Every finding on record at Generations Care Oh, LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 15 (27%) clinical records reviewed revealed that the agency did not ensure that all of the patient's current medications were included in the drug profile. Document 1: Agency Policy 2-004 "Medication Profile" dated 11/2023 read in part "Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications, and new or discontinued medications. Upon admission to hospice, the admitting nurse will initiate a medication profile.". Clinical Record 1: The start of care comprehensive assessment was 07/13/2024. The record revealed a physician's order dated 07/13/2024 that read "Oxygen 2-4 liters via nasal cannula as needed for shortness of breath.". The drug profile dated 07/13/2024 did not include oxygen. Clinical Record 2: The start of care comprehensive assessment was 05/30/2024. The record revealed a physician's order dated 05/30/2024 that read "Oxygen 2-4 liters via nasal cannula as needed for comfort.". The drug profile dated 05/30/2024 did not include oxygen. Clinical Record 5: The start of care comprehensive assessment was 01/21/2023. The record revealed a physician's order dated 01/21/2023 that read "Oxygen 2 liters via nasal cannula continuously.". The drug profile dated 01/21/2023 did not include oxygen. Clinical Record 9: The start of care comprehensive assessment was 12/09/2021. The record revealed an initial nursing assessment dated 12/09/2021 that read in part "Patient is using oxygen as needed for shortness of breath.". The drug profile dated 12/09/2021 did not include oxygen. In an interview on 07/17/2024, the Administrator reviewed the records and stated, "There is not oxygen on these medication profiles".

It is required that each patient’s individualized written plan of care Reflects patient and family goals; Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; Includes all services necessary for the palliation and management of the terminal illness, including the following: Intervention to manage pain and symptoms; A detailed statement of the scope and frequency of services necessary to meet specific patient and family needs; Measurable outcomes anticipated from implementing and coordinating the plan of care; Drugs and treatment necessary to meet the needs of the patient; Medical supplies and appliances necessary to meet the needs of the patient; Includes the Interdisciplinary Group’s documentation of the patient’s or representative’s level of understanding, involvement, and agreement with the POC; The documentation in the patient’s record is in accordance with the hospice’s policies and procedure. This standard was not met as evidenced by clinical record review and interview. In 1 of 15 (7%) clinical records reviewed revealed that the agency did not ensure that medical supplies and equipment necessary to meet the needs of the patient were included in the plan of care. Clinical Record 9: The record revealed an initial nursing assessment dated 12/09/2021 that read in part "Patient is using oxygen as needed for shortness of breath.". The plan of care dated 12/09/2021-03/07/2022 lacked documentation of oxygen in the medical supplies/durable medical equipment section. In an interview on 07/17/2024, the Administrator reviewed the record and stated, "There is no medical equipment listed on the plan of care."

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 7 of 13 (54%) clinical records with aide services provided reviewed revealed that the agency did not ensure that all patient care instructions were included in the aide care plan. Clinical Record 3: The record review revealed a physician's order for oxygen dated 07/24/2022. The aide care plan dated 07/28/2022 lacked instructions related to oxygen. Clinical Record 4: The record review revealed a physician's order dated 01/04/2023 that included wound care with a wound dressing for a wound to the sacrum. The aide care plan dated 01/06/2023 lacked instructions related to the wound dressing. Clinical Record 5: The record review revealed a physician's order dated 01/21/2023 that included wound care with a wound dressing for a wound to the sacrum, orders for oxygen, and orders for a suprapubic catheter. The aide care plan dated 01/23/2023 lacked instructions related to oxygen, catheter care and the wound dressing. Clinical Record 6: The record review revealed a physician's order dated 03/28/2023 that included wound care with a wound dressing for a wound to the sacrum and orders for a foley catheter. The aide care plan dated 03/28/2023 lacked instructions related to catheter care and the wound dressing. Clinical Record 11: The record review revealed a physician's order dated 03/11/2022 that included orders for wound care and wound dressing to a wound on the left heel. The aide care plan dated 03/11/2022 lacked instructions related to the wound dressing. Clinical Record 13: The record review revealed a physician's order dated 01/08/2022 that included wound care with a wound dressing to a wound on the left leg. The aide care plan dated 01/08/2022 lacked instructions related to the wound dressing. Clinical Record 15: The record review revealed a physician's order for oxygen dated 04/11/2022. The aide care plan dated 04/26/2022 lacked instructions related to oxygen. On 07/17/2024 the Administrator reviewed the records and confirmed the findings that the aide care plans did not include specific instructions.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group; included in the plan of care; permitted to be performed under state law and regulation; consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records with aide services provided review revealed that the agency did not ensure that aide services were provided as written in the plan of care. Clinical Record 8: The record revealed a physician's order dated 01/05/2022 that read "Aide services 3 times per week.". During the week of 01/30/2022-02/05/2022 the record revealed one aide visit dated 02/01/2022 with two visits outstanding. The record lacked missed visit notes for the two outstanding aide visits. In an interview on 07/17/2024, the Administrator reviewed the record and stated, "There are no missed visit notes in the patient chart.".

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 physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 15 (13%) clinical records reviewed revealed that the agency did not ensure that all physician orders were included in the patient's clinical record. Clinical Record 1: The record review revealed a physician's order dated 07/13/2024 that read "Urinary catheterization PRN.". The record lacked specific physician's orders for the indication, size and maintenance of the urinary catheter. Clinical Record 9: The record review revealed an initial nursing assessment dated 12/09/2021 that read in part "Patient is using oxygen as needed for shortness of breath.". The record lacked specific physician's orders for oxygen. In an interview on 07/17/2024, the Administrator reviewed the records and stated, "There are not specific orders in these patient charts for oxygen or the size and maintenance of the catheter."

Based on review of facility policy, review of Centers for Disease Control and Prevention (CDC) guidelines, and staff interview, the facility policy failed to follow CDC current guidelines for staff work restrictions if staff tested positive for Covid-19. The facility census was seven. Findings: include: Interview on 04/19/22 at 1:11 PM, Staff B revealed the facility has a new policy which was staff could return five days after a Covid-19 positive result and must be free of symptoms. Interview on 04/19/22 at 1:18 PM, Staff C stated the current policy was staff could return to work five days after a Covid-19 positive test without any symptoms. Review of the agency policy titled "Mandatory Vaccination Covid-19 Screening Policy," dated 02/08/22, revealed staff were required to notify the agency promptly if they tested positive for Covid-19. The agency would immediately remove an employee form the workplace if they received a positive Covid-19 test or had been diagnosed by a licensed healthcare provider with Covid-19. Employees with a positive Covid-19 test result would report the dated of symptoms onset and begin quarantine per CDC guidelines. The return to work criteria for people who were mildly ill with a laboratory confirmed infection and not moderately or severely immunocompromised included isolation could be discontinued at least five days after symptom onset, after resolution of fever for at least 24 hours, (without the use of fever-reducing medications), and with improvement of other symptoms. These people should continue to wear a well-fitted mask around others at home in public for an additional five days after the five day isolation period. The return to work criteria for people who test positive and are asymptomatic and not moderately or severely immunocompromised included isolation could be discontinued at least five days after the positive viral test. These people should continue to properly wear a well-fitted mask around others at home and in public for five additional day after the five day isolation period, if a person developed symptoms after testing positive their five day isolation period would start over. Review of the CDC guideline titled "Interim Guidance for Managing Health Care Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2," updated 01/31/22 revealed work restrictions for health care personnel with Covid-19 infection with conventional staffing levels included 10 days or seven days with a negative test, if asymptomatic with mild to moderate illness with improving symptoms. For a contingency staffing shortage, work restrictions for health care personnel with Covid-19 infection are five days with/or without a negative test if asymptomatic with mild to moderate illness with improving symptoms. For crisis staffing there are no work restrictions for Covid-19 positive health care personnel with prioritization considerations. Interview on 04/28/22 at 1:03 PM, Staff A confirmed the current policy was for five days isolation for Covid-19 positive staff. She thought she was following health care personnel isolation guidelines. Staff A stated she felt since she only had one nurse and there was a shortage of staff in healthcare in general the agency was always in contingency and crisis status. Staff A did state they had an emergency plan to work in collaboration with other agency's if the facility did not have staffing to cover shortages This citation substantiates Complaint Number OH00131074.

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 review of clinical record and interview that 1 of 3 (33%) records failed to document interventions for all problems identified on the initial comprehensive assessment. Record #60357: The initial comprehensive assessment documented 11/04/2021 for a patient with lung cancer with metastasis with verbalized fear of pain and the need for oxygen for respiratory distress. No documented intervention and goal for pain or for respiratory problem on any initial or updated plan of care as of review 01/31/2022. The initial hospice plan documented assessment for pain and the respiratory system each visit, but no documentation of specific interventions for these identified problems as of death 12/14/2021. The nursing visit note documented oxygen changes and instruction and pain medication changes but the plan of care failed to document the interventions that were planned. Interview with the nurse and administrator 01/31/2022 stated that the software is new and documentation of these problems are not on the plan of care.

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: Intervention to manage pain and symptoms. This standard was not met as evidenced by review of clinical record and interview that 1 of 3 (33%) records failed to document interventions to manage pain and symptom control. Record #60357: admitted 11/04/2021 with lung cancer with metastasis and a verbalized high concern for pain control. The single problem, identified on the plan of care was for general hospice care and included assessment for pain, but no other specific interventions to manage pain on any updated plan of care for pain control, as of death 12/14/2021. The pain medications were documented as changed and increased as the pain level increased. Documentation on nursing visit note was that patient died in comfort on 12/14/2021. The plan of care documented no interventions for the pain control or goals for the management of pain and symptom control. Interview with the nurse and administrator on 01/31/2022 stated that documentation in the visit note to provide care for the pain but that the plan of care should have included and been updated for the interventions as they are learning the software.

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. THIS IS A CMS CONDITION-LEVEL DEFICIENCY This CONDITION was not met as evidenced by record review and interview, and identified the agency failed to ensure staff who tested positive for COVID, the agency failed to follow their policy for management of COVID-19 positive staff (L578) and failed to ensure staff with documented positive COVID tests failed to document, tracing and follow agency policy for documentation of COVID return to work. Additionally verbalized process for employee screening for COVID failed to be documented after 11/30/2021. The lack of the COVID documentation has potential risk of communicable disease spreading (L581). The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment.

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes: Policies on protecting patients, staff, and families from bloodborne or airborne pathogens. This standard was not met as evidenced by review of agency infection log, documentation review and interview that 1 of 2 (50%) staff who tested positive for COVID, the agency failed to follow their policy for management of COVID-19 positive staff. Agency Policy, "Mandatory Vaccination Policy" (no date) stated in part, " Agency will immediately remove an employee from the workplace if they have received a positive COVID 19 test or have been diagnosed with COVID 19 by a licensed health care provider. For any employee removed because they are COVID 19 positive, the agency , will keep them removed from the workplace until the employee receives a negative result on a COVID -19 test or provides a written recommendation to return to work from a licensed healthcare provider. Personnel Record #14144: Registered Nurse record with a positive COVID test on 12/12/2021 visited patient ( #60537) for a death visit on 12/14/2021. Additionally made a death visit on 12/15/2021 with patient ( #24420). Interview with Office manager on 01/31/2022 stated that no further documentation was available for symptoms report or negative COVID test results for staff. Interview with Registered Nurse (#14144) on 01/31/2022 stated that COVID symptoms began 12/08/2021 with a rapid home test that showed positive results on12/10/2021 and a call to the clinical director with test results. A PCR test was completed 12/10/2021 with a positive result reported on 12/12/2021 and office kept documented in personnel record. The nurse provided a personal log of symptoms from her phone. She further stated that no temperature or symptoms had been evident 4 days prior to making the death visits. Decision for conducting the visits were made with the Clinical Director who is no longer at the agency. Interview with the Executive Director on 01/31/2022 stated that she was off the week the decisions were made for the registered nurse (#14144) to make the visit sooner than the policy 10 day quarantine and post testing and that she had wanted the clinical director to make the visit. The Clinical Director had stated she did not feel well and tested negative for COVID the day prior and the day of the visits but would not make the visits. The Clinical Director made the decision for the registered nurse (#14144) to make the visit and the Executive Director was aware of this decision.

It is required that the hospice maintains a coordinated, agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. The infection control program includes: A method for identifying infectious and communicable disease problems and a plan for implementing appropriate actions that are expected to result in improvement and disease prevention. This standard was not met as evidenced by review of agency infection binder, document review and interview that 2 of 2 (100%) of staff with documented positive COVID tests failed to document, tracing and follow agency policy for documentation of COVID return to work. Additionally verbalized process for employee screening for COVID failed to be documented after 11/30/2021. The lack of the COVID documentation has potential risk of communicable disease spreading. Agency Policy, "Mandatory Vaccination Policy" (no date) stated in part, " Agency will immediately remove an employee from the workplace if they have received a positive COVID 19 test or have been diagnosed with COVID 19 by a licensed health care provider. For any employee removed because they are COVID 19 positive, the agency , will keep them removed from the workplace until the employee receives a negative result on a COVID -19 test or provides a written recommendation to return to work from a licensed healthcare provider. Under CDC "Isolation Guidance" asymptomatic employees may return to work once 10 days have passed since the positive test, and symptomatic employees may return to work after all the following are true, at least 10 days have passed since symptoms first appeared and at least 24 hours have passed with no fever without fever reduction medication and other symptoms of COVID 19 are important." Personnel Record #14144: Registered Nurse with positive COVID test on 12/12/2021. No documentation was evident for removal from work or quarantine direction. Home visit documented on 12/14/2021 and 12/15/2021 for death visits. [ record #60357 (12/14/2021) and #99553 (12/15/2021)]. No documentation was evident for absence of symptoms, temperature or a negative COVID -19 test, or a return to work from a licensed healthcare provider. Personnel Record #46185: Chaplain with positive COVID test on 12/14/2021. No documentation was evident for removal from work or quarantine direction. No evidence of any visits made by clinician. Clinician resigned on 12/27/2021. Employee screening binder contained documentation of symptom screen of all employees until 11/30/2021. No evidence was provided of COVID screening for staff since 11/30/2021. Interview with staff nurse (#14144) on 01/31/2022 stated that no negative COVID test was obtained prior to return to work and no physician visit made prior to return to work. The nurse showed tracing on personal telephone of symptoms for COVID beginning 12/08/2021 with a rapid COVID test completed at home that was positive. No patient visits made 48 hours prior to this test. On 12/10/2021 a PCR test completed with results obtained 12/12/2021 that showed positive test. Nurse stated that symptoms were absent beginning 12/10/2021 and that death visit was made 12/14/2021 and 12/15/2021 with full PPE [include gown, N95 mask, face shield, gloves and booties]. Interview with Executive Director on 01/31/2022 stated that the decision for return to work was made by the Clinical Director. The Executive Director was on vacation during this week. The Executive Director stated that she was aware of the decision and that the Clinical Director is no longer at the agency.