Every finding on record at Choice Hospice Inc

Observed in Patient Home. In 2 of 3 home visits conducted, it was noted the organization failed to conduct medication reconciliation to assess potential medication-related problems, including adverse effects, drug reactions, significant side effects, and significant drug interactions, ineffective drug therapy, duplicate drug therapy, and noncompliance with drug therapy. For example, during home visit of HOSRRHV#2, and HOSRRHV#3, SN had failed to conduct medication reconciliation during home visit as required by organizational policy (Policy no. 3-002.1 Medication Profile).This finding was discussed and validated by the Director of Nursing.

Observed in Patient Home. In 3 of 3 home visits conducted, it was noted that the organization failed to conduct and document an environmental assessment as required by organization policy (Policy No. 2-077.1 Basic Home Safety). Based on staff interviews and patient record review, (HOSRRHV#1, HOSRRHV#2, HOSRRHV#3) no evidence of completed home environmental assessments was found in the clinical records. This finding was discussed and validated by the Director of Nursing.

Observed in Record Review. In 1 of 10 active patient records reviewed, it was noted the organization failed to ensure that the hospice plan of care plan includes all services needed for the palliation and management of the terminal illness and related conditions, including medications necessary to meet the patient’s needs. Upon review of the records, several PRN pain medication ordered to be given for pain without specifying which PRN medication should be administered based on defined parameters. For example, in HOSRRHV#2: Acetaminophen oral tablet 325 mg 2 tablets every 6 hours PRN for pain and Oxycodone HCL 10 mg 1 tablet every 8 hours for pain. This finding was discussed and validated by the Director of Nursing.

Observed in Record Review. In 1 of 10 active patient records reviewed, it was noted the organization failed to provide the patient care, treatment, or services in accordance with hospice plan of care. For example in review of record HOSRRHV#1 during the 5-day period from the beginning of care, there was an order for spiritual counselling and to conduct initial assessment. A missed visit submitted due to family had wanted to reschedule for a later date, however, there was no evidence documented that it was re-scheduled. This finding was discussed and validated by the Director of Nursing.

Observed in Record Review. In 1 of 10 active patient records with hospice aide services,, it was noted the organization had failed to ensure that the written patient care instructions for a hospice aide must be prepared by a registered nurse who is responsible for the supervision of a hospice aide. For example, in record of HOSRRHV#2, the patient was on continuous oxygen at 4 LPM via nasal cannula, however, the hospice aide care plan did not address whether the oxygen could be removed for the bath. This finding was discussed and validated by the Director of Nursing.

Observed in Record Review. In 3 of 3 home visits conducted, it was noted the organization had failed ensure that each patient and the primary caregivers receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care. For example during home visit conducted of HOSRRHV#1, HOSRRHV#2, and HOSRRHV#3, it was noted patient have Morphine Sulphate medication as part of the comfort kit. Based upon review of records, there were no evidence documented if patient/family have been educated/discussed on proper disposal of unused or expired narcotics as required by policy no. 3-005.1 Home Use and Disposal of Controlled Substances. This finding was discussed and validated by the Director of Nursing.

Observed in Data Session. The organization did not implement and maintain an ongoing program for quality improvement and patient safety. During the data management/leadership session, it was noted the Director of Nursing was collecting data and monitoring/trending key QAPI measures (infections, falls, complaints, medication-related adverse events, care planning, pain, equipment-related issues, bereavement, volunteer services), but had not yet documented goals and interventions for these measures/monitors as part of the organization's Quality Assurance and Performance Improvement (QAPI) Program. This was reveiwed and verified with the Director of Nursing.

Observed in Emergency Management Session. Identified during the review of the organization's Emergency Management Plan, and in conversation with the Director of Patient Care Services, the organization has not made arrangements with other organizations in the event that it cannot serve its own customers as the results of an emergency.

Observed in Individual Tracer. In 2 of 2 skilled nursing visits, the clinicians did not complete a comprehensive reassessment in accordance to the organizational policy 2-031.1 - Ongoing Comprehensive Assessment: 2) The nurse will assess the patient on each visit for: . . .G) Skin Integrity. Observed in HV#1, the Licensed Practical Nurse (LPN) assessed the bedbound patient's feet and legs from below the knees to the ankles, but did not do a full skin assessment. Observed in HV#2, the LPN assessed the patients right lower extremity but failed to conduct a full skin assessment, instead asking the patient is your bottom ok?. This was discussed with the Director of Patient Care Services who confirmed that the expectation was that the assessments were to be conducted per policy.

Observed in Leadership Session. Identified during review of the organization's Quality Assurance and Performance Improvement (QAPI) program, and in discussion with the Director of Patient Care Services, the QAPI program does not include all services provided by the organization, nor has the organization developed improvement activities to demonstrate that improvement in performance has occurred.

Observed in Leadership Session. Identified during review of the organization's QAPI program and in discussion with the Director of Patient Care Services, the data collected as quality priorities had not resulted in performance improvement plans. Therefore, there was no evidence of action taken when improvement was not achieved or sustained in the identified quality priorities and data collected. Observed in Leadership Session. Identified during review of the organization's QAPI program and in discussion with the Director of Patient Care Services, the data collected as quality priorities did not result in performance improvement plans. Therefore, the organization was not able to evaluate its actions to confirm improvement in identified quality priorities.

Observed in Leadership Session. Identified during review of the organization's QAPI program and in discussion with the Director of Patient Care Services, the organization had not developed any performance improvement projects with the data collected during the past three years.

Observed in Leadership Session. Identified during review of the organization's QAPI program and in discussion with the Director of Patient Care Services, the organization had not conducted any performance improvement projects with the data collected during the past three years.

Observed in Leadership Session. Identified during review of the organization's Quality Assurance and Performance Improvement (QAPI) program, and in discussion with the Director of Patient Care Services, the organization has not used its data collected to develop its QAPI program to include improvement activities: specific goals, interventions, and evaluations. For example, data collected in 2022 included pain at admission, but did not establish goals, interventions, or evaluations.

Observed in Leadership Session. Identified during review of the organization's Quality Assurance and Performance Improvement (QAPI) program, and in discussion with the Director of Patient Care Services (DPCS) the organization had not selected performance improvement activities based on high-volume, high-risk, and problem-prone areas. For example, during the conversation with the DPCS, Care Planning was identified as an a problem-prone area in need of improvement, but this had not been addressed or included in the QAPI program.

Observed in Infection Control System Tracer. Identified during review of the organization's Infection Control Program, and in discussion with the Director of Patient Care Services, the infection control program is not an integral part of the QAPI program.

Observed in Infection Control System Tracer. Identified during review of the organization's Infection Control Program, and in discussion with the Director of Patient Care Services, the organization did not develop prevention and control goals that addressed its prioritized infection risks.

Observed in Tracer Activities. During review of the Bereavement Program, the surveyor identified that the organization has not developed an individualized plan of care for bereaved in accordance with Policy No. 2-010.1 - Bereavement Services: 2) After the bereavement risk assessment is completed, a plan will be developed to address bereavement/grief issues and will be implemented and updated as needed. This was discussed and validated with the Director of Patient Care Services.

Observed in Tracer Activities. The Governing Body/Leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: 418.58 Quality Assurance and Performance Improvement; 418.100 Organization and Administration of Services; and, 418.104 Clinical Records. Observed in Tracer Activities. The Surveyor identified during review of the organization's policies that they were not operating in accordance to policy No. 1-005.1 - Do Not Resuscitate/Do Not Intubate (DNR/DNI). The organization was utilizing a DNR/DNI order which contained the pre-populated (image of) Medical Director Signature. According to policy, A written DNR/DNI order, signed by the patient's physician . . ., must be on file . . . This was discussed and validated with the Director of Patient Care Services.

Observed in Tracer Activities. The Surveyor identified during the review of the organization's admission packet that the Do Not Resuscitate Order contains a pre-populated signature of the Hospice Medical Director. This practice is not in accordance with the organization's policy No. 1-005.1 - Do Not Resuscitate/Do Not Intubate, which states A written Do Not Resuscitate (DNR) and/or Do Not Intubate (DNI) order, signed by the patient's physician (or other authorized licensed independent practitioner), must be on file in the patient's clinical record and admission folder in the patient's home. This was discussed and validated with the Director of Patient Care Services.