Every finding on record at Caring Shield Hospice,Inc.

Observed in Record Review. In 1 of 5 patient records reviewed, The Hospice Surveyor noted goals had been not specific to the patient, measurable and without an appropriate time frame. For example, in RRHV #1 the patient goals had been Respiratory status will remain in a comfortable level, Pt/Family/PCG will verbalize having urinary elimination needs met at an acceptable level and Use energy conservation techniques. This was validated with the CEO present during the survey.

Observed in Record Review. In 3 of 5 patient records reviewed, the Hospice Surveyor noted patient identified issues had not been added to the ongoing Plan of Care (POC). For example, in RRHV #1 Pain had not been on the POC and this was an ongoing issue for the patient with new medications added 3 weeks ago. RRNHV #4 the POC had been missing patient identified issues related to: Anxiety, Falls, Pain, and Respiratory. RRNHV #5 the POC had been missing Pain and Falls. Of note, the IDG documentation had reflected discussion of the issues, but these had not been established on the plan of care with interventions and goals. This was validated with the CEO present during the Survey.

Observed in Emergency Management Session. During reivew of the organization emergency/disaster plan for 2024 it was noted although in policy mitigation and preparedness are defined, there were no mitigation and preparedness activities or strategies documented to lessen the impact of a natural or man-made disaster. This was discussed with the CEO.

Observed in Emergency Management Session. The emergency operation plan reviewed for 2024 did not describe the patient population being served or the type of services it will provide during an emergency. This was discussed with the CEO.

Observed in Emergency Management Session. During review of the organization 2024 emergency operation plan it was noted lack of the method or who to contact if on-duty staff or patients are unable to be contacted. This was reviewed by the CEO.

Observed in Emergency Management Session. During review of the organization emergency operation plans it was noted lack of an emergency disaster drill documented in 2022. This was discussed with the CEO.

Observed in Record Review. In 2 of 2 patient records reviewed, During D/C RR#1, it was noted the patient was discharged with an extended prognosis. There was lack of documentation of a signed notice of non Medicare coverage (NOMNC) in the medical record. D/C RR#2 it was noted a signed NOMNC in the record with the same date as the discharge date. This was discussed with the CEO and DPCS.

Observed in Record Review. In 1 of 10 patient records reviewed, During HV#2 record review it was noted lack of documentation of an initial social worker visit within 5 days after the election of hospice. It was documented on the RN initial assessment and MSW was needed. This was discussed with the DPCS.

Observed in Record Review. In 10 of 10 patient records reviewed, During review of HV#1-3 and RR#1-7 it was noted goals were not measurable and not individualized. For example: multiple records had the same goals: for anxiety goal: Will minimize episodes of anxiety and or agitation. For pain the following goal was reviewed on multiple records: Patient states satisfactory comfort level is achieved within 1 week. Pain will be brought down to a comfortable level. Multiple records had the same goals for GI issues: Facilitate optimum bowel movement Pt/Family/PCG will verbalize having elimination needs met at an acceptable level. Nausea and or vomiting will be maintained at a comfortable level. Multiple records with goals for urinary deficits were the same: Pt/Family/PCG will verbalize having urinary elimination needs met at an acceptable level. Weakness goals on multiple records was documented: Use energy conservation techniques. For sleep issues the following goal was written for multiple patients: Promote optimal rest status for Pt/Family/PCG. Respiratory status will remain in a comfortable level. During RR#4 and 5, the POC lacked goals for the MSW. This was discussed with the DPCS and CEO.

Observed in Record Review. In 10 of 10 patient records reviewed, During HV#1-3 record review and RR 1-7 it was noted the frequencies of visits for the SN, MSW and SC included PRN visits without the documentation of the reason for the visits or lack of the number of PRN visits for the MSW and SC. Examples of frequency of visits: MSW: 1 One-time then PRN, MSW 1x then 1 PRN, SC: 1 One-time then PRN, SN: 1 per Week +3 PRN Visits.

Observed in Record Review. In 3 of 10 patient records reviewed, During RR#2 it was noted the physician order for wound care daily did not include who would perform the procedure since the SN visits were not daily. During RR#5 it was noted the end of March 2024 the SN was documenting wound care on a stage 2 pressure ulcer on the left buttock without a physician order in the patient medical record. During RR#5 it was noted the end of April 2024, an order for daily wound care to a skin tear on the left lower arm. The order lacked who would provide care daily since the patient was not visited daily by the SN. During RR#7 it was noted multiple pressure ulcer wound care orders were to be provided daily. The order did not indicate who would provide the wound care daily as the patient was not visited daily by the SN. This was discussed with the DPCS and CEO.

Observed in Record Review. In 6 of 10 patient records reviewed, During HV#1 and HV#2 record review it was noted on the POC the following gastrointestinal (GI) issues identified with interventions established that were not assessed as deficits during the initial RN assessments the end of May 2024. The deficits on the POC were Potential for constipation, Potential for diarrhea, Potential for nausea and or vomiting. In addition for HV#1 record the fall risk score on the RN initial assessment was rated as high risk. Although there is documentation on the POC under the ADL section to remove throw rugs, assist with ambulation, the specific findings from the risk assessment scoring is not included on the POC. They were hx of falls, intermittent confusion, gait disturbance, unable to follow directions and use of medications and dx leading to an increased risk score. HV#1 record review the end of May 2024 there was an order for thickened liquids added to the POC under the nutritional deficits. The interventions lacked instruction to the family on aspiration precautions. During RR#4 and 5 it was noted lack of interventions for the MSW on the POC. During RR#2 and RR# it was noted orders for oxygen 2-5L/min via NC PRN. The orders lacked the parameters to titrate the different liter flows. During RR#3 it was noted the POC was not updated to include interventions related to the respiratory infection and antibiotics ordered. In addition in RR#2 it was noted the patient developed skin lesions on his head was not added to the POC to include to interventions related to the lesions. This was discussed with the DPCS.

Observed in Data Tracer. During review of the QAPI program data for 2022, 2023 and 2024 to date, there was lack of documentation that reflects the complexity of the organization. This included lack of assessment and monitoring of services furnished under contract, significant medication errors, potential significant medication reactions, patient/family perception of care and a comprehensive infection control plan. This was discussed with the DPCS and CEO.

Observed in Data Session. During review of the QAPI data from 2022, 2023 and 2024 to data there is lack of data on patient/family perception of care. The reports state there is insufficient data to compare to state and national averages. The organization collected data via phone calls though a contracted service but did not review or analysis this information during QAPI meetings. This was discussed with the CEO.

Observed in Data Session. During reivew of the QAPI plan and data collection it was noted lack of documentation in the plan of the prevalence and severity of problems in its high-volume, high-risk, and problem-prone areas. The QAPI meetings reported data gathered from the EMR that did not include an in-depth analysis of issues in its high-volume, high-risk and problem prone patient care areas. This was discussed with the CEO.

Observed in Data Session. During reivew of the QAPI program and data for 2022 and 2023 it was noted there was lack of documentation that the program was evaluated annually. The data collected was the same each year. This was reviewed with the CEO.

Observed in Infection Control System Tracer. During review of the 2022-2024 infection control it was noted the infection control program and plan documentation was the same for each year with the only change documented was the date. The date changes reviewed were accomplished by using white out that was visible for each year. The plan did not take into account the presence of infectious diseases present in 2022. Prioritized risks were not identified in the plans reviewed and goals were written as limiting spread of infections. This was reviewed with the CEO and DPCS.

Observed in Patient Home. In 3 of 3 home visits conducted, During HV#1 it was noted the SN after donning gloves to clean the equipment used during the visit and after removing the gloves, placed the used gloves in her nursing bag. During HV#2 it was noted the SN went into her bag without disinfecting her hands after touching the patient environment. During HV#3 it was noted the CHHA entered her bag without disinfecting her hands after touching the patient's environment. This was discussed with the DPCS. Observed in Individual Tracer. In 3 of 3 home visits conducted, During HV#1 it was noted the SN placed her bag on a barrier and on the floor. In the room with the patient and the nurse were 2 dogs who were the patient's pets. During HV#2 it was noted the SN placed her bag on a barrier and on the floor. During HV#3 it was noted the CHHA placed her bag on the floor without a barrier and then placed the bag on an upholstered chair without a barrier under the bag. It was inconsistent with the organization policy on bag technique. This was discussed with the DPCS. Observed in Patient Home. In 2 of 3 home visits conducted, During HV#1 and #2 it was noted the SN disinfected the equipment used during the visit with a product requiring a 2 minute wet contact time. After the equipment was cleansed with the disinfectant it was immediately placed back in the nursing bag. The equipment included BP cuff, stethoscope, plastic coated tape measure, pulse oximeter and thermometer. This was discussed with the DPCS.

Observed in Infection Control System Tracer. The organization's written infection prevention and control goals lacked a goal limiting the spread of infections associated with the use of medical equipment, devices, and supplies for 2022, 2023 and 2024. This was discussed with the DPCS and CEO. Observed in Infection Control System Tracer. The organization's written infection prevention and control goals lacked a goal limiting unprotected exposure to pathogens for 2022, 2023 and 2024. This was discussed with the DPCS. Observed in Infection Control System Tracer. The organization's written infection prevention and control did not have a goal limiting the spread of infections associated with procedures for 2022, 2023, 2024. This was discussed with the DPCS and CEO. Observed in Infection Control System Tracer. During review of the infection control plan it was noted since a risk analysis was not documented for 2022, 2023 and 2024 to date, there were no prioritized risks identified. This was discussed with the DPCS.

Observed in Data Session. During review of the sign in forms for QAPI meetings, it was noted the participants were the CEO, CFO and DPCS. The QAPI committee lacked other professionals members such as the MSW, Chaplain, Medical Director. This was discussed with the CEO.

Observed in Record Review. In 2 of 10 patient records reviewed, During HV#1 record review it was noted the POC was updated the end of May 2024 to include the need for the use of liquids to be thickened. The dietary change and aspiration precautions were not added to the hospice aide POC. During RR#7 the aide POC was not updated to include the presence of multiple pressure ulcer wound dressings with direction on not removing the dressings and when to notify the RN. This was discussed with the DPCS.

Observed in Data Tracer. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by Conditional Level Deficiencies (CLD) in 418.100, 418.56, 418.60. 418.113 and 418.58. This was discussed with the CEO.

Observed in HR File Review. In 3 of 11 HR files reviewed, During reivew of HR#7 it was noted lack of an orientation to the specific duties of a spiritual counselor and bereavement coordiantor. During HR#2 it was noted lack of orientation to the specific duties for the position of Director of Patient Care Services. During reivew of HR#9 it was noted lack of orientation to the specific duties of a volunteer. This was discussed with the DPCS.

Observed in Record Review. In 1 of 10 patient records reviewed, During HV#1 record review it was noted the MSW documented the initial visit the end of May 2024. Six days later it was not in the patient's record. The note other than the time in and out was blank. Per the DPCS, notes are to be completed within 48 hours of a visit in the EMR.

Observed in Patient Home. In 3 of 3 home visits conducted, During HV#1-3 it was noted although the organization completes an emergency preparedness plan for each patient, a copy of the plan was not left in the patient's homes. This was discussed with the DPCS.

Observed in HR File Review. In 1 of 11 HR files reviewed, During HR#9 it was noted the volunteer gave permission for a background check to be performed in January 2024. To date the HR file lacked documentation that the background check was conducted. This was discussed with the DPCS. Observed in Document Review. During review of the contract for PT, OT, and ST, it was noted lack of a stipulation that staff who have contact or access to patient records have had a criminal background check performed. In addition, there is lack of a stipulation of the manner in which contracted services will be coordinated, supervised, and evaluated by the hospice. This was discussed with the CEO.

Observed in Record Review. In 4 of 4 patient records reviewed, the plan of care did not include time frames for achieving patient goals. In all records reviewed there was a mixture of goals to be achieved in 30 days or ongoing goals. There was no documentation of any short term goals or any other method of prioritizing which goals should be met in the short term in order to insure patient safety. This was validated with the administrator.

Observed in Record Review. In 3 of 3 patient records reviewed, for patients who received social work services, the plan of care did not include any identified problems, interventions or goals for social work. In RR#1, RR#3 and RR#4 the plan of care included an ordered visit frequency for social work but the plan of care only identified nursing problems, interventions, and goals. This was validated with the administrator.

Observed in Record Review. In 3 of 4 patient records reviewed, the agency failed to provide services according to the patient's plan of care. In RR#1 and RR#3 the plan of care called for MSW services monthly. In both charts there were gaps of 2-3 months between documented MSW visits. In RR#4 the aide care plan called for catheter care and emptying of a Foley drainage bag. These tasks were not documented on the aide notes. This was validated with the administrator.