Every finding on record at Delaware Hospice - Northern Division

Based on policy review and interview with staff, it was determined that the Agency failed to ensure that orientation and training regarding emergency preparedness had been completed for all employees of the agency. Findings include: --- Agency policy titled, ";Emergency Preparedness and Response (EPRP) Plan" stated, ";Hospice ensures that all employees...are trained and oriented about their responsibilities in the agencys EPRP upon initial implementation, upon hire and with any updates to the plan..." During an interview on 10/17/23 at 4:00 PM with Employee #1, it was confirmed that there was no evidence of the Agency employees having received education on the Agency's Emergency Preparedness and Response Plan.

Based on policy review and staff interview it was determined that the Agency failed to conduct a full-scale exercise that was a comprehensive test of the emergency plan. Findings include: --- Agency policy titled, ";Emergency Preparedness and Response (EPRP) Plan" stated, "...reviews its plan on an annual basis and conducts at least one (1) community-wide mock drill and one (1) tabletop exercise or similar drill per year (or review an actual event) that documents and demonstrates that employees have practiced their specific duties and assignments, as outlined in the emergency preparedness plan. The plan is evaluated and revised based on findings..." During an interview on 10/17/23 at 4:00 PM with Employee #1 it was confirmed that the agency had not conducted a full-scale exercise for the year 2022.

Based on policy review, record review, and interview with staff, it was determined that 2 out of 13 patients in the sample (Patient #'s 6 and 12) did not receive effective symptom control. --- Policy titled " Nursing Visits" stated, "...Initial and ongoing comprehensive assessment visits completed by an RN consist of ...assess the patient/family/PCG. This assessment includes verbal, visual, tactile and/or physical measurement of the following...distressing symptoms...Edmonton Symptom Assessment Scale (ESAS)...severity levels are assessed at each visit and are a tool used to demonstrate movement of problems toward resolution..." Policy titled, "Medication Administration and Management- Inpatient Unit", stated, "...all medications, their purpose, dose, route, and procedures for administration are reviewed with the patient/family/ PCG and the education is documented. Ensure understanding of the actions, side effects, adverse reactions, and the ability to administer the medications as ordered..." I. Patient #6 Review of medical record revealed: - Patient was admitted to the inpatient unit on 10/10/23. - Patient was receiving a continuous Hydromorphone infusion via CADD pump. - "Hospice Nursing Assessment Update" dated 10/16/23 indicated that patient was alert and oriented and the patients last bowel movement (LBM) was 10/10/23. - "Hospice Nursing Assessment Update" dated 10/15/23 stated, "No BS [bowel sounds] noted. LBM 10/10/23 refusing bowel med". - No evidence found that indicated that the patient received education on constipation or on the medications used to treat constipation in order to make an educated decision regarding their treatment. During an interview with Employee #11 on 10/16/23 at 12:00 PM, it was confirmed that no documentation was available that indicated that education was provided to the patient regarding a change in medication and the condition of constipation. II. Patient #12 Review of medical record revealed: - "Nursing Comprehensive Assessment" dated 9/20/23 stated, " pt [patient] reports SOB [shortness of breath] "huff and puff" after exertion." No evidence of additional assessment, interventions or follow-up. "Shortness of Breathing Screening" missing assessment information. No care plan initiated for identified symptom of shortness of breath. - "Nursing Comprehensive Assessment" dated 09/26/23 indicated on the "Shortness of Breath Screening" that patient is short of breath "when doing activities like dressing, toileting, ambulation more than 20ft." No evidence of additional assessment, interventions, education, or follow-up. "Shortness of Breath Screening" missing additional assessment information. No care plan initiated for ongoing symptom of shortness of breath. - "Nursing Comprehensive Assessment" dated 10/03/23 stated, "PCG [patient caregiver] reports pt with one episode of SOB last night. None this AM, lungs CTA, no signs of RR discomfort". No evidence found that indicated the patient or caregiver received education related to ongoing shortness of breath. "Shortness of Breath Screening" on the assessment was blank. No care plan initiated for ongoing symptom of shortness of breath. - "Nursing Comprehensive Assessment" dated 10/10/23 stated, "pt describes being SOB more often than not. Pt reports being SOB while ambulating and while trying to sleep, maybe anxiety related. Care plan and interventions initiated on this visit" (20 days after initial complaint of shortness of breath). During an interview with Employee # 3 on 10/17/23 between 10:00 AM and 12:00 PM it was confirmed that Patient #12 did not receive thorough evaluations/interventions/ or education related to the symptom of shortness of breath in a timely manner.

Based on record review, agency document review, and interviews with staff, it was determined that the agency failed to complete a comprehensive assessment in an acceptable timeframe for 1 out of 13 active patients in the sample (Patient #11). Findings include: --- Agency policy titled "Initial Comprehensive Assessment Completion" stated, "...The comprehensive assessment of the patient is completed...no later than five calendar days after the patient elects the hospice benefit..." Medical record review for Patient #11 revealed: The start of care date was 9/25/2023. The first comprehensive assessment was completed on 10/5/2023 (10 days after the start of care). This finding was confirmed with Employee #4 on 10/18/2023 at 9:32 AM.

Based on record review, document review, and staff interview, it was determined that the agency failed to conduct complete nursing assessments for 4 out of 13 active patients in the sample (Patients # 7,10, 11 and 12). Findings include: --- Agency policy titled "Nursing Visits" stated, "...Initial and ongoing comprehensive assessment visits completed by an RN consist of: 1. Review of the Plan of Care and/or notes from previous visits to assess problems and previous outcomes. 2. Assessment: ...Distressing Symptoms...Pain...Functional status...Physical systems, including as needed, wound assessment...Emotional and psychosocial status..." Medical record review for Patient #7 revealed: Initial comprehensive assessment conducted 10/6/2023 identified a skin tear on the patient's right upper arm. The wound care assessment was not complete and did not include measurements of the wound. This assessment data allows for monitoring of the wound that would demonstrate improvement or worsening condition. The same comprehensive assessment conducted on 10/6/2023 identified that the patient was experiencing hallucinations. No further assessment or care planning information was documented. The comprehensive assessment completed on 10/10/2023 did not include documentation of psychosocial, spiritual, gastrointestinal, and fall risk assessments. The above findings were confirmed with Employee #3 on 10/17/2023 at 11:15am. Medical record review for Patient #11 revealed: The nursing assessment conducted on 10/3/2023 did not include documentation of a pain assessment. In an interview on 10/18/2023 at 9:53am, Employee #4 indicated that it is an expectation that nursing would assess for pain at each visit as well as confirming the finding above. Patient #12 "Nursing Comprehensive Reassessment" dated 09/20/23 was missing a psychosocial/spiritual assessment; incomplete shortness of breath screening. "Nursing Comprehensive Reassessment" dated 09/26/23 was missing a psychosocial/spiritual assessment; incomplete shortness of breath screening. "Nursing Comprehensive Reassessment" dated 10/03/23 was missing a psychosocial/spiritual assessment. The above findings were confirmed with Employee #3 on 10/18/23 at 12:00 PM. Patient # 10 "Nursing Comprehensive Reassessment" dated 10/04/23 was missing a psychosocial/spiritual assessment. The above findings were confirmed with Employee #3 on 10/18/23 at 12:00 PM.

Based on policy review, record review, document review, observations, and interviews, the hospice failed to meet the Condition of Participation of IDG, Care Planning, Coordination of Services. The deficient practices identified below have the potential to affect all patients being serviced by the hospice. --- The hospice failed to coordinate services with contracted nursing facilities by failing to provide ongoing education to facility staff regarding hospice principles. The hospice failed to ensure that care planning was individualized and measurable. The hospice failed to ensure the revised plan of care included information from the patient's updated comprehensive assessment. The hospice failed to provide evidence of the patient's attending physician sign off on updates to the Plan of Care.

Based on policy review, record review and interview with staff, it was confirmed that 1 out of 13 active patients reviewed (Patient # 16) did not have a measurable outcome related to the plan of care. Findings include: --- Agency policy titled "Plan of Care" stated, "...Plan of Care Development...make as specific and measurable as is possible; reflect the goals of the patient/family..." Review of Patient #16's medical record revealed: "Nursing Comprehensive Reassessment" dated 10/11/23 indicates the following as the patient's respiratory goal: "Patient will be able to walk to __AEB reporting only taking__breaks and using deep breathing as needed for the next___... Achieve By Date: 10/18/2023. Start Effective Date: 06/28/2023". The goal set is not specific to the patient and is not measurable, as evidenced by the "blanks" in the goal statement. During an interview with Employee # 4 on 10/18/23 at 1:00 PM, it was confirmed that Patient #16 did not have an individualized or measurable respiratory goal.

Based on medical record review, document review, and staff interview, it was determined that the facility failed to show collaboration with the patient's attending physician for updates to the plan of care for 2 out of 13 active patients in the sample (Patients #5 and 13). Findings include: --- Agency policy titled, "Plan of Care" stated, "...The Plan of Care (POC) directs the care team to provide the individualized services necessary to meet the patient and family specific needs identified in the initial and comprehensive assessments. The POC serves as a communication tool between all members of the interdisciplinary team... Physician Orders are obtained by the RN/LPN to document new or changed medical orders, including...to update the Physician Plan of Care. They are faxed/mailed to the Attending Physician for signature...The Plan of Care is reviewed and updated at a minimum of every 15 calendar days by the Interdisciplinary Group during Team Meetings...and documented on the Interdisciplinary Team Meeting Note..." Medical record review for Patient #5 revealed: The patient's attending physician was affiliated with the skilled nursing facility where the patient resided. There was no evidence of the patient's attending physician signature on an update to the Plan of Care on 8/8/23. These findings were confirmed with Employee #4 on 10/18/23 at 12:02 PM. Medical record review for Patient #13 revealed: The patient's attending physician was affiliated with the skilled nursing facility where the patient resided. There was no evidence of the patient's attending physician signature on updates to the Plan of Care on 9/12/23, 9/26/23 and 10/10/23. These findings were confirmed with Employee #4 on 10/18/23 at 11:00 AM.

Based on record review, document review, and staff interview, it was determined that for 1 out of 13 active patients in the sample (Patient #11) the agency failed to ensure the revised plan of care included information from the patient's updated comprehensive assessment. Findings include: --- Agency policy titled "Plan of Care" stated, "...The content of the POC [Plan of Care] is based on needs identified in the initial and comprehensive assessments for patient and family..." Medical record review for Patient #11 revealed: -The patient was admitted to hospice care and had an initial assessment on 9/25/23. -The plan of care was updated on 10/3/23. -The comprehensive assessment was conducted on 10/5/23. There is no evidence that the revised plan of care was based on information from the patient's comprehensive assessment. This finding was confirmed with Employee #4 on 10/18/23 at 9:32 AM.

Based on policy review, document review, observation, and interviews with staff, it was determined, for one of 4 (four) observed patients (Patient #7), the Agency failed to ensure ongoing sharing of information between all disciplines providing care under arrangement. Findings include: --- Agency policy titled "Nursing Facility Admission, Care of and Discharge" stated, "...Hospice assumes professional management of the patient's hospice plan of care...formal communications between representatives of the facility and Delaware Hospice occur on a regular basis...Delaware Hospice offers in-service programs to the facility that may include but are not limited to...concepts/philosophy of care...pain management and symptom control...listening/communications skills...anticipatory grief and loss..." Contract titled "Nursing Facility Services Agreement" stated, "...The Hospice retains responsibility for ensuring that the required training of personnel who will be providing Hospice Patient care in the Facility has been provided and that a description of the training and the names of those giving the training are documented..." During an interview on 10/18/23 at 8:45 AM, Employee #3 confirmed that "some meetings are being held at the facilities on an as-needed basis, but hospice is not providing training to all members of staff the skilled nursing facilities/assisted living facilities on hospice philosophy". No evidence of formal communications or in-services provided at nursing facilities was able to be located. During an observation of patient care on 10/17/23 the following was observed: -The patient became agitated during the provision of care. -The hospice nurse, Employee #13 shared that they were coordinating with the skilled nursing facility nurse to get orders for an emergency dose of Ativan. During an interview with Employee #13 on 10/17/23 at 12:20pm it was indicated that the skilled nursing facility uses their own provider to order comfort medications and that they usually arrive within a day or two. The employee stated that Ativan was available at the facility, but orders were needed as it was not on the patient's medication profile. Record review for Patient #7 revealed: -Medication record at the skilled nursing facility did have comfort medications ordered with a start date of 10/5/23. These orders included Ativan. -Hospice medication record did not have comfort medications listed, including Ativan at the start of care on 10/5/23. -The Hospice Plan of Care dated 10/5/23 was signed by the physician on 10/10/23 did not have a complete medication list, including comfort medications. When asked why the medication list was incomplete, Employee #2 stated they "didn't know" on 10/18/23 at 10:36am. -An updated Hospice medication record was produced on 10/18/23 showing an update adding comfort medications was done on 10/17/23. The hospice failed to have accurate communication regarding the patient's comfort medications.

Based on document review and staff interview it was determined that the governing body failed to approve the frequency and detail of the QAPI program for 2 out of 2 years reviewed (2022 and 2023). Findings include: --- Facility staff were asked to provide documentation that the governing body approved the QAPI plans for both 2022 and 2023. Staff were unable to provide any documentation except for the Board of Trustees Meeting Minutes, Board of Trustees packet, and QAPI meeting minutes - all sources failed to include evidence of the governing body approving the past and current QAPI plan. Review of the Board of Trustees Meeting Minutes from 9/28/23 showed that collected QAPI data was presented to the Board, but documentation did not include governing body approval of the frequency and detail of data collection. In an interview on 10/17/23 at 3:05 PM, Employee #1 confirmed that the governing body did not approve the QAPI plan in 2022, saying that it was missed. In an interview on 10/17/23 at 3:30 PM, Employee #1 confirmed that the available documentation does not include governing body approval of the frequency and detail of data collection.

Based on policy review, observations, and staff interview, it was determined that the Agency failed to follow acceptable standards of practice. Findings include: --- Agency policy titled " Vaccine PPD Storage and Handling" stated, "...When vaccine or medication vials are opened for use the label is marked with the date of opening...Tuberculin Derivative (PPD solution) may be used for 28 days after opening..." Agency policy titled "Bloodborne Pathogens- Standard Exposure Control Plan" stated, "...containers for contaminated sharps...maintained upright throughout use; and replaced routinely and not allowed to overfill. When filled, sharps containers are not transported between offices, but removed from the premises using a biohazard transport service..." Observation of the inpatient unit on 10/16/23 between 12:00 PM and 12:30 PM revealed: I. Multidose medication vial containing Tuberculin was located in the medication fridge within the medication storage room. The vial was labeled as opened on 8/15/23 (34 days past usable date). During an interview on 10/16/23 between 12:00 PM and 12:30 PM, Employee # 11 confirmed that the medication vial was opened on 8/15/23 and was thus expired. II. 2 out of 8 sharps containers observed on the unit had contents above the "max fill" line in the container. During an interview on 10/16/23 between 12:00 PM and 12:30 PM, Employee #11 confirmed that the unit had 2 sharps containers that were overfilled.

Based on policy review, employee record review, and interview with staff it was determined that for 2 out of 8 (Employee #'s 7 and 12) employees in the sample, the agency was unable to provide evidence of staff competency. --- Policy titled "New Hire Orientation Program- Clinical Staff" stated, "Delaware Hospice, Inc. (DHI) provides a comprehensive orientation program for all new patient care staff, whether employed by Delaware Hospice or provided through contract. Prior to providing services independently, DHI staff demonstrate core competency skills as documented on the discipline-specific New Hire Skills Checklist..." I. Employee #7 Employee record review revealed: - No evidence of a completed competency evaluation. During an interview with Employee # 13 on 10/18/23 at 11:20 AM, it was confirmed that there was no evidence of a competency evaluation for Employee #7. II. Employee #12 Employee record review revealed: - No evidence of a completed orientation program. - No evidence of a completed competency evaluation. During an interview with Employee #13 on 10/18/23 at 11:20 AM, it was confirmed that that was no evidence of a completed orientation program or competency evaluation for Employee #12.

Based on record review, document review, and staff interview, it was determined that the agency failed to obtain physician orders for one (1) of 13 patients in the sample (Patient #7). Findings include: --- Agency policy titled "Physician Orders" stated, "...Prior to providing any type of care, treatment or service, a physician order is obtained from a licensed independent medical practitioner..." Medical record review for Patient #7 revealed: On 10/6/23 a skin tear was noted on the patient's right upper arm. There was no evidence of provider notification or obtaining wound care orders at this time. This finding was confirmed by Employee #1 on 10/17/2023 at 11:15 AM.

Based on record review, document review, and staff interview, it was determined that the agency failed to forward the discharge summary to the patient's attending physician on discharge for 2 out of 2 discharged patients in the sample (Patients #4 and 5). Findings include: --- Agency policy titled "Termination of Hospice Care and the Discharge Planning Process" stated, "...The interdisciplinary team is responsible for all discharge activities and communication with the patient. In situation of transfer of services from one clinical, organization, organizational program or service to another, Delaware Hospice is committed to shifting the responsibility for care in such a way that the needs of the patient will continue to be met..." Record review for Patient #4 revealed: -Patient was discharged from hospice services on 10/6/22 -No evidence of a discharge summary, medication list, plan of care, or other information needed for care coordination being sent to the patient's primary care physician or palliative care provider on discharge This finding was confirmed with Employee #4 at 12:03 PM on 10/18/23. Record review for Patient #5 revealed: -Patient discharged from hospice services on 8/18/23 -Discharge summary, medication profile, physician plan of care, and last interdisciplinary team meeting note faxed to the patient's primary care physician on 8/31/23 (13 days after discharge) In an interview on 10/18/23 at 12:39 PM with Employee #4 the above finding was confirmed, and it was indicated that the expectation is that the documents would have been sent prior to discharge to allow for continuity of care.