Every finding on record at Ghc-Brunswick LLC

Based on review of clinical records, review of the policy titled, ";Complaint/Grievance Process," and staff interviews, it was determined the hospice governing body failed to assume responsibility for the provision of all hospice services by not investigating an allegation of abuse or neglect reported to Adult Protective Services (APS) for one patient (P) (P1). --- Findings include: A review of an undated policy titled, ";Complaint/Grievance Process," Policy No. 9-003, reveals the following: Policy The Administrator will be informed of situations that may become detrimental to good patient relations and will be committed to maintaining a consistently high level of patient relations. The organization will investigate complaints regarding treatment or care, mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the organization. Procedure 1. The Clinical Manager will investigate the grievance and will make every effort to resolve the grievance to the patients satisfaction. 4. Complaints and actions taken will be documented. 10. Complaints will be tracked and trended as part of the QAPI program. P1 was admitted to hospice on 8/22/2023. P1 lived at home and was cared for by family and a part-time private-duty caregiver. P1 went to a Skilled Nursing Facility (SNF) on 7/16/2024 for a planned five-day respite (provides short-term relief for primary caregivers, giving them time to rest, travel, or spend time with other family and friends) stay. Visit note report by Social Worker (SW) AA dated 7/17/2024 reveals nursing home reported patients back wound to Adult Protective Services (APS). The clinical note further reveals SW AA and Registered Nurse (RN) BB informed the nursing facility that the patients needs were met at home. Additional review of the clinical record failed to reveal follow-up regarding the APS referral. Review of a document titled, ";QI Event Report" failed to reveal complaints documented for period 1/1/2024 through 8/12/2024. On 8/13/2024 at 10:20 am, a telephone interview with SW AA revealed nursing home staff informed her that APS was called due to concerns regarding the wound on the patients back. SW AA revealed she attended a care plan meeting with the facility and told nursing home staff that the patient was well cared for at home. SW AA stated she reported the APS referral to the Director of Operations (DO). On 8/13/2024 at 10:25 am, a telephone interview with RN BB revealed nursing home Administrator informed her APS was called because of concerns regarding P1s skin integrity. RN BB revealed she told the facility staff that the patient was well cared for at home. RN BB stated she reported the APS referral to the DO. On 8/13/2024 at 10:30 am, an interview with the DO confirmed she was aware of the APS referral before going on vacation 7/17/2024. The APS referral was reported by the DO via email to the Area Vice President (AVP) covering for the DO in her absence. The DO revealed the incident was not investigated because the hospice team agreed the patient was well cared for at home and the back wound was chronic and related to the disease process and not neglect. The DO revealed that P1s back was chronically inflamed despite multiple interventions by the hospice. On 8/13/2024 at 10:45 am, a telephone interview with the Area Vice President (AVP) confirmed he was aware of the APS report. The AVP revealed an APS investigator came to the hospice office on approximately 7/22/2024 and he referred her to the RN Case Manager (RN BB). He was unable to provide documentation of an investigation but stated the incident should have been investigated internally.

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. 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 and interview. In 3 of 19 (16%) records reviewed revealed the agency did not ensure a review of all of the patient's current prescription and over the counter (OTC) drugs. Clinical Record 2: The hospice election of benefit was dated 09/08/2023. The 09/08/2023 comprehensive assessment completed by the registered nurse included documentation that the patient was utilizing oxygen @ 2-3 Liters as needed for shortness of breath. Oxygen was not listed on the medication profile at the time of the review on 09/18/2023. Clinical Record 6: The hospice election of benefit was dated 07/06/2023. Upon review of the 09/04/2023 hospice episode of care, the 09/14/2023 registered nurse visit documentation included the 'application of zinc cream and antifungal cream to the buttocks and between legs due to rash secondary to yeast infection'. Zinc cream and antifungal were not listed on the medication profile at the time of review on 09/19/2023. Clinical Record 9: The hospice election of benefit was dated 05/26/2023. Upon review of the 08/24/2023 hospice episode of care, the 09/12/2023 licensed practical nurse visit note included documentation that the patient was utilizing oxygen at 2.5 L via nasal cannula. Oxygen was not listed on the medication profile at the time of the review on 09/20/2023. During interview 09/21/2023, Director of Quality reviewed the associated records and stated the medications had inadvertently been omitted from the medication profile and had since been corrected.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) records reviewed the agency did not ensure that an initial bereavement assessment was completed. Clinical Record 1: The hospice election of benefit was dated 05/06/2023. There was no evidence of completion of an initial bereavement risk assessment at the time of the review on 09/18/2023. During interview 09/21/2023, Director of Quality reviewed the associated record and was unable to locate the initial bereavement risk assessment.

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 drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) records reviewed the agency did not ensure the written plan of care including complete treatment orders necessary to meet the needs of the patient. Clinical Record 8: The hospice election of benefit was dated 06/07/2023. upon review of the 07/24/2023 hospice episode of care, the 07/24/2023 hospice plan of care read 'may flush indwelling catheter with 10 ml of as needed for catheter malfunction.' There was no specification of what solution to irrigate the catheter with. Clinical Record 16: The hospice election of benefit was dated 07/30/2023. The 07/30/23 hospice plan of care read 'Hospice nurse to place Foley catheter 18Fr 10 CC balloon, change Foley q month and prn', The order did not contain an as needed qualifier. During interview 09/21/2023, Director of Quality reviewed the associated records and stated orders were incomplete and had since been corrected.

It is required that the hospice’s policies and procedures define a system of communication and integration that sustains coordination of services and provides documentation of exchange of information. The policies and procedures ensure that care and services provided are in accordance with the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) records reviewed the agency did not ensure that services provided were in accordance with the plan of care. Clinical Record 14: The hospice election of benefit was dated 04/07/2023. Upon review of the 07/06/2023 hospice episode of care, the 07/06/2023 hospice plan of care included a nursing frequency of 1week 1, 3 week 12. During the week of 08/07/2023 there was documentation of two nursing visits made on 08/07/2023 and 08/09/2023, There was no evidence of a third nursing visit nor any documented explanation for visit not made per ordered frequency, During interview 09/21/2023, Director of Quality reviewed the associated record and stated frequency had not been met and that nurse had since entered a missed visit note and the physician had been notified.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 9 of 18 (50%) records reviewed that included the provision of aide service the agency did not ensure that the aide provided service as per the plan of care. Clinical Record 2: The hospice election of benefit was dated 09/08/2023. The aide plan of care created by the registered nurse on 09/08/2023 included a frequency of weekly for shampoo and linen change. During the week of 09/11/2023 the aide visit documentation dated 09/11/2023, 09/13/2023 and 09/15/2023 included linen change completion at each visit instead of once per week as ordered. The 09/08/2023 hospice plan of care included an aide frequency of 1week 1, 3 week 12 however there was no evidence of a visit for the week of 09/08/2023 nor a documented explanation of why service was not provided as ordered. Clinical Record 3: The hospice election of benefit was dated 07/31/2023. The aide plan of care created by the registered nurse on 07/31/2023 included instructions that shampoo was to be performed at the first visit of each week. During the week of 08/08/2023 the aide performed the visit on 08/11/2023 which was the second visit of the week. During the week of 08/19/2023 the aide performed the visit on 08/17/2023 which was the second visit of the week. During the week of 08/22/2023 the aide documented completion of shampoo on 08/24/2023 and 08/25/2023 which were the second and third visits of the week. During the week of 08/29/2023 the aide documented completion of shampoo on 09/01/2023 which was the third visit of the week. Clinical Record 4: The hospice election of benefit was dated 09/08/2023. The 09/14/2023 physicians order included an aide visit frequency of 2week 12, 1 week 1 effective 09/10/2023. There was documentation of one visit made the week of 09/10/2023 on 09/15/2023 and no explanation of why a second visit was not made as ordered. Clinical Record 6: The hospice election of benefit was dated 07/06/2023. The aide plan of care created by the registered nurse on 07/29/2023 included a frequency of weekly for bath and hair care. During review of the 09/04/2023 hospice episode of care, hair care was documented as completed at each visit dated 09/05/2023, 09/06/2023, 09/07/2023, 09/08/2023 for the week of 09/05/2023 and on visits dated 09/11/2023, 09/13/2023, 09/15/2023 for the week of 09/11/2023. Bath was documented as completed on 09/11/2023 and 09/13/2023 for the week of 09/11/2023. Clinical Record 8: The hospice election of benefit was dated 06/07/2023. During review of the 07/24/2023 hospice episode of care, the aide plan of care created by the registered nurse on 06/09/2023 included a frequency of weekly for shampoo and dressing. The aide documented completion of the tasks for each daily visit dated 09/05/2023 through 09/15/2023. Clinical Record 9: The hospice election of benefit was dated 05/26/2023. During review of the 08/24/2023 episode of care, the aide plan of care created by the registered nurse on 05/30/2023 included a frequency of weekly for shampoo. During the week of 09/05/2023 the aide documented completion of the task on 09/05/2023 and on 09/07/2023. Clinical Record 11: The hospice election of benefit was dated 008/31/2023. The 08/31/2023 hospice plan of care included an aide frequency of 1week 1 3week 12. There was no evidence of an aide visit for the week of 08/31/2023 nor evidence of an explanation of why services were not provided as ordered. Clinical Record 14: The hospice election of benefit was dated 04/07/2023. During review of the 07/06/23 hospice episode of care, the 08/27/2023 physicians' order included an aide frequency of 5week 5, 2week 1. During the week of 08/27/2023 there was documented evidence of aide visits completed on 08/28/2023, 08/29/2023, 09/01/2023 and a missed visit note for 08/30/2023 however there was no evidence of a fifth visit for the week of 08/31/2023 nor evidence of an explanation of why services were not provided as ordered. Clinical Record 16: The hospice election of benefit was dated 07/30/2023. The aide plan of care created by the registered nurse on 07/30/2023 included a frequency of weekly for shampoo and nail care. The aide visit documentation included completion of the asks at each visit dated 08/01/2023, 08/03/2023, and 08/04/2023 for the week of 08/01/2023 and on 08/07/2-23, 08/09/2023, ad 08/11/ 2023 for the week of 08/07/2023. During interview 09/21/2023, Director of Quality reviewed the associated records and stated aide plans of care had not been followed and remedial education will be provided where appropriate.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review and interview. In 1 of 18 (6%) records reviewed that include the provision of aide services the agency did not ensure a registered nurse made an on-site visit to the patient’s home no less frequently than every 14 days. Clinical Record 1: The hospice election of benefit was dated 05/06/2023. Upon review of the 08/04/2023 hospice episode of care, the number of days noted between the aide supervision dates of 08/22/2023 and 09/08/2023 completion exceeded the 14-day requirement. During interview 09/21/2023, Directo of Quality reviewed the associated record and stated the time between the supervisory visit exceeded the 14-day requirement and remedial education was provided to the appropriate clinician.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 4 (75%) records reviewed in which the patient care was provided in a SNF revealed the agency did not ensure the hospice plan of care specified which provider was responsible for performing the functions that were agreed upon and included in the plan of care. Clinical Record 5: The hospice election of benefit was dated 08/17/2023. The 08/17/2023 hospice plan of care did not contain interventions for the SNF. Clinical Record 6: The hospice election of benefit was dated 07/06/2023. The 07/06/2023 and the 09/04/2023 hospice plan of care did not contain interventions for the SNF. Clinical Record 12: The hospice election of benefit was dated 06/29/2023. The 06/29/2023 hospice plan of care did not contain interventions for the SNF. During interview 09/21/2023, Director of Quality reviewed the associated records and stated the delineation of duties had inadvertently been left off of the hospice plan of care.