Every finding on record at Coastal Hospice, Inc.

Observed in Data Session. Based on a review of the performance improvement plan provided to the surveyor by the PI educator, there was no comprehensive document that identified the frequency and detail of indicators that were approved by the governing body. For example, medication errors, adverse events, and contract oversight were not identified and therefore the frequency of reporting of these items were not identified and or approved.

Observed in Infection Control Tracer. In 1 of 1 home visits conducted, the hospice did not follow its infection control policy. The RN in RR#1 was observed doing wound care. RR#1 had multiple wounds on bilateral arms. The RN was observed cleaning used scissors off with her gloved hand and then proceeded to apply a dressing to the right arm without changing her gloves and or disinfecting her hands. Similarly, the nurse was observed removing a soiled dressing and then applied a clean dressing to the left arm. The RN did not change her gloves and or disinfect her hands prior to applying the clean dressing. This observation was discussed with the PI educator.

Observed in Infection Control System Tracer. Based on a review of the available infection control data and discussions with PI educator identified infections were not prioritized therefore this goal was not addressed.

Observed in Tracer Activities. This observation was based on a review of the available data and by discussions with the director. The organization has not provided continuous care in the home in over three years. Per leadership, based on the patient population characteristics, this service is not requested and or needed. Based on a review of the admission data given to patients, there was no description of continuous care included in the packet nor was there any documentation in the admission note advising patients that this service was available in RR#1, RR#2, and RR# who were all admitted within the last two weeks.

Observed in Tracer Activities. Based on a review of the temperature logs related to prepared food kept for the current month, there was data missing. Per the PI educator, meals were served to patients three times per day at the Berlin site. There were three days listed on the log that the temperature was checked only once per day, and the rest of the days the temperature was only checked twice per day. There were no comments and or additional documentation noted for the missing data.

Observed in Leadership Session. Based on discussions with the director and a review of the admission data given to patients, the Hospice did not educate patients on all of the covered services. The admission packet did not describe and or address continuous care in the home. The other levels of care were described which included respite, routine, and general inpatient services

Observed in Individual Tracer. In 1 of 18 patient records reviewed, the hospice did not reassess patients based on clinical changes. RR#3 was placed on an inhaler for congestion. The interdisciplinary group immediately following this change in treatment did not specifically document the effectiveness of the new treatment. This observation was discussed with the director,

Observed in Individual Tracer. In 4 of 18 patient records reviewed, the hospice care plan did not include measurable and or time bound goals. RR#3 had a wound that required care and the goal that addressed this wound reflected- the wound would heal during the admission. The goals listed on the care plans for RR#7, RR#8, and RR#9 were not time bound. This observation was discussed with the director.

Observed in Individual Tracer. In 3 of 18 patient records reviewed, the Hospice comprehensive care plan did not include all of the interventions to manage patient symptoms. RR#7 was provided a comfort kit and there was no interventions on the care plan that addressed instruction of the patient/caregivers in these emergency medications. RR#8 had a Foley and the care plan did not include the balloon size of the catheter. RR#9 had a stage 4 decubiti that had orders for daily wound care. The RN was visiting twice per week and there was no indication on the care plan who was doing the wound care and or interventions related to teaching family how to do wound care. This observation was discussed with the director.

Observed in Data Session. During the Data Session, the surveyor noted that the organization had not developed a hospice wide data driven quality assessment and performance improvement plan (QAPI). There was no evidence that the governing body had ensured that a program was in place and that all services provided (including those services furnished under contract) were included. Observed in Data Session. During the data session, the surveyor noted that the organization did not have a quality assessment and improvement plan (QAPI). There was no evidence that the organization had developed, implemented and maintained an effective, ongoing hospice wide data driven quality improvement program. The organization had collected raw data, but the data had not been aggregated and analyzed to drive process improvement. This observation was discussed with the Chief Clinical Officer at the time of discovery.

Observed in Data Tracer. During the Data Session, the surveyor noted that the organization did not have a quality assessment and performance program that addresses palliative outcomes. The organization was not collecting data related to palliative outcomes. This finding was discussed with the Chief Clinical Officer.

Observed in Data Session. During the Quality Assurance Process Improvement Session, the surveyor noted that the organization's governing body does not approve the frequency and detail of the data collection. The organization collects data, but the governing body does not approve the detail or the frequency of the data collected. This finding was discussed with the Chief Clinical Officer at the time of the observation.

Observed in Data Session. During the Data Session, the surveyor noted that the organization had not tracked and trended data relating to palliative outcomes, patient safety and the quality of care provided. Therefore, the organization was not able to determine its high-volume, high-risk and problem prone areas and develop performance improvement activities accordingly. This observation was discussed with the Chief Clinical Officer at the time of discovery.

Observed in Data Session. During the Data Session, the surveyor noted that the organization completed performance improvement projects without having measurable progress goals. The organization had no quantified data to support the goals of the performance improvement projects. For example, one project had a goal of 100% compliance with hand hygiene, but there was no goal number of observations, there was no data to demonstrate current compliance and the data collected during the project had not been quantified/analyzed/trended . This finding was discussed with the Chief Clinical Officer at the time of the observation.

Observed in Tracer Activities. During the data session, the surveyor noted that the organization had not developed a performance improvement plan. The leadership had not set priorities for data collection, performance improvement activities and patient health outcomes. The organization had not identified high-volume, high-risk, or problem prone processes for performance improvement activities. This finding was discussed with the Chief Clinical Officer at the time of discovery.

Observed in Individual Tracer. In 2 of 6 home visits conducted, the hospice nurse did not adhere to the Hand Hygiene Policy # PC_125 . The RN in RR#3 was observed cleaning pulse oximeter off with gloves on and then assessed patient without removing gloves or disinfecting hands. Additionally, the RN was observed cleaning the blood pressure cuff/stethoscope and proceeded to assess the patient without first removing the gloves and or disinfecting hands. The RN for RR#1 was observed entering and reentering her nursing bag to retrieve reusable items such as a tape measure without first washing her hands. This observation was discussed with the director.

Observed in Infection Control Tracer. Based on a review of the available data and confirmed with discussions with the director, there was no measurable goal that addressed limiting infections related to medical equipment, devices, and supplies. Observed in Infection Control System Tracer. Based on a review of the available data and confirmed with discussions with the director, there was no goal or measurable goals that addressed limiting infections related to procedures. Observed in Infection Control System Tracer. Based on a review of the available data and confirmed with discussions with the director, the Hospice did not have a prioritized risk assessment therefore there was no goal to address this risk.

Observed in Leadership Session. This observation was based on a review of the available data and by discussions with the director. The organization has not provided continuous care in the home in over three years. Per leadership, based on the patient population characteristics, this service is not requested and or needed. Based on a review of the admission data given to patients, there was no description of continuous care included in the packet.

Observed in Individual Tracer. In 4 of 4 patient records reviewed, that had hospice aide service, did not have a comprehensive aide care plan based on the patient assessment. RR#3 required assistance to ambulate and was on a blood thinner. The aide care plan of RR#3 reflected that the patient could receive a bed bath and a shower, and a shave. There was no further qualification of the shower (for example the use of a shower chair), and bleeding precautions was not reflected on the care plan. Based on the RN assessment RR#1 was at risk for aspiration and this risk was not reflected on the aide care plan. RR#2 had a wound and was on aspiration precautions and neither precaution was on the aide care plan. RR#4 was identified as a fall risk and this precautions was not reflected on the aide care plan This observation was discussed with the director.

Observed in Tracer Activities. In 1 of 2 volunteer records reviewed, there was no evidence that a volunteer had received orientation and training relating to the hospice philosophy consistent with the organization's orientation and training policy. This finding was discussed with the Chief Clinical Officer at the time of the observation.

Observed in Tracer Activities. During the review of volunteer services, the surveyor noted that the organization had not provided volunteer services in day to day administrative or direct patient care in an amount that equals 5% of the total patient care hours of all paid hospice employees and contracted staff. During the time period of January 1, 2024 and March 15, 2024 the volunteer hours amounted to 1.28% of all paid hospice employees and contracted staff. This finding was discussed with the Volunteer Manager and the Chief Clinical Officer at the time of the observation.

Observed in Leadership Session. Governance did not provide for the resources needed to maintain safe, quality care, treatment or services as evidenced by condition level deficiencies with COPs): 418.58, 418.64, 418:60, 418.100, 418.110.

Observed in Patient Home. In 2 of 6 patient records reviewed, the medication record did not reflect what was on the medication administration record located in the skilled nursing facility. There were discrepancies noted for an oral narcotic, a topical anesthetic, medications to treat constipation, mood, breathing, and secretions. RR#2 also had medication discrepancies. The following medications were not listed on the medication administration record however were on the hospice medication list- a muscle relaxant, antianxiety medication, a stool softener, and an antidepressant. Additionally, morphine was listed as every 2 hours prn on the medication administration record however the hospice record reflected that it should be given every hour prn. RR#6 was taking an iron supplement twice per day, the hospice medication record reflected that it was taking daily. Per RR#6, she never took a scheduled medication for acid reflux. This observation was discussed with the Director.

Observed in Individual Tracer. In 2 of 2 patient records reviewed, that were admitted to the hospital, the Hospice did not provide the receiving facility a copy of the transfer/discharge summary. Both RR#12 and RR#13 were transferred and discharged to the hospital and the discharge summaries were not sent to the hospital. This observation was discussed with the director.

Observed in Individual Tracer. In 6 of 6 home visits conducted, the Hospice did not provide patients with an individualized emergency management plan based on emergency risk score. RR#1-RR#6 did not have an individual emergency plan in the home. Based on discussions with the director, emergency evacuation is discussed with patient/family however they have not document and or left individualized emergency plans for patients.

Observed in Tracer Activities. In 1 of 2 tracers conducted, the Hospice did not comply with fire protection features designed to minimize the effect of smoke. The undercut on the fire door located on the IPU unit was greater than 2. This observation was discussed with the facility manager. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.

Observed in Building Tour. In 1 of 2 tracers conducted, the Hospice did not implement its policy regarding the storage of oxygen cylinders. The surveyor observed in the clean utility room of the IPU, an unlabeled e-tank comingled with a set of full oxygen tanks that were designated as full. Per the facility manager and the RN manager, this e-tank was actually empty.

Observed in Building Tour. The Hospice did not have a record of the testing of the temperature of the water, that is supplied to patient rooms. This observation was discussed with the facility manager.

Observed in Tracer Activities. In 2 of 2 tracers conducted, the Hospice did not ensure that food was stored under sanitary conditions. There were multiple expired food items located in the refrigerator which included a bottle of mustard and salad dressing. Additionally, there were opened, unlabeled food items (that contained multiple servings) observed in the refrigerator and the freezer. These items included; two bags of French Fries, Greens, and Fish Sticks. This was not consistent with policy #13285118. This was discussed with the facility manager and kitchen personnel. Observed in Building Tour. Based on a review of the available data, discussions with the facility manager, and kitchen personnel, the Salisbury Hospice IPU did not routinely monitor the temperatures of prepared food prior to serving food to patients. This was not consistent with policy #14256837 titled- Temperature Monitoring.

Based on the review of patient clinical records, the agencys home health aides failed to complete patient visit frequencies as ordered within the patients plan of care. The missed visits were undocumented on 7 out of 13 records reviewed. This placed the patients at risk of not meeting outcome goals and at risk for delays in appropriate treatments and care. --- Patients: #2, #5, #6, #7, #11, #12, and #13 Findings included: On 9/20/2023 and 9/21/2023, during clinical record review for the patient records listed above, the home health aides missed visits, in some instances multiple visits. There is no documentary evidence in any of the patients clinical records to indicate why the visits were missed. 2. On 9/20/2023 at 1:00 PM, an interview with the agencys administrative staff revealed that the home health aides are no longer allowed to complete self-scheduling due to a problem that was found with this process.

Based on a review of personnel records, an interview with the agency's administrator, and a review of the policies/procedures, the agency's administration did not obtain the required tuberculosis (TB) screening records for 2 out of 11 employees reviewed. Tuberculosis is a communicable disease (contagious and infectious), and the staff not having the appropriate testing placed the staff and patient population at risk of exposure to this disease. --- Findings included: 1. On 9/20/23, a review of the personnel files revealed no documentary evidence of tuberculosis screening for two direct care staff. 2. During an interview on 9/20/23 at 1:00 p.m., the agency's administrative staff acknowledged that the information was not in the files. 3. Reviewing the agency's policy confirmed: "The supervisor will obtain evidence of prior PPD testing or a negative chest x-ray at the start of employment."

Based on a review of records and interviews with staff, it was determined that the facility's leadership and staff failed to provide a safe and hazard-free environment by not conducting exercises to test various emergency scenarios in the facility's Emergency Program. This deficiency has an increased risk for harm to patients, visitors and staff during an emergency incident. --- The findings include:During the survey on April 20, 2023 between 12:45 PM and 4:30 PM, while reviewing the facility's documentation, there was no records of any emergency drills to test the facility's Emergency Program and Emergency Preparedness Plan. Various drills and scenarios should be exercised to test and observe staff reactions and response to emergency incidents that may occur in the facility. This finding was acknowledged by the Chief Clinical Officer, Director of Quality, Stansell Manager, and Facilities Coordinator during the exit conference.

Based on observation of the physical environment, a review of records and interview with staff, it was determined that the facility's leadership and staff failed to provide a safe and hazard-free environment by not conducting an annual (90 minutes) test of the facility's battery-operated emergency lights. Failure of the battery-operated emergency lights to operate properly has an increased risk for harm to patients, visitors, and staff in the event of a power failure, fire or other emergency. --- The findings include:During the survey on April 20, 2023 between 12:45 PM and 4:30 PM, while reviewing the facility's documentation, there was no record indicating an annual test of the battery-operated emergency lights was conducted in the previous twelve months.This finding was acknowledged by the Chief Clinical Officer, Director of Quality, Stansell Manager, and Facilities Coordinator during the exit conference.

Based on a review of records, interviews with staff and observations of the physical environment, it was determined that the facility's leadership and staff failed to provide a safe and hazard-free environment by not conducting an annual (90 minutes) test of the facility's illuminated exit signs. Failure of the illuminated exit signs to operate properly has an increased risk for harm to patients, visitors, and staff in the event of a power failure, fire or other emergency. --- The findings include:During the survey on April 20, 2023 between 12:45 PM and 4:30 PM, while reviewing the facility's documentation, there was no record indicating an annual test of the facility's illuminated exit signs was conducted in the previous twelve months.This finding was acknowledged by the Chief Clinical Officer, Director of Quality, Stansell Manager, and Facilities Coordinator during the exit conference.

Based on the review of patient clinical records, staff personnel files, and interviews with the agency's administrative staff, a non-certified employee was signed off by the agency's RN in the task of medication administration. This practice of not verifying staff certifications placed the agency's patients at risk for unsafe outcomes. --- Patient #1 and Employee #1 Findings included: A review on 12/07/2022 of employee #1 personnel file revealed on 11/3/2022, a certified medication technician (CMT) medication pass observation occurred with medications being administered to patient #1 by the uncertified staff. Observation of the medication pass occurred and was signed off by the agency's RN. There is no documentary evidence of an active CMT certification from the Maryland Board of Nursing in employee #1's personnel file. A review of the employee's personnel file revealed employee #1 was hired with a start date of 06/27/2022 as a certified nursing assistant and signed the job description for a hospice aide. An interview of the agency's administrative staff on 12/07/2022 at 1:00 pm revealed that the Aide was applying for the medication technician certification. The status of the certification was unknown at the time of the survey. A review of the Maryland Board of Nursing listed that the Aide's CMT certification expired on 10/28/2019. A review of the agency's "Employee Handbook" revealed that "employees are responsible for obtaining their license and certification, keeping it current, and providing a copy to Human Resources for their personnel file each time it is updated." Employers must verify employee certifications to validate that the employee has received the specialized knowledge.