Every finding on record at Epione Hospice, Inc.

Observed in Record Review. In 2 of 3 patient records reviewed, documentation was not entered in a timely manner or in accordance with the organizational policy 5-006.2 Entries in the Clinical Record 6) Entries into the clinical record will be made the day the care is provided to the patient. For example, RRDC#1 the patient received continuous care for over 24 hours, however only 2 hours of care was documented. Leadership reported that they are awaiting the documentation from the contracted staff who provided the care. RR#2 the LVN was seeing the patient 1 time a week opposite the RN and there are 4 LVN visits with no documentation. This was discussed with the Case Manager and CFO.

Observed in Record Review. In 2 of 3 patient records reviewed, the patients' care was not planned in accordance to the patients' identified needs. For example in the review for RR#2 the Medical Social Worker identified that in the IDG notes the social worker comment Continue with the current plan. There was 1 psychosocial goal for IHSS assistance with no time frame. Also the social worker visit frequency was prn with no indication for use. In the same record RR#2 the nurses initial comprehensive assessment included discussion of a G-tube/PEG tube, but this was not addressed in the POC and there were no goals or time frames identified. This was reviewed and validated with the Case Manager and CFO.

Observed in Record Review. In 2 of 3 patient records reviewed, the patients' plan of care were not developed to meet their individualized needs. For example, in review of the patient record RR#2 there were no documented goals or interventions to meet the patients' individualized needs related to the G-tube/PEG tube. The patient's psychosocial need included 1 goal and 1 intervention, but these did not included time frames. This was reviewed and validated with the CFO and Case Manager.

Observed in Record Review. In 3 of 3 patient records reviewed, the organization did not include a statement of the scope and frequency of the services necessary to meet the patient and family's needs. For example, during record review the organization is including PRN (as needed) MSW and Spiritual Counselor visit frequencies for the 3 patients without the inclusion of a reason for the visits. This was confirmed with the Case Manager.

Observed in Record Review. In 1 of 2 patient records reviewed, that include aide services, it was noted that care was not provided according to hospice plan of care. For example, in record RR#2 the aide services frequency on the individualized plan of care and on the IDG documentation required aide visits twice a week. The aide documented visits 3 times a week from the beginning of care. This was confirmed with the Case Manager.

Observed in HR File Review. In 2 of 4 personnel charts reviewed where the employees' hire dates were greater than one year, there was no evidence of ongoing competency assessments in accordance with the organizational Policy 1-008.1 Competency Assessment - Ongoing Assessments 1) Competency assessments will be completed at least one (1) time per year. . . 2) Using a Competency Skills Performance Checklist, the Supervisor will evaluate the competence in performing and rendering care . . . , and 3) Clinical staff will make a joint visit with a Clinical Supervisor/Supervisor annually for direct observation. For example, the Spiritual Counselor and Volunteer personnel records did not include annual competencies. This was reviewed and validated with the CFO and Case Manager present. Observed in HR File Review. In 1 of 7 HR files reviewed, there was no evidence of OSHA education to comply with law and regulation either upon hire or annually. For example, there was no evidence of OSHA education in the volunteer's record. This was reviewed and validated with the CFO and Case Manager.

Observed in Record Review. In 1 of 9 records reviewed, the organization did not respect the right of the patient to revoke hospice care, in accordance with the Medicare hospice regulations. Identified in the review for RR#5, the patient was discharged from services when choosing to be hospitalized for treatment, but no signed hospice revocation form was provided. This was reviewed and validated with the Director of Patient Care Services.

Observed in Patient Home. In 1 of 1 home visits conducted, the clinician did not complete an assessment in accordance to the organizational Policy No 2-031.1 - Ongoing Comprehensive Assessments: 2. The nurse will assess the patient on each visit, for: G. Skin integrity. Observed in HV#1, the Licensed Vocational Nurse (LVN) did not complete a skin assessment of the bedbound patient's posterior, nor did the LVN remove the patient's socks to complete an assessment of the patient's feet. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 2 of 9 patient records reviewed, the comprehensive assessment was not completed every 15 days. For example, in the review for RR#2, it was identified that approximately 2 months prior to the survey date there was a 25 day gap between Registered Nurse (RN) comprehensive assessments being completed, and in RR#5 it was identified that approximately 2 months prior to the survey date there was a 30 day gap from the RN admission visit and the next RN comprehensive assessment. This was reviewed and validated with the Director of Patient Care Services designee.

Observed in Record Review. In 2 of 9 records reviewed, the documentation was not entered in a timely manner or in accordance with the organizational Policy No. 5-006.2-Entries into the Clinical Record: 6) Entries into the clinical record will be made on the day care is provided to the patient. Reviewed in RR#1 on the first day of the survey, there was no documentation of a Registered Nurse visit made 4 days prior. Reviewed in the record for HV#1 the day following the home visit observation, the Licensed Vocational Nurse (LVN) documentation was not present. This was reviewed and validated with the Director of Patient Care Services designee. Observed in Record Review. In 1 of 9 patient records reviewed, the hospice start of care date was not accurate. Identified in the review for RR#1, the documented start of care date reflected the date that the Medical Director conducted a face-to-face visit to determine eligibility, one day prior to the hospice admission comprehensive assessment. This was reviewed and validated with the Director of Patient Care Services. Observed in Patient Home. In 1 of 1 home visits conducted, the patient's record was not accurate. Observed during the home visit, the hospice aide completed a partial bed bath. Reviewed in the record for HV#1, the hospice aide documented a complete bed bath including shampoo, blow dry hair, file nails, none of which were completed during the visit. Additionally, the hospice aide documented that she had completed the task of visualize condition of skin and report to RN, when the patient's socks were never removed during the visit. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 2 of 9 patient records reviewed, there was no Plan of Care (Poc) developed to address the patients' individualized needs. Reviewed in RR#6, there was no POC developed by the Interdisciplinary Group (IDG) until 21 days post admission date, and only Spiritual Care was addressed at that time. A Nursing POC was not added until the 4th IDG, and there was never a psychosocial POC developed. Identified in the review of RR#8, there was no POC developed by any of the involved IDG the entire episode of care, 33 days, prior to the patient's revocation from hospice. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 6 of 9 patient records reviewed, the patients' care was not planned in accordance to the patients' identified needs. For example in the review for HV#1 the Medical Social Worker identified that the patient did not have funeral plans, but this need was not included in the psychosocial plan of care, and there were no goals or time frames identified. In review of the patient records for RR#1, RR#2, RR#5, RR#6, and RR#8 there were no psychosocial plans of care developed, including no goals, and no timeframes developed to meet the patients' needs. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 5 of 9 patient records reviewed, the patients' psychosocial plan of care were not developed to meet their individualized needs. In review of the patient record for HV#1, RR#1, RR#2, RR#5, RR#6, and RR#8 there were no documented interventions to meet the patients' individualized psychosocial needs. This was reviewed and validated with the Director of Patient Care Services

Observed in Record Review. In 9 of 9 patient records reviewed, a statement of the scope and frequency of the services necessary to meet the patients' and families' needs was not included in the individualized Plans of Care. Identified during the record review, the organization is including for all disciplines accepted in the provision of care, PRN (as needed) visits in the visit frequencies of all patients without the inclusion of a reason for the PRN visits. This was reviewed and validated with the Director of Patient Care Services.

Observed in Patient Home. In 1 of 1 home visits conducted where reusable medical equipment was used, the clinician did not take action to reduce the risk of infections in accordance with the organizational Policy No. 9-014.2 - Bag Technique - 5) When the visit is completed, reusable equipment will be cleaned using alcohol and/or soap and water . . . A. Stethoscope, bell and diaphragm - alcohol; . . . D. Thermometer - soap and water . . . E. Blood Pressure cuff will be cleaned in accordance with the manufacture's guide . . . Observed in HV#1, the Licensed Vocational Nurse used a Clorox bleach wipe to clean the reusable medical equipment: stethoscope; electronic wrist blood pressure cuff; a no-contact infrared thermometer; and, a pulse oximeter. This was reviewed and validated with the Administrator.

Observed in HR File Review. In 1 of 2 Hospice Aide personnel charts reviewed, the 12 hours of in-service training was not met. Identified in HR#10, only 7 of the 12 hours required during 2022 was completed. This was reviewed and validated with the CFO and the Director of Patient Care Services Designee.

Observed in Patient Home. In 2 of 9 patient records reviewed, the record did not contain updated information reflecting the current care, treatment, or services. For example, identified in the record review for HV#1, the Aide Assignment had not been updated since the admission two years prior to the survey date and did not reflect the current care being provided. In the review of RR#4, the hospice aide frequency was documented in the plan of care as 1 visit weekly. In reviewing the hospice aide visits, the patient was seen twice weekly beginning the second week of hospice services with no update to the Aide Assignment of Plan of Care. This was reviewed and validated with the Director of Patient Care Services designee.

Observed in Tracer Activities. It was identified during the Volunteer Program Session with the Volunteer Coordinator that there have been no recruitment or retention efforts documented during the past 3 years: 2020, 2021, or 2022. This was reviewed and validated with the CEO and CFO.

Observed in Tracer Activities. The Surveyor identified there was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by the organization has not managed the implementation of policies and procedures that guide and support the provision of care in accordance with the Conditions of Participation: 418.54 - Initial and Comprehensive Assessment; 418.56 - Hospice Plan of Care; and, 418.100 Organization and Administration of Services. This was reviewed and validated with the CEO and CFO.

Observed in HR File Review. In 10 of 10 personnel charts reviewed, there was no evidence of OSHA education to comply with law and regulation either upon hire or annually in 2020, 2021, or 2022. This was reviewed and validated with the CFO and Director of Patient Care Services designee. Observed in HR File Review. In 6 of 10 personnel charts reviewed where the employees' hire dates were greater than one year, there was no evidence of ongoing competency assessments in accordance with the organizational Policy 1-008.1 Competency Assessment - Ongoing Assessments 1) Competency assessments will be completed at least one (1) time per year. . . 2) Using a Competency Skills Performance Checklist, the Supervisor will evaluate the competence in performing and rendering care . . . , and 3) Clinical staff will make a joint visit with a Clinical Supervisor/Supervisor annually for direct observation. This was reviewed and validated with the CFO and Director of Patient Care Services designee.