Every finding on record at Caris Healthcare LLC

Based on record reviews and reviews of the hospice's policy and procedure, the hospice failed to ensure its Emergency Preparedness Plan was reviewed and updated at least every two years. --- The findings include: On 02/06/23 at 10:31 AM, review of the hospice's Emergency Preparedness Plan(EP) revealed the EP plan was last revised on 10/21/20 with no additional documentation of a review and/or update at least every two years. The finding was verified on 02/06/23 at 10:35 AM by the Administrator. Hospice policy, entitled, ";Emergency Preparedness Plan", revealed, ";2.7 The Emergency Preparedness Plan will be reviewed annually, when there is a change in process, and revised as needed...".

Based on interview and record review, the hospice facility failed to ensure that the hospice facility developed and maintained an Emergency Preparedness (EP) training and testing program planned based on emergency plan. --- The findings include: During a record review on 02/06/23 at 10:31 AM of the facility Emergency Preparedness Plan revealed no documentation of training and/or testing of the facilities emergency preparedness program with the facility staff. During an interview on 02/06/23 at 10:35 AM with the Administrator stated, ";We have not done any training on Emergency Preparedness".

Based on interview, record review and review of facility policy and procedure, the hospice facility failed to ensure a full-scale community-based exercise to test the emergency plan annually with unannounced staff drills using the emergency procedures. --- The findings include: During a record review on 02/06/23 at 10:31 AM of the facility emergency Preparedness Plan revealed no documentation of a full-scale community-based exercise for the emergency plan with unannounced drills. During an interview on 02/06/23 at 10:37 AM with the Administrator stated, ";We havent done any community drills/mock codes. I havent been documenting any information until recently".

Based on record reviews, interviews, and review of the hospice's policy and procedure, the hospice failed to ensure reconciliation of the patient's hospice medication profile with the long-term care (LTC) facility's medication administration record (MAR) for 2 of 2 patients in a long-term care facility (Patient 3 and 4), and failed to reconcile the hospice's medication profile for the patient with the actual medications in the patient's home that the patient takes for 2 of 2 home visits. (Patient 1 and 2) --- The findings are:During a home visit on 02/07/23 from 10:05 AM to 11:04 AM, review of Patient 1's actual medications in the home showed the patient no longer takes Aspirin 325 mg (milligram) 1 tablet daily and Tamsulosin 0.4 mg 1 capsule, but both medications were listed on the hospice medication profile for the patient. Patient takes Xarelto 20 mg 1 tab daily per the hospice medication profile, but Xarelto 20 mg 1 tab daily was discontinued in the home. The findings were verified by the Director of Nursing (DON) on 02/10/23 at 10:39 AM. During a home visit on 02/07/23 at 2:18 PM to 2:27 PM, review of Patient 2s medications in the home when compared with the hospice medication profile revealed Patient 2s home showed Dexamethasone 4 mg, take one tablet by mouth twice a day while the hospice medication profile for Patient 2 revealed Dexamethasone 4 mg, take one tablet daily. Home showed Senna 8.6 mg 1 capsule, at bedtime while the hospice medication profile revealed Senna 8.6 mg 2 capsules, twice a day. Patient 2 reported he/she no longer takes Eliquis 5 mg, 1 tab twice a day, but the hospice medication profile revealed Eliquis 5 mg, 1 tablet daily. The findings were verified by the DON on 02/10/23 at 11:41 AM. During a LTC facility visit on 02/08/23 from 9:00 AM to 10:32 AM, review of Patient 3s mar in the facility when compared with the hospice medication profile revealed Patient 3s facility's mar listed the following medications that were not on the hospice medication profile: UTI-Stat liquid 3875 mg/30 ml (milliliters), take 30 ml daily at 5 PM, Cetirizine 10 mg, take 1 tablet at bedtime, and Adult Robitussin peak cold 10-100 mg/5 ml, take 2 teaspoonfuls every 4 hours as needed times 72 hours. The findings were verified by the DON on 02/10/23 at 11:50 AM. During a LTC facility visit on 02/08/23 at 10:35 AM to 11:51 AM, review of Patient 4s medications on the LTC facility's mar when compared with the hospice medication profile revealed Dulcolax (Bisacodyl) suppository 10 mg, one per rectum daily as needed for severe constipation while the hospice medication profile revealed Bisacodyl 5 mg tablet, 1 tablet twice a day. The following long-term care facility's mar had the following medications that were not listed on the hospice medication profile: Lactobacillus rhamnosus tablet 1 tablet, by mouth one time a day, Chlorehexidine gluconate 0.12 % (percent) swish 15 ml for 30 seconds and then spit , once in the morning and at bedtime, Clotrimazole-betamethasone cream 1-0.05% mix with Silvadene and apply under bilateral breasts three times a day, Silvadene cream 1% mix with Lotrisone and apply under bilateral breast three times a day, Salonpas (lidocaine) patch apply to lower back and one to right shoulder every morning. The findings were verified by the DON on 02/10/23 at 12:02 PM. Hospice policy, entitled, ";Medication Assessment and Reconciliation", revealed, ";1. On every skilled nurse visit, perform medication reconciliation to ensure all medications are correctly documented in the electronic electric record. 2. During every skilled nursing visit, ask the patient/caregiver to see all medication bottles, dispensers, etc...Medication Reconciliation 1. Medication reconciliation for patients residing in the long-term care centers includes the following as listed below: a. Review facility Medication Administration Record (MAR) and confirm against what is in the Medication Profile of the electronic medical record. If discrepancies noted, make changes in the electronic medical record...".

Based on record reviews, interviews, and review of the hospice's policy and procedure, the hospice failed to ensure an initial bereavement risk assessment was completed on admission for 3 of 15 patient charts reviewed. (Patient 4, 6, 11) --- The findings include: On 02/08/23 at 3:46 PM, review of Patient 4's chart revealed the patient was admitted on 08/16/22 for Hypertensive Heart Disease. Review of the patient's chart revealed there was no initial bereavement risk assessment completed with the patient's initial comprehensive assessment within 5 days of the patient's admission. The findings were verified by the Regional Director of Clinical Care (RDCC) on 02/10/23 at 12:02 PM. On 02/09/23 at 9:43 AM, review of Patient 6's chart revealed the patient was admitted on 07/08/22 for Senile Degeneration of Brain. Review of the patient's chart revealed there was no initial bereavement risk assessment completed with the patient's initial comprehensive assessment within 5 days of the patient's admission. The findings were verified by the RDCC on 02/10/23 at 12:08 PM. On 02/09/23 at 12:34 PM, review of Patient 11's chart revealed the patient was admitted on 02/25/22 for Parkinsons Disease. Review of the patient's chart revealed there was no initial bereavement risk assessment completed with patient's initial comprehensive assessment within 5 days of the patient's admission. The findings were verified by the RDCC on 02/10/23 at 11:16 AM. Hospice policy, entitled, ";Bereavement Plan of Care and Form", revealed, ";1. A Bereavement Plan of Care (BVPOC; OP 12.1.1) is to be initiated for every patient upon admission to (Hospice)...".

Based on record reviews, interview, and review of the hospice's policy and procedure, the hospice failed to ensure the patient's plan of care (poc) was individualized for 4 of 15 patient charts reviewed for care and services. (Patient 1, 2, 11, and 14) --- The findings include: Observations in Patient 1's home on 02/07/23 from 10:05 AM to 11:04 AM revealed an oxygen concentrator in the patient's home. There was no documentation of Oxygen or education on Oxygen safety in the patient's plan of care. During an interview on 02/10/23 at 10:39 AM, the Director of Nursing (DON) verified the findings. On 02/08/23 at 2:25 PM, review of Patient 2's chart revealed the Registered Nurse (RN) documented a Stage 1 Pressure Ulcer on 01/31/23. There were no physician orders for the wound care. During an interview on 02/10/23 at 11:41 AM, the DON verified the findings. On 02/09/23 at 12:34 PM, review of Patient 11's chart revealed the patient was ordered Oxygen on 04/12/22. There was no documentation of Oxygen use or patient education in the patient's plan of care. During an interview on 02/10/23 at 11:16 AM, the Regional Director of Clinical Care (RDCC) verified the findings. On 02/09/23 at 3:41 PM, review of Patient 14's chart revealed the patient was on continuous Oxygen on 12/1/22. There was no documentation of Oxygen use or patient education in the patient's plan of care. During an interview on 02/10/23 at 10:56 AM, the RDCC verified the findings. Hospice policy, entitled, ";Plan of Care" revealed, ";1. The patients plan of care specifies the care and services necessary to meet the needs of the patient/caregiver as identified in the initial, comprehensive and updated assessments of the patient. 2. Each patient and his or her primary caregiver(s) receive education and training from the hospice as appropriate to their responsibilities for the care and services provided in the plan of care and their participation in the care planning process...".

Based on record reviews and interview, the hospice failed to ensure the Skilled Nurses (SN), Master of Social Worker (MSW), Chaplain, and Hospice Aide completed home visits per the ordered frequency on the patient's plan of care for 5 of 15 patient charts reviewed. (Patient 3, 6, 7, 8, 14 and 15) --- The findings include: On 02/08/23 at 3:06 PM, review of Patient 3's chart revealed a visit frequency for the Hospice Aide (HA) for 2 times a week for 8 weeks starting 12/11/22. Review of the benefit period dated 12/09/22 to 02/06/23 revealed 1 missed HA visit the week of 01/08/23 and 1 missed HA visit the week of 01/15/23. During an interview on 02/10/23 at 11:50 AM, the Director of Nursing (DON) verified the findings. On 02/09/23 at 9:43 AM, review of Patient 6's chart revealed a visit frequency for the HA for 1 time a week for 9 weeks and Skilled Nursing (SN) visits for 1 time a week for 2 weeks, 2 times a week for 1 week, 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 1 week, 2 times a week for 1 week and 6 PRN (as needed) visits. Review of the benefit period dated 09/06/22 to 11/04/22 revealed 1 missed HHA visit the week of 10/16/23 and 1 missed SN visit the week of 10/30/22. During an interview on 02/10/23 at 12:08 PM, the DON, verified the findings. On 02/09/23 at 10:25 AM, review of Patient 7's chart revealed a visit frequency for the HA for 2 times a week for 9 weeks. Review of the benefit period dated 08/01/22 to 09/29/22 revealed 1 missed HA visit the week of 08/14/22 and 1 missed HA visit the week of 09/25/22. During an interview on 02/10/23 at 11:06 AM, the Regional Director of Clinical Care (RDCC) verified the findings. On 02/09/23 at 11:00 AM, review of Patient 8's chart revealed a visit frequency for the Master Social Worker (MSW) for 3 times a month for 1 month and 1 time a month for 2 months. Review of the benefit period dated 10/03/22 to 12/31/22 revealed 2 missed MSW visits the month of November 2022. During an interview on 02/10/23 at 11:25, the RDCC verified the findings. On 02/09/23 at 3:41 PM, review of Patient 14's chart revealed a visit frequency for the HA for 2 times a week for 8 weeks, and the Chaplain for 1 time a month for 1 month. Review of the benefit period dated 11/30/22 to 01/30/23 revealed 1 missed HA visit the week of 12/04/22 and 1 missed HA visit the week of 01/22/23 with a missed Chaplain visit the month of December 2022. During an interview on 02/10/23 at 10:56 AM, the RDCC, verified the findings. On 02/09/23 at 4:00 PM, review of Patient 15's chart revealed a visit frequency for the HA for 1 time a week for 1 week. Review of the benefit period dated 1/31/23 to 04/30/23 revealed 1 missed HA visit the week of 01/31/23. During an interview on 02/10/23 at 10:53 AM, the RDCC verified the findings.

Based on review of the hospice's Quality Assurance Process Improvement (QAPI) data and interview, the hospice had no documentation that the hospice developed, implemented, and evaluated performance improvement projects (PIPS). --- The findings include: Review of the hospice's Quality Assurance Process Improvement (QAPI) data on 02/10/23 at 12:15 PM revealed the hospice had no documentation that the hospice had developed and implemented PIPS. On 02/10/23 at 12:18 PM, the Administrator stated, ";We havent done any PIPS for this office, and I dont have any for the other offices (multiple locations)."

Based on review of the hospice's Quality Assurance Process Improvement (QAPI) data and interview, the hospice failed to have documentation of an annual Performance Improvement Projects (PIPS) based on the hospice population, organizational needs, and past services, and operations. --- The findings include: Review of the hospice's QAPI data on 02/10/23 at 12:15 PM revealed the hospice had no documentation of an annual PIPS based on the population, organizational needs and past services and operations. On 02/10/23 at 12:18 PM, the Administrator stated, ";We havent done any PIPS for this office, and I dont have any for the other offices (multiple locations)/."

Based on review of the hospice's Quality Assurance Proces Improvement (QAPI) and interview, the hospice failed to conduct, document reasons for, and measure any Performance Improvement Projects (PIPS). --- The findings include: Review of hospice's Quality Assurance Process Improvement documents on 02/10/23 at 12:15 PM revealed there was no documentation of development and/or measurement of any PIPS. On 02/10/23 at 12:18 PM, the Administrator stated, ";We havent done any PIPS for this office, and I dont have any PIPs for the other offices (multiple locations)."