Every finding on record at Delta Hospice and Palliative Care LLC

Observed in Record Review. In 1 of 19 patient records reviewed, the Surveyor noted in RRNHV2, the comprehensive assessment completed every 15 days had not included the patients wound. There had been no documentation of the wound assessment in collaboration with the facility. This was validated with the DOPCS.

Observed in Record Review. In 19 of 19 patient records reviewed, the Surveyor noted patient goals that had been generic, not patient specific, measurable or with an appropriate time frame. For example, in RRHV1, the patient had the following goals: Constipation: Optimal bowel elimination and comfort; Incontinence: Pt will verbalize having urinary needs met at an acceptable level; Skin: Minimize risk of bed sores. In RRHV2 the patient had goals: for constipation: Optimal bowel elimination and comfort; Incontinence: Pt will verbalize having urinary needs met at an acceptable level; Skin: Minimize risk of bed sores; RRHV3 had goals: Increase strength/energy for day to day activities; Patients needs will be met on a day to day basis. Pain level will remain in comfortable level during care. In RRNHV1, the patient dehydration: pt will have optimal fluid intake; Skin: altered skin will heal to maximum potential; pain: pain will remain in comfortable level during care; In RRNHV2 the patient had: Pt will verbalize having urinary needs met at an acceptable level on a daily basis. Pt will have optimum level of oxygen . This was in every patient record reviewed. Validated with the DOPCS.

Observed in Record Review. In 1 of 19 patient records reviewed, the Surveyor noted the patient plan of care (POC) had not been updated when changes to patient care had been implemented. For example, in RRNHV2, the patient started care in May with an indwelling catheter with orders for care. The patient requested the catheter be removed at the end of May. The catheter had been removed at the end of May by the RN; however, the order to remove the catheter had not been written until August, and the care for the indwelling catheter remained on the POC until the middle of October. This was validated with the DOPCS. Observed in Record Review. In 3 of 19 patient records reviewed, the Surveyor noted incomplete medication orders. For example, in RRNHV3, the patient had therapeutic duplicate medications without clear indications for use. These included: both Albuterol and DuoNeb every 4 hours as needed for shortness of breath and Acetaminophen every 6 hours and Morphine every 4 hours both as needed for pain. In RRNHV4 the patient had multiple duplicative medications for constipation, pain and shortness of breath (DuoNeb every 4 hours/Albuterol every 6 hours; Morphine, acetaminophen and ibuprofen all as needed for pain; miralax, and bisacodyl as needed for constipation) without clear clinical indications for use. This was validated with the DOPCS

Observed in Record Review. In 7 of 19 patient records reviewed, the Surveyor noted that care had not been provided according to hospice plan of care (POC). For example, in RRHV3, the orders were for the RN to visit the patient 3 times per week; however, the 2nd and 3rd week of January there had been only 2 visits made, the 1st week of February there had been only 1 visit made, and the 3rd week of February there had been only 2 visits made. There had not been any documentation present on why the visits had not been made, nor any communication with the prescribing physician/IDT. The same patient also had orders for the Hospice Aide to visit 3 times per week. The 1st and 3rd week of January and 4th week of February only 2 visits per week had been made. In RRNHV4, the HA had been ordered for 3 visits per week; however, the HA was only providing care 2 times per week. In RRNHV5, there had been a missing RN visit for the last week of February and no supporting documentation present. In RRNHV6, the HA had been ordered for 3 times per week, but only providing 2 visits per week in the last 6 out of 8 weeks. In RRNHV8, the HA had orders for 3 times per week visits; however, the 2nd, 3rd, and 4th week of February, there had only been 1 visit per week documented. In RRNHV9, the HA had been ordered 2 times per week, however, there was only 1 visit per week provided the last week of January and the first 2 weeks of February. In RRNHV10 the HA had only visited the patient 1 time per week during the end and 3rd week of February even though 2 times per week visits had been ordered. This was validated with the DOPCS.

Observed in Record Review. In 13 of 13 patient records reviewed, where the patient had a Hospice Aide (HA) assigned, the surveyor noted the HA checking vital signs (VS) without specific range parameters to report. In RRHV1, RRHV3, RRHV4, RRNHV1 - RRNHV10, the patient had a HA that had been checking VS; however, there had been no parameters for reporting VS out or range. In discussion with the HCO, identifying VS parameters has not been a part of their process. This was validated with the DOPCS.

Observed in Tracer Activities. Based on Volunteer Coordinator interview, the HCO failed to ensure that volunteer services contributed at least 5% of total patient care hours, as required by regulation. The volunteer hours of 0.42% did not meet the required 5% requirement. This deficiency was identified through review of volunteer documentation, service hour summaries, and validation with the Volunteer Coordinator.

Observed in Record Review. In 1 of 2 patient records reviewed, where the patient had an open wound, the HCO failed to ensure wound care documentation had been completed in accordance with the agency’s policy requiring weekly wound assessments with full measurements and detailed intervention documentation. For example, RRNHV2 revealed the patient had a large open wound on the left lower extremity requiring ongoing skilled nursing intervention. Over the past four months, clinicians had not documented weekly wound assessments. When wound documentation was present, the RN documented inconsistent or incomplete measurements. Entries lacked the required length, width, and depth measurements. Documentation of wound care interventions was incomplete. Several entries stated only “wound care provided” with no description of the specific interventions performed, type of cleansing, dressing used, patient response, or progress toward healing. This was validated with the DOPCS. Observed in Record Review. In 2 of 19 patient records reviewed, the Surveyor noted clinical documentation identifying new medications the patient was being administered; however, the medication list in the EMR had not been updated with the new medications. For example, in RRHV1, the RN documented that the patient had been given a 'breathing treatment' by the care giver, but there had been no respiratory medications on the patient medication profile. The same patient had RN notes from 2 months ago that the patient had been administered Miralax, but this had not been on the medication profile either. In RRHV2, 2 weeks prior to survey, the RN visit note identified that the patient started on Glimeperide 1 mg daily in the morning and Miralax but these had not been included on the Medication list as of survey. This was validated with the DOPCS.

Observed in Emergency Management Session. During review of the Emergency Management plan and discussion with the Alternate Administrator, DPCS, Office Manager and consultant, it was noted that an emergency exercise was documented in June 2022 and in 2021 with the description of the drill and sign in sheets for those involved. However, there was no documented evaluation of the emergency response exercises and as a result it did not include the identification of deficiencies and opportunities for improvement. This was confirmed with those present. Observed in Emergency Management Session. During review of the Emergency Management plan and discussion with the Alternate Administrator, DPCS, Office Manager and consultant, it was noted that an emergency exercise was documented in June 2022 and in 2021 with the description of the drill and sign in sheets for those involved. However, the management and staff had not evaluated the emergency response exercises. This was confirmed with those present.

Observed in Record Review. In 11 of 11 patient records reviewed, it was noted that the Plan of Care goals did not have time frames for achieving goals. For example, in records HV#1,2 and 3 and RR#1, 2, 3, 4, 5, 6, 7 and 8 there were multiple goals and intervention identified with no time frames indicated. The program included an area titled Target Date for each goal to include a time frame, but all of these were left blank and no other time frame had been added. This was confirmed with the DPCS present.

Observed in Record Review. In 3 of 3 patient records reviewed, for bereavement services it was noted that, the plan of care did not include services needed for the palliation and management of the bereaved, including the following: - Interventions to manage pain and symptoms - A statement of the scope and frequency of the services necessary to meet the family’s needs - Measurable outcomes anticipated from implementing and coordinating the plan of care. For example, in records BR#1, RR#2, and RR#3 there was no documented bereavement plan of care indicating interventions, goals, or frequency of services necessary to meet the bereaved's needs. This was confirmed with the DCPS present. Also, in 6 of 8 patient records reviewed the plan of care did not include services needed for the palliation and management of terminal illness and related conditions including a statement of the scope and frequency of the services necessary to meet the patient's and family's needs. For example, in records RR#3, RR#5, HV#2 and HV#3 there was no order in the plan of care for social worker visits and the records all contained document of multiple MSW visits with the patient's and families. In RR#4 and RR#2 there was documentation of Volunteer visits with the patient and no order in the plan of care for these visits. This was confirmed with the DPCS present.

Observed in Record Review. In 1 of 11 patient records reviewed, it was noted that care was not provided according to the individualized hospice plan of care. For example, in RR#1 the POC order was for the aide 3 times a week and during 1 week the aide documented 4 visits and during another week the aide documented 5 visits. There was no additional orders for these visits. This was confirmed with the DPCS present.

Observed in Data Session. During review of the organization's data, Infection Control plan, performance improvement projects, and discussion with the leadership team the surveyor noted that the organization had not identified infection risks based on the following: - Its geographic location, community, and population served - The care, treatment, or services it provides - The analysis of its surveillance activities and other infection control data. This was confirmed during discussion with the Alternate Administrator, RN/owner/DPCS, Office Manager and Consultant/CPA.

Observed in HR File Review. In 1 of 7 HR files reviewed, it was noted that the organization had not assessed and documented competence once every three years. For example, in the medical director's file the most recent competence was greater than 3 years ago. This was confirmed with the Office Manager present.

Observed in HR File Review. In 1 of 7 HR files reviewed, it was noted that the criminal background check had not been conducted or documented. For example, in the Volunteers file the criminal background was dated 9 months after start date. This was confirmed with the Office Manager present.