Every finding on record at Commonspirit Oregon

Upon patient record review 3 of 19 (Patient #10, 11, 17) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 10: The patient was admitted on 7/21/23, the initial psychosocial assessment was completed on 8/8/23. Patient 11: The patient was admitted on 6/1/23, the initial spiritual care assessment was completed on 6/16/23 Patient 17: The patient was admitted on 10/29/22, the initial psychosocial assessment was completed on 11/23/22.

Upon patient record review 2 of 19 (Patient #6, 16) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 06: The patient was admitted on 9/19/22, there is no evidence in the patient record that a psychosocial evaluation was completed during the first benefit period. Patient 16: The patient was admitted on 10/13/22, there is no evidence in the patient record that a psychosocial evaluation was completed.

Upon patient record review, 6 of 19 (Patient #5, 6, 10, 16, 17, 19) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes 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 is considered in the bereavement plan of care. Patient 05: The patient was admitted on 6/8/23, there is no evidence in the patient record of an initial bereavement assessment. Patient 06: The patient was admitted on 9/19/22, the initial bereavement assessment was completed on 2/9/23. Patient 10: The patient was admitted on 7/31/23, the initial bereavement risk assessment was completed on 8/8/23. Patient 16: The patient was admitted on 10/13/22, there is no evidence in the patient record of an initial bereavement assessment. Patient 17: The patient was admitted on 10/29/22, the initial bereavement assessment was completed on 11/23/22. Patient 19: The patient was admitted on 7/19/23, there is no evidence in the patient record of the initial bereavement assessment.

Upon patient record review, 5 of 19 (Patient #2, 3, 12, 13, 15) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 02: The patient was admitted on 11/1/22 with evidence of a newly placed colostomy due to perforation of the bowel. The plan of care does not include a problem statement with interventions and goals for management of the colostomy. (Updated on site.) Patient 03: The patient was admitted on 5/8/23 with a related diagnosis of atrial fibrillation. The patient medication profile includes Eliquis 5mg twice daily for management, the patient also has a history of repeated falls. The plan of care does not include interventions and goals for the bleeding risk/precautions. (Updated on site.) Patient 12: The patient was admitted on 7/15/23 with a primary diagnosis of Alzheimer's disease, unspecified, the plan of care does not include a problem statement with interventions or goals for the neurological condition. The patient uses Xarelto due to a history of pulmonary embolus, the plan of care does not include bleeding precautions. Patient 13: The patient was admitted on 4/12/23 with a diagnosis of alcoholic cirrhosis of the liver with ascites, the patients abdominal girth was 109cm. The plan of care does not include interventions and goals for the management of ascites. (Updated on site.) Patient 15: The patient was admitted on 3/26/23 with a diagnosis of lung cancer. The record indicates that the patient has a history of hypoxia and respiratory failure with oxygen saturation 88%, the patient uses oxygen for symptom management. The plan of care does not include a problem statement with interventions or goals for the management of the respiratory distress. (Updated on site.)

Upon patient record review, 3 of 19 (Patient #4, 8, 13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 04: The patient record reflects that the patient has wounds to the right buttock and the left heel. Orders on 9/7/23 for wound care are combined and are not specific to each wound. (Corrected on site.) Patient 08: The orders on 9/13/23 for wound care to "Clean with soap/water, apply non-stick pad, apply border foam or border gauze; replace dressing Q5-7 days or prn if soiled/dislodged, does not specify the location of the wound. (Corrected on site.) Patient 13: Orders on 7/12/23 for wound management to areas on the right thigh and right buttock, the orders do not indicate the frequency of dressing changes. (Corrected on site.)

Upon patient record review, 2 of 19 (Patient #1, 4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 01: The documentation by the SN for 9/12/23 and 9/18/23 indicates that the patient utilizes an "electric hospital bed," this is not included in the DME plan of care. (Corrected on site.) Patient 04: The patient was admitted on 1/10/23 and the SN documentation indicates that the patient utilizes a hoyer lift to get out of bed. Hoyer lift instructions are also provided in the hospice aid task assignment information, the DME list does not include the hoyer lift. (Corrected on site.)

Upon patient record review, 6 of 19 (Patient #1, 2, 3, 8, 11, 12) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 01: The patient has a related diagnosis' of hypertensive heart disease with heart failure and congestive heart failure, he is noted to have edema to bilateral lower extremities with multiple medication changes for management. The plan of care does not include a problem statement with interventions for the management of the edema. The patients primary diagnosis is interstitial pulmonary disease, the plan of care does not include interventions to include the ongoing assessment of patients respiratory status, effectiveness of treatment and comfort. Patient 02: The patient record indicates the patient has ongoing bilateral lower extremity swelling ranging from 1-4+ edema and noted continually throughout the continuum of care. Medications such as furosemide and spironolactone have been utilized for symptom management, with ongoing treatment required. The plan of care does not include a problem statement with interventions and goals for the management of the edema. Patient 03: The patient record reflects that the patient has an ongoing issue with symptom management related to edema documented in most of the patient visits, ranging from 2+ - 4+, the patient takes furosemide 20 mg 1-2 pills daily. The plan of care does not include interventions and goals for the management of the edema. Patient 08: The patient is admitted to services for a diagnosis of metastatic urinary/renal cancer with evidence of pain requiring medication and dosage changes for comfort. The plan of care for pain management does not contain interventions for assessing and managing the pain. The patient has wound care orders initiated on 9/13/23, the plan of care does not include interventions for the wound care management. Patient 11: The patient received respite care services on 9/7/23 - 9/11/23, the plan of care was not updated to include need for respite coordination with the SNF, the interventions needed or the goals for respite services. Patient 12: The patient record indicates that the patient has a history of aggression, combativeness and anxiety as noted in SN documentation on 8/11/23 and 8/18/23. The patient was prescribed new medications (ABH gel) along with Seroquel for the management of the symptoms. The plan of care does not include a problem statement with interventions and goals for the management of the patients behavior.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program.

Upon observation, there was no evidence the hospice ensures that non-core services are provided to hospice patients and their families according to applicable laws and regulations. Non-core services include Physical Therapy, Occupational Therapy and Speech-Language Pathology. Upon request of the contract for therapy services or evidence of the ability to provide services, it was noted that the agency does not have a contract or employee services for Occupational Therapy or Speech-Language Pathology. (A contract for Therapy services was obtained on 9/21/23 to include OT and SLP services.)

Upon patient record review, 2 of 19 (Patient #12, 14) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • 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 as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 12: The patient uses Xarelto due to a history of pulmonary embolus, the HHA plan of care does not include bleeding precautions for the patient. (Corrected on site.) Patient 14: The hospice aide plan of care assigned only the task for bathing the patient, it does not include dressing, or other personal care. The patient is not able to perform those task independently and requires assistance. (Corrected on site.)

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. The hospice agency was unable to provide evidence of the Governing body minutes that reflect the involvement in the hospice's management and administration of the hospice services.

Upon observation, there was no evidence the hospice designates a physician to serve as Medical Director which includes: • The Medical Director must be a doctor of medicine or osteopathy who is an employee or is under contract. • When the Medical Director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the Medical Director. At the start of the survey, the agency was unable to provide a contract for an alternate Medical Director. A contract was received on the final day of the survey.

Upon patient client record review, 2 of 19 (Patient #1, 7) did not have evidence that each patient record contains Advance Directives. Patient 01: The patient was admitted on 5/5/23, the RN documented that the patient has completed a POLST form for his advanced directives, there is no evidence in the patient record of the completed POLST. Patient 07: The patient was admitted on 9/15/23, the patient record does not contain advanced directives. (Corrected on site.)

Upon client record review, 1 of 19 (Patient #5) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 05: The patients visit frequency for SN for hospice is 1x week. The patient did not receive a SN visit for the week of 9/3/23.

Upon patient record review, 1 of 19 (Patient #13) did not have evidence that the hospice provided the following information to the SNF: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient 13: During the home visit at the SNF it was identified that the SNF record does not contain the Hospice Election form. (Corrected on site.)