Every finding on record at Cinta Hospice Care, Inc.

Observed in Record Review. In 1 of 10 patient records reviewed it was noted that the organization did not ensure patient education and training was provided based on the patient’s assessed needs. For example, during a review of the medical record for RRNHV#5, it was noted that the patient had stage II pressure injuries at the right second toe and left medial foot. The plan of care included instructions to educate the patient’s caregiver on proper wound care. However, there was no documented evidence that the patient’s caregiver received education and training related to wound care treatment. This observation was reviewed with the leadership team.

Observed in Record Review. In 1 of 10 patient records reviewed it was noted that the organization did not ensure the patient's caregiver understanding of education and training was evaluated. For example, during a review of the medical record for RRNHV#5, it was noted that the patient had stage II pressure injuries at the right second toe and left medial foot. The plan of care included instructions to educate the patient’s caregiver on proper wound care. However, there was no documented evidence that an evaluation of the patient’s caregiver to perform the wound care treatment was performed. This observation was reviewed with the leadership team.

Observed in Record Review. In 2 of 11 patient records reviewed, the hospice had not conducted and documented a patient-specific comprehensive assessment and reassessment that identified the patient’s need for hospice care and services. The assessment did not include the patient’s need for physical, psychosocial, emotional, and spiritual care. In the charts for RR#2 and RR#4, though the SN screen indicated a need for a bereavement assessment, one was not documented as part of the comprehensive assessment. This was discussed with the DPCS.

Observed in Record Review. In 2 of 11 patient records reviewed, the hospice’s interdisciplinary group had not updated the comprehensive assessment no less than every 15 days. In the chart for HV#2, for the most recent two IDG's there was no documented input from Nursing, MSW. There was no documented input from Nursing for the entire second benefit period. In the chart for RR #8, the Surveyor noted the registered nurse performed the comprehensive assessment 18 days apart. This was confirmed with the RN Supervisor.

Observed in Record Review. In 6 of 11 patient records reviewed, the written plan of care (POC) was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for HV#1, the patient had a history of constipation on assessment. The POC did not include any goals related to constipation. In the chart for HV#3, the goals all have the target date as the last day of the benefit period and thus not appropriate for safety problems such as this patient with risk of aspiration. Some are not measurable such as Optimal bowel elimination and comfort. In the chart for RR#1, goals were not measurable, e.g. altered skin will heal to maximum potential. There was no goal for fall risk, nor a goal related to patient's risk for development of additional pressure ulcers. In the chart for RR#2, the goal target dates were all the last day of the BP, even patient/family will verbalize understanding of safety measures re: oxygen use. In the chart for RR#6, the patient with oxygen in use and a high fall risk, the safety goal of Pt/pcg will verbalize understanding of medication/treatment and side effects target date is the last day of the benefit period. In the chart for RR#7, the patient is at risk for falls, yet the target date that the caregiver will verbalize understanding of treatment orders is not until the last day of the benefit period. This was discussed with the DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. In the chart for HV#1, the plan of care was not revised with the MSW and Chaplain visit frequencies after their initial evaluations. This was discussed with the DPCS.

Observed in Record Review. In 7 of 11 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: medications and treatment necessary to meet the patient's needs. During HV#1, the patient's PCG confirmed that he medicates the patient with Tylenol prn for complaints of pain every 2-3 days. This treatment was not on the POC. The patient was assessed to be at high risk for falls, yet the POC did not include any interventions related to this risk. In the chart for HV#2, there were three medications, Ibuprofen, Oxycontin and Tylenol #3 all ordered prn pain with no further direction. In the charts for HV#3, RR#6 and RR#7 the patients were at high risk for pressure ulcer development, yet the POC did not include any interventions related to this risk other than equipment. In the chart for RR#1, the patient was at high risk for falls. There were no interventions on the POC other than DME. In the chart for RR#8, the LVN noted that the patient was using a Lidocaine patch. This treatment was not on the POC. This was discussed with the DPCS.

Observed in Record Review. In 2 of 11 patient records reviewed, the plan of care (POC) revisions were not based on information from updates to the patient’s comprehensive assessment and did not address the patient’s progress toward goals and outcomes. In the chart for HV#2, the two most recent IDT documents did not include any progress toward goals. Five of six goals remain with a target date prior to the current benefit period. Additionally, the patient had experienced a pathological fracture during the time span and the POC was not updated with the interventions nor any new goals. In the chart for RR#5, the POC had not been updated; goals remain with target dates prior to the current benefit period. Additionally, the SN notes and communication notes document increased confusion, agitation, signs of dementia on the part of the patient with increasing familial issues. The MSW frequency remained at simply as needed with no update of the POC with the concerns raised by the clinicians visiting the patient. This was discussed with the DPCS.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization had not provided the patient with care, treatment, or services according to the patient's individualized plan of care. In the chart for HV#1, SN visits were ordered four times per week. The ordered frequency was not followed. Aide services were ordered twice weekly. No visits were made the first week of care; only one visit made week four of care. On at least one SN visit, when the LVN fully documented wound care, the order was not followed. The order included Calcium Alginate which was not included in the dressing change documentation. In the chart for RR#2, one note indicated the patients blood sugar was 397. There was no indication that the physician was made aware though the order was to report greater than 350. This was discussed with the DPCS.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization had not implemented the infection prevention and control activities it had planned. During HV#2, the clinician forgot paper towel and there were none in the home. He had to air dry his hands and turned off the water faucet using clean, bare hands at the beginning and end of the visit. The clinician missed a hand hygiene opportunity between glove changes during the wound care. Organizational policy Hand Hygiene required hand hygiene to be performed after removing gloves and also when washing with soap and water, ...dry the hands with a disposable towel...Use a dry disposable towel to turn off the faucet. This was discussed with the DPCS

Observed in Record Review. In 2 of 2 patient records reviewed, the hospice had not developed a bereavement plan of care that specified the type of bereavement services to be offered and the frequency of service delivery. In the charts for BR#1 and BR#2, the plans of care did not include the types and frequency of services offered. The bereavement counselor had a standardized template for what items are included in POC's based upon risk and documentation indicated this template is being followed for the bereaved parties, however neither charts contained a POC that included the required elements. This was discussed with the Nursing Supervisor.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization had not prepared written care instructions for the aide. In the charts for RR#3 and RR#5, the written aide plan of care did not include parameters for vital signs to inform the aide when to report findings to the RN. This was discussed with the DPCS.

Observed in Record Review. In 3 of 11 patient records reviewed, the patient record did not contain information that reflected the patient's care, treatment, or services. In the chart for HV#1 the patient record did not contain specific notes on care, treatment or services. The nursing staff was not documenting the wound care provided, rather a statement such as pressure wounds treated as per orders on each SN visit note. This same observation occurred in the charts for HV#2 and RR#1. This was discussed with the DPCS.

Observed in Record Review. In 2 of 3 patient records reviewed, in which the patient was discharged alive, the hospice discharge summary did not include: A summary of the patient’s stay, including treatments, symptoms, and pain management. The discharge summaries for RR#2 and RR#4 did not include this information as discussed with the DPCS.

Observed in Tracer Activities. In 1 of 3 contracts reviewed, The written agreement with the DME providing contracted services for the hospice did not include the following: A stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This was discussed with the DPCS.