Every finding on record at Creative Hospice Care, Inc

Observed in Record Review. In 3 of 20 patient records reviewed, the organization failed to assess and reassess its patients. During record review for RRNHV#5, the Hospice Nurse Surveyor observed the patient had no documented bereavement assessment and this was confirmed with leadership. Also for the same patient, she had a Stage 2 pressure ulcer noted over the course of a month in the nurses narrative but there was no description of the wound or measurement of the wound at least weekly, as required by policy. During record review for RRHV#2, the Hospice Nurse Surveyor observed the patient had a fall 2 weeks prior to survey with a nursing visit immediately following but a fall risk assessment was documented as NA and not performed per organizational policy. In RRNHV#10, the Hospice Nurse Surveyor observed the patient had no documentation of a comprehensive psychosocial assessment completed. The patient was on service for 7 days and the MSW documented that she was out of town when the assessment should have taken place. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 1 of 20 patient records reviewed, the organization failed to update the interdisciplinary group with the most current patient information. During record review for RRNHV#8, the Hospice Nurse Surveyor observed the patient had a stage II pressure ulcer to the buttocks with wound orders and orders to be turned every 2 hours. The nurse documented that the Assisted Living informed her that we cannot turn that patient every two hours but there was no documentation that the team was alerted or that the hospice physician was given this information. This was confirmed with the Hospice Leadership Team. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 6 of 20 patient records reviewed, the organization failed to maintain a complete and accurate patient record. During record review for RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#11, RRNHV#5, and RRDC#1, the Hospice nurse surveyor observed the patient records contained inaccuracies, errors or confusing documentation. For example in RRNHV#6, the nurse documented the patient is wearing oxygen at night yet the patient did not have oxygen ordered and no other staff documented the use of oxygen. In RRNHV#7, the nurse documented discharge for cause but all other documentation including that from the provider stated discharge for extended prognosis. In RRNHV#8, the nurse checked the oxygen box that patient was on oxygen and she did the assessment but there were no orders for oxygen. In RRNHV#11, the nurse documented that the patient was given 6 Blouses of MS. In RRDC#1, the documentation stated pain is controlled with ibuprofen and tramadol but neither medication was ordered. In RRNHV#5, the patient narrative on one nursing visit stated she increased the MA Robid for two days. Unclear what that meant. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 20 of 20 patient records reviewed, the organization failed to plan the patient's care. During record review for all records, the Hospice Nurse Surveyor observed the care plans did not contain timeframes for achieving goals. For example in RRHV#1, the patient had a goal of patient/ family aware of available resources and support throughout the process. In RRHV#2, the patient had a goal of facility staff to be knowledgeable and involved in hospice care by ______ but the blank was not filled in. In RRNHV#1, the patient had a goal of pt/ cg demonstrates understanding of insulin administration with no goal timeframe. In RRNHV#2, the patient had a goal of patient/ cg will verbalize and demonstrate understanding of skin integrity with no timeframe noted and the goal had been entered 1 1/2 years prior to survey. In RRNHV#7, the patient had a goal of pt/CG:pt/ CG verbalizes understanding of OTC medication/ herbs that may interact with prescription meds no timeframe. Place in POC 1 1/2 years prior to discharge. no updates verbalize understanding of OTC medications/ herbs that may interact with prescription meds. The goal was places at SOC with no timeframe and the patient was discharged 1 1/2 years later. During record review for RRHV#2, RRHV#3, RRHV#4, RRNHV#5, RRNHV#4, RRNHV#8, RRNHV#9, RRNHV#10, and RRDC#1, the patients plan of care did not reflect all goals related to problems identified in updated comprehensive assessments. For example in RRHV#2, the patient did not have goals related to a recent fall and high fall risk or goals related to aspiration, which had recently been noted by the provider and the nurse. In RRHV#3, the patient had a recent issue with diarrhea which included new orders but it was not addressed on the plan of care. In RRHV#4, the nursing documentation stated 2 plus pitting edema to bilateral lower extremities but it was not addressed on the plan of care. In RRNHV#5, the patient had several previous wounds that were not closed when the wounds closed and then the goals were not updated when the patient developed a new stage 2 pressure ulcer 6 months prior to survey. RRNHV#5 also had ongoing issues with constipation and it was not addressed on the plan of care. In RRNHV#1, the patient had two recent infections with medication orders and they were not addressed on the plan of care. In RRNHV#4, the patient had an upper respiratory infection with antibiotics ordered and it was not addressed on the plan of care. In RRNHV#8, the patient had multiple falls documented while on hospice but this was not addressed on his plan of care. In RRNHV#9, the patient had a diagnosis of Covid-19 over a year prior to survey and those goals were not updated on the plan of care. In RRNHV#10, the patient was end stage renal disease and had just stopped dialysis. The nursing notes identified agitation and delirium but these were not addressed on the plan of care. In RRDC#1, the patient was having issues with agitation and had multiple medication changes but it was not addressed on the plan of care. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 11 of 11 patient records reviewed, where recertification took place, the organization failed to plan the patient's care. During record review for RRHV#2, RRHV#3, RRHV#4, RRNHV#5, RRNHV#2, RRNHV#3,RRNHV#4, RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#9, there was no documentation of progress towards goals. For example in RRNHV#2, there was room in the IDG template for SW to document progress towards goals but the documentation contained LMSW to continue to provide therapeutic presense and companionship to patient. There was no measurable progress. The nursing IDG notes did not include the same information and progress was not located elsewhere. In RRNHV#3, the LMSW documented progress towards goals will support patient family when needing respite care for summer. This is not measurable progress. And the nursing notes did not contain any information about patient progress towards goals. Upon talking with the leadership team, it was noted that the IDG template contains progress towards goals but that it had been eliminated when the nurse did her charting. In RRNHV#7, the patient was discharged for extended prognosis after 3 1/2 years on service and there was no documentation of progress towards goals. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Patient Home. In 4 of 4 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned. During home visits for RRHV#1, RRHV#2, RRHV#3, and RRHV#4, the Hospice Nurse Surveyor observed staff did not follow the organization's bag technique policy. During all visits both staff members left their bags opened. For RRHV#3 and RRHV#4, the aide left her bag open while driving between visits besides inside each visit. This was discussed and reviewed with the Hospice Leadership Team. Observed in Patient Home. In 1 of 4 home visits conducted, the organization failed to implement the infection prevention and control activities, related to hand hygiene, it had planned. During the visit for RRHV#1, after the initial hand hygiene the nurse went into her bag several times with gloves on but did not complete hand hygiene as required by policy. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 9 of 11 patient records reviewed, of patients receiving aide services, the organization failed to plan the patient's care. During record review for RRHV#2, RRHV#3, RRHV#4, RRNHV#5, RRNHV#2,RRNHV#6, RRNHV#8, RRNHV#9, RRNHV#10, the Hospice Nurse Surveyor observed the aide plan of care did not contain all needed precautions. For example RRHV#2, the aide care plan failed to include bleeding precautions as the patient was on aspirin. For RRHV#3 and RRHV#4, the aide care plan did not include precautions for bleeding or aspiration. And in both RRNHV#5 and RRNHV#2, , the aide care plan did not contain precautions for fall risk yet the patients scored high risk of falling. In RRNHV#6, the patient was taking a blood thinner but there were no precautions on the aide plan of care. In RRNHV#8, the patient had many falls while on service and was receiving aide care but the aide care plan did not address the high risk of falls. In RRNHV#10, the patient was on oxygen but it was not addressed on the aide care plan. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Tracer Activities. The organization failed to implement policies and procedures that guided patient care, treatment, or services. During tracer activities for Leadership, the Hospice Nurse Surveyor observed the organization failed to implement policies related to condition level findings at 418.54, 418.56, 418.100. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 2 of 20 patient records reviewed, the organization failed to maintain an accurate patient record. During record review for RRNHV#3, the Hospice Nurse Surveyor observed the medication orders and record contained three antibiotics the patient was no longer taking. In RRNHV#7, the patient had an order for Macrobid for 7 days 1 1/2 years prior to discharge but the antibiotic was still listed on the discharge medication list. This was discussed and confirmed with the Hospice Leadership Team.

Observed in Record Review. In 1 of 4 home visits conducted, the organization failed to provide the patient with education and training based on the needs of the patient and family. During home visit for RRHV#3, the Hospice Nurse Surveyor observed there was no individualized disaster plan in the home and upon conversation with the daughter she stated mom was on the previous hospice so I am not sure if she ever had one, noting that the current hospice had a new owner. This was discussed and reviewed with the Hospice Leadership Team.

Based on clinical record reviews and staff interview, it was determined the agency failed to ensure that medical supplies and appliances were provided to meet the needs of the patient for 1 of 3 (#2) sampled patients (P). Findings were: --- Review of the plan of care for patient (P) #2 with a certification period of 6/2/22 to 9/1/22 and a diagnosis of malignant neoplasm of the lower lobe of left lung revealed the patient has a pleurx drain which is required to be drained every other day. The caregiver is competent to perform this procedure. However, the clinical record lacked any documentation to indicate that pleurx cannisters were provided to the family in order for the pleurx to be drained as ordered. Cannisters must be provided to ensure the pleurx can be drained every other day per the physician's order. The agency failed to ensure the family had the necessary supplies to meet the needs of the patient. During an interview on 11/22/22 at approximately 10:00 a.m., the Regional Director and Administrator did confirm that the agency is responsible for providing necessary supplies to meet the needs of the patient however, no documentation was provided to indicate the agency had provided the family any pleurx cannisters throughout the episode of care.

Based on clinical record reviews and staff interview, it was determined the agency failed to ensure that appropriate care and services were provided in conformance with the patients' plans of care as ordered by physician for 2 of 3 (#1 and #2) sampled patients (P). Findings were: --- Review of the plan of care for patient (P) #2 with a certification period of 6/2/22 to 9/1/22 and a diagnosis of malignant neoplasm of the lower lobe of left lung required the skilled nurse (SN) to visit the patient 2 times a week for 14 weeks starting 6/2/22. According to the clinical record, the SN only visited the patient 1 time the weeks of 6/5, 6/12, 6/19, and 7/10/22. The SN did not visit the patient the week of 7/3/22. This was a total of 6 unauthorized missed visits however, the clinical record lacked any documentation to indicate why the visits were missed and there was no documentation to indicate the physician was notified of the failure to follow the ordered plan of care for visit frequency. The SN failed to follow the ordered visit frequency. During an interview on 11/22/22 at approximately 10:00 a.m., the Regional Director and Administrator did confirm the SN failed to follow the ordered visit frequency and failed to document the reason for the missed visits. 2. Review of the plan of care for patient #1 with a certification period of 6/14/22 to 9/13/22 and a diagnosis of chronic diastolic congestive heart failure required the SN to visit the patient 1 time daily starting 6/21/22. According to the clinical record, the SN failed to visit the patient on 6/21, 6/24, 6/28, 7/3, 7/8, 7/12, 7/13, and 7/14/22. This was a total of 8 unauthorized missed visits however, the clinical record lacked any documentation to indicate why the visits were missed and there was no documentation to indicate the physician was notified of the failure to follow the ordered plan of care for visit frequency. The SN failed to follow the ordered visit frequency. During an interview on 11/22/22 at approximately 10:00 a.m., the Regional Director and Administrator did confirm the SN failed to follow the ordered visit frequency and failed to document the reason for the missed visits.

Based on clinical record reviews and staff interview, it was determined the agency failed to ensure the clinical record contained dated entries for all services provided for inclusion into the medical record for 1 of 3 (#2) sampled patients (P). Findings were: --- 1.Review of the on-call log dated 7/9/22 revealed a call placed to the on-call service from the daughter of P #2 requesting a SN visit to assess the patient for a status change. The clinical record lacked any documentation to indicate the SN returned the family call or if a visit was made to assess the patient as required. The SN failed to document a clinical note to indicate if an on-call visit was completed as requested on 7/9/22. During an interview on 11/22/22 at approximately 11:00 a.m., the complainant revealed the SN did visit the patient on 7/9/22 after hours for the on-call visit. However, the complainant reports the patient was having respiratory issues and the SN failed to do a complete respiratory assessment. According to the complainant the SN did not listen to the patients lungs to assess for any complications during the visit. During an interview on 11/22/22 at approximately 10:30 a.m., with Employee CC (LPN) confirmed that she did complete an on-call visit for the patient on 7/9/22 for reports of respiratory distress. However, Employee CC was unable to provide a clinical note to indicate a visit was made on 7/9/22. The Administrator also confirmed the clinical record lacked a documented evidence of a SN visit note for the on-call visit for 7/9/22.