Every finding on record at Canyon Arizona Home Care & Hospice, LLC

It is required that the hospice informs and distributes to the patient written information about its policies on advance directives, including a description of applicable state law. The hospice provides written information to patients about their rights under State law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives at the individual’s option. The hospice updates and disseminates changes to state law on advance directives no later than 90 days from the effective date. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 11 of 11 (100%) clinical records reviewed revealed the agency did not ensure that the patient was provided with written information on advance directives, specific to the description of the State law. . Upon review of the agency admission packet, it was revealed that the information provided regarding advance directives was a basic description and did not include the applicable State law; this impacted all patients. Hospice Patient Guidebook advance directives information was located within the guidebook on pages 18-19. At the bottom of page 19 it stated, "If you have any questions or would like the appropriate forms for your state regarding Advance Directives, Living Wills, and/or the Durable Power of Attorney please contact the supervisor at your agency or ask your case manager." The booklet did not contain any description specific to the State law. Clinical Record 1: The patient elected the Hospice Benefit on 9/29/22. The agency did not provide advance directive information specific to State law. Clinical Record 2: The patient elected the Hospice Benefit on 11/21/22. The agency did not provide advance directive information specific to State law. Clinical Record 3: The patient elected the Hospice Benefit on 7/6/22. The agency did not provide advance directive information specific to State law. Clinical Record 4: The patient elected the Hospice Benefit on 12/7/22. The agency did not provide advance directive information specific to State law. Clinical Record 5: The patient elected the Hospice Benefit on 12/9/22. The agency did not provide advance directive information specific to State law. Clinical Record 6: The patient elected the Hospice Benefit on 9/7/22. The agency did not provide advance directive information specific to State law. Clinical Record 7: The patient elected the Hospice Benefit on 2/21/22. The agency did not provide advance directive information specific to State law. Clinical Record 8: The patient elected the Hospice Benefit on 7/1/21. The agency did not provide advance directive information specific to State law. Clinical Record 9: The patient elected the Hospice Benefit on 8/14/22. The agency did not provide advance directive information specific to State law. Clinical Record 10: The patient elected the Hospice Benefit on 9/16/21. The agency did not provide advance directive information specific to State law. Clinical Record 11: The patient elected the Hospice Benefit on 5/13/22. The agency did not provide advance directive information specific to State law. In an interview with the Administrator on 12/22/22, it was confirmed that the patients had not been provided with the applicable state law on advanced directives. The Administrator reported the agency thought that providing the state "POLST" (Physician Orders for Live Sustaining Treatment) form, along with the basic definitions provided in the guidebook, met this requirement. Upon review of the agency admission packet, it was revealed that the information provided regarding advanced directives was a basic description and did not contain the applicable state law; this impacted all patients.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 11 (9%) clinical records reviewed revealed the agency did not ensure that the initial bereavement risk assessment was completed as part of the comprehensive assessment. Clinical Record 1: The patient elected the Hospice Benefit on 9/29/22. On the initial comprehensive nursing assessment dated 9/29/22, the Registered Nurse (RN) documented that the bereavement risk assessment was not completed. Neither the Chaplain nor the Social Worker initial assessments included documentation of an initial bereavement risk assessment. In an interview with the Administrator on 12/21/22, it was confirmed that the initial bereavement risk assessment for this patient was not completed or documented.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment relative to the terminal illness and associated conditions. This standard was not met as evidenced by a review of clinical records, interviews and observations. 2 of 11 (18%) clinical records reviewed revealed the agency did not ensure the plan of care specified the care and services required to meet the patients’ needs. Clinical Record 1: The patient elected the Hospice Benefit on 9/29/22. The registered nurse (RN) documented on 9/29/22, in the initial comprehensive assessment clinical note, that the patient fell resulting in a left hip and left femur fracture on 7/16/22. The family reported the patient experienced pain with movement. On 10/4/22 the RN narrative note documented, “Patient crying out with turning. Educated caregiver on non-verbal s/s (signs/symptoms) of pain. Requested patient be medicated for pain.” During the home visit observation on 12/20/22, the patient was observed grimacing and moaning when RN repositioned for wound care. The RN (Staff 8) spoke with caregiver who confirmed that the patient often had pain with repositioning; the caregiver and RN collaborated on pre-medicating the patient prior to wound care. The plan of care, effective from 9/29/22 to current did not include any problems, goals or interventions related to pain. Clinical Record 3: The patient elected the Hospice Benefit on 7/6/22. During the home visit conducted on 12/21/22, the Chaplain (Staff 6) communicated with the family in Spanish. The family member reported that their native language was Spanish, and that the patient was originally from Costa Rica. The plan of care effective from 7/6/22 to current did not address the communication needs or translation service needs of the patient and/or family. In an interview with the Administrator on 12/21/22, it was confirmed that these two plans of care were not individualized and did not include specific care and services required to meet the patients’ needs.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan: A revised plan of care includes information from the patient’s updated comprehensive assessment. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 11 (9%) clinical records reviewed revealed that the agency did not ensure that the care plan was updated to reflect the patient's need for management of constipation. Clinical Record 7: The patient elected the Hospice Benefit on 2/21/22. The registered nurse (RN) documented a PRN (as needed) visit at the patient's daughter's request on 12/15/22 to assess the patient for constipation. The RN documented in the Skilled Nursing Visit Note/Narrative, that following the assessment, a Fleet Enema was administered with good results. The nurse received additional orders from the physician for ongoing constipation management: Senna Plus once daily PRN, Dulcolax suppository PRN every 3 days, and Fleet Enema PRN every 3 days. Review of care plan documentation indicated that on 5/17/22 the problem, goals, and interventions related to constipation had been discontinued and as of the date of review (12/21/22) had not been updated/reinitiated to address the patient’s current symptom of constipation. In an interview with the Administrator on 12/21/22 and after reviewing the documentation, it was confirmed that the care plan for constipation should have been reinstituted.

It is required that nursing care and services are provided by or under the supervision of a Registered Nurse (RN) and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by a review of clinical records, document reviews, interviews and observations. 3 of 3 (100%) clinical records reviewed in which patients had a pressure ulcer, revealed the agency did not ensure that wound measurements were obtained per the agency policy. Policy Number N-11.5: Wound/Ulcer Management stated in relevant part, "Wound/ulcer measurements: at minimum, the wound/ulcer shall be measured using the following criteria: once a week for Stage 3 and Stage 4 pressure ulcers and infected wounds, and once every 2 weeks for Stage 1 and Stage 2 pressure ulcers." Clinical Record 1: The patient elected the Hospice Benefit on 9/29/2022. During the home visit observation conducted on 12/20/2022, the RN provided wound care which included dressing changes to four different wounds. None of the wounds were measured during this visit. Clinical record documentation on the wound care flow sheet detailed the following: right upper buttocks Stage 3 (effective date 9/29/2022), last documented measurement 10/27/2022; right lower buttocks Stage 3 (effective date 9/29/2022), last measurement 10/27/2022; right lateral foot unstageable (effective date 9/29/2022) only documented measurement 11/29/2022; and left lateral heel Stage 2 (effective date 12/6/2022) no measurements documented. Clinical Record 3: The patient elected the Hospice Benefit on 7/6/2022. Clinical record documentation on the wound care flow sheet detailed the following: sacrum/posterior buttocks Stage 4 (effective date 7/6/2022), last documented measurement 11/30/2022. Clinical Record 9: The patient elected the Hospice Benefit on 8/14/2022. Clinical record documentation on the wound care flow sheet detailed the following: Stage 2 pressure ulcer to the buttocks (effective 9/26/2022). The only documented measurement occurred on 9/26/2022. Patient’s date of death was 11/9/2022. In an interview and joint clinical record review with the Administrator on 12/21/2022, it was confirmed that although the documentation for wound care treatments followed the physician orders and the flow sheets had detailed descriptions of the wounds, the policy was not being followed in regard to wound measurements.