Every finding on record at Engrace Hospice LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 10 (10%) clinical records reviewed it was revealed that the hospice did not ensure the interdisciplinary group completed the comprehensive assessment within 5 calendar days after the election of hospice care. Clinical Record 5: The patient’s hospice benefit election was dated 1/25/2023. The need for a MSW evaluation was documented on the comprehensive assessment and there was no evidence that the medical social worker (MSW) performed a MSW assessment within 5 calendar days after the election of hospice care. The quality coordinator who participated in joint review of the clinical records on 6/26/2023 stated that she did not know why the MSW assessment was not completed within the 5 days.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview and observation. In 3 of 3 (100%) home visits, observation of handwashing revealed the hospice organization did not ensure clinical staff demonstrated adherence to the agency's infection prevention and control policy and procedure. The agency's policy and procedure titled, "Hand Hygiene", effective date 5/2/2022, read in relevant parts: “Decontaminate hands before having direct patient contact... Decontaminate hands after coming in contact with patient's intact skin, i.e., taking a patient's blood pressure, pulse, lifting/moving the patient." Home Visit 1: During a home visit on 6/27/23 at 0930, the RN (Staff 2) was observed during the visit. Observation revealed the RN did not sanitize her hands prior to her first contact with the patient and at the end of the site visit. However, the nurse did demonstrate sanitizing her hands throughout the patient assessment and service delivery visit activities. Home Visit 2: During a home visit on 6/27/23 at 1200, the RN (Staff 2) was observed during the visit. Observation revealed the RN did not sanitize her hands prior to her first contact with the patient and at the end of the site visit. However, the nurse did demonstrate sanitizing her hands throughout the patient assessment and service delivery visit activities. Home Visit 3: During a home visit on 6/27/23 at 1300, the RN (Staff 2) was observed during the visit. Observation revealed the RN did not sanitize her hands prior to her first contact with the patient and at the end of the site visit. However, the nurse did demonstrate sanitizing her hands throughout the patient assessment and service delivery visit activities. The DPCS, RN was interviewed on 6/27/23 at 1500 after the visits were completed and acknowledged she should have washed her hands before and after direct contact with the patient.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by clinical record review and interview. In 1 of 8 (12%) records reviewed in which a hospice aide provided services it was revealed that the hospice aide did not notify the RN when they were unable to or did not provide the assigned tasks as directed on the hospice aide plan of care. Clinical Record 9: The hospice aide care plan dated for the benefit period of 6/4/23 - 9/1/23, assigned the hospice aide to provide a bed bath. On the patient visit note dated 6/10/23, the hospice aide documented that no bed bath was provided. There was no documentation as to why the bed bath was not provided or that the RN was notified. The Quality Coordinator, who participated in joint review of clinical records on 6/26/23, confirmed that the aide did not notify the RN when they did not provide the bed bath as assigned.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care and documented in the patient record. This standard was not met as evidenced by clinical record review and interview. In 10 of 10 (100%) clinical records reviewed, there was no evidence that a volunteer was offered and/or the patient declined volunteer services. Clinical Record 10: Patient’s benefit election was dated 1/1/2023. There was no documentation that a volunteer was offered. Clinical Record 2: Patient’s benefit election was dated 4/13/2023. There was no documentation that a volunteer was offered. Clinical Record 1: Patient’s benefit election was dated 4/20/2023. There was no documentation that a volunteer was offered. Clinical Record 3: Patient’s benefit election was dated 2/10/2023. There was no documentation that a volunteer was offered. Clinical Record 4: Patient’s benefit election was dated 5/30/2023. There was no documentation that a volunteer was offered. Clinical Record 5: Patient’s benefit election was dated 1/25/2023. There was no documentation that a volunteer was offered. Clinical Record 6: Patient’s benefit election was dated 6/13/2023. There was no documentation that a volunteer was offered. Clinical Record 7: Patient’s benefit election was dated 4/24/2023. There was no documentation that a volunteer was offered. Clinical Record 8: Patient’s benefit election was dated 5/5/2023. There was no documentation that a volunteer was offered. Clinical Record 9: Patient’s benefit election was dated 3/6/2023. There was no documentation that a volunteer was offered. An interview with the Quality Coordinator on 6/26/2023 confirmed that there was no documentation present regarding the offer of volunteer services. She stated she always offers a volunteer when she does the referral/intake but has not been documenting it.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 10 (10%) clinical records reviewed it was revealed the hospice did not ensure that physician orders for all skilled services provided were documented in the clinical record. Clinical Record 3: The election of hospice benefit was dated 02/09/23, and on 2/10/23, documentation by the RN (Staff 2) stated that the abdominal catheter was drained of 650cc dark amber fluid. On 2/13/23, documentation by the RN (Staff 2) stated that the peritoneal catheter was drained. There was no evidence of a physician’s order present in the record to drain the Pleurx catheter. The DPCS, RN was interviewed on 6/26/23. She stated she was shown how to drain the catheter by the surgeon but was not aware that an order for the treatment was needed.