Every finding on record at Green Way Hospice, Inc.

Observed in Record Review. In 1 of 2 patient records reviewed, who were discharged alive. During Live D/DRR#1 it as noted lack of a signed Notice of Non Medicare Coverage (NOMNC) in the patient medical record. This was discussed with the organization leadership.

Observed in Record Review. In 2 of 10 patient records reviewed, During HV#2 and RR#4 it was noted the RN initial comprehensive evaluations lacked assessments of the patients' diabetic status both of whom were prescribed diabetic medications that were documented on the medication profiles. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 10 patient records reviewed, During RR#4 it was noted on the RN summary during an IDG meeting in September 2024 episodes of constipation, managed by prescribed laxative regimen and Preparation H Hemorrhoidal Rectal Suppository two times a day as needed for 10 days for Hemorrhoids. There was lack of GI issues added to the POC with interventions established related to the patient constipation and treatment. This was discussed with the organization leadership. Observed in Record Review. In 7 of 10 patient records reviewed, During RR#2 it was noted the RN entered interventions on the POC for the social worker (MSW) and spiritual counselor (SC) without documentation of input from the MSW or the SC. During RR#3 it was noted social work interventions added by the RN on POC lacked documentation of input from the MSW. During HV#1-HV#3, RR#5 and RR#7 it was noted the POCs lacked interventions established by the MSW. This was discussed with the organization leadership.

Observed in Record Review. In 4 of 14 patient records reviewed, During RR#2, and RR#4 it was noted a visit frequency order for the MSW and the SN lacked the number of PRN visits and the reason for PRN visits. The MSW frequency documented was once a month plus PRN and the SN visits were ordered once a week plus PRN. During RR#3 and RR#5 it was noted a frequency of visits of once a week plus PRN for the SN. The order lacked the number and reason for PRN visits. This was discussed with the organization leadership.

Observed in Record Review. In 8 of 10 patient records reviewed, During HV#1-#3, and RR# 3, 4, 5, 6 and #7 it was noted the spiritual counselor (SC) did not follow the POC. The SC visits provided were completed via telephone calls that were not indicated and approved by the IDG as a method to provide visits. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 14 patient records reviewed, During review of BRRR#2, it was noted during the documentation of the provision of continuous care, multiple handwritten entries had visible use of white out in the text of the documentation and in the time column of the documentation. This was discussed with the organization leadership.

Observed in Individual Tracer. In 2 of 3 home visits conducted, when narcotics were ordered and on the medication profile. During HV#2 and HV#3 it was noted lack of documentation that instructions on use and disposal of controlled substances was given to the patient when narcotics were ordered and lack of a copy of the organization policy on management and disposal of controlled medications were noted in the home education folder. This was discussed with the organization leadership.

Observed in Emergency Management Session. During review of the emergency operation plan with the organization leaders it was noted 3 plans were included with the data presented to the surveyor. The plans lacked the identification of response procedures that included maintaining or expanding services, conserving resources and curtailing services. The plan stated the strategies listed should be implemented but the actual procedures were not included.

Observed in Emergency Management Session. During review of the EM plan it was noted the organization tested their plan by conducting an earthquake drill in October 2021. The drill failed to evaluate its handling of communications, resources and assets, and staff.

Observed in Emergency Management Session. During review of the organization emergency operation plan it was noted the disaster drill performed in 2021 lacked the identification of a critique to identify deficiencies and opportunities for improvement.

Observed in Regulatory Review. During review of the organization forms it was noted the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs effective 10/1/2020 was not part of the consent/election of benefit form.

Observed in Record Review. In 3 of 5 patient records reviewed, During HV#2 record review it was noted the MSW has not documented participation in IDG meetings. There have been 4 IDG meetings documented without an update from the MSW. The MSW has visited the patient once a month for 2 months since the initial comprehensive assessment. During RR#1, it was noted the MSW and chaplain did not documents their updates at the first IDG after the initial comprehensive assessment. During RR#2 it was noted the MSW did not update the comprehensive assessment during any IDG meetings. The Chaplain documented one update during IDG meetings from August- October 2021.

Observed in Record Review. During HV#2 record review it was noted the lack of psychosocial interventions and goals for the MSW. The MSW documented 2 visits with the patient even though the POC indicated the MSW was declined. During HV#3 record review it was noted lack of psychosocial interventions and goals on the POC. The MSW documented visits performed each month.

Observed in Record Review. In 3 of 3 patient records reviewed, During HV#1 record review it was noted frequency of visits for SN, MSW and the chaplain contained PRN visits without an indication of the reason for the additional visits during the certification. During HV#2 record review it was noted the following frequencies on the POC: MSW: Declined, SC: 1 One-time then PRN, SN: 1 per Week + 1 PRN Visits. The PRN lacked the reason for the need of additional visit. Also noted the MSW completed and initial evaluation and 1 follow up visit the second month of the certification. During HV#3 record review it was noted PRN visits for the SN and MSW lacked an indication for the reasons to perform the as needed visits. In addition the frequency for the hospice aide was blank on the POC. During RR#1 it was noted the SN and MSW frequencies lacked an indication for PRN visits. The frequency was documented as MSW: 1 As needed and Recert), (SC: 1 One-time then PRN), (SN: 1 One-time then PRN).

Observed in Record Review. In 5 of 5 patient records reviewed, During HV#1 record review it was noted the goals/outcomes established on the POC lack a method to measure progress toward outcomes. For example the POC contained generic goals with target dates all identified to be accomplished by the end of the 90 day certification. They include: Pt will maintain optimum peripheral circulation. Optimal blood sugar management for pt. comfort. Pt/Family/PCG will verbalize having urinary elimination needs met at an acceptable level. Increase strength/energy for optimal functional activities. Promote optimal rest status for Pt/Family/PCG. During HV#2 record review it was noted the goals were generic with target dates for goals to be accomplished by the end of the 90 day certification. For example the goal for the respiratory deficit identified was Pt will have optimum level of oxygen. During HV#3 record review it was noted generic goals with target dates at the end of the certification period. For example within the diabetic status: Optimal blood sugar management for pt. comfort. During RR#1 and 2 it was noted the goals were generic with target dates at the end of the certification period.

Observed in Patient Home. In 2 of 3 home visits conducted, During HV#2 and #3 it was noted the staff did not follow the organization Bag Technique policy 9-014. During HV#2, it was noted the SN entered her bag during patient care without hand disinfection. During HV#3 it was noted the hospice aide entered her bag during patient care without hand disinfection. Observed in Patient Home. In 3 of 3 home visits conducted, During HV#1 and # 2 it was noted the SN did not follow the disinfectant contact time (wet time) when cleaning the equipment used during the visit as specified by the manufacturer guidelines. The equipment included a BP wrist cuff, pulse oximeter, and stethoscope. During HV#3 it was noted the hospice aide placed her used equipment in her bag without disinfection after patient use. Observed in Patient Home. During HV#1 and #2 it was noted the SN did not perform hand hygiene after glove removal. Organization policy on hand hygiene stated hands will be disinfected after gloves are removed.

Observed in HR File Review. During HR#4 file review it was noted the hospice aide competency was documented as a verbal assessment of skills. The competency lacked the following areas by observation of the hospice aide's performance of the tasks with a patient or pseudo-patient as part of a simulation in the following areas: appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination, safe transfer techniques and ambulation, normal range of motion and positioning.

Observed in Record Review. During HV#3 record review it was noted the hospice aide visits began in middle of August 2021 and assignment form was completed the middle of September 2021. The assignment form indicated the aide was to record vital signs. In addition, the assignment lacked parameters of vital signs for the aide to report to the RN.

Observed in Record Review. During HV#3 record review it was noted lack of documentation by the RN of supervisory hospice aide visits from August 2021 to October 2021. In discussion with the Administrator who called the RN, the RN stated to the Administrator that the supervisory visits had been completed every 14 days.

Observed in Record Review. In 2 of 2 patient records reviewed, who had medication orders for narcotics. During HV#2 and record review it was noted lack of documentation that instructions on use and disposal of controlled substances was given. In addition information was not found in admission packet, patient handbook or documents provided to patient and family in the home. The patient was prescribed Tramadol for pain. During RR#1 it was noted lack of documentation that instructions on use and disposal of controlled substances was given. The patient was prescribed tramadol for pain.