Every finding on record at Del Corazon Hospice LLC

Based on record review, policy review, and interview, the agency failed to ensure all required members of the hospice interdisciplinary group completed an initial assessment for seven of 14 patients (Patient (P)1, P2, P4, P7, P9, P10, and P12) within five days or the election of the hospice benefit. Failure of the interdisciplinary team members to complete the initial assessment had the potential for the plan of care to not address spiritual and psychosocial issues. --- 1.Review of P1's "Election of Hospice Benefit" located in the paper record revealed it was signed on 11/29/22. Review of the visit notes in the documents section of the electronic medical record (EMR) showed the initial Social Work visit occurred on 12/08/22 and was not signed as completed until 12/19/22. The initial Chaplain visit was on 12/14/22. The EMR did not include any documentation to show a reason for the delay in the initial assessment. 2.Review of P2's "Election of Hospice Benefit" located in the paper record revealed it was signed on 01/27/23. Review of the visit notes in the documents section of the EMR showed the initial Social Work visit occurred on 02/02/23 and the initial Chaplain visit occurred on 02/04/23. The EMR did not include any documentation to show a reason for the delay in the initial assessment. 3.Review of P4's "Election of Hospice Benefit" located in the paper record revealed it was signed on 08/18/23. Review of the visit notes in the documents section of the EMR showed the initial Social Work visit occurred on 08/29/23 and the initial Chaplain visit occurred on 09/06/23. The EMR did not include any documentation to show a reason for the delay in the initial assessment. 4.Review of P7's "Election of Hospice Benefit" located in the paper record revealed it was signed on 08/11/23. Review of the visit notes in the documents section of the EMR showed the initial Social Work visit occurred on 08/18/23 and was not completed or signed until 08/21/23. The EMR did not include any documentation to show a reason for the delay in the initial assessment. 5.Review of P9's "Election of Hospice Benefit" located in the paper record revealed it was signed on 07/31/23. Review of the visit notes in the documents section of the EMR showed the initial Social Work visit occurred on 08/07/23. The EMR did not include any documentation to show a reason for the delay in the initial assessment. 6.Review of P10's "Election of Hospice Benefit" located in the paper record revealed it was signed on 07/05/23. Review of the visit notes in the documents section of the EMR showed the initial Social Work visit occurred on 07/17/23 and the initial Chaplain visit occurred on 07/14/23. The EMR did not include any documentation to show a reason for the delay in the initial assessment. 7.Review of P12's "Election of Hospice Benefit" located in the paper record revealed it was signed on 06/19/23. Review of the visit notes in the documents section of the EMR showed the initial Social Work visit occurred on 06/29/23 and the initial Chaplain visit occurred on 06/27/23. The EMR did not include any documentation to show a reason for the delay in the initial assessment. Review of an agency policy titled, "Initial Hospice Assessment," dated January 2020, revealed, "The Hospice interdisciplinary group, in consultation with the patient's physician, shall complete the comprehensive assessment no later than five (5) calendar days after the election of Hospice care." Review of an agency policy titled, "Interdisciplinary Team/Plan of Care," dated 01/03/19, revealed, "The interdisciplinary team shall include at least the following individuals: A doctor of medicine or osteopathy. An RN [Registered Nurse] ... A social worker. A pastoral or other counselor." During an interview on 09/08/23 at 8:20 AM, the Clinical Director agreed with the above findings. The Clinical Director confirmed that the agency Social Worker and Chaplain should have completed their initial assessment within five days of the patient's election of the hospice benefit or should have documented that the patient was contacted during that time and the patient or caregiver requested the visit occur after the five days.

Based on record review, policy review, and interview, the hospice agency failed to complete an initial bereavement assessment for 14 of 14 patients (Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14). Failure to complete an initial bereavement risk assessment to identify the social, spiritual, and cultural factors present had the potential to impact the family members or significant others' ability to cope with the patient's death. --- Review of the documentation present in the electronic medical record (EMR) of P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14 failed to reveal the presence of an initial bereavement risk assessment. Review of an agency policy titled, "Initial Bereavement Assessment," dated 01/23/20, revealed, "Information obtained from the initial bereavement assessment shall be incorporated into the plan of care and in the bereavement plan of care ... On admission, the Hospice social worker or chaplain shall complete a Bereavement Risk Assessment, which is kept in the patient's clinical record." During an interview on 09/08/23 at 8:20 AM, the Clinical Director confirmed that the above medical records did not include an initial bereavement risk assessment and that an initial bereavement risk assessment should have been completed by the Social Worker or Chaplain.

Based on record review, policy review, and interview, the hospice agency failed to ensure the patient's plan of care was individualized for 14 of 14 patients (Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14). Failure to individualize the patient goals and frequency of services based on the assessment and input from the patient and caregiver had the potential to result in unmet needs. --- 1. Review of the patients "Plan of Care" provided by the Clinical Director revealed the following examples: P1, P4, P5, P8, P9, P13, P14 included a goal of "Patient will maintain adequate cardiac/circulatory function and fluid volume as long as possible." P1, P2, P3, P5, P6, P8, P9, P10, P11, P13, and P14 included a goal of "Patient will achieve and maintain optimal physical comfort." P1, P2, P3, P4, P5, P7, P8, P9, P10, P11, P12, P13, and P14 included a goal of "Promote optimal patient safety and prevention of injury." P1, P4, P5, P7, P8, P9, P10, P12, and P14 occurring during the first 60 days of hospice services included a goal of "Facilitate compliance with CMS [Centers for Medicare and Medicaid Services] regulation regarding new admissions to Hospice services." Review of an undated agency policy titled, "Patient/Family Plan of Care," revealed, "The plan of care is individually tailored to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient and family who are facing a terminal illness." During an interview on 09/07/23 at 3:45 PM, the Administrator stated that "we have to" include the goal of "Facilitate compliance with CMS regulation regarding new admissions to Hospice services" in the initial plan of care for all patients to have the interventions included. During an interview on 09/08/23 at 8:20 AM, the Clinical Director agreed that many of the patient plans of care contain the same patient goals. He/she stated the electronic medical record (EMR) "does not allow us to write a goal freestyle. The nurse must pick from the list provided." 2. Review of the "Plan of Care" provided by the Clinical Director for P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14 revealed all services provided included an as needed (prn) frequency of "seven prn visits every seven days." Review of an agency policy titled, "Interdisciplinary Team/Plan of Care," dated 01/03/19, revealed, "The plan of care shall state in detail the scope and frequency of services needed to meet the patient's and family's needs." During an interview on 09/08/23 at 8:20 AM, the Clinical Director stated he/she had thought seven prn visits every seven days would count as a "range of prn visits" but acknowledged that it was not specific to the individual patient assessment.

Based on record review, policy review, and interview, the hospice agency failed to identify a detailed statement of visit frequency individualized to meet the patient's needs based on an assessment when it included a frequency of seven prn (as needed) visits every seven days for 14 of 14 patients (Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14). The failure to identify visit frequency in the plan of care had the potential for practitioner ordered visits to be missed. --- 1.Review of P1's current "Plan of Care" provided by the Clinical Director revealed the frequency of visit orders as follows: Skilled Nursing (SN) two times a week and seven prn (as needed) visits every seven days, Aide three times a week and seven prn visits every seven days, Social Worker seven prn visits every seven days. 2.Review of P2's current "Plan of Care" provided by the Clinical Director revealed the frequency of visit orders as follows: SN two times a week and seven prn visits every seven days, Aide three times a week and seven prn visits every seven days, SW seven prn visits every seven days, Chaplain seven prn visits every seven days. 3.Review of P3's current "Plan of Care" provided by the Clinical Director revealed the frequency of visit orders as follows: SN three times a week and seven prn visits every seven days, Aide two times a week and seven prn visits every seven days, Chaplain seven prn visits every seven days. 4.Review of P4's current "Plan of Care" provided by the Clinical Director revealed the frequency of visit orders as follows: SN one time a week and seven prn visits every seven days, Aide two times a week and seven prn visits every seven days, SW seven prn visits every seven days, Chaplain seven prn visits every seven days. 5.Review of P5's current "Plan of Care" provided by the Clinical Director revealed the frequency of visit orders as follows: SN one time a week and seven prn visits every seven days, SW seven prn visits every seven days. 6.Review of P6's current "Plan of Care" provided by the Clinical Director revealed the frequency of visit orders as follows: SN two times a week and seven prn visits every seven days, Aide two times a week and seven prn visits every seven days, SW seven prn visits every seven days, 7.Review of P7's current "Plan of Care" provided by the Clinical Director revealed the frequency of visit orders as follows: SN two times a week and seven prn visits every seven days, Aide two times a week and seven prn visits every seven days, SW seven prn visits every seven days. 8.Review of P8's current "Plan of Care" provided by the Clinical Director revealed the frequency of visit orders as follows: SN one time a week and seven prn visits every seven days, Aide one time a week and seven prn visits every seven days, Chaplain seven prn visits every seven days. 9.Review of P9's current "Plan of Care" provided by the Clinical Director revealed the frequency of visit orders as follows: SN two times a week and seven prn visits every seven days, SW seven prn visits every seven days. 10.Review of P10's current "Plan of Care" provided by the Clinical Director revealed the frequency of visit orders as follows: SN two times a week and seven prn visits every seven days, Aide two times a week and seven prn visits every seven days. 11.Review of P11's current "Plan of Care" provided by the Clinical Director revealed the frequency of visit orders as follows: SN two times a week and seven prn visits every seven days, SW seven prn visits every seven days, Chaplain seven prn visits every seven days. 12.Review of P12's current "Plan of Care" provided by the Clinical Director revealed the frequency of visit orders as follows: SN two times a week and seven prn visits every seven days, Aide two times a week and seven prn visits every seven days, SW seven prn visits every seven days, Chaplain seven prn visits every seven days. 13.Review of P13's current "Plan of Care" provided by the Clinical Director revealed the frequency of visit orders as follows: SN two times a week and seven prn visits every seven days, SW seven prn visits every seven days. 14.Review of P14's current "Plan of Care" provided by the Clinical Director revealed the frequency of visit orders as follows: SN two times a week and seven prn visits every seven days. Review of an agency policy titled, "Interdisciplinary Team/Plan of Care," dated 01/03/19, revealed, "The plan of care shall state in detail the scope and frequency of services needed to meet the patient's and family's needs." During an interview on 09/08/23 at 8:20 AM, the Clinical Director confirmed that the agency would not be able to track missed visits in the electronic medical record if the frequency included seven prn visits every seven days. The Clinical Director stated he/she had thought seven prn visits every seven days would count as a "range of prn visits" but acknowledged that it was not specific to the individual patient assessment.

Based on record review, policy review, and interview, the hospice agency failed to include measurable outcomes using data elements as a component of the patient goals for 14 or 14 patient (Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, and P14) plans of care. The failure to include a measurable outcome had the potential to prevent the hospice interdisciplinary group from knowing if they are meeting the patient's goal or revising the plan of care if they are not meeting the goal. --- Review of the "Plan of Care" provided by the Clinical Manager revealed the goals were not measurable and did not include data elements. The plans of care included the following patient goals: 1.P1's patient goals included "Patient will maintain optimal nutrition and hydration as long as possible," "Patient will maintain adequate cardiac/circulatory function and fluid volume as long as possible," "Patient will achieve and maintain optimal physical comfort," "Patient will achieve and maintain optimal skin integrity as disease progresses." None of the patient goals included measurable data elements. 2.P2 patient goals included "Patient will achieve and maintain optimal physical comfort," "Patient will achieve optimal breathing patterns and respiratory comfort," and "Patient's infection process will be contained, comfort will be promoted, and further infection prevented if possible." None of the patient goals included measurable data elements. 3.P3 patient goals included "Patient will achieve and maintain optimal physical comfort," "Patient will achieve optimal breathing patterns and respiratory comfort," "Patient's infection process will be contained, comfort will be promoted, and further infections will be prevented if possible," and Patient will achieve and maintain optimal skin integrity as disease progresses." 4.P4 patient goals included "Patient will maintain adequate cardiac/circulatory function and fluid volume as long as possible," "Patient will achieve optimal breathing patterns and respiratory comfort," and "Patient will achieve and maintain optimal skin integrity as disease progresses." 5.P5 patient goals included "Patient will maintain adequate cardiac/circulatory function and fluid volume as long as possible," and "Patient will achieve and maintain optimal physical comfort." 6.P6 patient goals included "Patient will achieve and maintain optimal physical comfort," "Patient will achieve optimal breathing patterns and respiratory comfort," and "Patient will achieve and maintain optimal skin integrity as disease progresses." 7.P7 patient goals included "Patient will achieve optimal breathing patterns and respiratory comfort," and "Patient will achieve and maintain optimal skin integrity as disease progresses." 8.P8 patient goals included " Patient will achieve and maintain regular bowel elimination patterns," and "Patient will achieve and maintain optimal physical comfort." 9.P9 patient goals included "Patient will maintain adequate cardiac/circulatory function and fluid volume as long as possible," "Patient will achieve and maintain optimal physical comfort," and "Patient will achieve and maintain optimal skin integrity as disease progresses." 10.P10 patient goals included "Patient will achieve and maintain optimal physical comfort," and "Patient orientated to the extent possible." 11.P11 patient goals included "Patient will achieve optimal breathing patterns and respiratory comfort," and "Patient will achieve and maintain optimal skin integrity as disease progresses." 12.P12 did not have any patient goals identified. Goals on the plan of care were staff interventions/goals. 13.P13 patient goals included "Patient will maintain adequate cardiac/circulatory function and fluid volume as long as possible," "Patient will achieve and maintain optimal physical comfort," and "Patient will achieve and maintain optimal skin integrity as disease progresses." 14.P14 patient goals included "Patient will maintain adequate cardiac/circulatory function and fluid volume as long as possible," "Patient will achieve and maintain optimal physical comfort," and "Patient will achieve optimal breathing patterns and respiratory comfort." Review of the undated agency policy titled, "Patient/Family Plan of Care," revealed, "The plan of care must include ... Measurable outcomes anticipated from implementing and coordinating the plan of care." During an interview on 09/08/23 at 8:20 AM, the Clinical Director agreed that the goals were not measurable and did not contain data elements. He/she stated the electronic medical record (EMR) "does not allow us to write a goal freestyle. The nurse must pick from the list provided."

Based on observation, policy review, and interview, the hospice agency failed to ensure the Registered Nurse (RN) followed accepted standards of practice for infection prevention while providing wound care during one of three patient (Patient (P)3) observations. Failure to change gloves when moving from a contaminated area to a clean area and failure to complete hand hygiene after removing gloves had the potential to increase the risk of wound infection due to cross contamination. --- During a home visit observation of Registered Nurse (RN)2 providing wound care to P3 on 09/07/23 at 3:00 PM, the following was noted: RN2 entered the bedroom and placed her bag directly on the carpeted floor without a barrier. A private pay attendant was present and assisted with turning the patient so RN2 had access to the pressure ulcer on P3's coccyx. RN2 put on gloves without first completing hand hygiene. RN2 then removed the outer dressing and pulled out a saturated gauze that was packed inside the wound. RN2 was still wearing the same gloves and went over to the dresser where some supplies were located. RN2 held a plastic container containing powdered metronidazole and mixed it with saline. RN2 then picked up the can of wound cleanser and put it on the bed on top of a blue pad along with other clean wound care supplies. RN2 put on a second pair of gloves on top of the first gloves. He/she proceeded to pick up the wound cleanser and gauze and cleaned the wound. Next RN2 applied the metronidazole mixture deep into the wound using his/her gloved fingertip. RN2 applied silver alginate and gauze inside the wound and covered it with a dressing. Still wearing the two pairs of gloves, RN2 moved down to a second wound on the patient's outer left ankle and removed the dressing. RN2 removed the outer pair of gloves and put new gloves over the first pair of gloves. RN2 picked up the wound cleanser which he/she had previously touched with contaminated gloves and cleaned the wound around the ankle. RN2 picked up the metronidazole mixture which he/she had used on the first wound and with his/her fingertip applied some to the ankle wound. RN2 then applied a clean dressing over the wound. While still wearing the gloves, RN2 applied A&D ointment to P3's feet. RN2 then removed both sets of gloves without completing hand hygiene. During an interview on 09/07/23 at 3:45 PM, RN2 was asked why he/she had put on gloves over the gloves rather than removing gloves, completing hand hygiene, and putting on a new pair of gloves. RN2 stated that if he/she removes the first gloves his/her hands are "too moist" and "it is too difficult to get new gloves on." Review of an agency policy titled, "Hand Hygiene – CDC Guidelines," dated January 2020, revealed, "All staff will use the hand-hygiene techniques, as set forth in the following procedure. The CDC antimicrobial soap and water or an alcohol-based hand rub ... Before each patient encounter ... After working on a contaminated body site and then moving to a clean body site on the same patient ... After coming in contact with bodily fluids, dressings, mucous membranes, etc., ... Always after removing gloves ... Gloves are to be worn when contact with blood, bodily fluids, mucous membranes, dressings, non-intact skin, etc., is anticipated ... Change gloves when moving from a contaminated body site to a clean body site on the same patient." Review of an agency policy titled, "Standard Precautions," dated January 2020, revealed, "Goves: To be worn when touching blood, body fluids, secretions, excretions, mucous membranes, non-intact skin and other contaminated items, i.e., equipment ... Hands are to be washed after removing gloves. Gloves should be changed between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. During an interview on 09/08/23 at 8:20 AM, the above observations were reviewed with the Clinical Director who confirmed RN2 did not follow the guidance for gloving and hand hygiene while providing wound care for P3.

Based on record review and interview, the hospice agency failed to ensure the Registered Nurse (RN) completed supervisory visits at least every 14 days to assess the quality of care provided for nine of nine patients (Patient (P)1, P2, P3, P4, P6, P7, P8, P10, and P12) who were ordered Aide services in the plan of care. --- Review of the documentation section of the electronic medical record (EMR) for P1, P2, P3, P4, P6, P7, P8, P10, and P12 revealed hospice Aide visits were being completed and documented. Review of the RN documentation in the EMR for the past 60 days failed to show that a hospice Aide supervisory visit was completed. During an interview on 09/08/23 at 8:20 AM, the Clinical Director confirmed that hospice Aide supervisory visits are not documented in the patient's clinical record. The Clinical Director stated that there were recent changes to the EMR after another company purchased it and as a result the nurse had to go through another process to access the supervisory documentation. He/she stated that because of this change the supervisory visits were not being completed. The agency did not have a policy related to the completion of a supervisory visit being completed by the RN when the patient receives hospice Aide services.

Based on document review, policy review, and interview, the hospice agency failed to identify in the plan of care for one of one patient (Patient (P)2) who resided in a private pay nursing facility which provider was responsible for providing which services to ensure patient continuity of care. Failure to identify responsibility for services had the potential to result in the patient not receiving necessary services. --- On 09/07/23 at 9:00 AM, a home observation was attempted at the non-Medicare certified private pay nursing facility where P2 resides. P2 refused the visit because his/her acupuncturist was there for a treatment. During an interview on 09/07/23 at 9:05 AM, the Nursing Supervisor at the nursing facility stated the facility is not Medicare certified but did provide skilled nursing care. The Nursing supervisor also stated the facility had not received a plan of care for P2 from the hospice agency. Review of P2's "Plan of Care" provided by the Clinical Director failed to include information which identified what care and services the facility would provide. During an interview on 09/08/23 at 8:50 AM, the Administrator stated they do not provide a plan of care to that facility because the facility is not a "Skilled Nursing Facility." An agency policy titled, "Coordination of Care, Treatment and Services with Contracts/Agreements," dated January 2020, revealed, "Hospice retains quality improvement responsibility for evaluating services, maintain professional management responsibility and ensuring continuity of care in all settings."

Based on interview and policy review, the hospice agency failed to coordinate care with a nursing facility for one of one patient (Patient (P)2) who was seen for a home visit by providing copy of the plan of care, hospice election form, and Physician certification of terminal illness. Failure to coordinate care had the potential to result in the patients needs not being met. --- On 09/07/23 at 9:00 AM, a home observation was attempted at the non-Medicare certified private pay nursing facility where P2 resides. P2 refused the visit because his/her acupuncturist was there for a treatment. During an interview on 09/07/23 at 9:05 AM, the Nursing Supervisor at the nursing facility stated the facility does provide skilled nursing care. The Nursing supervisor also stated the facility had not received a plan of care for P2 from the hospice agency, a hospice election form or Physician certification of the terminal illness. During an interview on 09/08/23 at 8:50 AM, the Administrator stated they do not provide those documents to that facility because the facility is not a "Skilled Nursing Facility" and they did not have a contract with the facility because the agency treats the facility like they would an assisted living facility. The only policy provided by the hospice agency was titled, "Coordination of Care, Treatment and Services with Contracts/Agreement," dated January 2020, revealed, "To ensure the coordination of care, treatment and services provided by Hospice and by contractual providers ... Hospice retains quality improvement responsibility for evaluating services, maintain professional management responsibility and ensuring continuity of care in all settings." The policy did not specify what documents the hospice agency will provide to facilities in order to coordinate continuity of care.