Every finding on record at Good Shepherd Home Care and Hospice of Eastern Utah, Inc.

Based on interview and record review, the hospice agency failed to meet the Condition of Participation for Interdisciplinary Group (IDG), Care Planning, and Coordination of Services. Findings include: 1. The hospice failed to ensure the plan of care reflected patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. (Refer to tag L 0545) 2. The hospice failed to ensure the physician and other members of the IDG team were notified when a change of condition occurred. (Refer to tag L 0595)

Based on interview and record review, it was determined the agency did not ensure each patient had an individualized plan of care (POC) that reflected interventions based on problems identified in the initial, comprehensive, and updated assessments. Specifically, for 5 of 7 sampled patients a care plan was not developed that was individualized based on the initial, comprehensive and updated assessments. (Patient identifiers: 2, 3, 4, 5 and 6. ) Findings include: 1. Patient 3 was admitted to the agency with a terminal diagnosis of malignant neoplasm of vulva. Patient 3's medical record was reviewed on 4/20/2022. An initial nursing assessment was completed on 3/24/2022. The RN (registered nurse) documented that patient 3 had a pain level of "3" on a scale of 1-10 with 1 having no pain and 10 having excruciating pain. Patient 3 had facial grimacing, bracing and was rubbing the affected area. The pain was documented as being in the lower abdomen and was increased by movement and activities of daily living (ADLs). The pain was assessed as being sharp/stabbing and cramping that was intermittent. It was documented that patient 3 required considerable assistance and had functional limitations in ambulating, bathing, eating and transferring. Patient 3 had an unna boot that had been placed to the right lower leg which was to be changed weekly and as needed (PRN). A skilled nursing (SN) visit, dated 3/28/2022 was reviewed. The registered nurse (RN) documented an international normalization ratio (INR) of 3.1 and that another agency RN was notified of the results. The RN documented further "awaiting Coumadin orders." An interdisciplinary care plan, dated 3/29/2022 was reviewed. The problem areas documented were "Fall on 03/27/22 (without) injuries; edema RLE (right lower extremity); and Weakness, decline in cognitive status." The interventions documented were "Fall prevention; una (sic) boot (change every week) PRN; 24 (hour) care provided by spouse." The goal documented was "Comfort care (at) EOL (end-of-life)." The care plan did not address that INRs were to be obtained as ordered by the physician or patient 3's pain. The plan of care (POC) did not contain measurable goals. A SN visit, dated 4/11/2022 was reviewed. The RN documented, "Spouse discussed family dysfunctional issues, spouse is calm and feels overwhelmed with family issues." It was further documented "spouse discussed concern about family dysfunction of the daughter--patient has no s/sym (signs or symptoms) of apparent abuse." An interdisciplinary care plan, dated 4/12/2022 was reviewed. The problem areas documented were "Multiple falls in last 2 weeks (no) injuries; Bed bound; (increased) weakness; (decreased) cognitive status; (decreased) safety awareness; Family difficulty providing cares." The interventions documented were"Fall prevention teaching; Foley Cath (catheter) start, teach foley care, infection control; 24 (hour) care needed for supervision; and MSW (medical social worker) support, coordinate LTC (long-term care) placement. The goal documented as "Comfort care (at) EOL." The care plan did not address the family dysfunction. 2. Patient 2 was admitted to the agency on 3/22/2022 with a terminal diagnosis of heart failure. Patient 2's medical record was reviewed on 4/19/2022. An initial nursing assessment was completed on 3/22/2022. The RN documented that patient 2 had a pain level of "6" on a scale of 1-10 that was located in the mid to low back and bilateral lower extremities. Patient 2 had facility grimacing, bracing and restlessness. Patient 2's pain was only partially relieved with rest and pain medications. The RN documented patient 2 was on portable oxygen for treatment of dyspnea. Patient 2 lived alone and had functional limitations in bathing, continence, dressing and transferring. Per the Karnofsky Performance Status Scale, patient 2 was 40% disabled and required special care and assistance. Patient 2 was short of breath at rest and had oxygen saturation levels less than or equal to 88%. The nurse did not document any care plan problems. An interdisciplinary care plan, dated 3/22/2022, had the following: "'good level of pain' for pt (patient) = (equals) 4-6/10" Patient 2's medications were set up by a caregiver that patient was suppose to take himself but that he was not reliable for compliance and was not taking his medications regularly. The problems listed were "'Balance Issues' - r/t (related to) peripheral neuropathy. Medication caused Balance difficulty. Uses walker now - worsening since he uses the walker versus cane." The interventions documented included the use of a four wheeled walker. "Can get w (wheel)/chair for trial period for patient. DME (durable medical equipment) to support 02 need, safety features of stand-by assist. Family CG educated as well." The goals documented were, "safety w/cares at introduction - families are all a part of person's support et (and) care plan meetings..." The care plan did not address patient 2's pain, interventions to assure medication compliance, shortness of breath, or the need for assistance with activities of daily living. A SN visit, dated 4/1/2022 was reviewed. The RN documented, patient 2's hands were puffy and that the legs were tight with water retention. Patient 2 complained of pain and rated his pain at a "5" and that his pain was worse related to the pressure from edema. The RN documented that patient 2 had an increased need for pain medications. It was further documented that the RN "sets up medication." There was no documentation of what the new medications orders were. The interdisciplinary group (IDG) care plan, dated 4/7/2022 was reviewed. There was no documentation that patient 2's pain was worse and had an increase in his pain medications. Nor was there documentation that the RN set up patient 2's medications in a med set. 3. Patient 4 was admitted to the agency on 8/27/2021 with a terminal diagnosis of lung disease. Patient 4's medical record was reviewed on 4/19/2022. The IDG care plan, dated 3/15/2022 was reviewed. It was documented that patient 4 had intermittent right rib discomfort with an increase in respirations and shortness of breath. Patient 4 had dizziness upon rising and was a fall risk. The documented intervention included, "encourage Xanax to calm resps (respirations) et pain; encourage call light for one person assist on rise; use walker for stabilization et energy conservation." The only goal documented was "Comfort & EOL care." The IDG care plan, dated 3/29/2022 was reviewed. It was documented that patient 4 had a change in his lasix dosage to "as needed", that the prescribed Xanax was causing restlessness and hallucinations, and that the patient had increased fatigue and had difficulty swallowing some foods such as peas and corn. The interventions documented included to change the Xanax, encourage the patient to place the call light around the neck for safety, avoid small foods and start a mechanical soft diet as needed. The only goal documented was "Comfort et EOL care." The IDG care plan, dated 4/12/2022 was reviewed. It was documented that patient 4 had increased fatigue and shortness of breath with minimal activity. The interventions documented included, "use walker for energy conservation & frequent rests; Do breathing tx (treatment) et administer Lorazepam prior to increased activity." The only goal documented as "Comfort & EOL care." 4. Patient 5 was admitted to the agency on 12/23/2020 with a terminal diagnosis of Alzheimer's disease. Patient 5's medical record was reviewed on 4/19/2022. The IDG care plans, dated 3/24/2022 and 4/7/2022 were reviewed. The frequency of visits for the skilled nurse and the hospice aide were not documented. 5. Patient 6 was admitted to the agency on 7/26/2019 with a terminal diagnosis of heart failure. Patient 6's medical record was reviewed on 4/19/2022. The IDG care plan, dated 3/1/2022 was reviewed. The problem areas documented included intermittent pain with right inguinal hernia and a cough with phlegm. The interventions included to ask for percocet for pain and to brace the lower right quadrant with movement or coughing and to encourage hydration and and to add mucinex to the medication regiment. The only goal documented was "Comfort & EOL care" The IDG care plan, dated 3/15/2022 was reviewed. The problem areas documented were that patient 6 forgets his limits and that he was a fall risk. The interventions documented taht the patient was to use the call light, to have a one person assist and get up to ambulate, and to rise slowly and use the walker. The only goal documented was "Comfort & EOL care" The IDG care plan, dated 3/29/2022 was reviewed. The problem areas documented were shortness of breath with minimal activity and fall risk. The interventions documented were to use the walker and take frequent rest breaks. Patient 6 was to keep his call light on his person. The only goal documented was "Comfort & EOL care" A SN visit, dated 4/4/2022 was reviewed. It was documented that patient 6 had sustained a fall. The SN note did not document injuries. Upon review of the adverse event log, an entry was documented that patient 6 sustained a fall on 4/4/2022: The RN documented that patient 6's right forearm was bleeding and had "skin sluff." The area was cleansed and a pressure dressing was placed. It was further documented that patient 6 had superficial scrapes to the left lower flank. The IDG care plan, dated 4/12/2022 was reviewed. No wound care was documented and a physician's order for the treatment of the right forearm wound was not documented. The problem areas were that patient 6 was a fall risk due to shortness of breath and fatigue. It was documented that patient 6 had a sedentary life which placed him at increased risk for a pressure sore. The interventions included use of the walker for energy conservation and to reposition while seated. No goals were documented. There was no documented evidence that the POC's reflected the patient and family goals, had interventions based on problems identified in the initial and comprehensive assessments, and included all services necessary for the palliation and management of the terminal illness and related conditions for any of these patients. A telephone interview was conducted with the director of nursing (DON) on 4/21/2022 at 4:58 PM. The DON stated that an initial care plan was to be developed within five days from the day of admission. The DON stated that the care plan was developed based off assessments completed by all disciplines. The DON further stated that the care plan was to be updated every two weeks or as needed.

Based on interview and record review, it was determined the hospice agency did not develop and maintain a system of communication and integration to ensure that the interdisciplinary group (IDG) maintained responsibility for directing, coordinating, and supervising the care and services provided to all patients. Specifically, for 1 of 7 sampled patients, the agency did not ensure the physician and other members of the IDG were notified when a change of condition occurred. (Patient identifier: 3) Findings include: Patient 3 was admitted to the agency on 3/24/2022 with a terminal diagnosis of metastatic cancer of the vulva. Patient 3's medical record was reviewed on 4/20/2022. A skilled nursing (SN) visit was completed on 3/27/2022. The only thing documented on the visit note was vital signs. The registered nurse (RN) that made the visit, documented on the adverse event log that patient 3 had no injuries but had a "complaint of right shoulder soreness." The RN documented the physician was not notified of the fall. The adverse event log had that patient 3 sustained falls on: a. 4/2/2022 - It was documented patient 3 had no evidence of an injury and that the skin was intact. There was no documented evidence the physician was notified. There was no documented nurse visit associated with this adverse event. b. 4/6/2022 - It was documented, "Patient's SAT (saturation) was 65%--returned to N/C (nasal cannula) at 5LPM (liters per minute) with O2 (oxygen) SAT up to 95%--baseline neurologic status has been anxious/confused/hallucinations for the past couple of days--vital signs stable--Unknown if physician was notified--nurse notified case manager." There was no documented nurse visit associated with this adverse event. c. 4/7/2022 - It was documented, "Vital signs stable--no change in neurologic status--unknown if MD (medical doctor) was notified--on call nurse and/or case manager notified." There was no documented nurse visit associated with this adverse event. d. 4/8/2022 -It was documented, "No change in neurological status--remains confused with hallucinations--unknown if MD was notified--on call nurse and/or case manager notified of incident." There was no documented nurse visit associated with this adverse event. An SN visit was completed on 4/11/2022. The RN documented, "Spouse discussed family dysfunctional issues, spouse is calm and feels overwhelmed with family issues." It was further documented in the visit note, "spouse discussed concern about family dysfunction of the daughter--patient has no s/sym (signs or symptoms) of apparent abuse..." There was no documented evidence that other members of the IDG team were notified. An interview was conducted with RN 1, patient 3's primary nurse, on 4/19/2022 at 1:03 PM. RN 1 stated the falls should have been documented in the medical record and on an incident report. RN 1 was asked when the physician was notified after a patient sustained a fall. RN 1 stated the physician was only notified if an injury had occurred. When asked how RN 1 would know if an injury occurred, RN 1 responded "we go to the patient home." RN 1 stated he notified patient 3's case manager of the falls and that it was the case manager's responsibility to notify the physician. When asked why there was no communication related to the family's dysfunctional dynamics, RN 1 stated, "It was hearsay. I did not know if it was true." An interview was conducted with RN 2, patient 3's case manager as stated by RN 1, on 4/19/2022 at 2:17 PM. RN 2 was asked when physician notification should occur related to falls. RN 2 stated, "Basically, as soon as its (the fall) recorded by the nurse." RN 2 stated that she was not the case manager for patient 3. RN 2 stated the family dynamics should have been documented. An interview was conducted with the director of nursing (DON), who also functioned as a nurse practitioner, on 4/19/2022 at 4:58 PM. The DON was asked when physician notification of falls or change of condition should occur. The DON stated that if no injuries occurred, the fall was to be documented and discussed in the IDG notes. The DON stated the agency physicians had requested not to be notified of falls unless and injury occurred. The DON was asked to provide a copy of the agency policy on physician notification and change of condition. The requested policies were not provided to the surveyors.

Based on interview and record review, it was determined the hospice agency failed to provide core services in a manner consistent with acceptable standards of practice. Findings include: 1. The hospice agency failed to provide certified nurse aide services to patients that lived in the Manilla, Utah service area. (Refer to tag L 0588) 2. The hospice agency failed to provide on-site medical social services after being notified of care concerns and allegations of neglect. (Refer to tag L 095)

Based on interview and record review, it was determined the hospice did not provide core services in a manner consistent with acceptable standards of practice for 1 of 7 sampled patients. Specifically, certified nurse assistants (CNA's) were not provided for patients that lived in Manilla, Utah, who required those services. (Patient identifier: 3). Findings include: Patient 3 was admitted to the agency on 3/24/2022 with a terminal diagnosis of metastatic cancer of the vulva. Patient 3's medical record was reviewed on 4/20/2022. A communication note was documented on 3/17/2022 by an agency registered nurse (RN). The RN wrote, "...spoke to family and (patient 3) about services that we have available in Manilla. We have nursing and SW (social workers) but do not have CNA's available at this time. (Patient 3) also had questions about insurance and I spoke to her about those questions. She has requested that we visit another time and let them think about what they would like to do. We have let her know we are available and to reach out at any time." An initial RN assessment was completed on 3/24/2022. The RN assessed patient 3 as having functional limitations when ambulating, bathing, transferring and when eating. It was documented that patient 3 required considerable assistance and frequent medical care several times during the day and night. An interview was conducted with RN 1 on 4/19/2022 at 1:03 PM related to CNA services in Manilla, Utah. RN 1 stated the agency did not provide CNA services in Manilla, UT. An interview was conducted with RN 2 on 4/19/2022 at 2:17 PM related to CNA services in Manilla, Utah. RN 2 stated that the agency notified potential hospice patients in the Manilla area that CNA services were not available prior to admission to the agency. An interview was conducted with the administrator (ADM) on 4/19/2022 at 3:20 PM related to CNA services in Manilla, Utah. The ADM stated CNA services were not available in the Manilla area. The ADM was asked if the agency nurses provided CNAs services since a CNA was not available. The ADM stated, "I think your point is valid, (RN 1) could assist to your point. We have not assigned him to do that."

Based on interview and record review, it was determined the hospice agency did not make counseling services available to all patients. Specifically, on-site medical social services was not provided to 1 of 7 sampled patients who required those services. (Patient identifier: 3.) Findings include: Patient 3 was admitted to the agency on 3/24/2022 with a terminal diagnosis of metastatic cancer of the vulva. Patient 3's medical record was reviewed on 4/20/2022. A medical social worker (MSW) initial assessment was started on 3/28/2022. The MSW documented the assessment started at 1:40 PM and ended at 1:45 PM. The MSW did not document the educational level, martial status, funeral arrangements, assets, financial resources, risk assessments of abuse, the effect of the illness on everyday activities, or care plan problems. Note: Per interview with the MSW this assessment was conducted over the telephone. The MSW documented a bereavement assessment was completed on 3/29/2022 from 1:45 PM to 1:48 PM. The MSW further documented the family/support system was warm and supportive. On 4/5/2022, registered nurse (RN) 2 documented, "Please do not release any information on patient. (Name redacted) the husband doesn't want any information released. The children can go through him for any information." There was no evidence the MSW was made aware that patient 3's husband did not want information release to patient 3's children. On 4/5/2022, the administrator (ADM) documented a patient communication note. The ADM wrote, "...took a phone call from a social worker from (a hospital in the Salt Lake City area) inquiring about patient care delivered to our Manilla patients. The social worker was informed that without a release of information we could not disclose any confidential information. The social worker was informed that we have a RN that lives in the Manilla area to assist with patient visits. The Social Worker then stated she was calling on behalf of a family friend, of a patient. I told her again, that without the proper release of information that we can not release any information regarding patient care. The Social Worker was advised to reach out to the patients family, and determine who information could be discussed with, and that we would be more than happy to help coordinate requested care. The social (sic) was evasive and would not provider (sic) her last name. Social Worker would not tell us what patient she was discussing about, but (a co-owner) and, I believe she was referencing (patient 3)." There was no evidence that the agency MSW was notified of the family concerns related to patient 3's care. An IDG meeting was documented on 4/12/2022. There was no mention in the IDG meeting that a discussion was held related to the family dynamics surrounding patient 3. It was documented that patient 3's family had difficulty providing cares and that the MSW was to coordinate LTC (long-term care) placement. No further interventions were developed to assist with the family dynamics or to arrange for patient 3 to have additional services. A telephone call was documented by the MSW on 4/12/2022 from 9:45 AM to 10:00 AM. The MSW wrote, "I talked with (patient 3's husband) about how I could best help him and his wife, (patient 3). He has been receiving threats from his wife's children regarding his care for her. We talked about his options to help him best. He spoke to me about the threats he has been getting and explained how worried he has been about the effect it will have on (patient 3). He informed me that he had the police called on him and that the sheriff was called and showed up to check on him per an abuse report filed on him. The sheriff found nothing, and (he) told me that the sheriff said that the report was false and was harassment. We talked more about (his) options as he said they could not afford assisted living. (He) said he was going to file a restraining order against (patient 3's) children for the harassment." The MSW did not provide a face-to-face assessment with patient 3 or patient 3's husband to address the family dynamics or to conduct an abuse investigation to ensure patient 3 was receiving the care and services required. A patient communication note was documented by the ADM on 4/12/2022. The ADM wrote, "...took a phone call from (patient 3's) sister. The sister, was concerned about how her brother in law was caring for (patient 3). (ADM) informed the sister about services that Hospice provides and informed the sister that hospice was not 24/7 care. (ADM) advised the sister that she needed to work with her brother in law since he was the one listed as our contact person and she would need to work with him to modify the care plan. No details or specifics about (patient 3's) care were discussed, just a high level review of hospice services. It was explained to the sister that Good Shepherd does have a nurse that lives in Manilla, that helps care for the patients in that service area, but based off of the level of care the sister wanted, she would need to coordinate care with her brother in law." There was no evidence that the MSW was notified of patient 3's sisters' concerns. The MSW did not provide a face-to-face assessment to ensure patient 3 was receiving the hospice services needed. (Medicare regulations require a hospice to be avialble for needed services 24/7) A phone call was documented by the MSW on 4/13/2022 from 8:32 AM to 8:50 AM. The MSW wrote, "I talked with (patient 3's husband) about how we can best help him provide care for his wife, (patient 3). He said he has reached out to two medical friends who are nurses and now assisting him in between the scheduled Good Shepherd visits. He said they offered to help with changing and cleaning her and watch her while (he) steps out to get the mail or run errands. (He) said he went ahead and filed the restraining order and that he had a little more paperwork left but was working with the police and sheriff's office. (He) said he did threaten to shoot anyone on his property that was harassing him. He said the police are coming every hour to check on him and that he is on a suicide watch because he is under a high amount of stress. (He) expressed gratitude multiple times throughout the call, thanking me for helping him. He explained to him that he could call me whenever he needed, and I was always available to talk and assist however I could." The MSW did not complete a face-to-face visit to ensure patient 's husband was not suicidal or to assist him with completing the harrassment paperwork. A patient communication note was documented by the ADM on 4/14/2022. The ADM wrote, "...took a phone call from APS (Adult Protective Services). The social worker asked for details surrounding (patient 3's) case. It was explained to APS that Good Shepherd have provided (patient 3's) husband, (name redacted), with 1) resources to get additional resources to care for (patient 3) and 2) Good Shepherds social worker had presented to (patient 3's husband) the option of moving (patient 3) to a nursing facility which he declined. (The co-owner and ADM) informed APS they would help any (sic) anyway possible." There was no documented evidence that the phone call with APS had been communicated with the MSW. A phone call was documented by the MSW on 4/15/2022 from 4:20 PM to 4:24 PM. The MSW wrote, (Patient 3's husband) called me and updated me on his day with (patient 3). He said he had received more calls, one of which was a from a social worker saying she was from Salt Lake working with (patient 3's children but wouldn't give him any information other than what she wanted from (him). We discussed his options and feelings about what was happening to and around him. (He) remains positive and said he is trying his best and has explained he will remain cooperative with the Sheriff and Police, who have helped them a great deal. He said the police are reacting to the information he is giving them to help him with (patient 3) best." The MSW did not conduct a face-to-face assessment with patient 3 and patient 3's husband. A phone call was documented by the MSW on 4/18/2022 from 9:23 AM to 9:28 AM. The MSW wrote, "I talked with (patient 3's husband) about his weekend with (patient 3). He reported (patient 3) had a rough weekend but that she is currently doing well and has recovered from it. He said he has been updating the police and sheriff's department with this weekend's incidents. He said that on Friday when he came home from the grocery store, a car was outside of his home, but when he pulled into his driveway and got out, the car drove away. He expressed his gratitude for Good Shepherd's support. We talked more about visiting him and (patient 3) in person the next time I am in Vernal, Utah." A telephone interview was conducted with the ADM on 4/19/2022 at 3:20 PM. The ADM was asked if the MSW had conducted an onsite assessment of patient 3 and patient 3's husband related to the documented family dynamics documented above. The ADM stated the MSW was scheduled to visit patient 3 and patient 3's husband "this upcoming Monday." On 4/20/2022 at 10:15 AM, a surveyor with Utah Department of Health conducted a home visit. During the home visit, the agency MSW knocked on the door and gained entry as approved by patient 3's husband. At the end of patient 3's visit, the MSW was interviewed. The MSW stated that she had been a MSW for three months. The MSW stated that her visit was because patient 3's husband had asked her to come and visit. The MSW was asked what the agency policy was on conducting face-to-face assessments. The MSW stated, "we are not required to do a face-to-face." She then stated, "The nurse does the initial assessment and provides that information to the social worker." The MSW was asked what her involvement was in the development of the plan of care (POC). The MSW stated, I don't know about the POC, seems like a nurse job." A telephone interview was conducted with the director of nursing (DON), who also functioned as a nurse practitioner, on 4/21/2022 at 4:58 PM. The DON was asked if MSW services were available in Manilla, UT. The DON stated, "No." The DON stated that a MSW from the Salt Lake area completed visits in the Vernal area 1-2 times a month. The DON further stated that if an emergency arose, the agency would have a SW visit sooner.