Every finding on record at Global Hospice and Palliative Care, Inc.

Observed in HR File Review. In 3 out of 10 personnel records reviewed, the organization failed to provide ongoing emergency management education and training to their staff. For example, in personnel record review for HR#1-Administrator, HR#2-DPCS, and HR#3-SC/BC/Vol Coord, there was no evidence that training had been provided for 2024. This was reviewed, discussed, and validated with the DPCS and Administrator.

Observed in Patient Home. In 1 out 4 home visits conducted, the organization failed to maintain complete and accurate patient records. For example, in the home visit conducted for RRHV#2, the patient's plan of care included orders and equipment for oxygen therapy. It was documented that the patient had oxygen in use at 2 LPM via nasal cannula as needed for symptom management; however, there was no oxygen equipment in the home. Upon further observation, the visiting nurse confirmed with the patient that they have never had oxygen equipment in the home. This was reviewed, discussed, and validated with the DPCS and Administrator. Observed in Record Review. In 4 out of 14 active records reviewed, the organization failed to maintain complete and accurate patient records. For example, in record review for RRNHV#1, the initial comprehensive assessment documented that the patient was on continuous oxygen at 4 LPM via nasal cannula; however, the treatment and medication list documented that the patient was on oxygen at 2 LPM via nasal cannula continuously. All follow-up documentation notes that the patient is on oxygen at 4 LPM continuously via nasal cannula. In record review for RRNHV#3, it was documented in the comprehensive assessment that the patient was on oxygen at 3 LPM as needed for shortness of breath; however, the treatment list documented that the patient was on 2 LPM as needed. In record review for RRNHV#5, the registered nurse (RN) documented in the initial comprehensive assessment that the patient was on oxygen at 2 LPM via nasal cannula continuously; however, the treatment list and plan of care indicated that it was only used as needed. In record review of RRNHV#8, the recertification assessment documented continuous oxygen use at 4 LPM; however, the plan of care notes oxygen at 2 LPM continuously. This was reviewed, discussed, and validated with the DPCS and Administrator.

Observed in Record Review. In 19 out of 19 records reviewed, the organization failed to ensure that the written plan of care is based on the patient's goals and the timeframes, settings, and services required to meet those goals. For example, in all records reviewed, the plan of care did not include measurable goals. All goals were vague, not individualized, and did not include a realistic or appropriate timeframe for completion. Examples include, Patient will achieve optimal level of sleep, The patient will be free of injuries to maintain safety within the certification period, The patient will have adequate foods and fluids to maintain comfort, and The patient will have pain controlled at an optimal level. This was reviewed, discussed, and validated with the DPCS and Administrator.

Observed in Record Review. In 7 out of 14 active records reviewed, the organization failed to plan the patient's care. For example, in record review for RRHV#4, RRNHV#2, RRNHV#3, RRNHV#5, RRNHV#7, RRNHV#8, and RRNHV#9, the plan of care's included volunteer services with a frequency of as needed. However, there is no documentation to support why the volunteer services are needed, or how often and how long they are needed. This was reviewed, discussed, and validated with the DPCS and Administrator.

Observed in Record Review. In 4 out of 14 records reviewed, the organization failed to plan the patient's care. For example, in record review of RRNHV#2, the patient had a documented wound to the right heel as a result of a ruptured blister; however, there were no wound care orders or interventions listed on the plan of care. In record review for RRNHV#6, the patient had a documented stage II pressure injury to the coccyx, a right heel deep tissue injury (DTI), and a left ankle DTI; however, there were no wound care or treatment orders listed on the plan of care. In record review of RRNHV#8, the patient had a documented stage II pressure injury to the sacrum; however, there were no interventions or treatment orders included in the plan of care. In record review for RRHV#4, the patient had a documented skin tear to the right forearm, and multiple open abrasions to the right lower leg; however, there were no wound care or treatment interventions included in the plan of care. This was reviewed, discussed, and validated with the DPCS and Administrator.

Observed in Patient Home. In 1 out of 4 home visits conducted, the organization failed to plan the patient's care. For example, in the home visit conducted for RRHV#2, the patient was observed to be using a rollator with seat attachment for ambulation; however, this was not listed on the current plan of care. This was reviewed, discussed, and validated with the DPCS and Administrator.

Observed in Patient Home. In 1 out of 4 home visits conducted, the organization failed to implement activities for the prevention and control of infections and communicable diseases. For example, during the home visit conducted for RRHV#3, the Registered Nurse (RN) was observed entering her nursing bag on three separate occasions with gloved hands, and two occasions with ungloved hands. Each time the RN entered the bag on these occasions, she failed to perform hand hygiene. According to organizational policy [Policy# 9-014.1], hand hygiene must be performed prior to entering or re-entering the nursing bag. This was reviewed, discussed, and validated with the DPCS and Administrator.

Observed in Record Review. In 1 out of 14 active records reviewed, the organization failed to assess its patients. For example, in record review for RRNHV#1, there was no evidence that the organization had completed a spiritual assessment for the patient. There was no documentation that their spiritual concerns or needs were identified. This was reviewed, discussed, and validated with the DPCS and Administrator.

Observed in Record Review. In 8 out of 14 active records reviewed, the organization failed to plan the patient's care. For example, in record review for RRNHV#1 and RRNHV#9, the patient's were documented to be on continuous oxygen at 4 LPM via nasal cannula; however, the aide care plan's did not include instructions detailing if the oxygen could be removed during the bed bath. For RRNHV#5, the patient was documented to be on oxygen at 2 LPM via nasal cannula continuously; however, the aide care plan did not indicate if the oxygen could be removed during the bed bath. For RRHV#1, RRHV#4, RRNHV#3, RRNHV#8, and RRNHV#10, the patient's were documented to be on oxygen at 2 LPM via nasal cannula as needed; however, the aide care plan's did not include instructions for what to do if oxygen was in use during aide visits. This was reviewed, discussed, and validated with the DPCS and Administrator.

Observed in Patient Home. In 2 out of 3 home visits conducted with an observed medication reconciliation, the organization failed to ensure the patient record contains information that reflects the patient's care, treatment, or services. For example, in the home visit conducted for RRHV#3, the patient was noted to be taking Tylenol ES 500 mg one tablet every four hours as needed for mild pain; however, this medication was not listed on the medication profile in the home or medical record. In the home visit conducted for RRHV#4, the patient was noted to be taking Lorazepam 0.5 mg every four hours as needed; however, this was not listed on the medication profile in the home or medical record. Upon further review, the medication profile included Miconazole nitrate powder to be applied topically three times a day for 14 days; however, this medication was not present in the home and had been discarded eight months prior. It was also noted that the medication profile included Imodium A-D 2 mg caplet to be taken once daily as needed; however, this medication was not present in the home. This was reviewed, discussed, and validated with the DPCS and Administrator.

Observed in Record Review. In 3 of 5 patient records reviewed, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. For example: on home observation of HV#1 the patient caregiver noted she performs blood glucose monitoring 4 times a day and they discussed the patient's blood glucose trends yet there were no physicians orders for blood glucose monitoring to include parameters for reporting to hospice, nor was blood glucose monitoring reflected in the plan of care. In review of RR#4 the nursing documentation and plan of care noted a wound to the buttocks with ongoing treatments however there was no current order for the dressing changes. Upon discussion with the DPCS Designee, an order that wound had been in place but had been discontinued on 4/3/23, although treatment was continued. Further, order for the Lt 5 Metatarsal, Left lateral foot and Left Lateral heel had specifications for the dressing to be changed daily and as needed, yet no indication for when to change as needed. In RR#5 the nursing documentation noted an open wound with treatment on the patient's finger yet there was no wound care order noted in the plan of care. Further, there was an order for treatment to a skin tear but the order did not specify a frequency of when the treatment was to be performed. These observations were reviewed with the DPCS Designee.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization failed to ensure the care and services was provided in accordance with the plan of care. For example: in review of RR#2 the patient had orders for wound care to the left buttocks yet the SN documentation for over the last 2 weeks prior to survey does not indicate the wound care was performed as ordered. On discussion with the DPCS Designee the wound was now only redness, yet the order had not been discontinued. In Review of RR#4 the patient had a foley catheter and orders to flush the catheter each visit yet there was not documentation noted in the nursing notes that this care was being provided. These observations were reviewed with the DPCS Designee.

Observed in Patient Home. In 1 of 3 home visits conducted, the clinician had not conducted an effective medication assessment. During HOS HV #3, the clinician had been observed reviewing prescription bottles; however, she had not compared the medications to the medical record list for accuracy. When asked about comparing the medications to the medical record, she reported that she had the list 'in her head'. This was validated with the Director of Patient Care Services present during the visit.

Observed in Record Review. In 2 of 13 patient records reviewed, the Hospice Surveyor noted conflicting documentation in the patient medical record. For example, in HOS RR #7, the patient had been documented at initial evaluation as using 4 lpm home oxygen. The medication list for the patient had home oxygen at 2 lpm, and then in an Interdisciplinary group meeting, the patient had been reported as being on Home Oxygen 3 lpm. In HOS RR #8, the patient had been documented by the skilled nurse as being bedbound and transitioning, but the HA documented that the patient had been given a shower. This was validated with the Director of Patient Care Services.

Observed in Record Review. In 13 of 13 patient records reviewed, the Hospice Surveyor noted the patient goals had been broad, not measurable, and had not contained a time frame for achievement. Examples include: 'Pt will maintain optimum peripheral circulation' (for cardiac disease), 'Prevent physical and emotional stress due to preventable sickness', 'Optimal bowel elimination and comfort' (for constipation), 'Pt/Family/PCG will verbalize having urinary elimination needs met at an acceptable level' (for GU/Incontinence), Pt/Family/PCG will verbalize understanding of increased risk of fall (for falls), and These findings were validated with the Director of Patient Care Services.

Observed in Record Review. In 1 of 13 patient records reviewed, the Hospice Surveyor noted patient care orders that had been incomplete. In HOS RR #8, the patient had and indwelling urinary catheter. The orders for care and management of the catheter that had been written on different dates included: 1. Foley catheter 16french 10ml balloon to gravity drainage every shift; 2. Note: May reinsert foley catheter as needed for malfunction or dislodgment; 3. Foley cath flushing w/ 60ml NS PRN Q 8 H. The 3 orders had been missing who was to carry out the orders, the actual frequency of the catheter change, and the prn indications for flushing. This was validated with the Director of Patient Care Services.

Observed in Record Review. In 6 of 13 patient records reviewed, the Hospice Surveyor noted medication orders with titration based on patient symptoms that had not contained specific parameters for the titration. For example, HOS RR #3, the patient had Morphine Sulfate 20mg/mL Solution ordered 0.25-1, Oral, every 4 hours as needed, mild ,moderate and severe pain and shortness of breath. There had not been specific identification of what was patient specific mild, moderate and severe pain nor the specific dose for each. The same patient also had Tylenol ordered with the indication of as needed for pain. This had also been identified in records HOS HV #1,HOS HV #2, HOS RR #4, HOS RR #7, HOS RR #8, and HOS RR #11. This was validated with the Director of Patient Care Services Observed in Record Review. In 3 of 13 patient records reviewed, the Hospice Surveyor noted the patient Plan of Care (POC) had not addressed patient specific needs related to diagnosis and/or identified problems. For example, in HOS HV #1 the patient had been bedbound with a high Braden Pressure Injury risk; however, the POC had no goals or interventions related to pressure injury prevention. This same patient had a wound on the left foot that the organization had been providing care to, but this had not been included in the POC with goals and interventions as well as the patient was on 2 high risk medications (insulin and warfarin), and this had not been addressed on the POC. HOS RR #8, the patient had an indwelling urinary catheter that had not been addressed on the POC with goals and interventions, and HOS RR # 11, the patient had a PEG tube and a PICC line documented on admission assessment; however, there had been no orders, goals nor interventions included on the POC. This was validated with the Director of Patient Care Services. Observed in Patient Home. In 1 of 3 home visits conducted, the Hospice Surveyor observed care provided to a patient without first obtaining a physician order. HOS HV #3, the clinician had been observed providing wound care to the patient's left lower extremity. The Surveyor could not locate any orders for the wound care, no IDG discussion related to the fact that the patient had wounds on the left lower extremity, and this had not been on the POC. This was validated with the Director of Patient Care Services. Observed in Patient Home. In 1 of 3 home visits conducted, the Hospice Surveyor observed the current Plan of Care (POC) had not been updated to reflect the patient's current care needs. HOS HV #3, the patient had orders for wound care to bilateral upper extremities, and the right lower extremity; however both of the upper extremity wounds had healed and no longer required care, and the patient was receiving wound care to both lower extremities . The most recent Interdisciplinary Group Meeting had not reflected any discussion about the healing of the upper extremity wounds which no longer requiring dressing changes nor the addition of left lower extremity wound care. This same patient had a recent urinary tract infection that had been discussed, but not added to the POC. This was validated with the Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits conducted, the Hospice Surveyor noted the Plan of Care (POC) orders had not been followed. For example, HOS HV #3, the clinician had been observed providing care to the right lower extremity. The right ankle wound had been painted with betadine which hadn't been ordered and then the ordered retention stocking had not been applied. The patient also had ordered wound care to bilateral upper extremity skin tears; however, wound care had not been completed. This was validated with the Director of Patient Care Services present during the visit.

Observed in Tracer Activities. The Hospice Surveyor noted the HCO was not able to demonstrate the operation of its QAPI program as evidenced by the HCO was not able to produce the documentation of analysis and development of performance improvements at the time of survey.

Observed in Tracer Activities. During the Data Management/QAPI program review, the surveyor observed that the organization had been compiling data, but had not performed an analysis of the data to identify and develop improvement opportunities. The data also had not been compiled using methods to make it measurable and meaningful for improvement activities. This was validated with the Leadership Team.

Observed in Tracer Activities. The surveyor noted the HCO had not collected data on the improvements to patient care and safety that they had been trying to achieve as evidenced by the HCO was not able to produce this documentation at the time of survey. Observed in Data Session. The Hospice Surveyor noted the HCO had not performed any analysis related to if an improvement project had achieved an measure of success. For example, they noted high falls in quarter 3 and quarter 4. an in-service of staff was completed in December to educate staff; however, the education had been on the environment of care and not specific to falls. Since that time, there has been no measurement of whether or not falls were reduced.

Observed in Tracer Activities. The surveyor noted the organization failed to document what performance improvement projects were being conducted, the reasons for conducting these projects, and the measurable progress achieved as evidenced by the HCO was not able to produce this documentation at the time of survey.

Observed in Tracer Activities. The Hospice Surveyor noted the HCO Governing Body did not designate one or more individuals to be responsible for the QAPI program as evidenced by the HCO was not able to produce this documentation at the time of survey.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization had not implemented infection prevention and control activities according to the HCO's Bag Technique Policy No. 9-014.1. During HOS HV #3, the clinician had been observed setting reusable equipment on an unprotected surface, and then return them to the nursing bag after use without prior disinfection. The same clinician had been observed to remove her gloves, then without performing hand hygiene, utilize her cell phone for wound pictures. The phone had then been placed on a bedside table. At the end of the visit, the clinician placed the phone in her pocket without disinfection. This was validated with the Director of Patient Care Services present during the visit. Observed in Patient Home. In 1 of 3 home visits conducted, the Hospice Surveyor noted the HCO had not implemented the Hand Hygiene Policy No 9-009.1. During HOS HV #3, the Hospice Aide had been observed providing care to the patients peri area, then without changing gloves, nor performing hand hygiene, she provided care to the patients trunk and upper extremities. The same clinician had not performed hand hygiene with glove changes. The second part of HOS HV #3, the clinician providing wound care to the patients lower extremities had not changed her gloves between removing the dressings, cleansing the wounds and reapplying the dressings. She had also been observed touching inanimate objects in the patient vicinity without disinfecting her hands. This was validated with the Director of Patient Care Services present during the visits.

Observed in Tracer Activities. The surveyor noted the organization did not identify infection risks as evidenced by not conducting an infection control risk analysis.. This was confirmed with the Leadership Team.

Observed in Record Review. In 1 of 13 patient records reviewed, the Hospice Surveyor noted the Hospice Aide (HA) care documented had not been the care ordered on the HA Plan of Care (POC). For example, in HOS RR #5, the HA POC had a shower chair bath ordered; however, the HA documented that she provided a bed bath. The Surveyor had been unable to validate that the HA had communicated with the RN Case Manager for new care orders. This was validated with the Director of Patient Care Services.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by the QAPI program not analyzing aggregated data to develop performance improvement plans related to patient outcomes.

Observed in Record Review. In 1 of 3 home visits conducted, the Hospice Surveyor observed the Hospice Aide (HA) provide care to the patient; however, the documentation reflected care that had not been observed. For example, in HOS HV #3 the HA documented that she had provided a shampoo, oral care of dentures both upper and lower and linen change, when these had not been observed in the patient home. The HA orders had also included recording the last bowel movement, but this had not been completed as ordered. This was validated with the Director of Patient Care Services. Observed in Record Review. In 4 of 13 patient records reviewed, the Hospice Surveyor noted the documentation had not been complete to reflect all care provided to the patient. For example during HOS HV #3, the clinician had been observed providing care to bilat lower extremities; however the only documentation had been 'wound care rendered'. HOS RR #4, HOS RR #7 and HOS RR #11 had the similar documentation present related to wound care. The actual steps completed had not been documented. This was validated with the Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits conducted, the Hospice Surveyor noted the medications the patient had been taking were not accurately documented in the medication profile. In HOS HV #3, the patient had been taking TUMS 1000 mg as needed for indigestion, and had been applying Alclometasone ointment to wounds on her face; however, these medications had not been included on the hospice medication profile. This was validated with the Director of Patient Care Services.

Observed in Record Review. In 1 of 3 patient records reviewed, the Hospice Surveyor observed the Hospice Aide (HA) provide care to the patient; however, the documentation reflected care that had not been observed. For example, in HOS HV #3 the HA documented that she had provided a shampoo, oral care of dentures both upper and lower and linen change, when these had not been observed in the patient home. The HA orders had also included recording the last bowel movement, but this had not been completed as ordered. This was validated with the Director of Patient Care Services.

Observed in Competency Session. In 1 of 9 HR files reviewed, the Hospice Surveyor noted the Medical social Worker did not have the position qualifications defined in the agency position description. The position required a minimum of one year's experience in health care, hospice experience preferred. The MSW had no health care field experience prior to beginning with the HCO. This was validated with the HR staff.