patient record review, 7 of 20 (Patient #2,3,5,6,7,8,11) did not have evidence in the patient record that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home.

Upon client record review, 20 of 20 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed.

Upon observation, there was missing evidence of a copy of the CLIA certificate for the laboratory used for specimen testing. The agency did not show evidence of a copy of the CLIA certificate for the two reference laboratories identified with surveyor chart audits.