Every finding on record at Coler Hospice, Ltd

Observed in HR File Review. In 2 of 8 HR files reviewed, the organization had not provided initial education and training in emergency management. In the files for HR#2 and HR#7, there was no documentation of any training about the EM plan upon hire.This was discussed with the Administrator.

Observed in Record Review. In 5 of 5 patient records reviewed, for whom the hospice addendum was requested, the organization had not informed the patient of the patient rights in writing. In the charts for RRHV#1, RRHV#2, RRHV#3 RRNHV#7, the hospice addendum provided did not include information the patient’s right to immediate advocacy through the Beneficiary Family Centered Care-Quality Improvement Organization (BFCC-QIO) if they disagree with the determination which is a requirement of the notice per CMS regulation. In the chart for RRNHV#2, the patient/caregiver requested the addendum at admission, however there was no indication the addendum was provided. This was discussed with the Administrator.

Observed in Record Review. In 3 of 14 patient records reviewed, the written plan of care (POC) was not based on the patient's goals and the time frame required to meet those goals. In the chart for RRNHV#3, goals were not individualized to the patient and the patient's needs as all goals on the current POC have a target date of last day of the benefit period including Patient/caregiver will demonstrate necessary behaviors to maintain good safety awareness and minimize the risk of falls and/or injury for this patient who experienced a fall with a major injury during the previous benefit period and Patient will be pain free or verbalize an acceptable pain level with current pain management regimen for the patient with increasing pain management needs and frequent pain management adjustments to the POC. Also goals that were not measurable Pt will maintain optimal nutrition/hydration as disease process allows;. In the chart for RRNHV#10, for this pediatric patient on oxygen the care plan had no goals related to the safe use of oxygen. In addition, all goals were anticipated to be met on the last day of the benefit period, even medication safety related goals such as Patient/caregiver will verbalize understanding of the medications in the comfort pack. In the chart for RRNHV#5, all of the current goals are expected to be met on the last day of the of recertification benefit period and not individualized to an appropriate time frame for the issue. Examples included: Patient/caregiver verbalize/demonstrate proper skincare and Pt/CG can describe interventions to prevent skin breakdown on the recertification POC for patient with skin moisture issues and a need for Nystatin cream. The issues were first identified upon admission to the organization. This was discussed with the Administrator.

Observed in Record Review. In 3 of 14 patient records reviewed, the plan of care (POC) did not include all treatments necessary to meet the patient's needs. In the chart for RRNHV#2, the patient developed a wound after a fall. The RN applied hydrocortisone cream and a band-aid to the site. There was no order on the POC for this treatment. In the chart for RRNHV#5, the wound care order was missing the frequency that the wound care was to be performed. In the chart for RRNHV#7, during the week of the survey, the patient developed a wound which the RN cleansed and dressed. There was no order found for this treatment. This was discussed with the DON.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization had not developed a plan of care (POC) that included all of the services needed for the palliation and management of the terminal illness and related conditions. In the chart for RRNHV#4, there was no comprehensive POC for the admission benefit period nor the recertification benefit period. There were care plans with interventions and goals, however did not include the dressing supplies, hospital bed, transfer equipment, etc. that would be required for the patient. This was discussed with the DON.

Observed in Patient Home. In 1 of 4 home visits conducted, the organization had not implemented activities for the prevention and control of infections, including the use of standard precautions. During RRHV#2, the clinician wiped her used clinical equipment (BP cuff, thermometer, stethoscope, etc.) with Sani-wipes and immediately put the items back into the clinical bag. The manufacturers recommended wet time is 2 minutes. Additionally, the clinician did not wear gloves during the cleaning, yet the recommendation by the manufacturer is to wear gloves. This was discussed with the DON.

Observed in Data Session. The organization had not improved compliance with hand hygiene as it had not set goals for improving compliance as confirmed with the Administrator.

Observed in Record Review. In 3 of 3 patient records reviewed, the bereavement plan of care (POC) did not specify the type of bereavement services to be offered and the frequency of service delivery. In the charts for RRBR#1, RRBR#2 and RRBR#3, the bereavement POC's did not include the scheduled mailings, nor any phone contacts that are part of the bereavement program. This was discussed with the Bereavement Coordinator and Administrator.

Observed in Record Review. In 4 of 14 patient records reviewed, the comprehensive assessment did not include all required elements. In the charts for RRHV#2, RRHV#3, RRNHV#2 the spiritual care assessment did not include the patient and family spiritual orientation, including their desire for the involvement of a religious group; spiritual concerns or needs identified by the patient or family, such as despair, suffering, guilt, and forgiveness. In the chart for RRNHV#3, the initial Spiritual assessment - loss/coping stated not assessed; spiritual assessment marked not assessed; spiritual resources marked not assessed. This was discussed with the DON.

Observed in HR File Review. In 1 of 1 HR files reviewed, the hospice aide competency evaluation did not include the required elements. There were no initial documented competencies in the file for HR#4 as confirmed with the Administrator. Observed in HR File Review. In 1 of 1 HR files reviewed, the organization had not observed the required competencies for the aide by evaluating performance through written exam, oral exam, or after observation with a patient or pseudo patient, including: basic infection control procedures; basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor; maintenance of a clean, safe, and healthy environment; recognizing emergencies and knowing how to institute emergency procedures; the physical, emotional, and developmental needs of and ways to work with the populations served by the home health aide or hospice aide, including the need to respect the patient and their privacy and property; adequate nutrition and fluid intake; skills not covered in the basic checklist; other tasks that the organization may choose to have the aide perform as permitted under state law. There were no initial documented competencies in the file for HR#4. This was discussed with the Administrator. Observed in HR File Review. In 1 of 1 HR files reviewed, the organization had not evaluated the hospice aides performance of the tasks with a patient or pseudo-patient as part of a simulation: communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other staff; reading and recording temperature, pulse, and respirations; appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation;normal range of motion and positioning. This was discussed with the Administrator.

Observed in Record Review. In 2 of 10 patient records reviewed, the RN had not prepared written instructions for the aide consistent with the patient's condition. In the files for RRHV#1, and RRNHV#2, the aide plan of care (POC) included to trim the patient's fingernails and toenails, yet the patients are diabetic. Additionally, in the chart for RRNHV#2, the care plan was non-specific as to the type of bath to be provided and stated simply bath without clarification if this was tub, chair, bed bath. This was discussed with the DON.

Observed in Record Review. In 5 of 10 patient records reviewed, for whom aide services were ordered, the aide had not provided services as assigned on the plan of care. In the chart for RRNHV#1, on multiple visits, the aide completed only a portion of the tasks assigned and did not indicate why other tasks were not provided. As an example, the assignment included cleaning the patients living area, meal planning, assistance with meal prep, changing the linens an making the bed. These tasks were not provided at each visit. In the chart for RRHV#1, in multiple visits, the aide did not document the provision of all assigned tasks at each visit and the documentation did not include why all tasks were not completed. This included bathing, shampoo, nail care, peri care, etc. In the chart for RRNHV#3, in the week prior to the survey, the aide provided a bed bath, though a shower was assigned. Additionally, the aide was to document the last known bowel movement at each visit. There was only one entry in the month prior to the survey, and no entries the current month despite the aide seeing the patient twice weekly. In the chart for RRNHV#4, the assignment included shower, nail care and other homemaking tasks each visit; there were visits in the current benefit period that did not include all assigned cares. In the chart for RRNHV#7, not all cares were provided at each visit as assigned, for example laundry, bed bath. This was discussed with the DON

Observed in Record Review. In 1 of 10 patient records reviewed, for whom aide services were ordered, the aide was not supervised no less frequently than every 14 days. In the chart for RRNHV#1, 20 days lapsed between supervisory visits in the current benefit period. This was discussed with the Administrator.

Observed in HR File Review. In 1 of 1 HR files reviewed, a RN had not made an annual on-site visit to the location where the patient is receiving care in order to observe and assess each aide while the aide is providing care. In the file for HR#4, there was no supervisory visit for the previous year documented as confirmed with the Administrator.

Observed in HR File Review. In 1 of 8 HR files reviewed, the organization had not oriented its staff to key safety content including relevant policies and procedures including those related to infection prevention and control. In the file for HR#7, there was no documentation that the volunteer had been provided with infection control information including standard precautions and blood borne pathogens. This was discussed with the Administrator.

Observed in HR File Review. In 1 of 8 HR files reviewed, staff competence had not been initially assessed and documented. In the file for HR#7, there were no documented initial competencies as discussed with the Administrator. Observed in HR File Review. In 1 of 8 HR files reviewed, staff competence was not assessed annually as required by organizational policy. In the file for HR#7, there was no documented competency for 2025 as discussed with the Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, when a verbal order was received, staff had not sent it to the prescriber for signature. In the chart for RRNHV#1, the nurse obtained orders for wound care and updated the interventions on the POC, yet did not document the order for submission to the provider for signature. This was discussed with the Administrator.

Observed in Record Review. In 1 of 4 patient records reviewed, for the patient in a skilled facility, the hospice plan of care (POC) did not identify the care and services that were needed and did not identify which provider, the hospice or the facility, was responsible for the wound care the patient required. In the chart for RRNHV#4, there was no comprehensive POC developed and no orders found for the wound care that the RN documented was being provided by the skilled facility staff. This was discussed with the Administrator.

Observed in HR File Review. In 1 of 8 HR files reviewed, the organization had not obtained a criminal background check on the applicant as required by law and regulation. In the file for HR#2, there was no criminal background check documented. This was discussed with the Administrator.

Observed in Record Review. In 13 of 13 patient records reviewed, the organization failed to maintain a complete and accurate patient record. During record review for all records, the Hospice Nurse Surveyor observed the admission documents had not been completed. For example in HV#1 the doctor was not listed on the informed consent and cost was not filled out. The authorization to release information was blank except for the patient signature. The patient notice of non-coverage was signed, but was lacking the date and Dx of unrelated items. For HV#2, the EOB #9 and #10 sections were left blank and the patient did not date it, the photography consent had no patient date, the Patient Notice of Non-Coverage had no Dx or reason for non-coverage. The authorization release was not filled out, only signed. This was discussed and reviewed with the Hospice Team.

Observed in Regulatory Review. In 15 of 15 patient records reviewed, the organization failed to plan the patient's care. During record review for all records, the Hospice Nurse Surveyor observed all records reviewed each goal was to be expected to be achieved by the last day of certification. During record review for BR #1, the Hospice Nurse Surveyor observed there was no Plan of Care initiated and so there was no documentation of interventions based on the comprehensive assessment. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 1 of 15 patient records reviewed, the organization failed to plan the patient's care. During record review for BR#1, the Hospice Nurse Surveyor observed lack of an active Plan of Care. The patient had revoked hospice on 12/30 to go to the emergency room and returned onto service early hours of 12/31. EOB was signed and later that day an RN went out for symptom management and an initial assessment. The patient then passed away and a death visit was made. No care plan was initiated. This was discussed and reviewed with the DON.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned related to hand hygiene. During HV#1 and HV#2, the Hospice Nurse Surveyor observed the staff did not follow the hand hygiene policy. For example in HV#1, the RN was observed entering the clinical bag intermittently with bare hands without performing hand hygiene. For HV#2, the SW did not perform hand hygiene before beginning patient care. This was discussed and reviewed with the Hospice Team. Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to implement its infection prevention and control activities. During HV # 1, the Hospice Nurse Surveyor noted that the organization had not implemented activities to reduce risk of infection related to medical equipment. For example: the RN was observed to use her multi-use equipment including blood pressure cuff and pulse oximeter and then return them to her nursing bag without disinfection which was not in-line with the organizational policy. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 4 of 10 patient records reviewed, the organization failed to plan the patient's care. During record review for RR#3, RR#4, RR#8, and RR#9, the Hospice Nurse Surveyor observed the aide care plan was not prepared with all necessary instructions. For example RR#3, did not include risk for aspiration and had shower chair as type of bath. But Aide had been providing a bed bath since 4/17. The bath orders was changed to bed bath on 5/3. For RR#4, the aide care plan did not include fall precautions or instructions for the continuous oxygen during bath. For RR#8, the aide had orders to visit and did two visits but there was no aide care plan. In HV#9, a shower was ordered but on 4/6 a bed bath was provided, and on 4/11 and 4/18 the aide documented washed up on toilet but there was no documentation of notification to the RN or change in the shower order. This was discussed and reviewed with the Hospice Team.

Observed in HR File Review. In 1 of 1 HR files reviewed, the organization failed to document an annual on-site visit, to the location where the patient is receiving care, in order to observe and assess each aide while the aide is providing care. During HR file review for HR#3, the Hospice Nurse Surveyor observed the Aide had a documented competency assessment completed at hire but none documented for 2021 or 2022, as required by organizational policy and law/ regulation. This was discussed and reviewed with the Administrator.