Every finding on record at Care Givers Hospice, Inc.

Observed in Tracer Activities. The hospice surveyor noted that the organization developed an all hazards vulnerability assessment but did not complete the mitigation activities. This was reviewed and validated with the Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, the hospice surveyor observed in HOSRRHV #1 where the Revocation was signed by the patient's daughter on admission. This was reviewed and validated with the Administrator. Observed in Record Review. In 1 of 14 patient records reviewed, the hospice surveyor observed in HOSRRHV #1 where the patient's family requested a notice of non-covered items at admission; however, the HCO did not provide until 6 days later. This was reviewed and validated with the Administrator.

Observed in Patient Home. In 1 of 3 patient records reviewed, the hospice surveyor observed that the organization failed to provide patient education and training based on the patient's needs. In HOSRRHV #1 the patient had orders for Metoprolol 25 mg one tablet daily and Losartan 10 mg tablet daily with the parameters to hold if SPB is <100 or HR <60 per the medication orders. The pill bottle in the home that the granddaughter uses did not include the parameters and she stated she was no aware of the parameters. This was reviewed and validated with the Administrator.

Observed in Record Review. In 4 of 14 patient records reviewed, the organization failed to individualize the patient's care. In HOSRRHV #3 the patient's pain goal was assessed to be 4/10 or less but the plan of care stated a pain goal of 3/10 or less. The organization's Pain Assessment Policy 2-031 stated that the patient's pain goal will be assessed and entered into the plan of care. For this patient the MSW care plan stated, provide comfort and dignity and emotional well being. The MSW goal is not measurable. In HOSRRHV #2 the MSW goal stated, Patient adjustment to terminal diagnosis and anticipatory grief related to decline. The MSW goal was not measurable. In HOSRRNHV #3 the MSW plan of care stated Patient to remain free of signs or symptoms of psychosocial distress and the Chaplain care plan stated, Chaplain to facilitate a spiritual environment to begin the bereavement process. The MSW and Chaplain goals were not measurable. In HOSRRNHV #4 the MSW plan of care stated, Patient and family will verbalize understanding of hospice services and receive emotional support. The MSW plan of care was not measurable. This was reviewed and validated with the Administrator.

Observed in Record Review. In 2 of 14 patient records reviewed, the hospice surveyor observed that the Hospice plan of care was missing interventions. In HOSRRHV #1 the chaplain failed to include interventions in the Plan of Care. Additionally, this patient was assessed to be an aspiration risk and the RN did not include a care plan in the plan of care addressing this precaution. During the home visit the patient's granddaughter asked if a podiatrist could come out to cut the patient's toenails as they were fungal, thick and curling into the patient's skin and there was no care plan addressing this in the Plan of Care. In HOSRRHV #3 the patient was taking Hydroxyurea HCL daily for sickle cell disease, there was no care plan addressing this diagnosis and the pain the patient was eliciting during the visit. This was reviewed and validated with the Administrator.

Observed in Record Review. In 9 of 14 patient records reviewed, the hospice surveyor observed that there were duplicate medications for the same indication. In HOSRRHV #1 the patient had orders for Morphine Sulfate 20 mg orally every 4 hours as needed for mild pain or shortness of breath and there was also an order for Acetaminophen Rectal Suppository 650 mg one every 6 hours and as needed for mild pain or fever >100.1. It was not clear when to take one medication over the other for mild pain. In HOSRRHV #2 the patient had orders for Acetaminophen Rectal Suppository 650 mg 1 every 6 hours and as needed for mild pain or fever >100.1 and she also had orders for Norco 5mg-325 mg one tablet every 6 hours and as needed for pain. It was not clear when the patient should take one medication over the other for pain. In HOSRRHV #3 the patient had an order for Acetaminophen Rectal Suppository 650 mg one every 6 hours and as needed for mild pain and fever >100.1 and he also had an order for Tramadol 25 mg one tablet every day and as needed for mild pain, and Morphine Sulfate 20 mg oral every 4 hours and as needed for mild pain and Shortness of breath. It was not clear which one the patient should take for mild pain. In HOSRRNHV #2 the patient had orders for both Ibuprofen 600mg tablets 1 tablet every 6 hours and as needed for moderate pain, and Tramadol HCL 50 mg one tablet every 6 hours for moderate pain. It is not clear which one the patient should take for moderate pain. In HOSRRNHV #6 the patient had orders for Tramadol 50 mg one tablet every 6 hours and as needed for moderate pain and Norco 5-325 mg 1 tablet every 6 ours as needed for moderate pain. It is not clear which one the patient should take for moderate pain. This patient also had orders for Acetaminophen 500 mg 2 tablets every 12 hours as needed for mild pain and Acetaminophen 650 mg suppository one every 6 hours and as needed for mild pain. It is not clear which one the patient should take for mild pain. In HOSRRNHV #4 the patient had Morphine Sulfate 20 mg oral solution every four as needed for severe pain and Oxycontin 5 mg one tablet every 6 hours for severe pain. It is not clear which one to take for severe pain. In HOSRRNHV #5 the patient was on Tramadol 50 mg one every 12 hours for pain and Acetaminophen Suppository 650 mg one every 6 hours as needed for pain. It is not clear which one the patient should take for pain. In HOSRRDC #1 the patient was on Acetaminophen 325 mg two tablets every 6 hours for pain and also Hydrocodone Acetaminophen 5-325 mg 1 tablet every 6 hours and as needed for pain. It is not clear which medication should be taken for pain. In HOSRRDC#2 the patient was on Morphine Sulfate 20mg/ml sublingual every 4 hours as needed for pain and shortness of breath and Tylenol 325 mg 2 tablets every 6 hours as needed for pain. It is not clear which medication should be taken for pain. This was reviewed and validated with the Administrator.

Observed in Patient Home. In 1 of 1 home visits conducted, where the home health aide provided personal care the hospice surveyor observed that she used the same pair of gloves and water to clean the dirty to the clean areas e.g. perineal area. the aide washed the vaginal area then turned the patient and used the same water and gloves to clean her bottom and back. She then dressed the patient and began making the bed with the same gloves. The aide also failed to perform hand hygiene between her glove changes per the Hand Hygiene policy. This was reviewed and validated with the Administrator.

Observed in Tracer Activities. In 2 of 9 HR files reviewed, the hospice surveyor observed there was no evidence of competence assessment for the Medical director in the last 3 years and the Alternate Medical Director for 2025. This was reviewed and validated with the HR assistant.

Observed in Record Review. In 7 of 14 patient records reviewed, the hospice surveyor observed that the aide assignment did not include specific precautions. In HOSRRHV #3 the patient was on an Eliquis and there were no bleeding precautions in the home health aide assignment. In HOSRRNHV #1 the patient was on Oxygen 3 liters and there were no instructions if the aide could remove the oxygen during bathing. Additionally, this patient was a fall risk and this was not included on the aide assignment as a precaution. In HOSRRNHV #2 the patient was on Oxygen 2 liters and there were no instructions as to what the aide should do when bathing the patient. In HOSRRNHV #3 the patient was on Aspirin 81 mg daily and there was no bleeding precautions in the aide assignment. This patient was also on Oxygen 2-5 liters and the range was in the aide assignment with no instructions what to do with the oxygen during bathing. In HOSRRNHV #6 the patient was on Xarelto daily and the home health assignment did not include bleeding precautions. This patient was also on oxygen 2-5 liters and there were no instructions on what the aide should do with the oxygen during bathing. In HOSRRHV #7 the patient was on 4 liters of oxygen and there were no instructions for the home health aide as to what to do with the oxygen when bathing the patient. In HOSRRNHV #5 the patient was on Oxygen 2-5 liters and the aide care plan did not specify if the oxygen could be removed with bathing. This was reviewed and validated with the Administrator.

Observed in Patient Home. In 1 of 1 home visits conducted, where the home health aide was present and provided personal care the surveyor observed the aide failed to provide care as instructed in the aide assignment. In HOSRRHV #3 the aide assignment stated that the aide would provide oral care and nail care with each visit and neither were offered or provided. She applied deodorant but this was selected on the aide assignment. This was reviewed and validated with the Administrator.

Observed in Tracer Activities. In 5 of 9 HR files reviewed, the hospice surveyor observed that the NP, Alternate Medical Director, RN Bereavement Coordinator, and Volunteer Coordinator did not have an initial competency done as part of their orientation. This was reviewed and validated with the HR Assistant.

Observed in Patient Home. In 1 of 2 home visits conducted, where medication reconciliation was performed the hospice surveyor observed that the medication list was discovered to be inaccurate. The hospice surveyor observed in HOSRRHV #3 that the medication list from the organization was missing MiraLAX 17 gm in 8 ounces of fluid daily if no BM for 3 days. Dulcolax suppository 10 gm daily if no BM after the MiraLAX, Naloxone HCL 4 mg spray into each nostril and repeat 2-3 times as needed. Additionally, the Acetaminophen stated 650 mg 2 tablets every 6 hours for pain and as needed but the bottle showed that it was 325mg tablets 2 tablets every 6 hours and as needed for pain. This was reviewed and validated with the Administrator

Observed in Record Review. In 1 of 2 patient records reviewed, where the patient was discharged to another hospice the surveyor observed that the organization failed to provide a discharge summary to the receiving organization. In HOSRRDC #2 the patient was transferred to another agency and there was no proof that the discharge summary was sent. The organization failed to follow their Transfer Information Policy 2.070.1. This was reviewed and validated by the Administrator.

Observed in Record Review. In 1 of 3 home visits conducted, the patient record was not complete, promptly and accurately documented, readily accessible, and systematically organized to facilitate retrieval. During HV#2, it was found by the surveyor and RN present at the visit that the medication list used by the SNF did not match the Hospice POC. For example, the patient was not on Seroquel, Acephen prn, DuoNeb prn, Lorazepam prn, Zofran prn, Artificial tears prn, Robitussin prn which were all on the hospice POC. The patient was still on Zinc Sulfate daily which the hospice med profile indicated was for 30 days only, ending in 2022. The Vitamin D3 was 5000 units in the SNF chart; 125 mcg in the Hospice POC. This was discussed with the RN during the visit and the DPCS.

Observed in Record Review. In 2 of 11 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for RR#2, the patient was admitted with pain management needs, utilizing Morphine prn. The goal for pain management was not individualized/appropriate to the patient in that the target date for the patient/caregiver to verbalize non-verbal signs of pain was the last day of the 90 day benefit period. In the chart for RR#7 the goals were not appropriate to the patient. Family/PCG will verbalize understanding of non-verbal signs of pain with the target date the last day of the benefit period for this cancer patient with potential pain management issues. This was discussed with the DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: a detailed statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs. In the chart for HV#1, the POC was not updated to include the monthly Social Work visits after the initial eval was performed. This was discussed with the DPCS.

Observed in Record Review. In 3 of 11 patient records reviewed, the plan of care (POC) did not includes all services needed for the palliation and management of the terminal illness and related conditions, including the following: Medications and treatment necessary to meet the patient’s needs. In the chart for HV#2, the hospice POC included Prednisone daily x 5 days, begun more than 1 year prior to survey as a current medication. Zinc ordered daily x 30 days, more than one year prior to survey remained on the active medication list. The medication list/POC was not updated with this change. Additionally, Ensure and Ensure clear were on the list of supplies, however the POC did not address frequency of administration/use. In the chart for RR#2, the RN noted upon admission that the patient had a PICC line present which was not in use. The POC did not include any interventions related to the PICC line care/maintenance. In the chart for RR#3, the plan of care was not updated with Ben-Gay, documented as in use by an LVN during a routine visit.This was discussed with the DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization had not provided the patient with care, treatment, or services according to the patient's individualized plan of care. In the chart for HV#3, in the first full week of the current benefit period, the aide did not follow the ordered frequency of three visits. Only two visits were made with no indication why the third visit had not been provided.

Observed in Data Session. The quality assessment and performance improvement program did not demonstrate improvement in the indicators related to improved palliative outcomes and hospice services. While the organization had robust data collection processes, the organization had no current performance improvement project's focused on improved palliative outcomes as discussed with the DPCS. The most recent project was related to missed visits, not improved outcomes.

Observed in Record Review. In 3 of 11 patient records reviewed, a registered nurse had not prepared complete written patient care instructions for the hospice aide. During review of the charts for HV#1, RR#2 and RR#4 it was confirmed that the aide does take vital signs as directed on the hospice plan of care, however there were no parameters included outside of which the aide was to report to the RN. This was discussed with the DPCS.

Observed in HR File Review. In 3 of 8 HR files reviewed, for clinicians who make direct patient visits, the organization's education and training did not comply with law and regulation. The organization only provided annual OSHA infection control training to Nurses and Aides, but not to all clinicians who could be exposed due to actual or potential patient visits in person such as the Medical Director, Chaplain, Social Worker as discussed with the DPCS.

Observed in Record Review. In 4 of 11 patient records reviewed, the patient record did not contain the following clinical information: Any medications administered, including dose. In the chart for RR#2, the admission nurse documented RN administered Morphine as ordered. In the chart for RR#5, there was incomplete documentation of wound care provided, Wound care to coccyx had done as ordered. In the chart for RR#6, there was incomplete documentation of the wound care provided, Wound care provided per orders. on multiple SN visits. Multiple medications administered to patient at the last RN reassessment visit prior to the patient's death; most missing dosage and/or route of administration. In the chart for RR#8, the staff was no completely documenting wound care. This was discussed with the DPCS.