Every finding on record at Crossroads Hospice of Dayton, LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over the counter (OTC) drugs, supplements, herbal remedies, other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following, the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 4 (50%) clinical records reviewed, the organization did not ensure a medication review was completed with the patient’s current medications. Home Visit 1: During the home visit observation on 11/05/2024 with the Registered Nurse (RN) (Personnel Record 14), a medication review was completed by comparing the patient’s home medications with the patient’s home health medication profile. The medication profile with a printed date of 11/04/2024 included Propranolol 10mg twice daily. The patient’s home medications included Propranolol 10mg once daily started on 10/02/2024. The medication profile was not updated when the medication frequency was changed to once daily. Home Visit 4: During the home visit observation on 11/05/2024 with the Home Health Aide (HHA) (Personnel Record 9), a medication review was completed by comparing the patient’s home medications with the patient’s home health medication profile. The medication profile printed on 11/04/2024 included ClearLax 17GM 1 scoop daily as needed. The patient’s home medications included ClearLax 17GM 1 scoop daily on Tuesday, Thursday, and Saturday ordered on 09/09/2024, ClearLax 17GM 2 scoops daily on Monday, Wednesday, Friday, and Sunday ordered on 09/09/2024, Hydrocortisone External Cream 1% apply to forehead topically every 12 hours as needed for rash ordered on 08/08/2024, Triamcinolone Acetonide External Cream 0.5% apply to face/neck twice daily for dryness ordered on 10/10/2024, Probiotic Cap 25mg daily ordered on 08/08/2024, and Senna S 8.6mg/50mg twice daily ordered on 09/02/2024. The Hydrocortisone cream, Triamcinolone cream, Probiotic Cap, and Senna were not included on the patient’s medication profile and the ClearLax order was not updated with the increased dose on Monday, Wednesday, Friday, and Sunday. During a joint record review and interview on 11/06/2024, the Clinical Director confirmed there was no documentation in the clinical records that the patient’s current medications were reconciled at the time of the comprehensive assessment and updated to the drug profile.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, observation, and interview. In 2 of 4 (50%) home visit observations, the organization did not ensure staff performed hand hygiene as required by agency policy. Agency policy number 253, Universal - Standard Infection Control Precautions - Hand Washing Techniques and Practices, required in part, "[Agency] personnel and other caregivers having direct patient contact or contact with dirty equipment/supplies, will perform appropriate hand washing techniques, including, but not limited to the following tasks/duties/situations: Upon arriving at patient assignment; When hands are soiled; Before and after any direct patient contact; When moving from a dirty patient care task to a clean task; After personal use of the toilet; After assisting a patient to the toilet; Before and after eating, drinking, or smoking; Before leaving patient room and upon return; Upon completing duty; Before entering or leaving isolation rooms; Before and after gloves are used; After any direct contact with secretions and/or excretions of the patients; Before touching another patient; After cleaning equipment/supplies; If ever in doubt that a contaminant has been touched. Hand hygiene is performed in a manner that supports the processes of care provided in a given area, but two general rules apply throughout: Routine hand hygiene should include all surfaces of the hands up to an area above the wrist; Soap and water should be used whenever hands are visibly soiled. Washing with soap and water requires a process that includes wetting the hands, application of the soap, friction for at least 20 seconds, rinse with water, and pat dry with clean paper towels. Turn off the water faucet by using a dry paper towel; Use a dry paper towel to open doors - to avoid touching door handles." Home Visit 1: During the home visit on 11/05/2024 with the Registered Nurse (RN) (Personnel Record 14), the RN was observed to provide wound care to the patient’s coccyx wound with the assistance of the facility caregiver. The RN provided the wound care and covered the wound with border dressing, then changed gloves. The RN did not perform hand hygiene after glove removal. The RN then provided wound care to the patient’s wound on the foot, removed gloves and performed hand hygiene. The RN was observed to turn off the faucet with wet hands during hand hygiene. Home Visit 4: During the home visit on 11/05/2024 with the Home Health Aide (HHA) (Personnel Record 9), the HHA was observed to wash hands, turn off the faucet with the forearm/elbow, and dry hands with a hanging cloth hand towel. The HHA donned gloves, ambulated the patient to the commode, removed the gloves, removed a towel from the cabinet, and donned new gloves. The HHA did not perform hand hygiene after removing the gloves. During interviews on 11/06/2024, the Executive Director and the Clinical Manager agreed that staff did not follow the agency’s hand hygiene policy.

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the nursing needs of the patient were met as identified in comprehensive assessment and updated assessments. Clinical Record 3: The patient elected the hospice benefit on 08/28/2024 with diagnosis of hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease. The Registered Nurse (RN) documented on the Comprehensive Assessment Patient Assessment Report dated 09/26/2024, "Daughter reports increased confusion this past week. Reports odor with urination. Denies frequency but voiced increased incontinent episodes which is [not] typical for patient... This writer contacted Dr. (primary care provider [PCP]) office and left message with contact information." The RN documented on the Phone Call Patient Assessment Report dated 09/27/2024, "Dr. [PCP] also requesting urine sample brought to his office as previously done in the past. Updated on plan of care and agreeable." The next RN Comprehensive Assessment Patient Assessment Report was dated 10/03/2024, seven days after the patient’s symptoms were first identified. The RN documented, "Daughter reports they have not sent urine specimen to physician as patient 'was back to normal the following day.' However, she also stated the patient continues to display confusion and frequent episodes of incontinence... Advised [caregiver] to collect urine specimen as ordered to rule out urinary tract infection. Stated she would do so." The next RN Comprehensive Assessment Patient Assessment Report was dated 10/10/2024, fourteen days after the patient’s symptoms were first identified. The RN documented, "Per daughter, patient having increased incontinent episodes and remains confused. She provided a urine sample to PCP but has not received results. This nurse placed call x3 to Dr. [PCP] office, but they are closed." The RN documented follow up with the physician on the Phone Call Patient Assessment Report dated 10/11/2024, "Phone call to Dr. [PCP] office regarding results from the urinalysis obtained one week ago. Left message on nurse line with contact information." No further follow-up was documented until the next RN nursing visit dated 10/17/2024, 21 days after the patient’s symptoms were first identified. The RN Comprehensive Assessment Patient Assessment Report dated 10/17/2024 included documentation, "Daughter reports that she has to retake urine sample as Dr. [PCP] office 'lost sample'." The RN documented an emergency visit to the patient the following day on 10/18/2024. The Emergent Patient Assessment Report dated 10/18/2024 included documentation, "RN arrived at patient home, called out for an EV [emergency visit] as patient has had uncontrolled n/v [nausea/vomiting], patients daughter stated [patient] only has thrown up once today, this morning to be exact, and it was a lot. Patient's daughter reports the [patient] has increased confusion and is very unsteady. The daughter reported that after the patient vomited, she took [the patient’s] BP and it was 168/89, HR undetectable. Now, the patient is sitting in chair, FLACC 4/10, has a facial grimace, and whimpers every now and then... [patient] did fall today, assisted with the daughter. Patient skin is cool to touch, afebrile, and not diaphoretic. BP 136/74, HR 59, O2 [oxygen saturation] 98%. Daughter notes typically, the patient's BP is 90s systolic... RN educated daughter on the process of UTIs [urinary tract infections], urine was sent yesterday [21 days after symptoms where first identified and documented], but there are no results yet... Called PCP office, advised to call the physician on call at [number], spoke to the operator who directed this nurse to Dr. [name] himself. New orders: Zofran 4MG ordered q6hPRN [as needed] for n/v, Bactrim double strength BID [twice daily] for 5 days." The RN did not ensure the nursing needs of the patient were met, when the patient exhibited symptoms of UTI for 22 days before a physician order was obtained for treatment. During a joint record review and interview on 11/07/2024, the Clinical Director confirmed that the nurse should have followed up in a timely manner when the patient was exhibiting symptoms of a UTI.

It is required that a hospice aide provide services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 2 of 16 (12%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Hospice Aide (HA) provided services included in the plan of care. Clinical Record 2: The patient elected the hospice benefit on 10/15/2024. The hospice aide plan of care dated 10/15/2024 assigned the HA the tasks of "Bathing, Bed - Full, apply lotion, Comb/Brush hair, Dress, Foot Care, Oral Care, Shampoo, and Change adult brief." The HA documented on the aide visit notes dated 10/22/2024 and 11/01/2024 "this HHA provided a full shower visit." The task for patient shower was not assigned on the hospice aide plan of care. Clinical Record 17: The patient elected the hospice benefit on 03/21/2023. The hospice aide plan of care dated 03/22/2023 assigned the HA the tasks of "Make bed, change bed linens, change adult brief, up in chair, Oral care, Apply lotion, Comb/Brush hair, and Bathing: Bed-Full." The HA documented on the aide visit notes dated 05/05/2023 and 05/09/2023 "Gave pt [patient] a shower" and on the aide visit note dated 05/12/2023 "Showered pt." The task for patient shower was not assigned on the hospice aide plan of care. During a joint clinical record review and interview on 11/06/2024, the Clinical Director confirmed the hospice aide provided services not included in the plan of care.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 2 of 16 (12%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Hospice Aide (HA) reported changes in the patient’s needs. Clinical Record 2: The patient elected the hospice benefit on 10/15/2024. The hospice aide plan of care dated 10/15/2024 assigned the HA the tasks of "Bathing, Bed - Full, apply lotion, Comb/Brush hair, Dress, Foot Care, Oral Care, Shampoo, and Change adult brief." The HA documented on the aide visit notes dated 10/22/2024 and 11/01/2024 "this HHA provided a full shower visit." The task for patient shower was not assigned on the hospice aide plan of care and there was no documented evidence that the HA notified the Registered Nurse of change to the plan of care. Clinical Record 17: The patient elected the hospice benefit on 03/21/2023. The hospice aide plan of care dated 03/22/2023 assigned the HA the tasks of "Make bed, change bed linens, change adult brief, up in chair, Oral care, Apply lotion, Comb/Brush hair, and Bathing: Bed-Full." The HA documented on the aide visit notes dated 05/05/2023 and 05/09/2023 "Gave pt [patient] a shower" and on the aide visit note dated 05/12/2023 "Showered pt." The task for patient shower was not assigned on the hospice aide plan of care and there was no documented evidence that the HA notified the Registered Nurse of change to the plan of care. During a joint clinical record review and interview on 11/06/2024, the Clinical Director confirmed the Hospice Aide documentation lacked notification to the Registered Nurse of the changes in patient’s needs.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 16 (6%) clinical records reviewed with aide services provided, the agency did not ensure the Registered Nurse (RN) completed an on-site supervisory visit to the patient’s home no less frequently than every 14 days. Clinical Record 12: The patient elected the hospice benefit on 05/02/2024. Hospice Aide (HA) services started on 05/03/2024 and the HA made visits twice a week. The RN documented HA supervisory visits were completed on 09/03/2024 and 10/24/2024, a total of 44 days and 30 days outstanding. The RN Comprehensive Assessment visit notes dated 09/16/2024, 09/23/2024, 09/30/2024, 10/07/2024, 10/14/2024, 10/17/2024, and 10/21/2024 did not contain documentation that an aide supervisory visit was completed as part of the comprehensive assessment. There was no documented evidence in the clinical record that the RN documented aide supervisory visits no less frequently than every 14 days. During a joint clinical record review and interview on 11/07/2024, the Clinical Director confirmed that the Registered Nurse did not document on-site supervisory visits at least every 14 days.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by record review, interview, and observation. In 2 of 6 (33%) records reviewed of patients in the SNF the hospice plans of care did not specify which provider was responsible for performing the specific interventions that were agreed on and ordered in the plans of care. Record #56755 was reviewed and revealed a description of the specific interventions that were to be completed by the hospice and the facility were not included in the plan of care dated 10/11/2021. The hospice binder in the SNF was reviewed during the home visit conducted on 1/19/2022 with the RN [Record #28777] and it confirmed there was no evidence of the respective functions the facility and hospice were responsible for. Record #89523 was reviewed and revealed a description of the specific interventions that were to be completed by the hospice and the facility were not included in the plan of care dated 12/23/2021. The hospice binder in the SNF was reviewed during the home visit conducted on 1/19/2022 with the RN [Record #28777] and it confirmed there was no evidence of the respective functions the facility and hospice were responsible for. The Clinical Director was interviewed on 1/19/2022 and stated that the duties of each provider were not addressed in the plans of care nor was there any additional information to provide.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: The most recent hospice plan of care. This standard was not met as evidenced by record review, interview, and observation. 2 of 2 (100%) records reviewed during home visit observations conducted in the SNF revealed the hospice had not provided the facility with the patients' most recent plan of care. Home visits were conducted in the SNF on 1/19/2022 for Record #56755 and Record #89523. The hospice binders were reviewed with the RN [Record #28777] and it was revealed the most recent plans of care were not included. An interview with the Clinical Manager was conducted on 1/19/2022, and it was stated that the agency failed to provide the most recent plan of care to the facility and there was no additional information to provide.