Every finding on record at Good Samaritan Society Hospice

Based on observation, interview and document review, the agency failed to ensure all prescribed medications were part of the plan of care (POC) for 1 of 3 patients (P2) whose medications were reviewed during a home visit. --- P2's plan of care (POC) dated 1/3/25 to 3/3/25, identified start of care on 1/9/24. Diagnoses included chronic congestive heart failure (CHF), diabetes, and hypertension. Skilled nurse visits were ordered one time weekly and five as needed for symptom management, various assessments and teaching, including assessment and instruction on medication regimen and potential side effects. The POC included a clinical update progress note dated 12/17/24,which identified P2 experienced two CHF exacerbations over the past eight weeks with increased edema (swelling) to his legs and hand. P2's Lasix (for fluid retention) was increased. Prescribed and patient reported medications were listed including hydrochlorothiazide (for fluid retention) 25 milligrams (mg) every day, omeprazole 40 mg every day, and trazodone 50 mg two tablets at bedtime. During a home visit on 1/7/25, at 12:00 p.m. family member (FM)-A reviewed the medications P2 was currently taking. FM-A identified P2 was no longer taking hydrochlorothiazide, omeprazole or trazadone and had not been taking the medications for several months. When interviewed on 1/7/25, at 12:20 p.m. registered nurse (RN)-A stated she had not removed the medications from P2's active medication list so that they could use them if symptoms popped up. RN-A stated if a patient was no longer taking a medication, the medication should be removed from the active medication list or changed to as needed. When P2's recertification was done, RN-A should have updated the medication list on the POC to reflect what the patient was actually taking. It was important to have the medication list accurate in case another nurse made a home visit, she would wonder where the hydrochlorothiazide or trazodone was. During joint interview with administrator and director of nursing (DON) on 1/8/25, at 2:30 p.m. the DON stated nurses were to review medications every visit and her expectation was for the medication list to accurately identify the medications a patient was taking. The agency policy Medication Management Hospice dated 12/28/23, identified a comprehensive assessment of medication would include a review of all prescribed medications, herbal remedies, and over the counter medications the patient was currently using. Staff would ensure the patient's medication list would be current at each medication reconciliation. Once staff became aware of a new or change in medication, documentation in the medical record would include medication changes, observation and teaching.

Based on interview and document review, the agency failed to ensure scheduled visits were provided in accordance with the plan of care (POC) for 4 of 10 patients (P1, P5, P6, P7) reviewed for services planned. --- P1's plan of care (POC) for the certification date of 10/4/24, identified a start of care date 10/4/24. Diagnoses included cerebral infarction, vascular dementia, hemiplegia and depression. P2's planned visits as of 10/4/24, included volunteer visits one to two times per month for three months. P1's medical record reviewed 11/1/24 through 1/8/25, identified no volunteer visits were conducted throughout November or December. P1's medical record lacked volunteer visit documentation, the reason for lack of volunteer visits or notification to the provider of the missed visits. P5's POC for certification date of 11/17/24 identified a SOC date of 9/18/24. Diagnoses included senile degeneration of the brain, dysphagia, pneumonia, and malnutrition. P5's planned visits as of 11/17/24, included volunteer visits one to two times per month for two months. P5's medical record reviewed 11/1/24 through 1/8/25, identified no volunteer visits were completed throughout November or December. P5's medical record lacked volunteer visit documentation, the reason for the lack of volunteer visits or notification to the provider of the missed visits. P6's POC for the certification date of 11/11/24 identified a SOC date of 11/11/24. Diagnoses included lymphoma, kidney disease, diabetes, and malignant neoplasm of the breast. P6's planned visits as of 11/11/24, included chaplain visits two to four times per month plus ten visits as needed for three months. The Interdisciplinary Group note dated 12/5/24, identified visit frequency to continue for chaplain visits two to four times per month with no missed visits. P6's medical record reviewed 11/11/24 through 1/8/25, identified only one chaplain visit completed on 11/11/24, in which the patient declined any further visits. P6's medical record lacked notification to the provider of the refused services and discontinuation of the current orders for chaplain visits two to four times per month. P7's POC for certification date 10/18/24 identified a SOC 6/26/23. Diagnoses included malignant neoplasm of bilateral ovaries, heart disease, and Alzheimer's disease. P7's planned visits included volunteer visits one to two times per month for nine weeks P7's medical record reviewed from 11/1/24 through 1/8/25, identified no volunteer visits were completed in December. P7's medical record lacked volunteer visit documentation, the reason for the lack of volunteer visits or notification to the provider of the missed visits. A joint interview with the administrator and director of nursing (DON) was conducted on 1/9/25, at 1:30 p.m. The DON stated when a patient's services changed the staff were expected to obtain a verbal order to reflect the changes. The nurse should have written orders to either discontinue or change to as needed when the patient was no longer receiving visits as ordered from the chaplain or volunteers and update the POC. The POC should be reviewed and changes addressed at the patient's IDG meetings conducted every two weeks. When the POC was updated with changed services, the system automatically generated a verbal order for the provider. A policy on missed visits was requested, however none were received.

Based on interview and document review, the agency failed to ensure there was an agency-wide infection control program that tracked and trended patient infections to prevent potential outbreaks and use bring the information collected to the quality assessment and performance improvement (QAPI) program. This had the potential to affect all current hospice patients. --- The agency's Adverse Events report for 10/8/24, through 1/8/25, identified the patient, location, date, and event type. One patient was identified with an eye infection, two patients had respiratory infections, four patients had skin or wound infections, seven patients had a urinary infection, and seven patients with other infections. The report failed to identify if the infection was community acquired, catheter associated, if an organism was identified, if the infection was treated and/or type of treatment or if the infection had resolved. The agency QAPI minutes June 2024 to January 2025, identified the following: QAPI Meeting 6/18/24, agenda item infection control discussion identified all staff completed yearly hand washing test out and N-95 testing. No current restrictions were noted at facilities. Actions/Outcomes were listed to continue per policy and annual hand washing at all staff on 7/2024, and a follow-up of 9/19/24. Meeting notes lacked information if any hospice patients or employee infections had occurred during this time frame as part of the QAPI process. QAPI Meeting 12/11/24, agenda item infection control identified discussion were completed and flu season protocols and procedures were reviewed as well as annual N95 and handwashing clinic. Actions/Outcomes were listed yearly review and competence with a follow update on 12/30/24. Meeting notes lacked information if any hospice patients or employee infections had occurred during this time frame as part of the QAPI process. During interview on 1/9/25, at 1:30 p.m. the director of nursing (DON) stated she recorded all employee illnesses in the logbook but did not formally track or trend their illnesses. When a patient was ill or required an antibiotic, the nurses recorded it under the adverse events tab in the patient's medical record. The DON printed the Adverse Events Detail Report quarterly to discuss at QAPI and individual patient illness was discussed every two weeks at their Interdisciplinary Group meetings (IDG). Infection control was a part of QAPI but had not been doing any formal surveillance with patients other than the quarterly report. The agency was now working on the plan for the 2025 QAPI agenda. The agency policy Quality Assurance and Performance Improvement QAPI dated 10/9/23, identified the QAPI program was ongoing, comprehensive and data-driven and addressed the complexity and uniqueness of the care and services provided. The QAPI program would identify and prioritize problems and opportunities that reflect the organizational processes, functions, and services provided on performance indicator data, safety of the served, input from stakeholders and other information. The QAPI program used data to monitor the effectiveness and safety of the services and quality of care, identify and prioritize problems and process improvement opportunities and would take action to address areas that needed improvement. The agency policy Identification and Reporting of Suspected Infections dated 1/16/24, identified staff were to document the time of symptoms onset, any cultures obtained, any treatment initiated, any outcome, precautions initiated and the suspected infection in the electronic medical record, along with provider notification. Staff were to collect infection surveillance data including, symptoms, date of onset, location, etc. If infection was suspected, infections would be logged for trending and infections and outbreaks would be reported at QAPI committee for review and action planning, when needed.

Based on interview and document review, the agency failed to ensure a registered nurse (RN) provided a supervisory visit of home health aide services at least every 14 days for 4 of 9 patients (P1, P2, P7, P9) reviewed with hospice aide services. --- P1's plan of care (POC) for certification date 10/4/24, identified a start of care (SOC) of 10/4/24. Diagnoses included cerebral infarction, vascular dementia, hemiplegia, and depression. P1's orders identified P1 received skilled nurse visits (SNV) one time per week for 13 weeks and home health aide visits (HHA) one time per week for 13 weeks. P1's plan of care (POC) for certification date 1/2/25, P1's orders identified P1 received skilled nurse visits one time per week for 13 weeks and home health aide visits one time per week for 13 weeks. P1's medical record identified P1 received hospice aide services weekly throughout November and December with no missed visits recorded. The registered nurse (RN) completed home health aide supervision visit with the scheduled visit on 12/17/24, however, there was no evidence supervisory visits were conducted from 12/18/24 to 1/8/25. P2's POC for certification date 9/4/24, identified a SOC 1/9/24. Diagnoses included chronic congestive heart failure (CHF), diabetes, and hypertension. SNV were ordered one time weekly for nine weeks and HHA visits three times per week for eight weeks. P2's POC for certification date 1/3/25 , included orders for SNV one time weekly for nine weeks and HHA visits three times per week for eight weeks. P2's medical record identified P2 received HHA visits three times weekly throughout November and December with no missed visits recorded. The RN completed HHA supervisory visit on 11/5/24 and then again 11/22/24, 17 days after the 11/5/24 supervisory visit. P7's POC for certification date 10/18/24, identified a SOC 6/26/23. Diagnoses included malignant neoplasm of bilateral ovaries, heart disease and Alzheimer's disease. SNV were ordered one time per week for nine weeks and HHA visits two times per week for nine weeks. P7's POC for certification date 12/17/24, included orders for SNV one time per week for nine weeks and HHA visits two times per week for nine weeks. P7's medical record identified P7 had received HHA visits two times weekly throughout November and December with no missed visits recorded. The RN completed HHA supervisory visit on 12/12/24. There was no evidence any other HHA supervisory visits were documented throughout November or December. P9's POC for certification date 11/25/24, identified a SOC 8/27/24. Diagnoses included senile degeneration of brain, dementia and depression. SNV were ordered one time per week for 13 weeks and HHA visits two times per week for thirteen weeks. P9's medical record identified P9 received HHA visits two times weekly throughout November and December with no missed visits recorded. The RN completed HHA supervisory visit on 12/5/24 and 12/10/24. No other HHA supervisory visits were documented in December. A joint interview was conducted with the administrator and director of nursing (DON) on 1/9/25, at 1:30 p.m. The administrator stated the agency nurses were expected to complete a HHA supervisory visit every two weeks. The DON stated it was important to have the supervisory visits completed as the aides were not licensed employees and needed to be supervised to ensure they were following the patient's POC and supervisory visits were required every 14 days. The agency policy Home Health Aide Supervision and Delegation of Duties dated 6/14/24, identified when a home health aide provided services to the skilled patient, a supervisory visit to a patient's home must be completed by skilled personnel at least every 14 days.

Based on interview and document review the agency failed to ensure volunteers provide administrative or direct patient care services to patients to equal a minimum of 5 percent of the total patent care hours of all paid hospice employees and contract staff, which had the potential to affect all hospice patients. --- Findings include: The agency Home Health and Hospice Contact list updated 1/6/25, identified 9 volunteers. The Hospice Volunteer Hours Report from January 2024 through December 2024, identified a cost savings of 4.29% for the year. The monthly data identified the following cost savings per month: January 2024 = 5.18% February 2024 = 3.39% March 2024= 4.59% April 2024 = 3.11% May 2024 =4.34% June 2024 =3.43% July 2024 =2.39% August 2024= 3.55% September 2024= 6.88% October 2024 =5.83% November 2024= 3.85% December 2024 =6.36% When interviewed on 1/8/25 at 2:20 p.m. the volunteer coordinator (VC) stated they had volunteers do patient and family visits and assist with some administrative duties. She was aware they had not met the 5 percent cost savings. VC recently took over the volunteer coordinator position in September. VC was working on improving the volunteer hours since she took over the position in September and getting the hours within the required 5%. VC knew the low hours in November were related to having two of the agency full time volunteers on vacation. She did not know why the hours were not in the required 5% prior to taking over the position. A policy for volunteer hours was requested, however, none were received.

Based on interview and document review, the agency failed to ensure advanced directives were accurately documented in patient medical records for 1 of 10 patients (P3) whose advanced directives were reviewed. --- P3's plan of care (POC) for certification period dated 1/6/25, identified a start of care (SOC) date 1/12/24. Diagnoses included diabetes, kidney disease, and heart failure. Directives included informed consent signed and do not resuscitate. P3's Clinical Admission Summary note dated 1/12/24, identified P3 was appropriate for hospice with chronic kidney disease and co-morbidities of heart failure and diabetes. P3 was do not resuscitate (DNR), comfort measures only. P3's Provider Orders for Life-Sustaining Treatment (POLST) signed by P3 and dated 1/12/24, identified attempt resuscitation/CPR was selected for option A. During telephone interview on 1/8/25, at 3:00 p.m. registered nurse (RN)-B stated she had not completed the start of care assessment for P3 but was very familiar with P3 and was her current case manager. RN-B was sure P3 would have never chosen a full code and would wish to have DNR on her records. RN-B was sure the POLST had been documented incorrectly, as the admitting nurse was not familiar with the admission process and forms. RN-B knew P3 would never want to be CPR and she planned to go out to the home and complete a new POLST form with P3 as soon as possible to correct the error. RN-B never specifically talked about P3's code status with her because she had always thought P3 was a DNR and her POC indicated a DNR. P3 was always comfortable talking about her death and the dying process during their visits. RN-B would look at the POC for direction on code status. During telephone interview on 1/8/25, at 3:40 p.m. P3 stated her wishes were for DNR and she had that on all of her medical records. There was no way she would have asked to have full code and CPR. P3 had been DNR for a long time and all of her records reflected that. When interviewed on 1/9/25, at 1:30 p.m. the director of nursing (DON) stated the medical record should have code status match the patient's POLST or advanced directives. It was important for the agency to comply with the patient wishes. She knew P3 and felt P3's POLST was filled out in error as the admission note and all other documents indicated the P3 did not wish to be resusictated. She asked P3's case manager to go out to the home and clarify P3's wishes and fill out a new POLST document. An advanced directive policy was requested, however, none were received.

Based on interview and document review, the facility failed to ensure they conducted exercises to test their emergency plan at least annually, including participation and documentation of a full-scale and/or table top exercises. --- Tabletop and or full-scale exercises were requested and not provided. During an interview with the administrator on 9/22/22, at 10:00 a.m. the administrator confirmed although the facility had developed a training plan for emergency procedures, they had not conducted any tabletop or full-scale exercises. A policy was requested and not provided.

Based on staff interview and record review, the agency failed to ensure services were provided in accordance with the plan of care for 5 of 11 patients (P6, P8, P3, P7, P9) reviewed for services planned. --- P3's Team Care Plan reviewed 9/14/22, indicated P3's start of care (SOC) date was 8/5/22, and diagnoses included malignant neoplasm of lung and secondary to brain and pulmonary embolism. The plan identified ordered visits, which included massage therapy for therapeutic massage, one visit per week for 13 weeks.P3's electronic record identified P3 did not receive massage therapy for the week of 9/4/22 and failed to identify the reason P3 had not received the ordered visit.P7's Team Care Plan reviewed 9/14/22, indicated P7 SOC date was 7/15/22, and diagnoses included pneumonia, acute respiratory failure, heart disease and diabetes. The plan identified ordered visits, which included a home health aide (HHA) to assist with bathing, shaving, oral care, assist with transfers and ambulation, turning and repositioning, assist with eating and light housekeeping. A HHA was ordered one visit per week for 13 weeks.P7's electronic record identified P7 did not receive the scheduled HHA visits as ordered for the weeks of 7/17/22, and 9/4/22. P7's medical record failed to identify the reason P7 had not received the ordered visits for the two missed weeks.P9's Team Care Plan reviewed 9/14/22, indicated P9 SOC date was 6/28/22, and diagnoses included Parkinson's, dementia and anxiety. The plan identified ordered visits, which included a HHA to assist with bathing, catheter and perineal care, assist with transfers, turning and repositioning, dress/undress and oral cares. A HHA was ordered one visit per week for 13 weeks.P9's electronic record identified P9 did not receive HHA visits for the weeks of 6/26/22, and 7/3/22. P9's record failed to identify the reason P9 did not receive the ordered HHA visits for the two missed weeks.When interviewed on 9/21/22, at 11:00 a.m. the director of nursing (DON) stated the massage therapist missed some work due to a family illness. The therapist contacted the patients the visits would not be made and the patients indicated they were fine with not receiving them for a short time, but she did not document in the medical record. It was the agency's practice when skilled nurse or HHA visits were not completed, the missed visits would be discussed at the patients' interdisciplinary team meetings that were held every two weeks and be documented in the team meeting notes. The hospice physician would be notified in that way. The missed HHA visits were not documented in the meeting notes and should have been addressed during the review of the plan of care. A policy was requested but was not received. P6's Team Care Plan dated 9/21/22, identified P6 began services on 8/4/22, with primary diagnosis of aphasia (inability to comprehend or formulate language) following cerebral infarction (stroke). P8's plan identified planned visits, which included massage therapist (MT) 1 time a week times 13 weeks which began 8/4/22.P6's electronic record identified P6 did not receive a MT visit the week of 8/14/22. P6's record failed to identify the reason P6 did not receive a MT visit that week.On 9/21/22, at 10:58 a.m. interview with clinical manager (CM)-A confirmed a MT visit was not provided and no reason was identified the week of 8/14/22, then stated the massage therapist was out the week of 8/14/22, due to a family illness. CM-A indicated she thought the massage therapist called her patients when unable to visit, but she did not document those calls. CM-A indicated she would do education to assure missed visits were followed up on and documented. CM-A stated all missed visits should be discussed during interdisciplinary group (IDG) meetings and documented.P8's Team Care Plan dated 9/22/22, identified P8 began services on 6/2/22, with a primary diagnosis of pulmonary fibrosis (progressive terminal lung disease). The plan identified planned visits, which included: personal care aide (PCA) 2 times a week times 1 week ended 9/3/22, and 3 times a week times 8 weeks.P8's electronic record identified P8 had a missed PCA visit on 7/22/22. P8's record miss identified the reason as refused, when in fact the PCA was documented as being out on paid time off (PTO).On 9/21/22, at 3:12 p.m. clinical manager (CM)-A reviewed P8's electronic record and confirmed P8 had a missed aid visit on 7/22/22, but confirmed the reason was not appropriate. CM-A stated the reason of the missed visit should not have been written as refused, since the note identified the aid was out on PTO. CM-A indicated she would do education on that to assure reasons were appropriately documented, and stated the visit should have been rescheduled.

Based on observation, interview and record review the facility failed to ensure medication changes were based on assessments for 1 of 3 patients (P3) observed during home visits. --- P3's Team Care Plan was reviewed 9/14/22, identified a start of care of 8/5/22. Diagnoses included malignant neoplasm of the lung and secondary malignant neoplasm to the brain. The plan identified a problem of pain which included goals for the patient and family to verbalize and demonstrate understanding of pain management and proper medication administration. Identified interventions included to assess the patients level of comfort or discomfort utilizing a consistent pain scale and to identify comfort goal.When interviewed during a home visit on 9/20/22, at 11:15 a.m. P3's family member (FM)-A stated P3 was experiencing pain across her shoulders and mid back. FM-A was giving P3 liquid morphine ordered every hour as needed (PRN). P3 ply received the medication a couple of times and it was working well to control her pain. P3 complained of the taste of the liquid medication, so FM-A called the hospice agency and the morphine was ordered in a tablet form which FM-A picked up yesterday afternoon. Neither the agency or pharmacy discussed the new morphine order with P3 and she did not realize the Morphine was now a long-acting tablet. FM-A would give it as ordered and not PRN as she had previously thought. FM-A indicated P3 had one dose yesterday afternoon and at bedtime and had refused the medication that morning.When interviewed on 9/20/22, at 11:30 a.m. registered nurse (RN)-A stated she did not review P3's medications with FM-A and should have. When a patient received a new medication it was the agency's practice to go over the medication with the patient and family regarding what it is to be used for, potential side effects and to report if not effective. If she had reviewed the medications when she visited P3 on 9/20/22, she would have been aware of the change, from as-needed morphine to the long-acting scheduled morphine, and would have had the opportunity to educate the patient and family. RN-A did telephone FM-A after becoming aware the long-acting morphine was initiated and explained how to administer the medication and potential side effects she should report if noted. During interview on 9/20/22, at 12:10 p.m. the director of nursing (DON) identified she took a call from FM-A for P3's pain that was not being controlled by the liquid morphine. She did not have P3 rate her pain or ask specifically how much as needed pain medication P3 was using. She called the hospice physician and requested scheduled morphine tablets two times per day. She thought she told FM-A it would be a long-acting medication. DON did not document anything in P3's medical record regarding her conversation with P3's family, her conversation with the physician or the subsequent changes in medications. The DON did not write a verbal order or update the POC when she received the new orders.During interview on 9/20/22, at 12:30 p.m. the hospice medical director stated he did recall receiving a telephone call from the DON regarding P3's pain and the need for her pain medication to be adjusted. He did not typically change the medication to the direct equivalent; however, tended to titrate it up to represent better pain control. He did not know what P3 was taking for pain control and was not aware P3 only wanted to change from liquid to pill form due to she disliked the taste of the liquid.When interviewed on 9/20/22, at 1:00 p.m. the pharmacy filling the long-acting morphine medication on 9/19/22, for P3, indicated they did not provide any drug counseling to the patient or family and suspected counseling had been declined, as they always offered it when medications were picked up.During a telephone interview on 9/20/22, at 1:10 p.m. FM-A stated P3 only used the quick-acting liquid morphine three times since she was admitted to hospice and the medication worked well to control her pain when she gave it to P3. FM-A called the agency to inquire about getting the medication in tablet form as P3 did not like the taste of the liquid morphine. She did understand she was not to use the morphine tablets as needed as the label on the bottle indicated to take one tablet every 12 hours.The facility's policy Assessment and Reassessment Hospice with revision date 1/4/22, indicated the interdisciplinary team established and reviewed the plan of care (POC). The hospice POC must involve the participation of the patient and family. The family must be involved whenever possible in the implementation and continuous assessment of the hospice service POC. The comprehensive POC was to be reviewed an updated with patient reassessment as frequently as the patient's condition required but no less then every 15 days.

Based on interview and record review the facility failed to ensure a discharge summary contained all the components for 1 of 2 patients (P13) who revoked hospice benefits. --- P13s Team Care Plan (CP) indicated a start of care (SOC) date 11/9/21, with a diagnosis of prostate cancer. The plan identified P13 received skilled nursing, social work, spiritual visits, and nursing assistant visits. P13s discharge summary dated 5/23/22, included a summary of goals and services received. The skilled nurse clinical note indicated P13 was leaving the area for the summer and planned to receive services from another hospice agency in the new service area. The summary did not include P13s physician orders, information related to care for the pain pump currently being used, and other documentation to assist in the post-discharge continuity of care. The discharge summary lacked a physician's signature to ensure P13s primary care provider had reviewed and agreed with the information. P13s medical record lacked a physician's order for the discharge/revocation from the hospice agency. A transfer form or communication to the receiving hospice agency was not completed. The medical record did not identify if the agency had contacted P13s receiving agency to communicate a summary of P13s care needs and services received, as well as current orders and medication needs. When interviewed on 9/21/22, at 10:00 a.m. the director of nursing (DON) indicated a physicians order was not documented and the discharge summary was not signed by the physician. A transfer summary was not completed and should have been as it was important for the receiving agency to know P13s current orders and condition. It would also help to provide continuity of care and hospice services for P13. A discharge policy was requested; however, none were received.