Every finding on record at Gracious Nurses Hospice, Inc

Observed in Record Review. In 3 of 3 patient records reviewed, During RR#3-#5 it was noted lack of documentation by the IDG on the POCs of progress toward outcomes. RR#3 outcome: pt. will verbalize understanding of medications as evidenced by compliance and verbalizing it's uses/indication dosage and frequency by the end of the second week 5/20/23 Record reviewed the end of June 2023 without documentation of the progress toward achieving the goal. RR#4 outcome: by the end of the 4th week, mental status stabilized with current treatment as evidenced by no c/o worsening orientation and no exacerbation of dementia by 6/3/23. Record reviewed the end of June 2023 without documentation of the progress toward achieving the goal. Record #5 outcome: Pt's genito-urinary and gastrointestinal status improved with medication /treatment by the end of the 3rd week as evidence by no constipation and daily bowel movements by 5/27/23. Record reviewed the end of June 2023 without documentation of the progress toward achieving the goal.

Observed in Record Review. In 2 of 3 patient records reviewed, During RR#3and #4, it was noted lack of individualized goals updated since the end of the last survey in May 2023. The goals remained the same: for example the goal for pain control was the same for both patients, Patient achieved optimum level of comfort, function with current medication therapy with goals to reach a tolerable pain scale of 16/10 as evidenced by no verbalization of pain, no observable facial grimaces, able to verbally communicate level of comfort and increased tolerance to increasing level of activities.

Observed in Data Session. During review of the QAPI program it was noted lack of inclusion of data measures and collection related to palliative outcomes. This was discussed with the Administrator.

Observed in HR File Review. In 1 of 10 HR files reviewed, the organization had not provided emergency preparedness training to staff, volunteers, and individuals providing on-site services under arrangement at least every two years. There was no documented education on emergency preparedness in the file for the RN for more than two years at the time of survey as discussed with the Alternate Administrator.

Observed in Document Review. The hospice did not have business relationship agreements in place that would meet the HIPAA requirements for their contracted services.

Observed in Record Review. In 3 of 3 home visits conducted, the patient record was incorrect. During HV#1, HV#2 and HV#3, the patients were non-English speakers and the hospice surveyor relied upon the RN and the caregiver to translate in order to communicate with the patients. All of the patient's initial comprehensive assessments indicated that English was the patient's primary language. Additionally, the initial assessment for HV#1 indicated the patient was female; he was not. This was discussed with the Alternate Administrator.

Observed in Record Review. In 3 of 5 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the charts for HV#1, HV#2, HV#3, the goal for pain was not individualized to each patients as it read that the goal was 16/10 and the anticipated achievement date was the last day of the initial benefit period for all three patients. Additionally, by assessment, each patient has a BM 2-3x/week, yet the care plan goal was daily BM. This was discussed with the Alternate Administrator.

Observed in Record Review. In 3 of 3 home visits conducted, the plan of care (POC) was not individualized to the patient and included medical supplies and appliances not necessary to meet the patient's needs. During HV#2, the patient ambulated unassisted from the couch to the dining table upon request of the RN without difficulty and without assistive device. The POC indicated the patient required wheelchair or walker with caregiver assist. The patient was observed during the home visit on the couch conversing with one of the caregivers while holding a plate and silverware in her hands eating a confection without any assist from any caregiver. The POC and initial comprehensive assessment dated one week prior to the home visit indicated she needed assistance with feeding. Additionally, the POC/assessment indicated the patient was hard of hearing. The caregivers in the home were conversing in a normal tone with a loud television in the background. The patient did not have hearing aids, yet appeared to be not having any difficulty hearing and responding to the caregiver. During HV#1 and HV#3, the patients both ambulated to the dining table without an assistive device, without gait disturbance and without any observed shortness of breath. The POCs for all 3 patients indicated the patient/caregivers were to be taught in safety care of bed-confined patients. All patients were admitted to the organization within 1 week prior to the survey visit date. This was discussed with the Alternate Administrator.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization had not provided the patient with care, treatment, or services according to the patient's individualized plan of care. In the chart for RR#2, the aide frequency ordered was 2x/week. Actual was 1w1, 3w1. This was discussed with the Alternate Administrator.

Observed in Data Session. The hospice QAPI program failed to address bereavement and volunteer services. The QA plan addressed collecting Utilization data on PT, OT and ST services, yet failed to mention Chaplain services. This was discussed with the Alternate Administrator. Observed in Data Session. The organization had not maintained documentation of the quality assessment and performance improvement program and was not able to demonstrate its operation. The organization had no improvement projects documented until approximately one month prior to the survey date. This was discussed with the Alternate Administrator.

Observed in Data Session. The QAPI program did not include issues related to palliative outcomes. The current QAPI improvement project addressed communication from field staff and did not address any patient outcomes. This was discussed with the Alternate Administrator.

Observed in Record Review. In 1 of 1 patient records reviewed, in which aide services were ordered, the registered nurse had not prepared complete instructions for the aide. In the chart for RR#2, the patient used oxygen continuously. The aide care plan did not address the patient's oxygen use. This was discussed with the Alternate Administrator.

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 Condition Level observations at 418.56, 418.58, 418.100.

Observed in HR File Review. In 8 of 10 HR files reviewed, the hospice had not provided orientation about the hospice philosophy to all employees and contracted staff who have patient and family contact. This orientation was not present in any HR file except for the Volunteer and the aide. This was discussed with the Alternate Administrator.

Observed in HR File Review. In 1 of 10 HR files reviewed, the RN had not completed annual OSHA training for blood borne pathogens since hire more than two years prior to the survey. This was discussed with the Alternate Administrator.

Observed in Tracer Activities. The organization had not protected records against unauthorized access, use, and disclosure of health information. Upon arrival to the organization, located in a multi-business office building, the surveyor found the office door unlocked, the office un-manned and patient records in an unlocked cabinet. This was discussed with the Alternate Administrator.

Observed in HR File Review. In 4 of 7 HR files reviewed, the organization had not verified and documented the credentials of care providers using the primary source at time or hire or when credentials were renewed. In the file for the DPCS, the RN license had not been verified until over 1 year post-hire. The Alternate DPCS, the RN licensure which expired 11/30/22 was not verified as renewed until 1/31/23. The Aide verification of certification was not dated, thus the surveyor was unable to determine when the verification occurred. In the file for the Chaplain, the job description read - Qualifications for Spiritual Counselor Ordained, commissioned or credentialed according to the practices of an organized religious group, OR Has a degree in theology or from a seminary. The credentials for the Chaplain were not dated, so there was no way to determine when they were verified. This was discussed with the Alternate Administrator.

Upon patient record review, 1 of 5 (Patient #2) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: Patient 2: The medication profile contains Acetaminophen 500mg 1 tab every 8 hours as needed for pain. The plan of care contains orders for 1-2 tabs every 8 hours as needed for pain. Corrected on site.

Upon client record review, 1 of 2 applicable (Patient #4) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: Patient 4: The medical record did not contain evidence a copy of the hospice discharge summary, or a copy of the clinical record was sent to the patient's attending physician.