Every finding on record at First Primary Home Care Inc

It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 7 of 15 (47%) clinical records reviewed the agency did not ensure that plans of care included individualized interventions based on problems identified in the initial or updated comprehensive assessments. CLINICAL RECORD 1: The hospice benefit election date was 10/23/2023 with a primary diagnosis of Alzheimer's Disease. A documented physician order was written 06/30/2025, "May check capillary blood glucose as needed for signs and symptoms of hyper/hypoglycemia." The interdisciplinary plan, updated 07/09/2025 and updated every two weeks, did not document interventions for endocrine or blood sugar management. CLINICAL RECORD 7: The hospice benefit election date was 06/20/2024 with a primary diagnosis of Chronic Lymphocytic Leukemia. A physician order was written 06/25/2024 for oxygen via nasal cannula as needed. No oxygen was used by the patient until the nursing assessment documented on 02/21/2025 when it was used PRN (as needed). On the nursing assessment documented 02/24/2025 the oxygen was used at 2 liters prn and then documented as continuous on the 03/07/2025 assessment. On the nursing assessment documented on 03/08/2025, the oxygen was at 4.5 liters per nasal cannula. The IDG (interdisciplinary group) updated plans of care dated 02/20/2025 and 03/06/2025 following IDG meetings did not include interventions for oxygen. CLINICAL RECORD 8: The hospice benefit election date was 09/29/2024 with a primary diagnosis of Chronic Obstructive Pulmonary Disease. A physician order was written 10/07/2024 for a foley catheter, 16 French, to be changed monthly using sterile technique. There were no interventions documented. During record review the Case Manager noted that the patient had been admitted with the Foley catheter in place and wrote the order for this mode of elimination. There were no updated interventions documented on the plan of care updated every two weeks until the patient's date of death 01/22/2025. CLINICAL RECORD 10: The hospice benefit election date was 10/19/2024 with a primary diagnosis of Lung Cancer. The interventions written for respiratory status were not individualized for this patient. The initial nursing comprehensive assessment documented on 10/19/2024 that the patient was using oxygen at 3 liters per nasal cannula and increased to 4 liters on 11/04/2024. The plan of care intervention was "Review oxygen and morphine for shortness of breath with caregivers" but was non-specific for assessment regarding safety related to the oxygen use. The orders were specific for the oxygen flow rate and use per nasal cannula. CLINICAL RECORD 12: The hospice benefit election date was 11/22/2024 with a primary diagnosis of Diabetes and secondary diagnosis of Atherosclerosis. A documented physician order on 11/22/2024 was for a Foley catheter to dependent drainage, change every 30 days. The plan of care was not updated with interventions for the Foley catheter, up to the patient's death on 11/30/2025. CLINICAL RECORD 14: The hospice benefit election date was 12/10/2024 with a primary diagnosis of Alzheimer's Disease and comorbidity of Congestive Heart Failure. Physician orders documented on 12/10/2024 were for albuterol 0.083% every 6 hours for shortness of breath or congestion, morphine sulfate oral concentrate 20mg/milliliter take 0.25 milliliter to 1 milliliter by mouth as needed for shortness of breath, and oxygen one to 4 liters per nasal cannula for shortness of breath. The initial plan of care dated 12/10/2024 and updated every two weeks did not document respiratory interventions for oxygen or shortness of breath. The patient was using the morphine and oxygen during care received. CLINICAL RECORD 15: The hospice benefit election date was 02/07/2025 with a primary diagnosis of Hepatic Bile Duct Cancer. The physician ordered on 02/07/2025, for a Foley catheter, 16 French to be changed as needed using sterile technique, a Denver drain to be emptied up to 1000ml every day and the dressing changed every day or as needed. The initial plan of care and every two week updated plans of care did not include interventions for the Foley catheter or the Denver drain up to the patient's death on 2/27/2025. During interview with the Case Manager (PERSONNEL RECORD 4) on 11/05/2025 she stated that she created interventions during the visit but if the family understood she ended them. If the family needed more education, it was reinforced later. She stated that leaving the interventions for problems that were current did make sense and would be done in the future. She stated that documentation of interventions in some of the records was not in the note like it should have been.

It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 15 (13%) clinical records reviewed, the agency did not ensure that measurable, individualized goals were documented. CLINICAL RECORD 10: The hospice benefit election date was 10/19/2024 with a primary diagnosis of Lung Cancer. The patient was using oxygen per nasal cannula. The respiratory goal on the initial plan of care and the plans of care updated every two weeks was, "Shortness of breath will be managed by 11/13/2024." This was not measurable as it was not clear what "managed shortness of breath" would be for this patient. CLINICAL RECORD 15: The hospice benefit election date was 02/07/2025 with a primary diagnosis of Hepatic Bile Duct Cancer. The respiratory goal that was written on the initial and every two week updated plans of care was, "Patient will have optimum level of oxygenation." This was not measurable as to what "optimum" would be for this patient. During interview with the Case Manager (PERSONNEL RECORD 4) she stated that the goals were not measurable.

It is required that each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record where the patient requested evaluation with therapists, the agency did not ensure that documentation of the therapy evaluations or updates were documented in the clinical record. CLINICAL RECORD 8: The hospice benefit date of election was 09/29/2024 with a primary diagnosis of Chronic Obstructive Pulmonary Disease. A physician order was written on 10/03/2024 for physical therapy and occupational therapy to evaluate for transfer and home safety. As of the date of record review on 11/05/2025 there was no documentation of the therapy evaluations or updates of the status of the therapy evaluations in the record. The patient died on 01/22/2025. During interview with the case manager (PERSONNEL RECORD 4) she stated that the family declined the therapy evaluations, and she had thought that (the declination) was documented in the record but was unable to find the documentation of this. She stated that the patient was declining, and the son no longer wanted the service.

Observed in Emergency Management Session. On review of the emergency management plan with the ADON and QAPI Coordinator it was noted noted the organization’s integrated emergency management policies, procedures, or plans did not address all required elements as evidenced by there was no documentation of a process in place to contact/connect with local, state, tribal, regional, federal EM officials for the purpose of collaborating in emergency management training.

Observed in Record Review. In 4 of 11 patient records reviewed, the organization did not conduct a patient specific comprehensive assessment and reassessment that identified the patient's need for hospice care and services related to severity of symptoms. For example: on review of the RR#6 and RR#7 the documentation noted that the patients had wounds, however there was no documentation that a comprehensive wound assessment had been conducted since patient admission. In review of RR#6, RR#8, and RR#9 the patients were noted to be diabetic and on insulin, yet there was no documentation of an assessment of the endocrine system throughout the hospice admission. These observations were reviewed with the ADON.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization failed to ensure the individualized written plan of care reflect patient and family goals based on the problems identified in the comprehensive assessments, nor were the goals established specific, measurable, attainable, relevant, and time bound. For example: On review of HV#2 the goals were not specific, measurable, or time bound, such as patient will maintain pain controlled at acceptable level for pt/cg , ADL needs are met, and Pt infection will be resolved. Further the patient had nephrostomy tubes yet there were no goals established for urinary. In HV#3 there was a goal stating Pt/cg will demo how to care for wound yet there was no time specified for the goal to be accomplished. Another goal that lacked being specific, measurable, and time-bound was aspiration risk minimized. In RR#6, RR#8, and RR#9 the patients were diabetic on insulin yet there were no goals established for diabetes management as the patient declined. Similar goals that lacked being specific, measurable, and time-bound can be seen throughout all records reviewed. These observations were reviewed with the ADON.

Observed in Record Review. In 4 of 11 patient records reviewed, the organization failed to ensure the plan of care include all services, drugs, and treatments needed for the palliation and management of the terminal illness. For example: on review of HV#1 the patient had a foley catheter however there were no current orders included with the plan of care of the management of the foley. There was an order noted on the record that had expired approximately 6 months ago. In review of RR#6 the patient had documentation of a wound to the sacrum and mention of status ulcers, however there were no physicians orders noted on the record for wound care. In review of RR#7 the patient also had documentation of a wound, where was a wound care dressing change noted in the nursing notes, however there was no physicians order for wound care. There was also documentation of a stage 1 wound to the left heel, yet no physicians order for treatment. Both patients resided in nursing facilities, and there was documentation the wound care was the facility responsibility. On review of RR#8 the patient was diabetic and ordered sliding scale insulin, yet there were no physician orders for blood glucose monitoring. This observation was reviewed with the ADON, and QAPI Coordinator.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to ensure the infection prevention and control activities were conducted per policy. For example: during the home observation for HV#2 the RN performed dressing changes for the nephrostomy tubes, yet failed to perform hand hygiene and change gloves after removing the dirty dressing and cleaning the site, and replacing the new clean dressing. This observation was reviewed with the RN, and ADON.

Observed in HR File Review. In 1 of 7 HR files reviewed, the organization failed to ensure that the hospice aide competency initial evaluation was evaluated by observing the aides performance of the task with a patient. On review of HR#4 for the Hospice aide the initial competency was documented as part of orientation in 2019 however there was no indication that the method of evaluating competency was by observation. Further the required task of normal range of motion and positioning section was left blank. This observation was reviewed with the ADON.

Observed in HR File Review. In 2 of 7 HR files reviewed, the organization failed to ensure that staff competence is initially assessed and documented as part of orientation. For example: upon review of HR#6 for the Bereavement Coordinator, and HR#7 the Medical Director there was no competency assessment documented as part of orientation. This observation was reviewed with the HR director and ADON. Observed in HR File Review. In 2 of 7 patient records reviewed, the organization failed to ensure that skills and competence of individuals furnishing care were assessed per policy. For example: the hospice aide had not had competency evaluation documented since orientation in 2019. The organization policy states at least annually on-site in a patient's home for all hospice aides. For all other staff the competency policy noted at least every three years. The Medical Director had been contracted since 2017 with no ongoing competencies performed. This observation was reviewed with the ADON.

Observed in Record Review. In 3 of 11 patient records reviewed, the organization failed to ensure the patient record contain all information related to the patient's care, treatment, and services. For example: on review of HV#1 the patient had a foley catheter that per documentation was changed monthly, yet on review of the documentation on the day of the catheter change there was no documentation in the record of the procedure used to accomplish the catheter change, nor the patient's response to the procedure. Example 2: on review of RR#6 and RR#7 where both patients resided in a nursing facility, the patients had documentation of wounds however there was no documentation in the record of the wounds size, description, or progress of the wound as noted in the organization's documentation guidelines. The records noted the wound was the responsibility of the facility with no further explanation. These observations were reviewed with the QAPI Coordinator, and ADON.

Observed in Record Review. In 1 of 3 home visits conducted, the organization failed to ensure the clinical record reflect the patient's care, treatment, and services. For example: upon observation of the RN's medication reconciliation during the home visit, the Lorazepam order on the patient's med profile specified 0.5mg tablets q 6 hours PRN, yet the facility medication profile noted Lorazepam liquid q 4 hrs PRN. On discussion with the facility staff the patient had been receiving the liquid Lorazepam and Lorazepam tablets were not available in the facility. This observation was reviewed with the RN and ADON.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to ensure the clinical record was complete, promptly, and accurately documented. For example: on review of RR#9, the nursing documentation noted in the musculoskeletal section no amputation 5 toes bilaterally on feet, however in the MD's documentation on the CTI and the MSW documentation on safety noted multiple amputations to toes that affected mobility. In RR#10 on the final skilled nurse visit the nurse's narrative noted the patient had died upon arrival, yet in the comments for systems assessed there were comments such as no distress, pt is not always compliant with caregiver instructions, today patient received Lorazepam... in another system was the comment no SOB, denies any pain, is semi cooperative with SN visit but somewhat anxious. These same comments were noted on the previous 2 nursing notes reviewed. These observations were reviewed with the ADON.

Observed in Tracer Activities. On review of the organization's CLIA Certificate the appointed Lab Director was a former owner who was no longer involved with the hospice for over an extended period of time, as the change of ownership was conducted in 2021. The CLIA Certificate director had not been updated. This observation was reviewed with the ADON.