Every finding on record at Contigo Hospice LLC

Observed in Record Review. In 1 of 3 patient records reviewed, the hospice surveyor noted that the plan of care did not include all the needed treatments for the management of the patient's assessed needs. Following record review (RR#2) of a patient with a Pleurx drainage chest tube, the surveyor noted that the plan of care/orders did not include a frequency order for the drainage of the catheter nor was there anything related to the care and dressing of the site around the chest tube. This was confirmed with the Administrator.

Observed in Individual Tracer. In 10 of 10 patient records reviewed, and in discussion with the Volunteer Coordinator and Administrator, the surveyor noted the organization failed to document it had assessed and offered volunteer services. The Volunteer Coordinator stated that the services were not assessed or offered at this time due to the pandemic. She stated the families are not receptive to additional services, however this communication was not documented in the clinical record, the IDG notes or in a communication note. This was validated by the Coordinator and the Administrator.

Observed in Individual Tracer. In 2 of 10 patient records reviewed, HV1, RR3 the organization had not assessed potential medication related problems. For example, the surveyor noted the RN placed a current medication profile in the home folder upon arrival to the home. The medication list the nurse had with her, was reconciled against medication bottles in the home. The nurse reviewed medication changes with the spouse, including refills needed and changes made by spouse due to cost/preference. However, there were medications present on admission (Trulicity) and at the time of the previous RN visit that were not in the patient record list or on a medication list in the home. In addition, the changes in several medications were not assessed or discussed regarding the impact. RR3 there was no documentation regarding the effectiveness of the antibiotic treatment or the patient's response to the medication. The patient was prescribed antibiotic medications (11/29/21), however, there was no documentation in the subsequent skilled nursing notes regarding the effectiveness of the antibiotic as the notes indicated there were no new medications. The IDG notes did not include any documentation regarding the symptoms leading to the antibiotic, the effectiveness or response to the treatment or updated plan of care. This was validated by the ADON.

Observed in Individual Tracer. In 1 of 10 patient records reviewed, In 1 of 10 patient records reviewed, RR 3, during the record review, the surveyor noted the organization had not shown evidence it had collaborated in their efforts to support the plan of care. RR3 for example, the patient was prescribed antibiotic (11/22/21). There was no documentation in the clinical record regarding the reason for the antibiotic. There was no documentation in the skilled visit note or a communication note that the nurse collaborated with the ADON regarding symptoms and intervention. There was no documentation that the physician had been called to report the change in condition or documentation in the IDG notes regarding the symptoms related to the medication. In addition, neither the subsequent nursing notes or IDG notes reflected awareness of the new medication. This was validated by the ADON who stated the communication had occurred, but they had failed to document the reasons and the subsequent collaboration with the physician and IDG.

Observed in HR File Review. In 3 of 3 hospice aide personnel files, HR 4, HR5 , HR 11, during personnel file review, the surveyor noted the organization failed to demonstrated the hospice aides had successfully completed a competency evaluation program. For example, there were no competencies documented in the files for the hospice aides. This was validated by the Administrator.

Observed in Leadership Session. The Governing body/leadership did not ensure the following Conditions of Participation were met as determined through observations, documentation and staff interviews: 418.54 , 418.76, 418.100

Observed in HR File Review. In 3 of 8 eligible personnel files, HR7, HR8, HR10, in 3 of 8 eligible HR files reviewed, the surveyor noted there was no evidence of clinical competencies for the Medical Director; Medical Social Worker or Spiritual Care Counselor. There was no documentation of competency conducted for the Medical Director. The MSW and Spiritual Care Counselor had initial self assessment documents in the record but no verification by peer. The surveyor noted the DON and Volunteer had documentation of clinical competencies conducted since prior survey. This was validated by the Administrator.

Observed in Individual Tracer. In 1 of 2 home visits conducted, HV1, during the home visit the surveyor noted the patient's record failed to demonstrate it contained the following clinical information: A list of medications, including dose, strength, frequency, route, date and time of administration for prescription and nonprescription medications, herbal products, and home remedies that relate to the patient's care, treatment, or services. For example, the patient was admitted four weeks prior to the survey, however, the medication list did not include Trulicity 10 mg 1/week which according to the wife, was ordered September 2021 and patient had been taking at the admission date. In addition, the patient was started on Albuterol Sulfate inhaler three weeks prior to the survey visit (1/29/22), however, the medication list was not updated to include the medication. The RN had made a home visit for her comprehensive assessment one week prior to survey date, which was after the date the medication had been ordered. The wife stated the patient had resumed taking the medication at that time. This was not compliant with the organization's Medication List and Monitoring policy which states the medication monitoring will include appropriate date /information to develop an accurate patient medication history and complete medication profile. (V). The ADON indicated medication reconciliation and documentation was required every 60 days. This was validated by the ADON/RN.

Observed in Individual Tracer. In 2 of 3 discharge patient records, During record review, the surveyor noted the organization had not demonstrated, when the patient revoked services or was discharged, that they had sent the attending physician a copy of the hospice discharge summary and, if requested, a copy of the patient’s clinical record. For example, RR9, RR 10 discharge records, there was no documentation that a discharge summary had been sent to the receiving provider or the attending physician. This was validated by the ADON.

Observed in Individual Tracer. In 10 of 10 patient records reviewed, During clinical record reviewed and in discussion with the Volunteer Coordinator and Administrator, the surveyor noted the organization failed to document it had assessed and offered volunteer services. The Volunteer Coordinator stated that the services were not assessed or offered at this time due to the pandemic. She stated the families are not receptive to additional services, however this communication was not documented in the clinical record, the IDG notes or in a communication note. This was validated by the Coordinator and the Administrator.

Observed in Individual Tracer. In 2 of 10 patient records reviewed, HV1, RR3 the organization had not assessed potential medication related problems. For example, the surveyor noted the RN placed a current medication profile in the home folder upon arrival to the home. The medication list the nurse had with her, was reconciled against medication bottles in the home. The nurse reviewed medication changes with the spouse, including refills needed and changes made by spouse due to cost/preference. However, there were medications present on admission (Trulicity) and at the time of the previous RN visit that were not in the patient record list or on a medication list in the home. In addition, the changes in several medications were not assessed or discussed regarding the impact. RR3 there was no documentation regarding the effectiveness of the antibiotic treatment or the patient's response to the medication. The patient was prescribed antibiotic medications (11/29/21), however, there was no documentation in the subsequent skilled nursing notes regarding the effectiveness of the antibiotic as the notes indicated there were no new medications. The IDG notes did not include any documentation regarding the symptoms leading to the antibiotic, the effectiveness or response to the treatment or updated plan of care. This was validated by the ADON.

Observed in Individual Tracer. In 1 of 10 patient records reviewed, RR 3, during the record review, the surveyor noted the organization had not shown evidence it had collaborated in their efforts to support the plan of care. RR3 for example, the patient was prescribed antibiotic (11/22/21). There was no documentation in the clinical record regarding the reason for the antibiotic. There was no documentation in the skilled visit note or a communication note that the nurse collaborated with the ADON regarding symptoms and intervention. There was no documentation that the physician had been called to report the change in condition or documentation in the IDG notes regarding the symptoms related to the medication. In addition, neither the subsequent nursing notes or IDG notes reflected awareness of the new medication. This was validated by the ADON who stated the communication had occurred, but they had failed to document the reasons and the subsequent collaboration with the physician and IDG.

Observed in Individual Tracer. In 1 of 1 home visits conducted, HV1, during the home visit the surveyor noted the organization failed to ensure the organization implemented its infection prevention and control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection. For example, HV1 during the home visit the surveyor noted the RN placed the backpack directly on the floor without a barrier. The bag remained open during the visit. This was not compliant with the organization's Bag Technique Policy IC#12. E #V which states the bag is placed on a clean safe surface in the home....a barrier is to be placed under the bag. Bags should never be placed on the floor. This was validated by the ADON/RN.

Observed in HR File Review. In 3 of 3 hospice aide personnel files, HR 5, HR6, HR11 during personnel file review, the surveyor noted the organization failed to demonstrate it the hospice aides had successfully completed a competency evaluation before providing patient care. There was no skills competency documents in the files. There was a blank competency checklist form that was not completed or signed by a registered nurse in the personnel files. This was validated by the Administrator.

Observed in Leadership Session. The Governing Body/leadership failed to ensure that the following Conditions of Participation were met as determined through observations, documentation and staff interviews: 418.54, 418.100.

Observed in HR File Review. In 3 of 8 eligible personnel files reviewed, HR7, HR8, HR10, in 3 of 8 eligible HR files reviewed, the surveyor noted there was no evidence of clinical competencies for the Medical Director; Medical Social Worker or Spiritual Care Counselor. The MSW and Spiritual Care Counselor had initial self assessment documents in the record but no verification by peer. The surveyor noted the DON and Volunteer had documentation of clinical competencies conducted since prior survey. This was validated by the Administrator.

Observed in Individual Tracer. In 1 of 2 home visits conducted, HV1, during the home visit the surveyor noted the patient patient record failed to demonstrate it contained a list of medications, including dose, strength, frequency, route, date and time of administration for prescription and nonprescription medications, herbal products, and home remedies that relate to the patient's care, treatment, or services. For example, HV1 the patient was admitted four weeks prior to the survey however, the medication list did not include Trulicity 10 mg 1/week. The wife reported it was ordered September 2021 and that the patient had been taking the medication since September. In addition, the patient resumed Albuterol Sulfate inhaler (1/29/22), three weeks prior to the survey visit and the RN assessment visit dated one week prior to the survey visit. The medication list was not updated to include these medications. This was not compliant with the organization's Medication List and Monitoring policy which states the medication monitoring will include appropriate date /information to develop an accurate patient medication history and complete medication profile. (V). This was validated by the ADON/RN.

Observed in HR File Review. In 4 of 8 HR files reviewed, the organization had not provided emergency preparedness training to staff, volunteers, and individuals providing on-site services under arrangement at the following intervals initial training. There was no documentation of initial training in the files for the Medical Director, MSW/BCC, Aide, Volunteer, as confirmed with the DON. Observed in HR File Review. In 5 of 8 HR files reviewed, the organization had not provided orientation to staff on key safety content including specific processes and procedures related to provision of care, treatment and services, environment of care and infection control. There was no documentation of orientation in the files for DON, MSW/BCC, Volunteer, Medical Director, nor Aide. This was confirmed with the DON.

Observed in Emergency Management Session. The organization had not conducted an exercise to test the emergency plan at least annually. The last documented exercise of the Emergency Operations Plan was in 2019 as discussed with the DON.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization had not informed the patient of his or her rights both orally and in writing. During HV#2 and HV#3, in the home folders for hospice, there was no information about payment for services. The organization does not provide the patients with copies of the consent forms which include this information per discussion with the Alternate DON.

Observed in Record Review. In 11 of 11 patient records reviewed, the hospice had not documented an assessment of the need for volunteer services. This was not present in any patient record as confirmed with discussion with the Volunteer Coordinator who indicated she performs this assessment but does not document it in the record unless the patient accepts volunteer services.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization had not assessed potential medication related problems. During HV#2, the RN did not have a medication list either in the home, nor with her to compare the medications the patient was actually taking with orders. The discussion/review consisted of what medications were needed to be refilled. This was discussed with the RN after the visit and the DON.

Observed in Record Review. In 11 of 11 patient records reviewed, the update of the comprehensive assessment was not based on changes that have taken place since the initial assessment and did not include information about the patient’s progress toward desired outcomes and a reassessment of the patient’s response to care. There were no progress toward goals updates included in IDT notes in any record reviewed. Examples included - In the charts for HV#1, HV#2 and RR#1, there is no IDT note which included progress toward any goals. In the chart for HV#3, the Initial IDT notes for this patient included staff meeting items as well as the names/status of every patient reviewed in each meeting. In the current benefit period, there is no progress toward goals noted. This was discussed with the DON.

Observed in Record Review. In 11 of 11 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. This observation applied to all patient records reviewed in that goals were not measurable and/or the time frames for anticipated achievement were not appropriate and/or individualized. Examples included, in the chart for HV#1, goals had not been individualized as all goals have as outcome timeframe - within one certification period, including patient will not be in pain or distress. All goals for RR#1 were within 1 certification period, additionally, the goal for impaired mobility was not measurable, Patient will have few if any, complications related to immobility. In the chart for RR#7, the goals were not measurable/appropriate, such as “Patient will have adequate intake” “Patient will not be in respiratory distress by death/discharge”, and all are “within one certification period.”There were no goals of care on any plan of care for SCC or MSW; all patient charts reviewed included these disciplines. This was discussed with the DPCS.

Observed in Record Review. In 11 of 11 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including medications and treatment necessary to meet the patient’s needs. In the charts for HV#1 and RR#1 the patients had PEG tubes. The POC's did not include the patient's dietary needs related to PEG tube feedings, flushes, site care, etc. Additionally, both patient's had oxygen ordered prn, however the plan of care did not include any interventions/goals related to oxygen safety. In the record for HV#1, the patient was at high risk for pressure ulcer development. This potential issue was not addressed on the POC with any interventions. There were no signed orders on the patients chart except for Certifications of terminal illnesses. In the chart for HV#2, the Morphine order was Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML (LS), Dose: 0.25 without clarity if that is mg or ml. In the chart for RR#1, the RN put oxygen on the patient during the initial visit; there was no order found for oxygen. Per SN notes there was skin breakdown to the L buttock area at time of a visit, wound to the sacrum looks clean and free of infection both wounds are being cleansed with wound cleaner gel and applying Zinc, TAO, and Lidocaine cream to both areas and covered with adapti gauze. It was unclear who was providing wound care; there was no order found for wound care. In the chart for HV#3, the first medication order written stated Please continue all medications previously ordered. Medications (Mirtazapine, Olanzapine, Tylenol, etc.) were then added to the medication list. Additionally, the plan of care never included any interventions/goals related to oxygen safety and falls safety. In the chart for RR#2, the admission nurse documented RN administered O.5ML OF Lorazepam AND 1 ML OF ABH GEL. No orders were found for either medication. Neither was on the plan of care. In the chart for RR#5, the assessment included the patient was on oxygen. There was no order for oxygen found on the POC or in the record. In the chart for RR#7 the patient with oxygen, there were no interventions related to oxygen use/safety. At risk for pressure ulcer development, yet no interventions/goals on the POC. In the chart for RR#8, the original POC did not include any medications; no orders for medications found. patient was on Tramadol, Naproxen and Albuterol per initial SN assessment. There were no signed orders for routine medications until the recertification POC. No patient record included interventions/goals for the MSW and SCC disciplines; all patient charts reviewed included these disciplines. This was discussed with the DON.

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, including medical supplies and appliances necessary to meet the patient’s needs. In the chart for RR#8, the original POC did not contain the patient’s DME. The patient was on home oxygen and nebulizer treatments.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization did not provide the patient with care, treatment, or services according to his or her individualized plan of care. All patients had physician visits included on the hospice POC, yet no physician visits were ever documented in the patient charts. Examples In the charts for HV#1, physician visits were ordered weekly. There were no physician visits documented. In the chart for HV#2 again physician visits were ordered, yet no physician visits were made to the patient. In the chart for RR#1, SN was ordered 3-5/week; actually seeing the patient 2/week. No physician visits were made, yet the order was 1-2/month. In the chart for HV#3, physician visits were ordered 1-2/month, yet no visits were documented. RR#7 – SCC was ordered 1-2/week; actual was 1-2/month. Physician ordered 1-2/month; no visits documented. RR#8 – no physician visits were documented, though the POC included monthly physician visits. This was discussed with the DON.

Observed in Record Review. In 2 of 11 patient records reviewed, all disciplines that provided care, treatment or services to the patient did not collaborate in the care of the patient and coordinate their efforts to support the goals outlined in the plan of care. In the chart for RR#2, there was no documentation that the Admission RN notified the physician about a suspected abscess or infection in the patient's penis. In the chart for RR#5, the patient was assessed to be at high nutritional risk. The assessment document indicated that when high nutritional risk is assessed, the clinician is to collaborate with other members of the IDT to discuss goals of care. There was no indication any other member of the IDT was aware of the risk. This was discussed with the DON.

Observed in Data Session. The organization did not have an effective, ongoing, organization-wide, data-driven quality assessment and performance improvement program. There was no QAPI plan found for 2020, no performance improvement projects identified. There was monitoring of data only. There were no QAPI annual program evaluations documented for 2019 nor 2020. The QAPI plan for 2021 included only one PIP (performance improvement project), beginning in February 2021 which indicated improvement in the issue. There are no current PIP's as confirmed with the DON.

Observed in Data Session. The organization had not improved compliance with hand hygiene guidelines based on established goals as goals had not been established, nor was there any documentation that any hand hygiene data had been collected as confirmed with the DON. Observed in Data Session. The organization's written infection prevention and control goals did not include the following: Limiting the spread of infections associated with the use of medical equipment, devices, and supplies. There were no goals for the organization's infection prevention and control program as confirmed with the DON. Observed in Data Session. The organization's written infection prevention and control goals did not include the following: Limiting unprotected exposure to pathogens. There were no goals for the organization's infection prevention and control program as confirmed with the DON. Observed in Data Session. The organization's written infection prevention and control goals did not include the following: Addressing its prioritized risks. There were no goals for the organization's infection prevention and control program as confirmed with the DON. Observed in Data Session. The organization's written infection prevention and control goals did not include the following: Limiting the spread of infections associated with procedures. There were no goals for the organization's infection prevention and control program as confirmed with the DON. Observed in Data Session. The organization's written infection prevention and control goals did not include the following: Improving compliance with hand hygiene guidelines. There were no goals for the organization's infection prevention and control program as confirmed with the DON.

Observed in HR File Review. In 1 of 1 HR files reviewed, the hospice aide had not successfully completed a competency evaluation program. There were no competencies documented in the file for the hospice aide as confirmed with the DON.

Observed in Record Review. In 1 of 11 patient records reviewed, the RN had not supervised the hospice aide at least every 14 days. In the chart for RR#7, there were no documented aide supervisory visits for more than 8 weeks. This was discussed with the DON.

Observed in HR File Review. In 1 of 1 HR files reviewed, for a volunteer, there was no documentation of any orientation for the hospice volunteer; there was no HR file to review as confirmed with the Volunteer Coordinator and DON.

Observed in Tracer Activities. The hospice had not documented the cost savings achieved through the use of volunteers. There was no documentation of volunteer hours/work time/cost savings available to review as confirmed with the Volunteer Coordinator.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.100 and §418.54, §418.56, §418.58, §418.114. Observed in HR File Review. In 1 of 8 HR files reviewed, staff did not have the qualifications required by the position. The job description required compliance with Texas Administrative Code (TAC) for the Administrator. The Administrator did not have the required qualifications as outlined by TAC RULE §558.259 which specified the requirement for 8 hours of training as an Administrator prior to designation as the Administrator. The Administrator did not possess this training per review of the HR file and confirmed with the DON and Administrator.

Observed in HR File Review. In 5 of 8 HR files reviewed, the organization had not provided orientation to staff on relevant policies and procedures, specific job duties including those related to infection prevention and control and assessing and managing pain. There was no documentation of orientation in the files for DON, MSW/BCC, Volunteer, Medical Director, nor Aide. This was confirmed with the DON.

Observed in HR File Review. In 5 of 8 HR files reviewed, staff competence was not initially assessed and documented as part of orientation. In the files for the DON, Medical Director, Volunteer and MSW/BCC there were no initial competencies documented. In the file for the SCC, there was a self-assessment only at hire with no verification of the required competencies. This was confirmed with the DON.

Observed in Record Review. In 1 of 11 patient records reviewed, the patient record did not contain the following clinical information: medications administered, including dose. In the chart for RR#2, the admission nurse documented RN administered 0.5ml Lorazepam and 1ml of ABH gel - missing route as discussed with the DON.

Observed in Record Review. In 1 of 1 patient records reviewed, when the patient was transferred to another Medicare/Medicaid-certified facility, the hospice had not provided the receiving facility with a copy of the hospice discharge summary and, if requested, a copy of the patient’s clinical record. In the chart for RR#4, there was no discharge summary, thus no discharge summary had been provided to the receiving facility as confirmed with the DON.

Observed in Record Review. In 3 of 3 patient records reviewed, when the patient revoked the election of hospice care or was discharged from hospice care, the hospice had not provided the patient’s attending physician with a copy of the hospice discharge summary. There was no discharge summary in the charts for RR#2, RR#3 and RR#4 as confirmed with the DON.

Observed in Patient Home. In 1 of 3 home visits conducted, based on the patient’s condition and assessed needs, the education and training provided to the patient by the organization did not include the following: Information on the safe and effective use of medical equipment or supplies provided by the organization. During HV#2, it was discovered and confirmed by the patient and primary caregiver that no education had been provided by the hospice, nor the DME provider about basic use of the concentrator including cleaning of the oxygen concentrator filter, type of water to use for the humidifier, how often to change cannulas and tubing, etc. The patient had the concentrator for over a year and the filter had never been cleaned per discussion with the primary caregiver. This was discussed with the DON.

Observed in Patient Home. In 1 of 3 home visits conducted, staff had not taken action to minimize identified safety and security risks. During HV#3, it was noted there were 5 oxygen tanks free-standing, (not in a stand or holder) as witnessed by the aide in the home during the visit. During HV#2, this safety risk was also present, however identified by the RN and addressed during the visit. This was discussed with the DON.

Observed in HR File Review. In 2 of 6 HR files reviewed, the organization had not verified and documented credentials of care providers using the primary source when licensure, certification, or registration was required by law and regulation to practice their profession. In the file for the hospice aide, there was no confirmation with the primary source of current standing in the state nurse aide registry as required by the job description upon hire. There was no HR file for the Medical Director; no verification of his licensure at hire, nor current. This was verified as time of survey. This was confirmed with the DON.

Observed in HR File Review. In 8 of 8 HR files reviewed, the hospice had not obtained a criminal background check on the applicant as required. Criminal background checks were not documented in the files for any employee as confirmed with the DON.