Every finding on record at Eden Hospice at Whatcom County LLC

Condition of Participation: Patient’s Rights. L500

Upon patient record review, 3 of 14 (Patient #3,5,7) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient #3, Patient signed own consents. MD statement on CTI documents Parkinson dementia. Election of benefit date was patient date of birth and no evidence of date of election. Patient #5, Patient signed own consents. Initial RN assessment documents patient is confused, distracted easily, memory loss and starts his sentence in English and ends in German. Patient #7, Patient signed own consents, Initial RN assessment documents oriented to person, place, forgetful and confused.

Upon patient record review, 3 of 14 (Patient #3,5,7) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #3, Patient signed own consents. MD statement on CTI documents Parkinson dementia. Election of benefit date was patient date of birth and no evidence of date of election. Patient #5, Patient signed own consents. Initial RN assessment documents patient is confused, distracted easily, memory loss and starts his sentence in English and ends in German. Patient #7, Patient signed own consents, Initial RN assessment documents oriented to person, place, forgetful and confused.

Upon patient record review, 3 of 14 (Patient #3,5,7) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient #3, Patient signed own consents. MD statement on CTI documents Parkinson dementia. Election of benefit date was patient date of birth and no evidence of date of election. Patient #5, Patient signed own consents. Initial RN assessment documents patient is confused, distracted easily, memory loss and starts his sentence in English and ends in German. Patient #7, Patient signed own consents, Initial RN assessment documents oriented to person, place, forgetful and confused.

Upon patient record review, 3 of 14 (Patient #3,5,7) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #3, Patient signed own consents. MD statement on CTI documents Parkinson dementia. Election of benefit date was patient date of birth and no evidence of date of election. Patient #5, Patient signed own consents. Initial RN assessment documents patient is confused, distracted easily, memory loss and starts his sentence in English and ends in German. Patient #7, Patient signed own consents, Initial RN assessment documents oriented to person, place, forgetful and confused.

Upon patient record review, 3 of 14 (Patient #3,5,7) did not have evidence of the appropriate documentation for release of confidential information. Patient #3, Patient signed own consents. MD statement on CTI documents Parkinson dementia. Election of benefit date was patient date of birth and no evidence of date of election. Patient #5, Patient signed own consents. Initial RN assessment documents patient is confused, distracted easily, memory loss and starts his sentence in English and ends in German. Patient #7, Patient signed own consents, Initial RN assessment documents oriented to person, place, forgetful and confused.

Upon patient record review, 7 of 14 (Patient #1,3,4,5,7,8,13) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #3, Patient signed own consents. MD statement on CTI documents Parkinson dementia. Election of benefit date was patient date of birth and no evidence of date of election. Patient #5, Patient signed own consents. Initial RN assessment documents patient is confused, distracted easily, memory loss and starts his sentence in English and ends in German. Patient #7, Patient signed own consents, Initial RN assessment documents oriented to person, place, forgetful and confused. Patient #1,3, Hospice financial agreement, no evidence of financial responsibility documented on agreement. Patient #4, 8,13,Hospice financial agreement, no evidence of payor source or financial responsibility documented on agreement.

Upon patient record review, 3 of 14 (Patient #3,5,7) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #3, Patient signed own consents. MD statement on CTI documents Parkinson dementia. Election of benefit date was patient date of birth and no evidence of date of election. Patient #5, Patient signed own consents. Initial RN assessment documents patient is confused, distracted easily, memory loss and starts his sentence in English and ends in German. Patient #7, Patient signed own consents, Initial RN assessment documents oriented to person, place, forgetful and confused.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #2, No evidence medication profile updated for over 3 weeks upon home visit. Patient is using new skin which is not on the medication profile instead of hydrogel topical. Patient is no long taking aspirin or Lipitor which is currently on medication profile.

Upon patient record review, 1 of 14 (Patient #10) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #10, Patient has documented wound, RN documents completed by facility nurse. No evidence of wound assessment on initial RN assessment.

Upon patient record review, 2 of 14 (Patient #1,5) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1, Agency has lives alone addendum to admission agreement which states; if I live alone I/or POA will have medial alert operations available should I choose to live alone. No evidence of medical alert operations documented on care plan. In addition, RN initial assessment documents patient rates their pain at a 10 out of 10. Questions asks was the MD contacted, RN documents no. RN documented instructed on the use of pain medications however, no update to the POC with problems/goals/interventions. Patient #5, No evidence of care plan for straight catheter required when and who would provide.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions which including interventions to manage pain and symptoms. Patient #1, RN initial assessment documents patient rates their pain at a 10 out of 10. Questions asks was the MD contacted, RN documents no. RN documented instructed on the use of pain medications.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #5, MD order 7/18/24 states insert Foley add visit for Friday for follow up. There was not an indication of the quantity of visits.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient # 2, No evidence of orders. Upon home visit, identified patient is using new skin which is not on the medication profile instead of hydrogel topical. Patient is no long taking aspirin or Lipitor.

Upon patient record review, 2 of 14 (Patient #3,10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #3, Plan of care documented DME as none, RN initial assessment documents patient has raised toilet seat, walker, w/c, shower chair. Patient #10, DME documents none, per RN note patient has hospital bed, air mattress, alternating, over bed table and bed rails.

Upon patient record review, 2 of 14 (Patient #1,6) did not have evidenc.e that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care Patient #1, No evidence of Foley catheter and UTI updated on plan of care. Patient #6, No evidence of nurse to assist with ostomy bag changes 2x/week was updated on care plan. No evidence of patient having increased confusion and member problems updated on care plan.

Upon client record review, 5 of 10 (Patient #1,4,5,8,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, MSW visit completed initial assessment as a telephone visit. No evidence of order for telephone visit. 7/19/24 RN order for daily RN visits ( this order was rejected by the DPS without any documentation or MD order to cancel this order). No evidence of RN visit on 7/20, 7/21, 7/25. LVN made a visit on 7/22/24. No evidence this visit was completed by RN. In addition, on 7/17/24 12 F catheter inserted, on 7/22/24 catheter had fallen out and a 14 F catheter was placed without order for change in size of catheter. Patient #4, MSW frequency 1w1 effective 6/5/24. MSW visit completed on 6/11/24. No evidence visit was completed in the first week. Patient #5, MSW frequency 1w1 effective 5/30/24. MSW visit completed on 6/13/24. No evidence visit was completed in the first week. SC frequency 1w1 effective 5/30/24. SC visit completed on 6/6/24. No evidence visit was completed in the first week. Patient #8, SC frequency 1w1 effective 7/23/24. No evidence of SC visit completed. Patient #10, SC frequency 1w1 effective 7/10/24. No evidence of SC visit completed.

Upon observation, there was no evidence the organization develops, implements, and maintains an effective, on-going, organization wide Quality Assessment and Performance Improvement (QAPI) program.

Upon observation, there was no evidence the program shows measurable improvement in indicators related to improved palliative outcomes and hospice services.

Upon observation, there was no evidence the program must use quality indicator data, including patient care, and other relevant data, in the design of the program.

Upon observation, there was no evidence the QAPI program uses quality indicator data, including patient care and other relevant data in the design of its program. The hospice must use the data collected to: • Monitor the effectiveness and safety of services and quality of care • Identify opportunities and priorities for improvement

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection. No evidence the governing body approved the frequency and detail of the data collection.

Upon observation, there was no evidence QAPI activities focus on high risk ,high volume, or problem prone areas.

Upon observation, there was no evidence Quality Assessment and Performance Improvement activities focus on high risk, high volume or problem-prone areas by considering incidence, prevalence, and the severity of problems.

Upon observation, there was no evidence Quality Assessment and Performance Improvement activities focus on high risk, high volume or problem-prone areas by understanding how they affect palliative outcomes, patient safety and quality of care. No evidence of high risk, high volume area.

Upon observation, there was no evidence the number and scope of distinct QAPI projects conducted annually is based on the needs of the hospice's population and internal organizational needs and must reflect the scope, complexity, and past performance of the hospice's services and operations.

Upon observation, there was no evidence the hospice documents what QAPI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program.

Upon observation, there was no evidence the hospice's governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1, MSW sat her hospice bag on patient's bed without a barrier to lay down the barrier pad on the floor to place bag on the floor. Patient #2, RN placed roller bag on barrier then laid clean barrier next to roller bag to lay out clean items. Upon taking the blood pressure, RN needed to stand where the wife was sitting. The wife walked to the other side of the patient and stepped right in the middle of the clean area that was laid out.

Upon observation, there was no evidence in QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the hospice's Quality Assessment and Performance Improvement program.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon observation, there was no evidence the Home Health Aide competency evaluation is performed by a Registered Nurse in consultation with other skilled professionals, as appropriate. No evidence of competency evaluation performed by Registered Nurse. LVN completed aide competency.

Upon observation, there was no evidence in-service training for Hospice Aides are supervised by a Registered Nurse. All hospice aide in-service training is completed on line. No evidence of training supervised by RN.

Upon observation, there was no evidence the hospice must maintain a written description of the in-service training provided during the previous 12 months. No evidence of written description of the in-service training provided the previous 12 months.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #6, Aide care plan documents patient is cognitive and physically able to choose between two bed bath types. No evidence of bath type or why they are able to choose between the two baths. IDG note on 7/10/24 documented by RN states, patient having increased confusion and memory problems. No evidence aide care plan was updated.

Upon patient record review 4 of 14 (Patient #,6,7,9,10) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #6, Aide note documents nail care and shaving as no. Patient #7, Aide note 7/29 documents transfer bed to chair; no, transfer chair to bed; no, assist to commode; no, nail care; no. Patient #9, Aide note documents 5/14 shower, hair care, shaving, nail care, dressing as no. Patient #10, Aide documented on 7/12 bed bath, hair care, perineal care not completed as up in w/c. Aide documented assisted to dining room, no evidence this was a direction on patient care plan.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78 No evidence of the cost savings achieved through the use of volunteers.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. No evidence of agency meeting the 5% volunteer hours. Volunteer hours for end for 2023 4.11%.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice, aeb no documentation of qualified administrator appointed which is also a requirement per the state of Washington, located in WAC 246-335-615. In addition, now evidence of job description for alternate administrator, oversight of QAPI and infection control reporting to QAPI, as well as consents/election of benefits signed by person capable of making informed decisions.

Upon personnel record review, 2 of 13 (Personnel #7,8 ) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #7,8, No evidence of hospice philosophy noted in HR chart.

Upon contract review, 2 of 4 (Medical Director and Alternate Medical Director contracts) did not have evidence of a contract to fulfill the role of medical director or alternate medical director, if applicable. Contract #1,2, Medical Director contract identified both the Med Director and the Alt Med Director names on the contract. The Alt Medical Director contract identified the business name of the providers. Both contracts were corrected while on survey to each contract having the appropriate name per role.

Upon patient client record review, 3 of 14 (Patient #3,5,7) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #3, Patient signed own consents. MD statement on CTI documents Parkinson dementia. Election of benefit date was patient date of birth and no evidence of date of election. Patient #5, Patient signed own consents. Initial RN assessment documents patient is confused, distracted easily, memory loss and starts his sentence in English and ends in German. Patient #7, Patient signed own consents, Initial RN assessment documents oriented to person, place, forgetful and confused.

Upon patient client record review, 1 of 14 (Patient #14) did not have evidence that each patient record contains Advance Directives. Patient #14, No evidence advanced directive was documented as having or not on consents.

Upon client record review, 1 of 14 (Patient #12) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #12, No evidence of discharge summary or that it was faxed to attending physician.

Upon client record review, 1 of 14 (Patient #12) did not have evidence that the discharge summary includes all required information. Patient #12, No evidence of discharge summary or that it was faxed to MD.

Upon patient record review,1 of 14 (Patient #1) did not have evidence that if a drug order is verbal or given via an electronic transmission, it is given to a Registered Nurse, Nurse Practitioner, pharmacist, physician or other licensed individuals as designated by state regulations. The person receiving the order records and signs it immediately and has the prescribing person sign it in accordance with state and federal regulations. Patient #1, Patient had catheter order for insertion documented in nurses note on 7/17/24. No evidence of written order until 7/29/24 after chart was reviewed. The order on 7/29/24 reads verbal order from Dr. Brogan on 7/17/24 to insert an indwelling Foley catheter due to no urine output in over 24 hours and patient history of urinary retention.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. Patient #3, Patient signed own consents. MD statement on CTI documents Parkinson dementia. Election of benefit date was patient date of birth and no evidence of date of election. Patient #5, Patient signed own consents. Initial RN assessment documents patient is confused, distracted easily, memory loss and starts his sentence in English and ends in German. Patient #7, Patient signed own consents, Initial RN assessment documents oriented to person, place, forgetful and confused.

Upon observation, there was no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs. Patient #3, Patient signed own consents. MD statement on CTI documents Parkinson dementia. Election of benefit date was patient date of birth and no evidence of date of election. Patient #5, Patient signed own consents. Initial RN assessment documents patient is confused, distracted easily, memory loss and starts his sentence in English and ends in German. Patient #7, Patient signed own consents, Initial RN assessment documents oriented to person, place, forgetful and confused.

Upon client record review, 3 of 14 (Patient #3,5,7) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #3, Patient signed own consents. MD statement on CTI documents Parkinson dementia. Election of benefit date was patient date of birth and no evidence of date of election. Patient #5, Patient signed own consents. Initial RN assessment documents patient is confused, distracted easily, memory loss and starts his sentence in English and ends in German. Patient #7, Patient signed own consents, Initial RN assessment documents oriented to person, place, forgetful and confused.