Every finding on record at Cfhc No15 Inc

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan. A revised plan of care includes information from the patient’s updated comprehensive assessment and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. 2 of 5 (40%) clinical records reviewed revealed the agency did not ensure that findings from patients' updated comprehensive assessment and progress toward outcomes and goals were reflected in the revised plan of care (POC). Clinical Record 1: The patient elected the hospice benefit on 3/21/2023. In the registered nurse (RN) initial assessment visit on 3/21/2023, the nurse documented, "Patient prefers full code at this time, declines to discuss decline in disease process." It was also noted that the patient refused social work and chaplain services. In the RN visit note documentation on 3/29/2023, 4/6/2023, 4/12/2023, 4/21/2023, 4/26/2023, 5/4/2023, and 5/11/2023, the nurse assessment under the "Psychosocial" section, "denial" and "unrealistic expectations" boxes are checked indicating that this was an ongoing problem for the patient. Per the POC orders dated 3/22/2023 and the documented POC review and updates to the comprehensive assessment in the interdisciplinary meetings on 3/22/2023, 4/5/2023, 4/19/2023, and 5/3/2023, the identified problem list included: shortness of breath, UTI prophylaxis, UTI, fall risk, declining ability to perform ADLs, medication management, edema, emotional support (grief due to loss of husband and daughter), and the potential for issues with diabetes management. The POC did not include documented evidence of a problem, interventions, goals or outcomes that addressed the patient's decline in physical condition and disease advancement and refusal to discuss advanced care planning. Clinical Record 2: The patient elected the hospice benefit on 3/7/2023. During the RN visit on 3/21/2023, the nurse documented, "...pupils sluggish but reactive, patient is legally blind. HX of seizures none recent." Per the POC orders dated 3/22/2023, the patient's medication list included two seizure medications: Phenytoin Sodium Extended Oral Capsule 400mg daily and Topiramate 50mg BID. For the POC orders dated 3/22/2023 and the documented POC reviews and updated comprehensive assessment documentation in the interdisciplinary meetings on 3/22/2023, 4/5/2023, 4/19/2023, and 5/3/2023, the identified problem list included: congestion, constipation, forgetfulness, edema, pain, fall risk, hypertension, declining ability to perform ADLs, insomnia, medication management, shortness of breath, fear, family dynamics, emotional support, and struggling with belief system. The POC did not include documented evidence of a problem, interventions, goals, or outcomes that addressed monitoring for potential seizure activity, potential uncontrolled seizure activity, or a potential plan to address the patient's seizures if the patient became unable to swallow medications. In an interview during the end of day one review on 5/15/2023, the Director of Nurses (DON) and the RN Case Manager (RNCM) confirmed that interventions and goals related to problems identified in the patients' updated comprehensive assessments were not included in the patients' updated individualized POC. Again on 5/17/2023 during the Exit Conference, an interview with the DON to review and discuss the inclusion of the information for each patient where updated identified problems occurred. No new information was presented.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services. This standard was not met as evidenced by document review, interview and personnel record review. 1 of 12 (8%) applicable personnel records reviewed in which a competency assessment was required, revealed the agency did not ensure that all employees that provide patient care had a skills competency assessment completed on hire as required by agency policy. The "Medical Director Contract" with the effective date of 6/6/2022 stated under the heading of "Responsibilities of the Physician" in section 1.05, that the doctor will "Provide services and visits to hospice patients according to the Plan of Care (POC)...Schedule patient/family visits through the Interdisciplinary meetings and in conjunction with the plan of care." Agency Policy, " Personnel Records", HR.11, with a revised effective date of 3/3/2022, stated on page two, number 6, "Personnel contents for contractors may include but not be limited to ... competency skills checklist, as appropriate." Agency Policy, "Staff Competency", HR.2, with a revised date of 3/3/2023, stated, "The agency will provide for competency assessments by qualified individuals on hire ....to assess direct care staff's basic skill levels for all staff providing care ... on hire ...competency assessment or self-competency checklist, accomplished either by demonstration or verbally." Personnel Record 12: The personnel file for the Alternate Medical Director with date of hire 6/6/2022 did not include documented evidence of an assessment of skills and competency upon hire. In an interview on 5/17/2023, the Director of Nursing (DON)/Administrator confirmed that a competency assessment was not completed for the Alternate Medical Director upon hire. On 5/4/2023, the agency initiated a "Skills Competency on Hire" QAPI Performance Improvement Project (PIP). The CHAP Site Visit took place less than two weeks after the initiation of the PIP, and therefore there had been minimal time to reflect improvement. At the time of the PIP initiation, the compliance score presented at the QAPI Committee meeting on 5/4/2023 was 70%.