Every finding on record at Caring Hospice Services of Ohio, LLC

Observed in Record Review. In 2 out of 4 applicable records, the hospice did not conduct and document wound reassessments and measurements per HCO policy, which states wounds are to be assessed by the RN every visit and measured weekly. Examples: In RRNHV#3 during the 9th benefit period, wound assessments were not documented for 2 nursing visits. Wound measurements were not completed per policy during weeks 1, 3, and 4 of the 9th benefit period. In RRNHV#6 during benefit 2 weeks# 8-11, wound assessments and care were not documented for 4 nursing visits. Wound measurements were not completed per policy during weeks 8, 10, and 11. This was confirmed with the DON.

Observed in Record Review. In 7 out of 7 records, there were plan of care goals that were not measurable. Examples in RRHV#1: Patient's desired nutrition/hydration needs will be met; Patient will maintain optimal mobility Examples in RRHV2: Patient care needs will be safely met; Home environment safety concerns will be resolved. Examples in RRHV#3: Patients emotional and physical needs will be met; Patient's desired nutrition/hydration needs will be met; Patient will remain safe in environment. Examples in RRNHV#1: Patient will feel empowered and supported during his hospice care; Provide patient/family grief support knowing realistic emotions and understanding of patient death; Create a safe, nonjudgmental environment for patient and family; Provide companionship, support and presence as patient continues hospice journey. Examples in RRNHV#2: Patient will remain safe in environment. Example in RRNHV#3: Generic integumentary goal noted for a patient with wounds: maintain current integumentary status. In RRNHV#4: Develop therapeutic relationship; Patient will find forgiveness for past decisions and relationships

Observed in Tracer Visit. In 3 out of 10 records, the plan of care did not include a frequency of the services necessary to meet the patient’s needs. Example: In RRNHV#3, RRNHV#5, and RRNHV#7 wound care orders did not specify a frequency of when the care was to be provided and who would perform the wound care on days hospice did not make a visit. This was confirmed by the DON. Observed in Tracer Visit. In 4 out of 5 applicable records, the plan of care included range orders for oxygen that did not have defined parameters and indications for adjusting and/or changing the settings. Examples: In RRHV#1, RRHV#3, RRNHV#3, there were oxygen orders at 2-4 LPM without defined parameters and indications for adjusting and/or changing the settings. In RRNHV#4, there were oxygen orders at 6-10 LPM without defined parameters and indications for adjusting and/or changing the settings. This was confirmed with the DON.

Observed in Tracer Visit. In 3 out of 3 records, the organization did not maintain a system of communication and integration of the provision of care. Examples: IDG meeting notes for RRHV#1, RRHV#2, and RRHV#3 did not include the integration of the Chaplain and Social Worker visit activity and findings between IDG meetings when applicable. IDG notes only included nursing activity, findings and coordination with the ALF staff. This was confirmed by the DON.

Observed in Tracer Visit. In 1 of 1 observed aide home visit, the hospice aide did not provide services that are ordered by the physician or allowed practitioner in the plan of care. Example: In RRHV#3, the aide care plan indicated a bed bath to be provided at every visit. During the observation with Aide, the Aide informed the Surveyor that the patient receives a shower or bath 3 times per week. The aide reports that on the alternate days she assist with feedings, clean the room, and provide ADLs as needed for that day. This was confirmed with the DON.

Observed in Record Review. Volunteer staff did not provide day-to-day administrative or direct patient care in an amount that equals 5% of the total patient care hours of all paid hospice employees and contract staff. Example: Current year to date average is less than 2%. This was confirmed with the DON.

Observed in Tracer Visit. In 2 out of 10 records, the medication profile in the medical record was inaccurate. Example: In RRHV#1, the medication profile in the medical record listed Oxygen at 2-4 LPM continuous. The patient who resides within an ALF was only using the oxygen PRN. In RRNHV#4, the medication profile in the medical record listed the Oxygen at 6-10 LPM Daily. The DON verified that the frequency was continuous not daily. Both findings were confirmed by the DON.

Observed in Record Review. In 1 out of 2 applicable discharge records, the hospice did not provide the patient’s attending physician with a copy of the hospice discharge summary after the patient revoked or transferred hospice services. Examples: A discharge summary was not sent to the attending physician in RRDC#1 who revoked services. This was confirmed by the Office Manager.

Observed in Individual Tracer. In 4 of 11 patient records reviewed, HV1, HV2, HV3, RR4 during the record review, the surveyor noted the organization had not shown evidence it had conducted an initial bereavement risk assessment that included identification of the risk level such as low, moderate or high for the bereaved. For example, the factors were identified but there was no documentation of a level of risk associated with these factors or the subsequent individualized bereavement plan developed. This was discussed with the Program Director/DON and Director of QAPI.

Observed in Individual Tracer. In 4 of 11 patient records reviewed, HV1, HV2, HV3, RR4 during the record review the surveyor noted 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 multiple records, the goals were not measurable as to how the outcomes were achieved. For example, HV1, the cardiac goal was listed as changes in cardiac status will be identified and managed.; the patient will maintain optimal mobility; the patient care needs will be safely met; HV2, MSS goals stated, patient needs will be met. HV3, the MSS goal stated, patient will be treated with dignity and respect; Nursing goal was stated patient's desired nutrition/hydration needs will be met. This was discussed with the Program Director /Director of Nursing.

Observed in Record Review. In 7 of 11 patient records reviewed, RR1, RR2, RR3, RR4, RR5 RR6, RR7 during record review, the surveyor noted that oxygen was ordered 2-4 L/NC either continuous or PRN for shortness of breath. There was no indications or parameters in the order, regarding the flow level/rate adjustment based upon either pulse oximeter results or symptoms of mild, moderate or severe shortness of breath. This was discussed and validated with the Director of Nursing.

Observed in Individual Tracer. In 4 of 11 patient records reviewed, HV1, HV2, HV3, RR4, during the home visit and record review, the organization had not shown evidence it had revised the plan of care based on information from updates to the patient’s comprehensive assessment and address the patient’s progress toward goals and outcomes. For example, the interdisciplinary group had not documented progress toward goals in the revised plan of care. For HV/RR1, there was no documentation of progress toward goals, the chaplain goal for spiritual coping was established upon admission February 2022, stated patient/caregiver will express feelings and questions openly and will identify spiritual needs for end of life. Interventions included assess spiritual needs and life review, however, there was no documentation of the current status of achieving this goal. HV2/RR2, the MSS goal stated: needs will be met , and interventions included companionship visits initiated dated December 2020, however there was no evidence of progress toward achieving the goal which had been a continued problem/goal in current benefit period. HV1, HV3 the same Pre-Bereavement problem and interventions were identified as anticipatory grief with the same goals as patient/family will discuss bereavement needs established upon admission in February 2022 and May 2022, however there was no documentation of status or progress toward achieving these goals. This was discussed with the Program Director/DON.

Observed in Individual Tracer. In 1 of 3 home visits conducted, HV1, during the home visit the surveyor noted the organization failed to use standard precautions, including the use of personal protective equipment, to reduce the risk of infection. For example, Personal Protective Equipment, consistent with exposure risk, was not utilized correctly as evidenced by the improper use of the face mask by the nurse. During the entire home visit, the nurse's face mask was not place over the nose as required. This was not compliant with the organization's Standards Precaution Policy and validated by the Program Director/DON. Observed in Individual Tracer. In 3 of 3 home visits conducted, HV1, HV2, HV3 during the home visit the surveyor noted the organization failed to demonstrate it used standard precautions, including the use of personal protective equipment, to reduce the risk of infection. For example, HV1, the nurse used the patient's bar soap as she did not have hand sanitizer or cleanser available in her bag; did not conduct hand hygiene or glove change prior to direct contact with the patient and after touching multiple inanimate objects; did not change gloves or conduct hand hygiene prior to accessing her nurse bag. HV2, the nurse used the facility soap and did not consistently use hand hygiene with glove changes. HV3, the aide failed to change gloves and/or conduct hand hygiene prior to direct contact with the patient, after touching multiple inanimate objects and supplies in the facility shower room. This was not compliant with the organization's Hand Hygiene Policy and validated by the Director of Nursing. Observed in Individual Tracer. In 1 of 3 home visits conducted, HV3, during the home visit the surveyor noted the organization had not shown evidence it had implemented the acceptable standards of practice of infections and communicable diseases when cleaning equipment. For example, HV3 the nurse was noted to use disinfectant wipes which she had purchased to clean her equipment. The organization had provided equipment PDI disinfectant wipes and barriers for equipment cleaning which were available to her. This was not compliant with the organization's Equipment Cleaning Policy and validated by the Program Director/DON and Director of QAPI. Observed in Individual Tracer. In 1 of 3 home visits conducted, HV1 during the home visit, the surveyor noted the organization failed to implement infection prevention and control activities when doing the following: Cleaning and performing disinfection of medical supplies and devices. For example, the nurse failed to clean her stethoscope, thermometer and blood pressure machine after patient use and prior to placing the items into her bag. This was not compliant with the organization's Bag Technique Policy and validated by the Director of Nursing.

Observed in Infection Control System Tracer. During the Infection Control Session with the Program Director/Director of Nursing and the Administrative Assistant, the organization's written Infection Prevention and Control Plan goals failed to set goals for limiting the spread of infections associated with procedures. For example, the plan included the language to limit the spread of infections associated with procedures, however there was no measurable goal/outcome defined. This was discussed with and validated by the Program Director/DON. Observed in Infection Control System Tracer. During the Infection Control Session, the surveyor noted the organization's written Infection Prevention and Control Plan goals regarding limiting the spread of infections associated with the use of medical equipment, devices, and supplies were not measurable. The Infection Control Plan included the statement that the organization goals included limiting the spread of infection associated with use of equipment, devices and supplies, however, there was no measurable goal identified. This was discussed and validated by the Program Director/DON.

Observed in Individual Tracer. In 2 of 3 home visits conducted, HV1, HV2 during the home visit and the subsequent record review the surveyor noted the registered nurse had not prepared a written patient care instructions for the hospice aide. For example HV1, HV2 the aide care plan/assignment sheet's Safety section was incomplete. The safety precautions regarding bed in low position and oxygen safety, review care with facility nurse, maintained a safe, clean environment were left blank. However, HV1, the patient with diagnosis of senile dementia, had two recent falls, was on continuous oxygen and resided at a facility. These sections were completed in previous assignment sheets. HV2, the patient was on continuous oxygen and resided at a facility, however the sections were not completed. Secondly, the Activity section of the assignment sheet was incomplete. In HV/RR1, the patient was bedbound but there were no instructions regarding repositioning the patient; HV2 the patient was non-ambulatory, obese, required maximum assist and unable to reposition herself in bed, however the assignment sheets did not include repositioning the patient. This was discussed and validated by the DON.

Observed in Individual Tracer. In 1 of 1 home visit with hospice aide, HV3, during the home visit the aide failed to provide services as ordered in the plan of care. For example, the surveyor noted the aide failed to inquire about the patient's pain, offer oral care or apply lotion to the patient's skin as ordered/instructed on the aide assignment sheet. In addition, the aide was observed to perform incorrect and incomplete peri-care, as it was noted she used a quick, back and forth cleaning motion that was not thorough, rather than a front to back procedure. This was not compliant with the organization's policies and discussed with the Program Director/DON.

Observed in Individual Tracer. In 1 of 3 home visits conducted, HV1, during the home visit, the surveyor noted the patient record did not show evidence it contained the following clinical information: an accurate list of medications, including dose, strength, frequency, route, date and time of administration for prescription and nonprescription medications, herbal products, and home remedies that relate to the patient's care, treatment, or services. For example, the patient was recently diagnosed with aspiration Pneumonia and Levequin 750 mg 1 tablet po for 5 days was ordered four days prior to survey date. The antibiotic was not listed in the medication profile /record presented to the surveyor. In addition, several medications, including Naproxen, Albuterol, Budesonide had been discontinued, but no date was indicated on the medication profile. Oxygen was listed as continuous 2-4 L/NC on the profile for shortness of breath but did not include the same parameters listed on the facility MAR: apply oxygen when 02 saturation is less than 90%. This was not compliant with the organization's medication management policy related to medication reconciliation and validated by the Director of Nursing.

Observed in Individual Tracer. In 1 of 3 home visits conducted, HV1, during the home visit, the surveyor noted the organization failed to demonstrate it implemented its infection prevention and control activities, to minimize, reduce, or eliminate the risk of infection. For example, the nurse placed her bag on the sink counter without a barrier, failed to close her nurse bag during the visit; accessed the bag multiple times without conducting hand hygiene or glove changes and returned her equipment to the bag without cleaning it. This was not compliant with the organization's Bag Policy and validated by the Director of Nursing.