Every finding on record at Chippewa County Health Department

It is required that the patient’s pain is assessed as part of a comprehensive assessment. The documented assessment of the patient’s pain includes the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) records reviewed it was revealed that the agency did not ensure that the patient's goal for pain management and when to report patient's pain to the physician was documented. Clinical Record 1: The Plan of Care dated 03/30/2023-06/27/2023 stated, "Assess pain severity, frequency, location, quality, precipitating factors, and side effects of pain." There was no documented evidence of what parameters to report to the physician or what level of pain the patient would be comfortable with. The Nursing Supervisor was interviewed on 05/24/2023 and after review of the clinical record stated, "There should be parameters as to when to notify the physician and what the patient would be comfortable with."

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed it was revealed that the agency did not ensure that the patient had an initial bereavement assessment at the start of the benefit period. Clinical Record 1: Plan of Care dated 03/30/2023-06/27/2023 stated, " Medical Social Worker to Assess and Evaluate 03/30/2023-04/03/2023." The Medical Social Worker visit note dated 03/31/2023, stated, "Pt called to cancel the visit scheduled for today and prefers to have only one home visitor at this time, which will be the hospice RN." There was no documented evidence in the clinical record that an initial bereavement risk assessment was completed. The Nursing Supervisor was interviewed on 05/24/2023 and after reviewing the clinical record, stated, "The physician was not notified that the patient did not want the Medical Social Worker and the initial bereavement assessment was not done. The MSW is the one that completes the initial bereavement assessment."

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care and to ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed it was revealed that the agency did not ensure that the agency provided coordination of care and to ensure the implementation of the interdisciplinary plan of care. THIS IS A CONTINUING PRIOR REQUIRED ACTION Clinical Record 2: The Initial Admission Spiritual Assessment was completed by the Skilled Nurse dated 04/03/2023. The patient responded "Yes" to question 1: Can our Hospice Clergy Contact you, on the Admission Consent dated 04/03/2023 signed by the patient's Power of Attorney, giving consent for treatment of the Spiritual Counselor 1xwk. The Medical Social Worker Visit note dated 04/06/2023, under the Spiritual Assessment-Spiritual Status, Spiritual Support from Clergy, the social worker documented, "wants clergy notified." There was no documented evidence in the clinical record that the physician was notified. The SN visit note dated 4/10/2023 stated "Patient removed his NG tube just prior to my arrival at the house. He stated he was immediately more comfortable." There was no documented evidence that the physician was notified. The Plan of Care dated 04/03/2023-07/01/2023, included the Intervention: SN Assess NG tube placement." On the Skilled Nurse initial comprehensive assessment, the Skilled nurse documented, "He is currently NPO with an NG tube placed in his right nare." Clinical Record 3: The skilled nurse visit note dated 05/20/2023 stated, "Patient requested her foley catheter to be removed. The registered nurse (RN) removed the catheter by deflating the balloon." There was no documented evidence in the clinical record that the physician was notified the foley catheter was removed or to get the order to discontinue the foley catheter. The Nursing Supervisor was interviewed on 05/24/2023 and after reviewing the clinical records stated, "We should have gotten the chaplain to see the patient and notified the physician for an order for the Chaplain for Record 1 and notified the physician about the foley for Record 2." THIS IS A CONTINUED REQUIRED ACTION

It is required that medical social services are provided per the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, it was revealed that the agency did not ensure that the physician was notified the Medical Social Worker (MSW) Services were refused by the patient. THIS IS A CONTINUING PRIOR REQUIRED ACTION Clinical Record 1: The Plan of Care dated 03/30/2023-06/27/2023 stated. " MSW one x week x 12 weeks." The patient refused the Social Work services. There was no documented evidence in the clinical record that the physician was notified that social work services were being refused by the patient. The Nursing Supervisor was interviewed on 05/24/2023 and after reviewing the chart stated, "The physician was not notified that the patient refused the social worker services." THIS IS A CONTINUED REQUIRED ACTION

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed for patients receiving aide services, it was revealed that the agency did not ensure the aide care plan had specific instructions. THIS IS A CONTINUING REQUIRED ACTION Clinical Record 3: The Benefit Period 05/09/2023-08/06/2023 stated, "Aide two times a week for 13 weeks." The Aide care plan dated 05/09/2023 stated nothing under the section "Hygiene Bath". The Aide care plan prepared by the Registered Nurse did not include specific instructions on the type of bath to be performed by the aide. The Nursing Supervisor was interviewed on 05/24/2023 and after reviewing the clinical record stated, "The aide care plan should have a specific type of bath for the aide to provide." Document 1: The Aide Care Plan Policy 8.03.014 effective 01/02/2023 stated in part, "H. Specific procedures are to be included." THIS IS A CONTINUED REQUIRED ACTION

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum, signed copies of the hospice election statement. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed it was revealed that the agency did not ensure the Hospice Election of Benefit form included the date the patient elected the hospice benefit. Clinical Record 2: The Initial Comprehensive Assessment completed by the Registered Nurse was dated 04/03/2023. The Hospice Election of benefit date was blank on the Consent for Treatment. The Consent for Treatment was dated 04/03/2023. Clinical Record 4: The Initial Comprehensive Assessment completed by the Registered Nurse was dated 04/14/2023. The Hospice Election of benefit date was blank on the Consent for Treatment. The Consent for Treatment was dated 04/14/2023. The Nursing Supervisor was interviewed on 05/24/2023 and after reviewing the clinical records, stated "The Registered Nurse did not include the Election of Benefit date on the Consent for Treatment form. These were both completed by the same Registered Nurse."

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care and ensure the implementation of the interdisciplinary plan of care. THIS IS A CONTINUED REQUIRED ACTION This standard was not met as evidenced by a review of clinical records, document review and interview that in 2 of 9 (22%) records providing hospice care fail to document registered nurse coordination of care for the team and assure implementation of the plan of care. Agency Policy #8.03.013 titled Hospice Care (rev.5/27/16) stated in part "The plan of care will identify the patient's needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient's and family/caregiver's needs." "The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, but the interdisciplinary group, with input from the attending physician, the patient, and the family/caregiver, based on ongoing comprehensive assessments of the patient and family/caregiver. Review of the plan of care will be documented in the clinical record. Revision dates will be noted on the plan of care. Any change in the patient's condition must result in a change in the plan of care, prior to implementation of the new service". Record #15324: The plan of care updated 09/29/2021 and 10/13/2021 for MSW (medical social work) to visit 1 EOW (every other week) 8. A MSW visit documented 09/29/2021, a missed visit 10/06/2021 and no additional visit document with patient deceased 10/25/2021. (missing required visit the week of 10/17/2021). The registered nurse oversight to assure clear communication that the patient no longer was under quarantine for COVID as of 10/10/2021 resulted in all disciplines not following the order visit frequency. Record #84679: Physician order 09/29/2021 for volunteer frequency 3 week 4 with duty spousal support. The week of 10/03/2021 two volunteer visits documented and no reason for the third visit not provided. The patient died the following week. The registered nurse oversight to assure communication to all members of the interdisciplinary team when a change of location of service delivery resulted in all services not following the order for visit frequency. Interview with the Clinical Supervisor stated that the visits should have been made as ordered.

It is required that medical social services are provided: Per the plan of care. This standard was not met as evidenced by clinical record review, document review and interview that in 1 of 9 (11%) records accepting social work services, failed to ensure the MSW (master in social work) visits followed the POC (plan of care). Agency Policy 8.05.021 (Effective Date 06/30/1993), stated in part, "Social work services are provided..., in accordance with the plan of treatment." Record #15324: The plan of care updated 09/29/2021 and 10/13/2021 for MSW to visit 1 EOW (every other week) 8. A MSW visit documented 09/29/2021, a missed visit documented 10/06/2021 and no additional visit documented. Visit note documented patient deceased 10/25/2021. A visit should have been delivered the week of 10/17/2021. Interview with MSW and Clinical Supervisor (11/05/2021) indicated a visit should have been provided the week of 10/17/2021.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, document review, and interview that in 1 of 8 (13%) record in which a hospice aide was accepted, revealed a lack of clear and specific updated written instruction for the aide assignment. Agency Policy 8.03.014 (Effective Date 09/26/2008) stated in part, "The patient's case manager, ...., will develop the home health aide plan of care, consistent with the comprehensive plan of care and physician orders." Record #15324: Hospice aide ordered in the plan of care for weekly visits. The patient nursing assessments documented patient decline with the addition of oxygen 10/01/2021; change from a pivot transfer to bed-bound 10/13/2021; application of barrier cream on 10/15/2021 (the aide reported this to the nurse and received verbal approval for application); and addition of Foley catheter 10/18/2021. The hospice aide plan of care failed to document any of these changes in care as of patient death on 10/25/2021 and review of record on11/04/2021. Interview with Clinical Supervisor and nursing staff on 11/04/2021 stated the plan was not updated for these care items.

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by review of clinical records and interview that in 4 of 8 (50%) records reviewed of patients who received aide services the aide failed to provide the services in accordance with the plan of care Record #84679: The Hospice Aide plan of care updated 09/29/2021 included the following duties: lotion to torso/extremities, powder to skin folds, barrier cream to buttocks every visit. The aide visit note 10/05/2021 failed to document powder to skin fold. The aide visit note 10/08/2021 failed to document barrier cream to the buttock. Record #38000: The Hospice Aide plan of care updated 09/08/2021 included the following duties: bed bath, shampoo every visit, nail care, file and trim every 3rd week of the month. The aide visit note 10/01/2021 documented shampoo - not needed. There was no nurse notification. The aide visit note 10/05/2021 failed to document any bath or any reason it was not provided. The aide visit note 10/12/2021 documented shower, (bed bath ordered, no nurse notification); nail care not documented (this visit was the third week of the month). Record #25219: The Hospice Aide plan of care updated 09/07/2021 included the following duties: bed bath - sponge, oral hygiene, shave, right leg clean w/soap and water, rinse and dry every visit. The aide visits 10/01/2021 and 10/04/2021 documented oral hygiene, shave refused. There was no communication with the nurse The aide visit 10/26/2021 failed to document any bath or washing of leg, nystatin cream to groin documented but this was not on the plan. There was no nurse notification. Record #15324: The Hospice Aide plan of care updated 09/01/2021 included the following duty: shower each visit. The aide visits 10/15/2021, 10/19/2021, and 10/22/2021 documented a bed bath. There was no communication with the nurse about the change in bath. During an interview with the Clinical Supervisor on 11/04/2021 they stated, we are auditing and working with the aides and nurses on this.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are: Noted in the plan of care. This standard was not met as evidenced by review of clinical record and interview that 1 of 1 (100%) records in which a volunteer accepted failed to document compliance with the volunteer plan of care. Record #84679: Physician order 09/29/2021 for volunteer frequency 3 times a week for 4 weeks with duty spousal support. The week of 10/03/2021 only two volunteer visits were documented. The record did not include a reason why the third ordered visit did not occur. The patient died the following week. Interview with the case manager (11/04/2021) stated the patient went to the hospice house so we did not need the volunteer. The case manager agrees the plan of care and orders were not updated for the volunteer change in frequency prior to the patient's death on 10/11/2021. Interview with the volunteer coordinator (11/05/2021) stated I thought we did not need a volunteer at the hospice house.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. THIS IS A CONTINUED REQUIRED ACTION This standard was not met as evidenced through review of clinical record, document review, and interview in 1 of 4 (25%) record in which the patient had a Foley catheter, the clinical notes failed to document complete details for catheter care. Agency Policy #8.03.040 titled Intermittent Care Clinical Record (rev. 2/26/16) stated in part "The hospice medical record shall document the patient's condition, problems, progress, and services rendered and shall include: physician orders for medications, procedures, and tests; current medications list." Record #15324: A nursing visit note on 10/18/2021 included the change of a Foley catheter. The note documented inserted 18Fr/10cc catheter with clear amber urine return. Documentation lacked the amount of water instilled in the balloon, what drainage device the catheter was attached to and how the catheter was secured as of review 11/04/2021. Interview with the Clinical Supervisor 11/04/2021 stated that the documentation should include areas of the catheter process and staff have been educated. Interview with case manager 11/04/2021 stated that the documentation is missing the amount of water instilled in the balloon, securement and large bag attachment.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum Physician certification and recertification of terminal illness as required. THIS IS A CONTINUED REQUIRED ACTION This standard was not met as evidenced through clinical record review, document review and interview that in 2 of 9 (22%) record reviewed lacked evidence of a brief narrative statement as a component of the CTI (certificate of terminal illness). Agency Policy #8.05.020 titled Medical Director (rev. 5/27/16) stated in part that the duties of the Medical Director are to include "Providing written certification of the terminal illness including a short clinical narrative for all subsequent benefit periods". Record #55236: The patient was admitted to service on 09/27/2021. The CTI is signed by both the Attending and the Medical Director yet it included only the patient's diagnoses as a narrative statement and failed to include the patient's individual clinical circumstances and brief clinical justification narrative. Record #88572: The patient was admitted to service on 10/11/2021. The CTI is signed by both the Attending and the Medical Director yet it included only the patient's diagnosis as a narrative statement and failed to include the patient's individual clinical circumstances and brief clinical justification narrative. Interview with the Medical Director on 11/04/2021 stated we are trying to educate our independent physicians but it is not working.

It is required that the hospice has written policies and procedures for the management and disposal of controlled drugs in the patient’s home. The policies and procedures address the circumstances under which controlled drugs are disposed of (e.g., the patient’s death, a change in drug regimen, etc.) and the method to be used in accordance with the state and federal law and regulation. THIS IS A CONTINUED REQUIRED ACTION. This standard was not met as evidenced through clinical record review, document review and interview that 1 of 8 (13%) records for patient requiring documentation of medication destruction at the time of death, lacked evidence of the amount of medication destroyed. Agency Policy #8.03.023 titled Client Death (rev. 5/27/16) stated in part "The nurse will instruct the family/caregiver to dispose of all medications, including controlled substances, per federal, state, and local regulations and organization policy. (See "Medication Disposal" Policy No. 8.04.009). This instruction and the specific medications will be documented in clinical note". Agency Policy #8.04.009 titled Home Use & Disposal of Controlled Substances (rev. 8/28/15) stated in part "The hospice nurse, social worker, or chaplain attending the death of a hospice patient will inform the family/caregiver of their responsibility to dispose of all the patient's prescribed medications and will document this instruction in a clinical note. When a hospice patient dies, is discharged from hospice care, or when the drugs are discontinued, the hospice covered medications are to be disposed of properly and documentation of such disposal is to be made with patient or caregiver and the professional nurse". Agency Policy #8.03.023 titled Client Death (rev. 5/27/16) stated in part "The nurse will instruct the family/caregiver to dispose of all medications, including controlled substances, per federal, state, and local regulations and organization policy. (See "Medication Disposal" Policy No. 8.04.009). This instruction and the specific medications will be documented in clinical note". Agency Policy #8.04.009 titled Home Use & Disposal of Controlled Substances (rev. 8/28/15) stated in part "The hospice nurse, social worker, or chaplain attending the death of a hospice patient will inform the family/caregiver of their responsibility to dispose of all the patient's prescribed medications and will document this instruction in a clinical note. When a hospice patient dies, is discharged from hospice care, or when the drugs are discontinued, the hospice covered medications are to be disposed of properly and documentation of such disposal is to be made with patient or caregiver and the professional nurse". A review of the above policies revealed the policies lacked verbiage specific to documentation of the amount of each medication destroyed. Record #28196: the patient died on 10/14/2021 and a nursing visit was documented post death in which the RN documented that controlled substances destroyed by XXXXX(staff name). A form titled Disposable Medication Checklist documents that Morphine sulfate concentrate and lorazepam placed in chemical disposal bog for opioids. Documentation lacked evidence to the amount of each medication destroyed. Interview with Clinical Supervisor 11/05/2021 stated our Disposable Medication Checklist has been updated to include strength and should have been documented.