Every finding on record at Friends of Caroline

Observed in Record Review. In 3 of 6 patient records reviewed, the organization failed to ensure the written plan of are was based on goals that were specific, measurable, and time-bound. On review of RRNHV#1 there was a goal that was not measurable in it read edema will decrease. In RRNHV#3 an example of a goal that was not measurable was patient will be safe in home environment as evidenced by decreased number of falls. In RRNHV#6 an example was patient will have adequate care of catheter within 2 weeks.. These observations were reviewed with the Compliance officer and the Clinical Leader.

Observed in Record Review. In 6 of 6 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#1 the documentation noted the patient was a high fall risk and was treated for a UTI yet the issues were not reflected on the plan of care. In RRNHV#2 the patient was on antibiotics for a UTI, and had documentation of difficulty swallowing but no care plans to guide the care. In RRNHV#3 the patient had a primary diagnosis of Pulmonary Fibrosis yet no care plan for respiratory. In RRNHV#4 there was a foley catheter and Peg tube but no related care plans to guide the care. In RRNHV#5 there was documentation of an infection and issues with vaginal bleeding yet the issues were not reflected in the plan of care. In RRNHV#6 the patient had pain issues with oxycodone ordered but no care plan for pain. There was documentation of a UTI but no care plan related to the infection open. These observations were reviewed with the Compliance Officer and Clinical Leader.

Observed in Record Review. In 2 of 6 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions to include drugs and treatments necessary to meet the needs of the patient. On review of RRNHV#1 there were as needed (PRN) medications as part of the plan of care that failed to include an indication as required. Example: Cephalexin 250 mg take one capsule once daily only if symptomatic yet the order failed to specify what symptoms. The orders for dicyclomine and MiraLAX did not have an indication for PRN use. In RRNHV#4 The documentation showed the patient had a foley and later a PureWick yet there were no related physician orders noted on the record. The patient also had tube feeds via peg tube but no orders for the tube feeds noted. These observations were reviewed with the Compliance Officer and Clinical Leader.

Observed in Record Review. In 2 of 21 patient records reviewed, the hospice’s interdisciplinary group, in consultation with the patient’s attending physician, if any, had not completed the comprehensive assessment no later than five calendar days after the election of hospice care. In the chart for RRHV#2, the initial spiritual assessment was not conducted until 12 days post the date of election. In the chart for RRNHV#8, neither the social worker nor the chaplain completed the initial assessment within the 5 day window. This was confirmed with the Director of Compliance.

Observed in Record Review. In 8 of 21 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for RRHV#1, there were no goals related to the patient's high risk of falls as assessed at the time of admission. In the chart for RRNHV#5, the goal of patient will be safe in the home environment did not include a timeframe; there was no goal on the plan of care related to oxygen safety. In the chart for RRHV#2, there was a non-specific safety goal on the plan of care which did not specifically address the oxygen use and fall risk. In the chart for RRHV#3, there was no goal related to safe use of oxygen nor fall risks. In the chart for RRHV#4, the POC was updated with Seroquel for hallucinations and anxiety, yet the POC was not updated with a goal related to this change in treatment. In the chart for RRNHV#7, there is no actual goal on the POC for anxiety, yet the goal was to be met within 2 weeks; there was no goal related to the patient's risk of falls. In the chart for RRNHV#11 reflexology treatments every 2 weeks for relaxation and increased circulation were added. The POC was not updated with a goal related to this problem and new intervention. In the chart for RRIPU#1, the POC was not updated with a goal for pain management with new pain post fall with rib fractures and the addition of a Fentanyl patch. This was confirmed with the Compliance Officer assisting with record review.

Observed in Record Review. In 2 of 21 patient records reviewed, the plan of care (POC) did not include interventions to manage pain and symptoms. In the chart for RRHV#3, the POC did not include any interventions related to pain management other than medications. The patient, per the SN report during the home visit, has chosen not to get out of the hospital bed, nor elevate the head of the bed more than approximately 10 degrees as these interventions are what is managing his pain. In the chart for RRIPU#1, the POC was not updated when the patient developed new pain post fall with rib fractures and the addition of a Fentanyl patch and prn pain medications. This was discussed with the Director of Compliance.

Observed in Record Review. In 9 of 21 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. In the chart for RRHV#1, the patient was assessed to be at high risk for falls. There were no patient specific interventions on the plan of care that addressed this risk. Additionally, the plan of care had not been updated as the patient had been admitted more than 6 months prior to the survey, yet the goal of Patient will be safe within one week remained on the current plan of care. In the chart for RRHV#2, there were no individualized fall reduction interventions on the POC. During the visit, the primary caregiver stated she uses multiple interventions including bilateral bed rales, a baby monitor, motion detector lights in bedroom, etc. In the charts for RRHV#3 and RRNHV#5, there were no interventions on the plan of care related to the safe use of oxygen. In the chart for RRHV#3, the current plan of care (POC) included 2 different, inaccurate medication list which included numerous duplicate medications including Oxycodone, Hyoscyamine, Ativan, Tylenol, Bisacodyl, etc. In the chart for RRHV#4, the medication orders were incomplete and did not include the reason for administration of prn medications including Dulcolax suppository, Haldol, Morphine, etc. which is required per organizational policy for medication orders. Additionally, prn visits were on the plan of care for all disciplines, however did not include an indication for when a prn visit would be made nor a number of prn visits allowed. In the chart for RRNHV#8, the order for Novolog was incomplete and stated - see sliding scale - as needed without inclusion of the sliding scale. Additionally, the assessment included information that the caregiver was using Zinc and Allevyn to the patient's sacral decub. There was no order found on the POC. In the chart for RRNHV#9, the order for oxygen was not obtained and included on the plan of care until at least one day after the documentation indicated the patient was using oxygen in the IPU. In the chart for RRIPU#2, the patient developed a skin tear after a fall. The RN washed and dressed wound with Tegaderm and absorbent gauze. The POC was not updated with orders for this care. This was confirmed with the Compliance Officer assisting with record review.

Observed in Record Review. In 1 of 21 patient records reviewed, there was not evidence of collaborative, coordinated care. In the chart for RRNHV#14, there was no documented input from nursing in the interdisciplinary meeting approximately three weeks prior to the survey. This was discussed with the Compliance Director.

Observed in Record Review. In 3 of 21 patient records reviewed, the organization had not provided the patient with care, treatment, or services according to the patient's individualized plan of care. In the chart for RRNHV#14, SN was ordered weekly. In at least the 2nd and 3rd weeks of the cert period, only one visit weekly made by nursing. In the chart for RRNHV#9, spiritual care was ordered monthly yet no visits had been documented since the initial eval more than 6 months prior to the survey. In the chart for RRHV#1, spiritual care visits were ordered monthly on the plan of care. No spiritual care visits had been provided for more than 3 months as confirmed with the Compliance Officer assisting with record review.

Observed in Record Review. In 1 of 21 patient records reviewed, all disciplines that provide care, treatment or services to the patient had not collaborated in the care of the patient and coordinated their efforts to support the goals outlined in the plan of care. In the chart for RRNHV#9, the patient was started on oxygen during a respite stay in the IPU. There was no order for oxygen, and there was no indication that the physician was made aware of the change in the patient's condition. This was discussed with the Compliance Director.

Observed in Tracer Activities. No evidence that the governing body and leadership had established processes to support patient care treatment and services through sustained compliance as evidenced by repeated condition level observations provision of care, 418.56. This was discussed with the Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, in which a transfer occurred when the patient was transferred to another Medicare/Medicaid facility, the hospice had not provided the receiving facility with a summary of care. In the chart for RRDC#1, the patient revoked the benefit to pursue treatment. There was no indication in the record that any information was provided to the receiving facility; there was no discharge summary in the record. This was confirmed with the Compliance Director.

Observed in Tracer Activities. The organization had not provided care, treatment, or services in accordance with licensure requirements, laws, and rules and regulations. During survey activities it was found that the organization had no process to inform the patient in writing of the charges related to room and board when the patient's level of care changed from respite or GIP back to routine hospice care, yet remained in the hospice inpatient unit. This was discussed with the Compliance Director.

Observed in Building Tour. It was observed in the gas fired dryer room that the dryer vent penetrated the suspended ceiling and was not properly sealed with smoke detection present. This was verified by the Facility Manager. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. It was observed in the oxygen tank manifold room that the fire damper wall penetration was not properly sealed. This was verified by the Facility Manager. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy: Observed in Building Tour. It was observed that the fire doors in Administration did not latch when tested. This was verified by the Facility Manager. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy:

Observed in Document Review. It was observed in the fire alarm report that there was no inventory of pull stations, smoke detectors, duct detectors, heat detectors or carbon monoxide detectors. This was verified by the Facility Manager.

Observed in Tracer Activities. Linens were not stored in such a manner to prevent the spread of contaminants. In the IPU storage room, there was a wire rack with miscellaneous fabric items on a bottom shelf which was open to the floor. This was discussed with the IPU supervising nurse.

Observed in Tracer Activities. The organization had not stored all food under sanitary conditions. In the Inpatient Unit family refrigerator, there was an open unlabeled jar of pickles and in the Nursing station refrigerator, there was an open unlabeled bottle of condiments. The organization required open contents be labeled with the date and room number. This was discussed with the Kitchen Manager.

Observed in Patient Home. In 1 of 3 home visits conducted, the hospice surveyor noted that the hospice nurse failed to conduct a medication assessment. For example during HV#1 the hospice nurse prefilled Roxanol syringes, but failed to conduct a medication assessment. This was discussed with the Executive Director and Director of Clinical Operations.

Observed in Record Review. In 1 of 11 patient records reviewed, the hospice surveyor noted that the initial bereavement assessment had not been completed. For example, HV#2 there was no documentation of the initial bereavement assessment by the MSW. This was confirmed with the Bereavement Coordinator.

Observed in Record Review. In 1 of 11 patient records reviewed, the hospice surveyor noted that the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. For example, in record RR#7 there were multiple Reflexology visits documented, however reflexology was not included on the plan of care, IDG documentation or the additional/supplemental order sets. This was confirmed with the Executive Director and Director of Clinical Operations present.

Observed in Record Review. In 11 of 11 patient records reviewed, the hospice surveyor noted that the plan of cares were not individualized. For example, the goals were not measurable and did not include time frames. This was discussed with the Executive Director and Director of Clinical Operations.

Observed in Patient Home. In 3 of 3 home visits conducted, that included staff using nursing bag and equipment, the surveyor noted that the disinfectant manufacturer instructions for use were not followed. For example, the nurses HV#1, HV#2 and PCHV used Web 70% Isopropal Alcohol wipes to disinfect the equipment prior to returning the equipment to the nursing bags. The manufacturer's IFUs and the packaging referenced use of the product as an antiseptic use on minor scrapes and burns. No reference to the product for disinfection of equipment. This was discussed with the Executive Director, Director of Community Engagement and Director of Clinical Operations. Observed in Patient Home. In 1 of 4 home visits conducted, the hospice surveyor noted that the staff had not followed accepted standards of practice to prevent the transmission of infections. For example, during PCHV the nurse failed to perform hand hygiene consistent with the organization's process. The nurse used bare hands to assess the patient's legs and feet, but did not perform hand hygiene afterwards and continued to work with the environment using equipment. The nurse also used bare hands to assess the patient's buttocks for redness and did not perform hand hygiene afterwards. This was discussed with the nurse and Executive Director.

Observed in Data Session. During the Data/Infection Control System tracer the hospice nurse surveyor noted that the organization had not documented identification of or prioritization of infection risks and did not set goals to improve compliance with hand hygiene guidelines. This was confirmed with the Executive Director and Director of Clinical Operations present. Observed in Data Session. During the Data/Infection Control System tracer the hospice nurse surveyor noted that the organization had not documented identification of or prioritization of infection risks and did not set goals to limit infections associated with the use of medical equipment, devices, and supplies. This was confirmed with the Executive Director and Director of Clinical Operations present. Observed in Data Session. During the Data/Infection Control System tracer the hospice nurse surveyor noted that the organization had not documented identification of or prioritization of infection risks and did not set goals to limit unprotected exposure to pathogens. This was confirmed with the Executive Director and Director of Clinical Operations present. Observed in Data Session. During the Data/Infection Control System tracer the hospice nurse surveyor noted that the organization had not documented identification of or prioritization of infection risks and did not set goals to limit the spread of infections associated with procedures. This was confirmed with the Executive Director and Director of Clinical Operations present. Observed in Data Session. During the Data/Infection Control System tracer the hospice nurse surveyor noted that the organization had not documented identification of or prioritization of infection risks and did not set goals based on the risks to minimize the possibility of spreading infections. This was confirmed with the Executive Director and Director of Clinical Operations present. Observed in Data Session. During the data/infection control session the hospice surveyor noted that no data had been collected to evaluate hand hygiene compliance or improvement of hand hygiene compliance. This was confirmed with the Executive Director and Director of Clinical Operations present.

Observed in Record Review. In 2 of 6 patient records reviewed, that included aide care, the hospice surveyor noted that the aide failed to provide care as instructed in the POC. For example, during review of record HV#1, the POC included that the aide was to provide shower, pericare and skin care at every visit. However, at every visit (5 days a week for 15 weeks) the aide record stated either Not scheduled this visit. or Patient/family declined. Also, at the end of the aide note was a comment that stated that there was nothing to report to the nurse case manager. Record review RR#3, the POC included that the aide was to provide a shower, skin care, and pericare at every visit. However, at 3 visits the care was declined and the aide note stated there was nothing to report to the nurse case manage. This was discussed and reviewed with the Executive Director and Director of Clinical Operations.

Observed in Record Review. In 2 of 6 patient records reviewed, that included aide services, the surveyor noted that the supervising nurse did not assess the aide’s ability to demonstrate satisfactory performance in completing the tasks in the plan of care assigned to the hospice aide by the registered nurse. For example, during record review HV#1 and RR#3 the supervising nurse did document a supervisory note every 14 days and the supervisory documentation included Patient's Plan of Care is being followed. However, the POC included that the aide was to provide shower, pericare and skin care at every visit and at every HV#1 visit (5 days a week for 15 weeks) and 3 of the RR#3 visits the aide record stated either Not scheduled this visit. or Patient/family declined. No indication was made by the supervising nurse related to the care that was not provided. This was discussed and reviewed with the Executive Director and Director of Clinical Operations.

Observed in Tracer Activities. Condition level findings at: 418.60 and 418.56 Observed in Tracer Activities. Condition level findings at: 418.60 and 418.56

Observed in Record Review. In 1 of 1 patient records reviewed, that included a foley catheter, the hospice surveyor noted that there was incomplete documentation regarding the initial foley catheter placement. For example, record RR#4 the nurse recorded SNV to patient to insert Foley catheter. Placed 16 Fr. Urine dark yellow. No documentation of balloon size, amount of liquid used to inflate the balloon, or a measurement of the amount of urine initially drained. This was confirmed with the Director of Clinical Operations.

Observed in Patient Home. In 4 of 4 home visits conducted, the hospice surveyor noted that no education had been provided for an individualized Disaster/Emergency Management plan. For example, HV#1, HV#2, HV#3 and PCHV records did not include an Emergency Management plan. This was discussed with the Executive Director and Director of Clinical Operations.