Every finding on record at Eagle Pass Hospice and Palliative Care LLC

Observed in Document Review. The organization failed to ensure care furnished to the patient and families follow an individualized written plan of care with goals that are specific, measurable, and time-bound. On review of RRHV#1, RRNHV#4, RRNHV#5, RRNHV#6, and RRNHV#7 there were no goals established in the record to guide the care for the patient and family. In RRNHV#2, and RRNHV#3 there were examples of goals that were not specific, measurable, and time bound such as patient's pain will be controlled throughout the benefit period. All goals established were noted to be continued throughout the benefit period, and were not individualized as all goals were alike for RRNHV#2 and RRNHV#3. These observations were reviewed with the Administrator, and Office Manager.

Observed in Record Review. In 1 of 1 patient records reviewed, discharged for extended prognosis, the organization failed to ensure the patient was involved in making decisions about their care, treatment, or services as required. On review of RRDC#1 the patient was discharged for extended prognosis and signed the Notice of Medicare Non-Coverage yet the form was signed on the day of discharge and not at least two days prior as required. This observation was reviewed with the Administrator.

Observed in Record Review. In 2 of 7 patient records reviewed, the organization failed to ensure the comprehensive assessment was completed no later than 5 calendar days after the election of hospice. On Review of RRHV#2 there was no documentation that a psychosocial and spiritual initial assessment was completed in the record and there was no documentation noted to explain why the assessments were not completed. In RRHV#3 the patient was admitted in mid August and there was no documentation of an initial psychosocial assessment to date. These observations were reviewed with the Administrator.

Observed in Record Review. In 7 of 7 patient records reviewed, the organization failed to ensure the comprehensive assessment identified the patient's need for hospice care and services. On review of RRHV#2 there was no documentation that a psychosocial or spiritual initial assessment was completed since admission in early August and there was no documentation to explain why the assessments were not completed. In RRHV#3 there was no documentation that a psychosocial assessment was completed with no documentation of why the assessment was omitted. In RRNHV#5 the patient had documentation of a wound to the hip yet there was no documentation of a wound assessment as required to include size, description, odor, color, or surrounding tissue noted in the record beyond the initial assessment in February. Throughout all records reviewed there was no documentation that need for volunteer services was assessed or offered to the patient. These observations were reviewed with the Administrator.

Observed in Record Review. In 2 of 7 patient records reviewed, the organization failed to ensure the initial bereavement assessment was completed. On review of RRHV#1 and RRHV#2 there was no documentation of an initial bereavement risk assessment noted on the patient record. These observations were reviewed with the Administrator, and Office Manager.

Observed in Record Review. In 7 of 7 patient records reviewed, the organization failed to ensure the comprehensive assessment by the interdisciplinary group consider changes that have taken place since the initial assessment and include information on the patient progress toward goals and desired outcomes. Throughout all records reviewed there was a lack of documentation of progress toward goals as specific goals and desired outcomes had not been established in the record. This observation was reviewed with the Administrator.

Observed in Record Review. In 7 of 7 patient records reviewed, The organization failed to ensure care furnished to the patient and families follow an individualized written plan of care with goals that are specific, measurable, and time-bound. On review of RRHV#1, RRNHV#4, RRNHV#5, RRNHV#6, and RRNHV#7 there were no goals established in the record to guide the care for the patient and family. In RRNHV#2, and RRNHV#3 there were examples of goals that were not specific, measurable, and time bound such as patient's pain will be controlled throughout the benefit period. All goals established were noted to be continued throughout the benefit period, and were not individualized as all goals were alike for RRNHV#2 and RRNHV#3. These observations were reviewed with the Administrator, and Office Manager.

Observed in Record Review. In 7 of 7 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#1 there were no care plans established with goals and interventions to guide the patient's care. In RRHV#2 there was documentation of orders for IV fluids yet the treatment was not reflected in the care plans. On observation/discussion in the home and documentation in the record, the patient had a purewick catheter, and issues with dysphagia, and a UTI yet there were no care plans to guide the care. In RRHV#3 there was documentation of issues with appetite, a UTI with antibiotics ordered, and constipation yet there were no goals and interventions to address the issues. In RRNHV#4 the patient was admitted in late May yet there were no care plans to guide the care included on the plan of care to date of survey. In RRNHV#5 admitted in February yet there were no care plans established on the record at time of survey. In RRNHV#6 and RRNHV#7 there were no care plans established to guide the care. These observations were reviewed with the Administrator.

Observed in Record Review. In 5 of 7 patient records reviewed, the organization failed to ensure the plan of care included a statement of the scope and frequency of the services necessary to meet the patient and family needs. On review of RRNHV#4 there was no documented frequencies for all disciplines noted on the plan of care until late July, nearly 2 months after the start of care. In RRHV#1, RRNHV#4, RRNHV#5, and RRNHV#7 the plan of care noted a frequency of PRN for psychosocial and spiritual yet there was no indication of how many PRN visits were ordered. In RRNHV#6 there the spiritual frequency was noted to be PRN but no ordered amount of PRN visits was specified. These observations were reviewed with the Administrator.

Observed in Record Review. In 1 of 7 patient records reviewed, the organization failed to ensure the hospice interdisciplinary group (IDG) review, revise, and document the individualized plan as frequently as the patient condition required but no less frequently than every 15 days. For example on review of RRNHV#6 the last documented IDG meeting to review and revise the plan of care was in early July and not at least every 15 days as required. This observation was reviewed with the Administrator.

Observed in Record Review. In 4 of 7 patient records reviewed, The organization failed to ensure the services were provided in accordance with the plan of care. On review of RRHV#1 the skilled nurse was ordered a frequency of 3 times a week yet the documentation noted the patient was being seen 2 times a week. The orders noted the MSW was 1 time a month yet there were no social work visits documented as the initial noted social worker was declined. In RRHV#3 the plan of care ordered MSW and spiritual care 1 time a month yet there were no visits documented since admission in August. In review of RRNHV#5 the MSW was ordered a frequency of 1 time a month up until July yet no visits were documented beyond the initial in February. In RRNHV#6 the skilled nurse was order 3 times a week but documentation show the patient was being seen 2 times a week. These observations were reviewed with the Administrator and Office Manager.

Observed in Data Session. The organization failed to analyze and compare internal data over time to identify levels of performance, patterns, trends and variations. On review of the QAPI program each quarter stood alone and therefore did not allow of trending over time. This observation was reviewed with the Administrator and Office Manager.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned. For example: on home observation for RRHV#1 the aide was observed to provide care that included multiple glove changes yet was not observed to cleanse and/or sanitize hands during the patient visit as required by CDC guidelines and organization policy. The aide was also observed to access the bag to obtain supplies multiple times without performing hand hygiene as required. These observations were reviewed with the Administrator.

Observed in Infection Control Tracer. the organization failed to evaluate the effectiveness of its planned infection prevention and control activities. On review of the Infection Control hand hygiene program there was a goals set for 100% compliance yet there was no evidence that hand hygiene data was gathered and analyzed to assess progress toward the goal. This observation was reviewed with the Administrator and Office Manager.

Observed in Record Review. In 4 of 7 patient records reviewed, the organization failed to ensure the hospice aide plan of care included written patient care instructions. On home observation of RRHV#1 with the hospice aide it was noted that the patient had a foley catheter yet there was no instructions on the aide plan of care on how to handle the foley. Further the plan of care noted a shower every visit with bed bath noted as needed. The aide noted the family prefers a bed bath as they rarely get the patient up and so a bed bath is given each visit but the plan of care had not been updated to reflect the patient changes. In RRHV#2 the patient had a purewick catheter in use yet there were no instruction for how the aide was to handle the device while providing care. In RRHV#3 and RRNHV#6 the aide plan of care did not specify what type of bath the aide was to give as shower, partial bath/shower and bed bath were all noted as needed. These observations were reviewed with the Administrator.

Observed in Record Review. In 2 of 7 patient records reviewed, the organization failed to ensure the hospice aide provide services as ordered by the plan of care. In review of RRHV#1 the aide was observed to provide foley care in the home and applied moisture barrier to the patient sacrum yet these tasks were not specified in the aide plan of care. In RRNHV#6 the noted that on each visit the aide completed 3 types of bath as the bed bath, shower, and partial bath were documented to be completed each visit. These observations were reviewed with the Administrator.

Observed in Record Review. In 1 of 7 patient records reviewed, the organization failed to ensure the RN supervise the hospice aide during an on-site visit to the patient's home no less frequently than every 14 days. For example: on review of RRHV#1 there was a 29 day gap in documentation of aide supervisory from June to July and a 15 day gap in August. These observations were reviewed with the Administrator.

Observed in Leadership Session. Upon review of all tracer activities, it was noted that there was a pattern of staff failing to follow established organization policy and the governing body/leadership did not ensure that the Conditions of Participation for 418.100, 418.60, 418.54, and 418.56, were met per policy as determined through observations, documentation, and staff interviews.

Observed in HR File Review. In 2 of 8 HR files reviewed, the organization failed to ensure that staff competence was assessed and documented once every 3 years or as frequently as required by policy. On review of HR#3 and HR#5 there was no documentation of annual competency assessment as required by organization policy per discussion with the Administrator. Observed in HR File Review. In 1 of 8 HR files reviewed, the organization failed to ensure staff competence was initially assessed and documented as part of orientation. On review of HR#2 for the Director of Nursing there was no documentation of an Initial competency assessment. This observation was reviewed with the Administrator.

Observed in Record Review. In 3 of 7 patient records reviewed, the organization failed to ensure the medical director review the clinical information for each hospice patient and provide written certification that the patient's life expectancy is six months or less if the disease runs its normal course to include all required elements. On review of RRNHV# 5, and RRNHV#6 it was noted that the physicians certificate of terminal illness (CTI) narrative for the last 3 benefit periods were nearly identical each benefit period and lacked current subjective and objective medical findings. In RRNHV#7 there was no CTI noted on the record for the current benefit period that started in August. These observations were reviewed with the Administrator.

Observed in Record Review. In 2 of 7 patient records reviewed, the organization failed to ensure the patient record reflect the patient's care, treatment, and services. For example: on review of RRHV#2 there were physicians orders for IV fluids and although there was documentation in the record of the peripheral IV being discontinued, there was no documentation noted of the IV being initiated nor the patient's response to the treatment. In RRNHV#5 the patient had a wound to the hip and documentation in the record noted wound care treatments performed yet throughout the documentation lacked specific information on what steps of the procedure were performed. Example of documentation stated using aseptic technique and sterile supplies wound care performed to lateral proximal RLE, scant purulent exudate noticed, procedure tolerated well by patient These observations were reviewed with the Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to ensure the patient record contain all information to reflect the patient's care, treatment, and services. On the home observation for RRHV#2 during the medication reconciliation and discussion the family stated the Levetiracetam was being given in liquid form in the home yet the medication profile noted oral tablets. In the medication reconciliation for RRHV#3 the patient was noted to be on the final day of an antibiotic for UTI and taking Linzess for constipation yet the medications were not listed on the patient's medication profile. There were several medications Metoprolol, Sotalol, Amlodipine that were noted to be stopped Mid August per the written medication list in the patient home yet were still active on the medication profile. These observations were reviewed with the Administrator.

Observed in Tracer Activities. the organization failed to ensure a copy of the hospice written policies and procedures on the management and disposal of controlled drugs was provided to the patient or patient representative/family as the written documentation was not noted to be included in the admission packet distributed to the patients/families. This observation was reviewed with the Administrator.