Every finding on record at Community Care Hospice, Inc.

Observed in Record Review. In 3 of 5 patient records reviewed, the organization failed to ensure the patient record was complete, promptly, and accurately documented. For example: In RRNHV#1, RRNHV#3, and RRNHV#4 the IDG documentation noted a frequency for the spiritual counselor was for every certification period, yet the Chaplain's documentation noted monthly visits. These observations were reviewed with the Administrator.

Observed in Record Review. In 1 of 5 patient records reviewed, For active patients, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. For example: in review of RRNHV#1 there was documentation of a UTI however its presence was not reflected in the plan of care. This observation was reviewed with the Administrator.

Observed in HR File Review. In 2 of 2 HR files reviewed, for the Hospice Aide the organization failed to ensure the supervisor evaluates the required areas by observing the hospice aide's performance of the tasks with a patient or pseudo-patient as part of a simulation. On review of HR#1 and HR#2 the initial aide competency did not indicate that required tasks were evaluated by observation with a patient or pseudo patient. In HR#2 the competency was also not conducted by an RN. as the CEO was noted to be completing the competency for the Aide. This observation was reviewed with the CEO, and Administrator.

Observed in HR File Review. In 2 of 2 HR files reviewed, for the Hospice Aide, it was noted that there was no documentation of an annual on-site supervisory visit to the location where a patient was receiving care in order to observe and assess each aide while he or she was preforming care was performed. This observation was reviewed with the CEO, and Administrator.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization failed to ensure the patient record contain information that reflects the patient's care, treatment and services. For example: on review of RRNHV#1 and RRNHV#4 the LVN visit note from 8 days prior to survey was not submitted per organization policy, as it was found to be incomplete in the record.These observations were reviewed with the Administrator.

Observed in Leadership Session. the organization failed to ensure the written agreement with an outside agency providing contracted services for the hospice include 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, as the DME contract reviewed did not contain a stipulation for background checks. This observation was reviewed with the Administrator.

Observed in Record Review. In 5 of 5 patient records reviewed, for active patients, the organization did not develop a individualized written plan of care with goals that were specific, measurable, achievable, realistic, and time-bound. On review of all records reviewed many patient goals were noted to not time-bound. All goals were noted to have an achieve by date of the end of the benefit period, or the date of the next IDG meeting yet there was no correlation between the target date set and the established goals. In RRNHV#1 an example of a goal was Nurse will monitor the cardiac status of patient during every visit and will report findings to the MD, this goal is continuous. Throughout the records many of the stated goals were interventions such as assess for, observe, and educate. In RRNHV#2 example of goals were -Pt will maintain optimum peripheral circulation within 2 weeks from SOC date and The attending RN will educate the PCG on how to manage syncope episodes and proper teachings on fall risk and safety within 48 hours from the SOC date. Throughout all records reviewed the were not noted to be individualized, specific and measurable, with interventions listed as goals. Example in RRNHV#3 a goal was Provide end of life care education as part of the coping process and Will minimize episodes of confusion and forgetfulness. In RRNHV#4 example was -Prevent discomfort due to increasing edema and Pt will maintain optimum peripheral circulation. Assess / monitor cardiac status every visit. A psychosocial the goal was Feeling better, improve his memory and be more active. In RRNHV#5 examples of listed goals were Assess Pt. status for on-going care. -Blood sugar management for pt. comfort. These observations were reviewed with the Administrator, and CEO.

Observed in Record Review. In 2 of 5 patient records reviewed, For active patients, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRNHV#1 the patient was being seen by the MSW and Chaplain yet there were no psychosocial or spiritual care plans to guide the care. In RRNHV#4 the documentation noted issues with pain and a high fall risk, yet the issues were not reflected in the plan of care. These observations were reviewed with the Administrator.

Observed in HR File Review. In 2 of 2 HR files reviewed, for the Hospice Aide the organization failed to ensure the supervisor evaluates the required areas by observing the hospice aide's performance of the tasks with a patient or pseudo-patient as part of a simulation. On review of HR#1 and HR#2 the initial aide competency did not indicate that required tasks were evaluated by observation with a patient or pseudo patient. For HR#2 the competency was not conducted by an RN, as the CEO was noted to complete the initial competency. This observation was reviewed with the CEO, and Administrator.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to involve the patient in making decisions about their care, treatment, or services. For example: on RRNHV#8 and RRNHV#9 there was no indication on the record that the patient was informed of their right to receive the Medicare Notice of Non-Covered Items, supplies, and drugs, and the documentation was not found on the record. This observation was reviewed with the Administrator. Observed in Record Review. In 2 of 2 patient records reviewed, where patient was discharged live, the organization failed to ensure the patient's right to revoke hospice was in accordance with Medicare hospice regulations. For example: on review of RRDC#1 the discharge summary noted the patient wished to revoke hospice and revocation form for was presented for signature, however there was no signed revocation form found on the record. Later, the Administrator was able to contact the patient and obtain a copy of the signed revocation form, but was not on the record at the time of survey. Similar lack of revocation form was noted on RRDC#2. These observations were reviewed with the Administrator.

Observed in Record Review. In 5 of 10 patient records reviewed, the organization failed to ensure the hospice conduct conducts and documents a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. For example: on review of RRHV#2, RRNHV#5, RRNHV#6, and RRNHV#7 there was no documentation of a bereavement risk assessment as part of the initial comprehensive assessment. In RRHV#1 the initial comprehensive assessment did not include a fall risk assessment as required. These observations were reviewed with the Administrator.

Observed in Record Review. In 7 of 10 patient records reviewed, the organization failed to ensure the comprehensive assessment was updated by the hospice interdisciplinary group and consider changes that have taken place since the initial assessment. For example: or review of RRHV#1, RRHV#2, RRNHV#6, RRNHV#7, and RRNHV#8 there was no documentation on an update to the comprehensive assessment was completed as there was no IDG meeting documented since the 1st week in October to the date of survey greater than 15 days. In RRNHV#4 and RRNHV#9 there is documentation of an IDG meeting taking place, yet there was no documentation of updating the comprehensive assessment noted. Further, in RRNHV#6 the last RN comprehensive assessment documented was 22 days prior to survey, and in RRNHV#7 there was no documentation of an RN comprehensive assessment since the last week of September. These observations were reviewed with the Administrator.

Observed in Record Review. In 4 of 10 patient records reviewed, the organization failed to ensure the patient record was complete, promptly, and accurately documented. For example: In RRNHV#5, RRNHV#6, and RRNHV#7 the IDG documentation noted a frequency for the spiritual counselor was for 1 time and PRN, yet the Chaplain's documentation noted a follow up for the next month. In RRNHV#5 the care plan for pain noted the patient was taking hydrocodone, but the physicians order was for Tramadol. In RRHV#2 and RRNHV#7 the current physician's orders noted the hospice aide frequency of 2 times a week, yet the IDG documentation of frequency noted hospice aide was declined and no aide visits had taken place. In RRNHV#7 the MSW per the IDG frequency was 1 time and PRN yet the MSW's documentation noted the visits would be monthly. These observations were reviewed with the Administrator.

Observed in Record Review. In 10 of 10 patient records reviewed, for active patients, the organization did not develop a individualized written plan of care with goals that were specific, measurable, achievable, realistic, and time-bound. On review of all records reviewed the patient goals were noted to not time-bound. All goals were noted to have an achieve by date of the end of the benefit period, or the date of the next IDG meeting yet there was no correlation between the target date set and the established goals. In RRHV#2 an example of a goal was patient will maintain optimal peripheral circulation. Throughout the records many of the stated goals were interventions such as assess for, observe, and educate. In RRHV#3 example of goals were maintain optimal mobility and independence and minimize complications due to impaired mobility. Throughout all records reviewed the were not noted to be individualized, measurable and time bound, with interventions listed as goals. Example in RRNHV#6 a goal was Pt needs will be met on a day to day basis as communicated and Will minimize episodes of confusion and forgetfulness. In RRNHV#8 example was Increase strength/energy for functional activities.-Educate family about increase in pt. weakness & fatigue due to expected decline. In RRNHV#9 and example of a listed goals was - Check Oxygen saturation PRN during SN visits. -Identify SOB as effected by activity. -Instruct on sign and symptoms of impending exacerbation and how to manage. These observations were reviewed with the Administrator, CEO, and Office Manager.

Observed in Record Review. In 10 of 10 patient records reviewed, For active patients, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#1, RRHV#2, RRHV#3, and RRNHV#9 the patients were being seen by the MSW and Chaplain yet there were no psychosocial or spiritual care plans to guide the care. In RRHV#2 the documentation noted issues with anxiety and agitation, and a recent fall resulting in hospitalization, yet the issues were not reflected in the plan of care. In RRNHV#4 there was documentation of issues with pain and type 2 diabetes, yet no care plans for the issues. In RRNHV#5 there was documentation of issues with constipation and teaching of the use of a walker for safety but not reflected in the care plans. In RRNHV#6 documentation noted constipation and severe head ache/pain yet no GI or pain care plans open. In RRNHV#7, RRNHV#8 and RRNHV#9 the documentation demonstrated that pain was an ongoing problem for the patient but no care plan for pain established. In RRNHV#10 the documentation noted a boil on the patient's eye yet no care plan to drive the care related to the eye issue. During the home observation for RRHV#3 the SN was observed providing wound treatment to the patient's forearm, yet there were no specific orders for the care noted in the Plan of Care. These observations were reviewed with the Administrator.

Observed in Record Review. In 5 of 10 patient records reviewed, the organization failed to ensure the plan of care contain all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#2 an order as part of the plan of care read Blood sugar checks (how often and when) and as needed for signs and symptoms of hypo and hyperglycemia. The order did not specify how often and when, nor did it specify who was to perform the monitoring. In review of RRNHV#4 the documentation noted the patient was using diclofenac for pain yet there was no physicians orders for the medication on the med profile. In RRNHV#5 the documentation noted the patient was taking hydrocodone for pain, but there were no physicians orders for hydrocodone. In RRNHV#7 the physicians orders noted a knee brace in supplies, but the order failed to specify directions for use for the brace such as how long use and frequency. In RRNHV#9 the documentation noted the patient to be utilizing oxygen in the home yet there were no physicians orders for oxygen. Further in RRNHV#9 there was documentation from the SN that blood glucose was checked in the patient home, yet there were no physicians orders for blood glucose monitoring. These observations were reviewed with the Administrator.

Observed in Record Review. In 7 of 10 patient records reviewed, the organization failed to ensure the hospice interdisciplinary group review, revise and document the individualized plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. On review of RRHV#1, RRHV#2, RRNHV#6, RRNHV#7, and RRNHV#8 the last IDG meeting documented was noted to be the 1st week of October. In discussion the Administrator noted that the IDG team had met last Wednesday yet there yet there was no documentation of the review. In review of RRNHV#4, and RRNHV#9 there was documentation of an IDG meeting taking place however there was no documentation in the IDG meeting note that the individualized plan of care was reviewed or revised. These observations were reviewed with the Administrator.

Observed in Record Review. In 5 of 10 patient records reviewed, the failed to ensure the are and services were provided in accordance with the patient's individualized plan of care. For example: On review of RRNHV#5 the LVN was ordered a frequency of every 2 weeks yet there was no visit documented the 1st week of October as ordered. In RRNHV#6 the LVN was ordered weekly patient visits yet there were no visit documented since the last week of September. The RN was ordered a frequency of every 2 weeks but no visits documented since the 1st week of October. In RRNHV#7 the LVN was ordered weekly yet no documented visits to date of survey since the 1st week of October, and the RN was ordered every 2 weeks but no documented visits since the last week of September. In RRNHV#9 the Chaplain was declined per the IDG but a spiritual visit was made to the patient at recertification. Further the MSW was ordered a frequency of every 2 weeks but no visits had been documented since the initial assessment nearly 3 months ago. In RRNHV#10 the Chaplain was ordered 1x and PRN, but a spiritual visit was made at recert, and the LVN was scheduled weekly but no visit was made last week. These observations were reviewed with the Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to implement infection prevention and control activities when cleaning and performing disinfection of medical supplies and devices per manufacturer guidelines and policy. On RRHV#1, and RRHV#3 the SN cleansed equipment after use with Lysol wipes and did not allow for the recommended wet time before replacing equipment in bag. The nurses cleansed the equipment and promptly returned to the bag. The organizations policy specifies alcohol for cleansing of equipment. This observation was reviewed with the Administrator.

Observed in HR File Review. In 1 of 1 HR files reviewed, for the Hospice Aide the organization failed to ensure the supervisor evaluates the required areas by observing the hospice aide's performance of the tasks with a patient or pseudo-patient as part of a simulation. On review of HR#6 the initial aide competency did not indicate that required tasks were evaluated by observation with a patient or pseudo patient, nor was the competency conducted by an RN, as the CEO was noted to be completing the competency for the Aide. This observation was reviewed with the CEO, and Administrator.

Observed in HR File Review. In 1 of 1 HR files reviewed, for Hospice aides and in discussion with organization leadership, there was no documentation of hospice aide education over the last 12 months. The leadership was able to present a binder with aide in-service courses, but acknowledged that the org did not have documentation that the education was provided. This was reviewed with the CEO, and Administrator.

Observed in Record Review. In 1 of 1 patient records reviewed, where hospice aide services were being provided, the organization failed to ensure the registered nurse supervises the hospice aide during an on-site visit to the patient’s home no less frequently than every 14 days. On review of RRHV#1 there was a greater than 14 day gap between documentation of aide supervisory visits as the last documented supervisory was noted to be in mid September. This observation was reviewed with the CEO, and Administrator.

Observed in HR File Review. In 1 of 1 HR files reviewed, for the Hospice Aide it was noted that an annual supervisory was documented yet the supervisory form did not indicate where and how the visit was performed. Further the visit form was completed by the CEO who was not an RN. This observation was reviewed with the CEO, and Administrator.

Observed in Tracer Activities. the organization failed to document and demonstrate viable and ongoing efforts to recruit and retain volunteers. On discussion with the Administrator serving as Volunteer Coordinator the organization was not actively recruiting volunteers and there was no documentation of efforts.

Observed in Leadership Session. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by the leadership did not ensure that the Conditions of Participation for 418.100, 418.116, 418.56, 418.76 and 418.54 were met per policy as determined through observations, documentation, and staff interviews.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to ensure that before the recertification period for each patient, the medical director, physician member of the interdisciplinary team, or physician designee reviews the patient’s clinical information. On review of RRHV#1 the CTI for certification #5 that began 3 days prior to survey was not completed by the hospice Medical Director. In RRNHV#9 the CTI for benefit period 2 that began 1 week prior to survey was not completed and signed to indicate the physician had reviewed the clinical information for the next recertification period. These observations were reviewed with the CEO, and Administrator.

Observed in Record Review. In 8 of 10 patient records reviewed, the organization failed to ensure the patient record contain information that reflects the patient's care, treatment and services. For example: on review of RRHV#2 the LVN visit note from 14 days prior to survey was not submitted per organization policy, as it was found to be incomplete in the record only containing a time in and time out. In RRHV#3 there was an RN visit note that was 12 days past visit date and continued to be incomplete in the record. There were no vital signs recorded, no review of systems, nor was there a narrative or a signature. In RRNHV#4 all 3 RN visits to date were incomplete in the record with only a time in and time out. Further, incomplete clinical records can be seen in RN notes in RRNHV#5, RRNHV#8 and RRNHV#9 from week 2 of October. In RRNHV#6 the MSW initial assessment, and LVN note the last week of September were incomplete. Additional SN incomplete notes were noted in RRNHV#7 the last week of September and 1st week of October. These observations were reviewed with the Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed, for live discharge, the organization failed to ensure the discharge summary include all of the required elements. In review of RRDC#1 and RRDC#2 the discharge summary noted the reason for discharge, but did not include a summary of care, treatment, or services it provided to the patient, nor the patient's progress toward goals. This observation was reviewed with the Administrator.

Observed in Competency Session. In 1 of 4 contracts reviewed, the organization failed to ensure the written agreement with an outside agency providing contracted services for the hospice include 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, as the DME contract reviewed did not contain a stipulation for background checks. This observation was reviewed with the Administrator.

Observed in Record Review. On review of the clinical record, it was noted that the organization clinicians were engaged in performing waived testing for blood glucose monitoring. In RRHV#2 there were physician orders for blood glucose monitoring and in RRNHV#9 there was documentation in the record of the SN performing blood glucose monitoring in the patient's home. On RRHV#3 interview with the patient daughter, she described a typical SN visit and noted that the SN obtains blood glucose in the home during visits. Review of policy for waived testing noted that the organization will perform waived testing in the patient home. Upon discussion with the Administrator the organization had not obtained a CLIA waiver.