Every finding on record at Dft Healthcare Group, Inc.

Observed in Record Review. In 1 of 8 patient records reviewed, The hospice nurse surveyor noted (RR#7) that the record indicated that the patient had a stage 4 coccyx wound. The surveyor noted that the wound was being managed by a consulting wound care specialists weekly (not indicated on the plan of care). The surveyor noted that there was no evidence in the record that the registered nurse had observed and assessed the wound since December. The management and assessment of the wound was left to the wound care consultant. There was no order for the wound care consultant on the current plan of care. The surveyor noted that there was no specific policy in place about the assessment and management of wounds. The assessment policy indicated that the comprehensive assessment is updated by the interdisciplinary group as frequently as the patient's condition requires at a minimum of every 15 days and when there is a change in condition. The surveyor noted that the patient was started on Bactrim for a wound infection in January. This was confirmed with the director of nursing via telephone call.

Observed in Record Review. In 2 of 8 patient records reviewed, The hospice nurse surveyor noted (RT#1) that the reassessment and certification of terminal illness indicated that the patient was receiving continuous oxygen at 2LPM; however the oxygen order was for O2 2-5 lpm as needed and did not address the specific need of the patient. Also, in (RR#7), the plan of care orders did not include orders for either the hospice nurses or the wound consultant to assess the wound and perform the wound care. The surveyor noted that the nursing assessment indicated that the wound was being managed by a wound consultant that was contracted to perform the care; however there were no orders on file and the current plan of care did not specify who was to perform the wound care. The surveyor noted that there was no evidence in the record that the hospice registered nurse had assessed the wound or performed wound care since December. This was confirmed with the director of nursing.

Observed in Record Review. In 7 of 8 patient records reviewed, The hospice nurse surveyor noted (RR#1) that the patient assessment indicated that the patient was a full code and that the social worker assessment indicated that the plan was to complete a DNR; however, there was no psycho-social care plan established, goals or interventions to meet the need identified in October or since. Also, in (RR#2), (RR#3), (RR#4), (RR#5)and (RR#6), the psycho-social assessment and frequency orders indicated a plan to visit monthly; however there were no goals of interventions established. In (RR#3), the surveyor noted that the patient had an infected mouth lesion that was painful to touch. The goal did not include any outcome measures or time frames to resolve the problem and simply stated minimal episodes of mouth pain to the end of the episode. In (RR#4) none of the goals had measurable outcomes. For example the cardiac goals stated heart rate with be at acceptable range, BP will be in acceptable range with optimal circulation. Also, there were no goals to manage the patient frequent periods of anxiety and agitation, only verbal understanding of terminal agitation. In (RR#6) the goal for high blood pressure was BP at acceptable range. The surveyor noted that the pre- bereavement risk was identified as moderate; however there was no plan to manage the pre-bereavement risk. In (RR#7), the surveyor noted that the patient assessment indicated that the patient had dysphagia and was regurgitating enteral feedings; however, there were no goals to manage the aspiration risk. Also, the social work assessment indicated that there were no funeral arrangements in place and there was no care plan established to meet the patient needs for end-of -life preparation. This was confirmed with the alternate administrator.

Observed in Record Review. In 7 of 8 patient records reviewed, The hospice nurse surveyor noted (RT#1), noted that the social worker was ordered 1 x per month; however, there were no visits completed in December, January or February. Also, the chaplain was ordered 1 x month and there was no visit completed in February. In (RR#1) the social worker was ordered 1x per month and there were no visits documented in November, December and February. In (RR#2) the social worker was ordered monthly and was not provided in November, January or February. Also, the chaplain was ordered monthly and was not provided in January or February. In (RR#3) the social worker was ordered monthly and was not provided in November, or January. In (RR#4), the social worker was ordered monthly and was not provided since November. In (RR#6) the social worker was ordered monthly and was not provided in November or January and in (RR#7), the social worker was ordered monthly and was not provided in November, December or January. This was confirmed with the alternate administrator.

Observed in Tracer Activities. The hospice nurse surveyor noted that the HCO failed to implement the policies and insure compliance thereof as it related to COP 484.54 and 418.56.

Observed in Tracer Activities. The hospice nurse surveyor noted that the organization contracted with a wound care consultant group to assess and manage wounds and gastrostomy tubes, for their patients; however the written agreement with for providing contracted services for the hospice did not include the following: A stipulation that services will be delivered in accordance with the patient’s plan of care - The manner in which contracted services will be coordinated, supervised, and evaluated by the hospice - The delineation of the role of the hospice and contractor in the admission process, patient/family assessment, and the interdisciplinary group conferences - Requirements for documenting that services are furnished in accordance with the agreement . This was confirmed with the alternate administrator.

Observed in Tracer Visit. In 1 of 8 patient records reviewed, The hospice nurse surveyor noted (RT#1) an order for Heparin 5000 Unit give 1 ml by injection 3 x daily; however in telephone discussion with the facility nurse, the surveyor confirmed that the patient had not been on heparin since he was admitted to hospice in October. The surveyor confirmed with the hospice nurse that the medication list had not been accurately reconciled.

Observed in Record Review. In 1 of 8 patient records reviewed, The hospice nurse surveyor noted (RR#7) that the patient was ordered advance wound care including cleansing the wound with 1/4 strength Dakin's solution and packing a stage 4 coccyx wound. The visit notes indicated that the patient's daughter was performing the care; however, there was no evidence in the record to confirm that the caregiver was observed and competent to perform the wound care. This was confirmed with the alternate administrator.

Observed in Tracer Activities. The hospice nurse surveyor noted that the organization contracted with a wound care consultant group to assess and manage wounds and gastrostomy tubes, for their patients; however the written agreement with for providing contracted services for the hospice did not include the following: The qualifications of the individuals providing the services - A stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This was confirmed with the alternate administrator. Observed in Tracer Activities. The hospice nurse surveyor noted that the organization contracted with a wound care consultant group to assess and manage wounds and gastrostomy tubes, for their patients; however the written agreement with for providing contracted services for the hospice did not include the following: A stipulation that services may be provided only with the authorization of the hospice - A stipulation that services will be delivered in accordance with the patient’s plan of care - The manner in which contracted services will be coordinated, supervised, and evaluated by the hospice - The delineation of the role of the hospice and contractor in the admission process, patient/family assessment, and the interdisciplinary group conferences - Requirements for documenting that services are furnished in accordance with the agreement - The qualifications of the individuals providing the services - A stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This was confirmed with the alternate administrator.

Observed in Emergency Management Session. The organization had a list of seven potential emergencies, however the list was not an all hazards approach and did not reflect the complexity of potential emergency situations that might occur. The organization had a template of a hazard vulnerability form available and a policy which indicated it was to be completed annually, however it had not been completed as confirmed with the Alternate Administrator.

Observed in Record Review. In 1 of 13 patient records reviewed, the organization had not assessed potential medication-related problems, including adverse effects, drug reactions, significant side effects, and significant drug interactions, including ineffective drug therapy, duplicate drug therapy, and noncompliance with drug therapy. In the chart for RR#4, the patient chart indicated an allergy to Lorazepam. Lorazepam was ordered and administered by the caregiver prior to any documented follow up by the RN related to this documented allergy. Organizational policy Identification of Medications for Administration required that prior to administration, the nurse will verify and/or review information to determine that the medication is not contraindicated for the patient based on the following: A. Known drug allergies... This was discussed with the Alternate Administrator.

Observed in Record Review. In 1 of 13 patient records reviewed, the patient record was not accurately documented. In the chart for RR#4, the RN noted a phone visit three days post admission to discuss medication questions. In that note, she documented that a MAC reading was obtained. This was discussed with the DPCS.

Observed in Record Review. In 1 of 13 patient records reviewed, the hospice had not provided education and training to the primary caregiver as appropriate to the responsibilities assigned to the caregiver in the plan of care. In the chart for RR#6, the patient had orders for daily wound care, yet there was no indication that the primary caregiver was either already competent at the initial visit nor taught how to perform the wound care for the patient. Nursing was ordered twice weekly. This was discussed with the DPCS.

Observed in Record Review. In 2 of 13 patient records reviewed, the written plan of care (POC) was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for RR#4, the patient was at risk for pressure ulcer development and had oxygen in the home. The POC did not include any goals related to these issues as confirmed with the DPCS. In the chart for RR#5, the patient was at risk for pressure ulcer development. There were no goals related to this problem on the POC.

Observed in Record Review. In 4 of 13 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: Medications and treatment necessary to meet the patient’s needs. In the chart for RR#2, the patient had wound care orders from a wound care organization. These orders were not included on the patient's hospice POC. In the chart for RR#3, the order Flush peg tube per protocol before and after administering feeding and medications. was incomplete, missing volume and solution. In the chart for RR#4, the patient was at high risk for pressure ulcer development. This problem and associated interventions were not included on the POC, though the SN was teaching about pressure relief. Additionally, this patient was on oxygen. There was nothing about oxygen safety included on the POC. In the chart for RR#5, the patient was at high risk for pressure ulcer development and the SN's were instructing on prevention, this problem and associated interventions were not on the POC. This was discussed with the DPCS.

Observed in Record Review. In 1 of 13 patient records reviewed, the plan of care revisions were not based on information from updates to the patient’s comprehensive assessment and did not address the patient’s progress toward goals and outcomes. In the chart for HV#1, the SN visits were ordered 2/weekly. Approximately 3 weeks prior to the date of this survey, the patient experienced unexpected changes. SN visits were increased to 7/week x 1 week and 3/week x 1 week. The plan of care was not updated to reflect this change. In addition, the patient had some wounds earlier in her care, however, the wounds are healed and the patient's skin is intact. The plan of care was not updated to remove this problem and goal which had been met. This was discussed with the Administrator and Alternate Administrator.

Observed in Record Review. In 5 of 13 patient records reviewed, the organization had not provided the patient with care, treatment, or services according to the patient's individualized plan of care. In the chart for RR#3, SN visits were ordered 2/week on the plan of care; the SN visits were made daily. In the chart for RR#2, during the seventh SN visit, the LVN had not followed the most recent order. The SN documented Cleanse with NS, pat dry, apply Santyl to wound bed, cover with calcium alginate, cover with gauze. however the order was cleanse with NS, pat dry, apply Mupiricin, apply collagen, apply bordered, dry dressing - change every 2-3 days. In the chart for RR#4, during 2 SN visits the oxygen was documented at 10lpm. Order was 14-18lpm. In the chart for RR#5, Nursing was ordered 2/week. SN's were routinely seeing the patient 3-4 visits/week at the beginning of service. The aide was ordered 3/week. Weeks one and two, only one visit was made by an aide each week with no indication why the frequency was not followed. Weeks five and six, the frequency was not followed. In the chart for RR#8, SN visits were routinely provided over the ordered frequency of 2/week. This was discussed with the DPCS.

Observed in Data Session. The organization's QAPI program did not involve all services provided by the organization. During discussion with the DPCS and Quality Coordinator, it was noted that the QAPI program did not include any monitoring of contracted services such as Pharmacy, Medical Equipment nor SNF services; nor did it involve any monitoring of bereavement or volunteer services.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization had not used standard precautions, including the use of personal protective equipment, to reduce the risk of infection. During HV#3, the hospice aide wiped her cleaned hands on a fabric hand towel provided by the caregiver rather than paper towels. This was discussed with the Alternate Administrator present at the visit. Observed in Patient Home. In 1 of 3 home visits conducted, the organization had not implemented infection prevention and control activities when doing the following: Cleaning and performing disinfection of medical supplies and devices. During HV#1, the RN cleaned her equipment with the agency provided wipes, however did not follow the 4 minute wet time required by the manufacturer, rather immediately after wiping, replaced the equipment in her clinical bag. This was observed by and discussed with the Alternate Administrator present during the visit.

Observed in Data Session. The organization's written infection prevention and control goals did include the following: Limiting unprotected exposure to pathogens, however there was no measure of attainment included as confirmed with the DPCS. Observed in Data Session. The organization's written infection prevention and control goals did include the following: Limiting the spread of infections associated with procedures however there was no measure of attainment included as confirmed with the DPCS.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: - §418.56, §418.58, §418.60 and §418.100 as discussed with the Administrator/DPCS.

Observed in Document Review. In 2 of 3 contracts reviewed, the written agreements with the DME and Pharmacy providing contracted services for the hospice did not include the following: A stipulation that services may be provided only with the authorization of the hospice. This was discussed with the Administrator.

Observed in Record Review. In 3 of 13 patient records reviewed, the patient record did not contain the following clinical information: specific notes on care, treatment or services. In the chart for RR#2, the SN's did not always document the care provided. For example, notes read Wound treatment rendered as ordered. Wound care was rendered to wound on buttocks. In the chart for RR#1, in the recert assessment documentation of wound care, the SN wrote Treatment to redness to coccyx with skin barrier cream to maintain skin integrity. Left heel DTI treatment done as well. without specifying what treatment was provided to the DTI. In the chart for RR#6, the RN wrote Treatment orders for scattered open blisters on bilateral lower legs in place. Treatment rendered as ordered, well tolerated.. This was discussed with the DPCS.

Observed in Tracer Activities. The organization had no process for routine and preventative maintenance for equipment used by staff in care of patients including electronic thermometers, pulse ox's, electronic blood pressure cuffs as confirmed with the DPCS.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization had not taken action to minimize identified safety and security risks. During HV#2, it was noted by the surveyor that the oxygen tank was stored in a closed closet. This was not identified by the Alternate Administrator present during the visit until it was discussed.

Observed in Record Review. In 3 of 13 patient records reviewed, for the patient who was a resident of a SNF, the hospice plan of care did not identify which provider was responsible for performing the functions that have been agreed upon and included in the plan of care. In the chart for RR#1, the patient had orders for daily wound care, however the hospice plan of care did not address which provider was to provide the wound care to the patient. In the chart for RR#3, the POC did not specify who was to provide the patient's wound care and g-tube site care. In the chart for RR#9, the POC failed to address which provider was to perform wound care. This was discussed with the Administrator.

Observed in Document Review. In 2 of 3 contracts reviewed, the written agreements with the Pharmacy and DME providing contracted services for the hospice did not include the following: A stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This was discussed with the Administrator.