Every finding on record at Egan Hospice Services of the Northshore, LLC

Based on record review and interview, the Hospice Agency failed to ensure the Initial Bereavement Risk Assessment was incorporated into the Plan of Care for 4 (#6, #8, #13 and #14) of 10 (#5, #6, #7, #8, #9, #10, #11, #12, #13 and #14) patient records reviewed. --- Review of the Hospice policy titled ";Assessment" revealed the following, in part:Purpose: To ensure appropriate and coordinated bereavement services are provided to families and caregivers of hospice patients. Policy: The agency will make available bereavement services that focus on the spiritual, social and cultural factors that may impact the family/caregivers ability to cope with the patients death. This information is incorporated into the Plan of Care. Procedure:The Social Worker or designee will complete a Bereavement Risk Assessment within 5 days of admission to hospice. Patient #6Review of Patient #6's Clinical Record revealed a start of care date of 03/10/2023 with a terminal diagnosis of Vascular Dementia. Review of Patient #6's Interdisciplinary Plan of Care revealed an Initial Bereavement Risk Assessment had not been completed. Patient #8Review of Patient #8's Clinical Record revealed a start of care date of 09/22/2023 with a terminal diagnosis of Alzheimers Disease. Review of Patient #8's Interdisciplinary Plan of Care revealed an Initial Bereavement Risk Assessment had not been completed. Patient #13Review of Patient #13's Clinical Record revealed a start of care date of 03/18/2023 with a terminal diagnosis of Alzheimers Disease with Late Onset. Review of Patient #13's Interdisciplinary Plan of Care revealed an Initial Bereavement Risk Assessment had not been completed. Patient #14Review of Patient #14's Clinical Record revealed a start of care date of 07/12/2023 with a terminal diagnosis of Chronic Atrial Fibrillation. Review of Patient #14's Interdisciplinary Plan of Care revealed an Initial Bereavement Risk Assessment had not been completed. An interview was conducted on 02/06/2024 at 12:40 p.m. with S3PCM. She confirmed Patient #6, #8, #13 and #14 did not have an Initial Bereavement Assessment completed and should have. An interview was conducted on 02/06/2024 at 12:40 p.m. with S1ED. She confirmed Patient #6, #8, #13 and #14 did not have an Initial Bereavement Assessment completed and should have.

Based on interviews and record reviews, the Hospice Agency failed to follow an individualized Plan of Care established by the Hospice Interdisciplinary Group in collaboration with the attending Physician in accordance with the patient's needs for 3 (#6, #10 and #11) of 10 (#5, #6, #7, #8, #9, #10, #11, #12, #13 and #14) patients reviewed for Hospice Aide services. The Hospice agency failed to ensure Hospice Aide visits were conducted as ordered. --- Patient #6 Review of the Clinical Record for Patient #6 revealed an admit date of 03/10/2023. Patient #6 had diagnoses which included Vascular Dementia. Review of the Plan of Care for Patient #6, during certification period 12/10/2023 - 02/07/2024, revealed he was to receive Hospice Aide visits 2 times a week for 8 weeks. Review of the Hospice Aide Visit Calendar for Patient #6 revealed missed visits for Hospice Aide services during the weeks of 12/25/2023, 01/01/2024 and 01/08/2024. Patient #10 Review of the Clinical Record for Patient #10 revealed an admit date of 04/26/2023. Patient #10 had diagnoses which included Alzheimers Disease with Late Onset. Review of the Plan of Care for Patient #10, during certification period 12/22/2023 - 01/24/2024, revealed he was to receive Hospice Aide visits 3 times a week. Review of the Hospice Aide Visit Calendar for Patient #10 revealed missed visits for Hospice Aide services on the following dates: 01/12/2924, 01/15/2024, 01/18/2024 and 01/19/2024. Patient #11 Review of the Clinical Record for Patient #11 revealed an admit date of 04/27/2023. Patient #11 had diagnoses which included Hypertensive Heart Disease and Chronic Kidney Disease with Heart Failure. Review of the Plan of Care for Patient #11, during certification period 12/23/2023 - 01/15/2024, revealed she was to receive Hospice Aide visits 2 times a week. Review of the Hospice Aide Visit Calendar for Patient #11 revealed missed visits for Hospice Aide services for the weeks of 12/25/2023, 01/01/2024 and 01/08/2024. An interview was conducted on 02/05/2024 at 2:30 p.m. with S2PCM. She reviewed Patient #6, #10 and #11s Clinical Record and verified the missed Hospice Aide visits listed above. She confirmed the visits should not have been missed without being rescheduled. She said she expected her Hospice Aide to reschedule missed visits at a later time during the same week and they had not. An interview was conducted on 02/06/2024 at 1:00 p.m. with S1ED. She confirmed she would expect missed visits to be rescheduled and made-up during the same week, or at least attempted and had not been. She said she was responsible for ensuring the patients received their Hospice Aide visits as ordered by the Physician.

Based on interviews and record reviews, the hospice agency failed to ensure nursing services met the needs of the patients for 1 (#8) of 3 (#6, #8 and #9) patients reviewed for pressure wounds. The agency failed to follow acceptable standards of practice for wound care specifically for complete wound assessments and weekly wound measurements, including the size and stage of the wounds for Patient #8. --- Review of the Louisiana State Board of Nursing Declaratory Statement Scope of Practice for Registered Nurses - Wound Care Management adapted 02/1999 revealed the following in part: Registered nurses render care that is directed towards the prevention and treatment of wounds. Wounds are a common health care challenge that often occur with or result from chronic disorders such as impaired circulation and malnutrition. Nursing care of skin/wound conditions involves the identification, assessment, management, and ongoing evaluation of patients with alterations in skin/tissue integrity that includes but is not limited to draining wounds, pressure ulcers, and vascular ulcers, and conditions resulting from incontinence, surgical procedures, and/or trauma. Scope of Practice - The Louisiana State Board of Nursing recognizes that assessment, planning, intervention, teaching, evaluation, and supervision are the major responsibilities of the registered nurse in the practice setting. The registered nurse is responsible for performing a nursing assessment and physical examination for preventative and restorative nursing and for providing patient/family teaching. Recognizing that the physician must always prescribe wound care, the following roles are defined to delineate the scope of practice for each member of the nursing team members. The registered nurse initiates appropriate wound preventative measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by an authorized prescriber. Review of the National Pressure Ulcer Advisory Panel Prevention and Treatment of Pressure Ulcers: Quick Reference Guide revealed, in part, the following:Pressure Ulcer Assessment 1. Assess the pressure ulcer initially and re-assess it at least weekly.1.1. Document the results of all wound assessments. Assess and document physical characteristics including: location, Category/Stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. A review of the agencys policy titled ";Care, Treatment and Services: Wound Assessment, Documentation and Photography" revealed, in part, the following: Purpose:To ensure the accurate and consistent assessment and documentation of wounds. Procedure: 3. Document the following in the medical record:g. Stage the wound weekly. A review of Patient #8s Clinical Record revealed a Start of Care Date of 09/22/2023 with a current Certification Period of 12/21/2023 through 03/19/2024. Further review revealed diagnoses which included, in part, Alzheimers Disease with Late Onset; Pressure Ulcer of Right Buttock, Stage 2; and Pressure Ulcer of Left Hip, Stage 3. A review of Patient #8s Plan of Care revealed a Frequency of twice-weekly Skilled Nurse Visits. A review of Patient #8s Physician Orders revealed, in part, the following: 12/08/2023 – Cleanse wound with wound cleanser. Pat dry with gauze. Apply 0.5 inch bacitracin to wound base. Cover with calcium alginate to wound bed. Cover with optifoam bordered dressing. Change 2 times weekly and as needed for soiled or displaced dressing until healed. A review of Patient #8s Wound Record Report revealed, in part, the followingWound #2: Right Buttock Stage 2 Pressure Ulcer12/22/2023 – No wound measurements;12/26/2023 – No wound measurements;12/29/2023 – No wound measurements;01/05/2024 – No wound measurements; and01/19/2024 – No wound measurements. Wound #4: Left Iliac Crest Stage 2 Pressure Ulcer01/19/2024 – No wound measurements;01/26/2024 – No wound measurements; and 02/02/2024 – No wound measurements. A review of Patient #8s Client Coordination Note Reports revealed, in part, the following: 12/22/2023 - No documentation of wound measurements for Wound #2; 12/26/2023 - No documentation of wound measurements for Wound #2; 12/29/2023 - No documentation of wound measurements for Wound #2; 01/05/2024 - No documentation of wound measurements for Wound #2; 01/19/2024 - No documentation of wound measurements for Wound #2; 01/19/2024 - No documentation of wound measurements for Wound #4; 01/26/2024 - No documentation of wound measurements for Wound #4; and02/02/2024 - No documentation of wound measurements for Wound #4. An interview was conducted on 02/05/2023 at 3:30 p.m. with S3PCM. She confirmed an RN was required to performed wound measurements at least weekly. She confirmed there was no documentation to indicate wound measurements were performed for Patient #8s Wound #2 on the weeks of 12/22/2023, 12/26/2023, 12/29/2023, 01/05/2024 or 01/19/2024. She confirmed there was no documentation to indicate wound measurements were performed for Patient #8s Wound #4 on the weeks of 01/19/2024, 01/26/2024 or 02/02/2024. An interview was conducted on 02/07/2024 at 1:25 p.m. with S1ED. She confirmed an RN should measure, assess and document each wound weekly and had not.

Review of the Hospice Agencys policy titled ";Volunteer Program Reporting Process" revealed, in part, the following: Purpose: To ensure the hospice agency is compliant with the Medicare Conditions of Participation related to volunteer hours. Policy: A. Hospice agency must document and maintain a volunteer staff sufficient to provide administrative or direct patient care hours of all paid hospice employees and contract staff. Hospice must document the cost savings achieved through the use of volunteers. Procedure: B. The Executive Administrator/Executive Director will report results at least monthly. Documentation of the Hospice Agencys 2023 Volunteer Activity was requested with no documentation available for review. Documentation of the Hospice Agencys 2023 Cost Savings via Volunteer Usage was requested with no documentation available for review. An interview was conducted on 02/07/2024 at 10:55 a.m. with S2PCM. She confirmed the agency achieved a total of zero volunteer hours during 2023. An interview was conducted on 02/07/2024 at 11:00 a.m. with S1ED. She confirmed the agency did not achieve the required volunteer hours during 2023 and should have.