Every finding on record at Carilion Medical Center

Observed in Tracer Activities. The organization did not have a policy that addresses/defines the assessment of bereavement needs. There was nothing defining the services that would be provided based on the assessment. In 3 of 3 bereavement records reviewed, there were no documented initial bereavement risk assessments that outlined the patients' bereavement needs. The hospice manager and the bereavement coordinator were present during the review and observed the same. Observed in Record Review. In 16 of 16 patient records reviewed, it was noted that a pre death bereavement assessment was not conducted as stated in agency policy entitled Bereavement Assessment Process. For example, during the initial nursing assessment a Bereavement Risk Assessment/Complications and Risk Factors form listing triggers that would necessitate a face to face bereavement assessment by the Bereavement Coordinator was completed. However, even in records that indicated triggers were identified there was no bereavement assessment completed by the Bereavement Coordinator. For example, in record review #4, a pediatric hospice patient there was no formal bereavement assessment completed. In another record review for hospice home visit #4 there were several triggers identified including lack of social support, financial concerns and job-related stress however there was no formal bereavement assessment completed. In another example, in hospice record review #3, multiple triggers were identified including loss of other parent in the last six months and multiple losses of family members in the past two years however there was no formal bereavement assessment done. In all other records there was documentation in the initial IDT notes that bereavement was assessed as low or medium but there was no documentation of a numerical score or any parameters to define grief levels. In another example in hospice record review #8 there was documentation in the record that the patient had found his wife following a suicide 29 years ago and had suffered anxiety and depression since then. There was no check mark to indicate that a face to face assessment should occur although mental health concerns were listed as a particular trigger. In another example, in record review #7 documentation in the IDT note indicated that the wife was at a moderate bereavement risk due to the loss of her brother six months ago however SN did not document this a trigger and there was no documentation that a face to face assessment was indicated. This was discussed with hospice leadership.

Observed in Record Review. In 16 of 16 patient records reviewed, it was noted that the hospice organization was using a three page standing orders document for all patients that were not consistent with assessed clinical needs. For example, the standing orders included 18 different symptoms with multiple corresponding medications, treatments as well as care of infusion devices, wound care, urinary retention and caregiver crisis. Agency policy entitled Provider Orders stated that the provider can exclude any components of the standing orders however there were none that were excluded. This was discussed with hospice leaders.

Observed in Record Review. In 4 of 16 patient records reviewed, it was noted that the stated goals on the plan of care were not measurable. For example, in record review for hospice home visit #1 one goal was stated as pt/cg will verbalize how to care for cardiac disease process. In the same record there was no goals stated for oxygen education. In record review #4 another example of a goal that was not measurable or timed was stated as Caregiver distress will be decreased and be able to express grief. In another example, in record review #9 a goal for Coping Issues was stated as Pt/Caregiver will demonstrate healthy attributes of effective coping by the end of the certification period. In record review #8 the following goal was stated for Liver Disease, pt. will verbalize understanding of and strategies to manage liver disease by verbalizing appropriate diet and med compliance. The goal was not timed. This was discussed with the Hospice Clinical Team Leader assisting with record reviews.

Observed in Record Review. In 5 of 16 patient records reviewed, it was noted that there was no frequency for volunteer services involving the visitation of the hospice choir to patient homes. This was noted in hospice record reviews for home visit #2 and #3. In record review #2, there were no orders for frequency on the hospice plan of care for music therapy visits. In record review for hospice home visit #4 and hospice record review #1 it was noted that the plan of care did not contain planned visit frequencies for MSW and the monthly visits were entered on an individual visit by visit basis. This was reviewed with hospice leadership.

Observed in Record Review. In 1 of 4 home visits conducted, an RN was observed performing a point of care PT/INR during hospice home visit #2. There were no orders on the plan of care for this treatment. This was confirmed by Hospice director and Hospice Clinical Team Leader. Observed in Record Review. In 6 of 16 patient records reviewed, it was noted in record review for hospice home visit #3 that the current order for Gabapentin was not what the patient was taking although the documentation indicated that the staff was aware that the patient was taking a different dosage. Gabapentin 200 mg BID was ordered on the plan of care but the patient had told the nurse that she was taking Gabapentin 300 mg BID. In another example, in record review for hospice home visit #2 there were no orders to discontinue multiple oral medications as well as two types of insulin. The nurse stated that the patient had chosen to stop taking the medications and insulin three weeks ago. Additionally for this patient there was no location for Voltaren gel to be applied and was stated as apply to affected areas and no location for Nystatin apply externally was the only indication. Additionally, there was no order to discontinue Levaquin which the patient refused to take after multiple doses caused her nausea. In another example, in record review for hospice home visit #4, Dexamethasone was not stated as a PRN medication however it was not being given daily as stated. In another example, in review of record for hospice home visit #1, Oxycodone was ordered for pain with no indication for pain level. In record reviews for hospice home visits #1, 2, 3, and 4 all oxygen orders were stated in ranges from 3-5 L to 4-10 L with no indication for titration. In record review for hospice home visit #4 there were no orders to discontinue Humira and aspirin which were not given after the patient had a nose bleed and an ear bleed. In hospice record review #4 it was noted that there were no orders for new medication Trazadone which was added to the medication list and the standing order used to insert a foley catheter lacked the balloon size. In record review #8 there were no orders for how often the patient was to monitor blood glucose and no parameters for holding insulin. The order was for 3 units of Humulog Insulin in the morning, at noon, at dinner and Lantus Insulin at HS. Additionally for this patient there was an intervention to apply heat for pain no longer than 20 minutes but no location was stated and the patient had multiple areas of pain including shoulder, leg and scrotum. This was discussed with the Hospice Clinical Team Leader assisting with record reviews.

Observed in Record Review. In 3 of 16 patient records reviewed, it was noted that the hospice plan of care was not updated. For example, in review of record for hospice home visit #1 a problem entitled, hospice orientation entered by the MSW had not been met and the patient had been on services for over 1 year. In another example, in record review #10 it was noted that a goal related to teaching enteral feeding was met and achieved one month after start of care however, the plan of care was not updated and this remained an open issue 7 months later. In another example, in record review #9, the plan of care indicated that the patient had Enteral Feedings with stated goals that referenced diarrhea and pain however, the patient was not receiving enteral nutrition therapy and had not been revised or corrected for three months. This was discussed with the Hospice Clinical Team Leader.

Observed in Record Review. In 1 of 16 patient records reviewed, it was noted that in record review for hospice visit #1 the plan of care stated that the hospice volunteer was to visit at least 3 times per month however in review of the past three months this frequency was not met. This was confirmed by the Hospice Clinical Team Leader.

Observed in Record Review. In 1 of 16 patient records reviewed, it was noted that the physician had not been notified when a change in condition occurred. For example, in record review for hospice home visit #2 the patient complained of nausea and vomiting from new course of antibiotic Levaquin. Documentation also indicated that the patient was not eating so she stopped taking her insulin. There was no documentation that the physician had been notified of these changes. This was discussed with and confirmed by hospice leadership.

Observed in Data Session. During the data session, the surveyor noted that the organization's quality assessment and performance improvement program (QAPI) did not involve all of the services provided by the organization. The program did not address contracted services (DME, pharmacy, skilled nursing facilities), volunteer services, or bereavement services. This finding was discussed with hospice leadership.

Observed in Record Review. In 2 of 16 patient records reviewed, it was noted that surveillance activities were not implemented. For example, in review of record for hospice home visit #3 the patient had a positive stool culture for C-diff. There was no infection report documented. In another example, in hospice record review for hospice home visit #2 the patient was treated for an upper respiratory infection and no infection report was documented. This was reviewed and confirmed by hospice leadership. Observed in Patient Home. In 1 of 4 patient records reviewed, it was noted in hospice visit #3 that following patient use, the nurse cleansed her equipment and placed them back onto the same barrier to dry. This was observed by the Hospice Clinical Team Leader present during the visit.

Observed in Tracer Activities. In 3 of 3 bereavement records reviewed, the organization had not developed a bereavement plan of care that specified the type of bereavement services to be offered and the frequency of service delivery. The bereavement coordinator stated that phone calls, mailings and visits may be made. The plan of care did not have the type of services, the frequency or service or any measurable goals. This finding was discussed with the bereavement coordinator and the hospice manager.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by Condition Level Deficiency at 418.56, 418.58 and 418.100. This was discussed at length with hospice leadership and in daily briefings.

Observed in Record Review. In 2 of 4 patient records reviewed, it was noted that for patients who received visits from the hospice volunteer choir there was no documentation of the visits to include date, time, attendees or patient response. This was discussed with hospice leadership. This was noted in record reviews for hospice visits #2 and #3.

Observed in Record Review. In 2 of 2 patient records reviewed, that were revocations it was noted that the hospice discharge summary was not sent to the receiving facility. For example, in hospice discharged record reviews #1 and #2, both patient's revoked hospice care and were sent to the hospital. This was discussed with and confirmed by hospice leadership during record review.

Observed in Patient Home. In 2 of 4 home visits conducted, unsecured oxygen tanks were noted in hospice home visits #1, where an E tank was leaning against the wall and in hospice home visit #4 two tanks were unsecured and standing upright. No education was provided by staff at the time of visits. This was observed by the Hospice Clinical Team Leader present on the visits.