Every finding on record at Handmaids of Charity Healthcare, Inc.

Observed in Record Review. In 5 of 5 patient records reviewed, During RR#1 it was noted multiple goals that were not individualized and not measurable. Multiple goals were to be accomplished within 2 weeks. For example: Pt will maintain optimum peripheral circulation as manifested by absence of non-verbal signs of pain or discomfort within these two weeks, Pt/Family/PCG will verbalize having urinary elimination needs met at an acceptable level and prevent UTI within these two weeks, Pain will remain in comfortable level during care. During RR#2 it was noted that many goals were not measurable. For example: SBP to be within range of 90-160 mmHg and DBP to be within range of 60-80 mmhg within __, (no measure, left blank in the EMR), Prevent hospitalization related to hypothyroidism within these two weeks. Patient/cg to report 3-4x/week BM without discomfort within two weeks,(no evidence of constipation assessed, patient assessed to have bowel incontinence), The patient will safely participate in physical activities as tolerated within 2 weeks (patient assessed as bedridden with max assist with ADLs), Pt needs will be met on a day to day basis as communicated within these two weeks. During RR#3 it was noted many goals were not individualized and not measurable. For example: Patient will have a behavioral manifestation of decreased/absent episodes of anxiety/agitation within 2 weeks. Patient will not inflict any harm to self or others within 2 weeks (In discussion with the Administrator, there is lack of documentation in the medical record that the patient inflicted self harm or harm to others), Pt needs will be met on a day to day basis as communicated. During RR#4 it was noted many goals were the same as the other medical records reviewed. Goals not individualized with end dates within 2 weeks. For example:Pt will maintain optimum peripheral circulation during these two weeks, Patient will not inflict any harm to self or others within 2 weeks (In discussion with the Administrator, there is lack of documentation in the medical record that the patient inflicted self harm or harm to others. This goal is taken from a list within the EMR). During RR#5 it was noted many goals were the same as other medical records reviewed with end dates of within 2 weeks. For example: Pt will maintain optimum peripheral circulation, Patient will have a behavioral manifestation of absent /controlled anxiety within 2 weeks. Patient will not inflict any harm to self or others within 2 weeks. ( In discussion with the Administrator the goal was chosen from a list in the EMR. There was no documentation of self harm or harm to others). In addition RR#3 and #4 lacked goals for visits established by the spiritual counselor. This was discussed with the Administrator and DPCS.

Observed in Record Review. In 2 of 5 patient records reviewed, During RR#3 and RR#4 it was noted the spiritual counselor visit frequency was once a month. The POCs lacked interventions established for spiritual care. This was discussed with the Administrator and DPCS. Observed in Record Review. In 1 of 5 patient records reviewed, During RR#2 it was noted an order to cleanse Perineal area and vagina and apply triple antibiotic. The order lacked who would perform the treatment and the frequency of the treatment. This was verified and discussed by the Administrator and DPCS.

Observed in Record Review. In 1 of 5 patient records reviewed, During RR#1 it was noted PRN visit orders for the SN, MSW and SC without reasons for the visits to be performed. This was reviewed with the Administrator and DPCS.

Observed in Record Review. In 2 of 5 patient records reviewed, During RR#1 it was noted multiple medication orders with directions to be crushed and administered via a G tube. The orders lacked the flushing protocol before or after the medication administration. During RR#2 it was noted on the medication profile an order for Acetaminophen and Norco for pain. The order lacked pain scale parameters of when to administer each medication. This was discussed with the Administrator and DPCS. Observed in Record Review. In 1 of 5 patient records reviewed, During RR#1 it as noted an order for G-tube feedings of Jevity 237mL Enteral Suspension, 1 can each meal given bolus via gravity. The order lacked the flushing protocol before or after the bolus feeding. This was discussed with the Administrator and DPCS.

Observed in Record Review. In 2 of 5 patient records reviewed, The registered nurse who is a member of the interdisciplinary group and is responsible for hospice aide supervision had not prepared complete written patient care instructions for the hospice aide. During RR#1 and #3, it was noted the aide plans of care did not include the prn oxygen order. This was discussed with the Administrator and DPCS.

Observed in Emergency Management Session. The organization had not prioritized hazards, thus had not used that list to identify and implement mitigation and preparedness actions. This was discussed with the Administrator. Observed in Emergency Management Session. The organization had not prioritized the findings of the hazard vulnerability analysis to determine which hazards present the highest likelihood of occurring and the impacts those hazards will have on the operating status of the organization and its ability to provide services. This was discussed with the Administrator.

Observed in Emergency Management Session. The emergency operations plan did not identify the patient population(s) that it will serve and the types of services it would have the ability to provide in an emergency or disaster event. This was discussed with the Administrator. Observed in Emergency Management Session. The organization did not have a written continuity of operations plan (COOP) that was developed with the participation of key executive leaders, business and finance leaders, and other department leaders as determined by the organization. These key leaders had not identified and prioritized the services and functions that are considered essential or critical for maintaining operations.

Observed in Emergency Management Session. The organization’s emergency operations plan did not include a process for cooperating and collaborating with other health care organizations, relevant community partners (such as fire, police, local incident command, public health departments), and relevant authorities (such as federal, state, tribal, regional, and local emergency preparedness staff). This was discussed with the Administrator.

Observed in Emergency Management Session. The organization’s plan for providing patient care and clinical support did not include written procedures for determining what services are needed in the event that there is an interruption in services during or due to an emergency or disaster incident.

Observed in Emergency Management Session. The organization’s communications plan did not identify its primary and alternate means for communicating with staff and relevant authorities (such as federal, state, tribal, regional, and local emergency preparedness staff). The plan did not include procedures for the following: How and when alternate/backup communication methods are used; Testing the functionality of the organization’s alternate/backup communication systems or equipment. This was discussed with the Administrator.

Observed in Emergency Management Session. The organization’s plan for providing patient care and clinical support did not include policies and procedures that describe how it will inform state and local emergency preparedness officials about its patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment.

Observed in Emergency Management Session. The organization’s staffing plan did not address the management of all staff and volunteers as follows: Reporting processes; Roles and responsibilities for essential functions; Integrating staffing agencies, volunteer staffing, or deployed medical assistance teams into assigned roles and responsibilities; Verifying the identity and licensures of volunteer practitioners (such as nurses, respiratory therapists, physical therapists). Observed in Emergency Management Session. The organization had not developed a staffing plan for managing all staff and volunteers based on the settings and services provided to meet patient care needs during the duration of an emergency or disaster incident or during a patient surge. The plan did not include the following: Methods for contacting off-duty staff; Acquiring staff from its other health care facilities; Use of volunteer staffing, such as staffing agencies, and those deployed as part of the disaster medical assistance teams.

Observed in Emergency Management Session. The organization’s plan for providing patient care and clinical support did not include written procedures and arrangements with other health care providers for how it will share patient care information and medical documentation and how it will provide transportation to other health care facilities to maintain continuity of care.

Observed in Emergency Management Session. In the event of an emergency or evacuation, the organization’s communications plan did not include a method for sharing and/or releasing location information and medical documentation for patients under the organization’s care to the following individuals or entities, in accordance with law and regulation: Patient’s family, representative, or others involved in the care of the patient; Disaster relief organizations and relevant authorities; Other health care providers; This was discussed with the Administrator.

Observed in HR File Review. In 1 of 7 HR files reviewed, the organization had not provided ongoing education and training to all staff, individuals providing services under arrangement, and volunteers that is consistent with their roles and responsibilities in an emergency: At least every two years. There was no re-education documented in the file for HR#4 who had been employed for five years as confirmed with the DPCS.

Observed in Emergency Management Session. The organization did not have a written delegation of authority plan that provides the individual(s) with the legal authorization to act on behalf of the organization for specified purposes and to carry out specific duties.

Observed in Record Review. In 1 of 14 patient records reviewed, assessments were not conducted according to organizational policy. In the chart for RRNHV#5, the patient was admitted with wounds on the face. There were no wound measurements in the patient's chart. Organizational policy for wounds indicated that wound measurements were to be documented weekly. This was discussed with the DPCS.

Observed in Record Review. In 6 of 14 patient records reviewed, goals were not individualized to the patient needs. For example, in the chart for RRHV#1, the problem identified on the POC was bowel incontinence. The goal was Facilitate bowel elimination and comfort. This goal was not measurable and the target date was approximately 60 days after the problem was identified, thus not individualized to the patient. Additionally, the patient was non-communicative due to her diagnosis, yet the spiritual care goal indicated that the patient would freely verbalize spiritual needs and concerns, and receipt of desired spiritual support. In the chart for RRNHV#4, goals were all anticipated to be met on the last day of the benefit period and/or were not measurable, e.g. Patient will achieve optimal bowel elimination and free of acid reflux at all times for comfort. In the chart for RRNHV#5, there were orders for the SN to perform and teach the caregiver to perform wound care daily and to assess the caregivers competence with that care. The wound care goal did not speak to the caregiver's competence and was not individualized to this patient's need for daily wound care as the target date was the last day of the current benefit period and the goal was written, Patient will be free of infection and achieve optimal comfort.. In the charts for RRNHV#6 and RRNHV#8, the patients were at high risk for pressure ulcer development yet the POC did not include any individualized goal related to this risk. In the charts for RRNHV#7 and RRNHV#8, new oxygen was ordered at the admission. The POCs did not include any goals related to oxygen use/safety. This was discussed with the DPCS.

Observed in Record Review. In 5 of 14 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions. In the chart for RRHV#1, the patient was assessed to be at high risk for pressure ulcer development, yet the plan of care did not include any interventions/goals related to this risk. In the chart for RRHV#3, the POCs indicated the patient was at risk for skin breakdown due to incontinence and the interventions included changing incontinence pads frequently. However the patient still had a foley catheter according to the orders. The catheter care/education interventions and goals did not appear on the POC until the sixth IDT review, though they had been present since admission. In the chart for RRNHV#6, the patient was at high risk for pressure ulcer development yet the POC did not include any interventions related to this risk. In the charts for RRNHV#7 and RRNHV#8, new oxygen was ordered at the admission for these patients. The POC's did not include any interventions related to oxygen use/safety. In the chart for RRNHV#8, the patient was at risk for pressure ulcer development, yet there were no intervention on the POC. This was discussed with the DPCS.

Observed in Data Session. The organization did not have documentation of the quality assessment and performance improvement program and was not able to demonstrate its operation. Data collection was present; quarterly meetings present, however no actual documentation of a successful program was available for review during the survey as confirmed with the Alternate Administrator. Observed in Data Session. The Hospice QAPI program did not address bereavement or contracted services such as DME, pharmacy, SNF services.

Observed in Data Tracer. The QAPI plan did not include detail on the frequency and detail of data collection, thus leaders could not approve this. This was discussed with the Administrator and Alternate Administrator.

Observed in Data Session. The hospice identified specific performance improvement projects that were being conducted but did not document the reasons for conducting the projects. For example, the current QAPI projects included decreasing falls to less than 2 per 1000 patient care days, decreasing the number of unwanted hospitalizations to less than 20%, however there was no reason documented to support why these projects had been chosen. This was discussed with the Administrator and Alternate Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization had not implemented the infection prevention and control activities it had planned. During RRHV#1, the surveyor observed the RN using Skin Prep pads to clean her equipment after patient care use. Upon questioning by the surveyor, she indicated she is supposed to use Sani-clothes, however could not find them in her bag. She continued to use the Skin Prep pads until the surveyor requested she stop and take time to find Sani-clothes in either her clinical bag or her vehicle, as the nurse confirmed she checked before the visit to ensure that she did have them with her for the visit. This was observed by and discussed with the DPCS.

Observed in Data Session. The organization's written infection prevention and control goals did not include the following: Improving compliance with hand hygiene guidelines. This was discussed with the Administrator. Observed in Data Session. The organization's written infection prevention and control goals did not include the following: Limiting the spread of infections associated with the use of medical equipment, devices, and supplies. This was discussed with the Administrator. Observed in Data Session. The organization's written infection prevention and control goals did not include the following: Limiting unprotected exposure to pathogens. This was discussed with the Administrator. Observed in Data Session. The organization's written infection prevention and control goals did not include the following: Limiting the spread of infections associated with procedures. This was discussed with the Administrator. Observed in Data Session. The organization's written infection prevention and control goals did not include the following: Addressing its prioritized risks. This was discussed with the Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, the hospice had no developed a bereavement plan of care (POC) that specified the type of bereavement services to be offered and the frequency of service delivery. This was missing in the chart for RRBR#11. The bereavement assessment post-death indicated there was a plan for routine mailings, however did not any frequency. The organization was using the EMR bereavement POC function to document actual encounters, rather than a plan for the entire bereavement episode of care as discussed with the DPCS.

Observed in HR File Review. In 1 of 1 HR files reviewed, the supervisor had not evaluated the following areas by observing a hospice aide's performance of the tasks with a patient or pseudo-patient as part of a simulation: Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other staff; Reading and recording temperature, pulse, and respirations; 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. Upon review of the file for HR#3, and verified with the RN who documented the initial competencies, the required competencies in this element of performance had not been observed, rather verbal discussion occurred. Of note, the RN assessing competency had worked with the aide and observed competency in the past while both worked for another organization.

Observed in Record Review. In 1 of 14 patient records reviewed, the registered nurse who is a member of the interdisciplinary group and is responsible for hospice aide supervision had not prepared complete written patient care instructions for the hospice aide. In the chart for RRNHV#8, the aide plan of care did not address the prn oxygen. This was discussed with the DPCS.

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 CLD observations at 418.58, 418.60, 418.100, and 418.113

Observed in Document Review. In 1 of 3 contracts reviewed, the written agreement with an outside agency providing contracted services for the hospice did not include the following: A stipulation that services may be provided only with the authorization of the hospice. This stipulation was missing in the contract for pharmacy services as confirmed with the Administrator.

Observed in HR File Review. In 3 of 7 HR files reviewed, staff did not participate in on-going required annual education regarding Blood Borne Pathogens. This documentation was missing for 2021 in the file for HR#1; 2021 and 2022 for HR#4; 2022 for HR#6. This was discussed with the DPCS.

Observed in Record Review. In 1 of 14 patient records reviewed, the patient record did not include specific notes on care, treatment or services. In the chart for RRHV#3, PT was ordered more than two months prior to the date of the survey. The evaluation/order/POC update was filed and stated 2w3, 1w1. No visit notes were found in the record except for the initial evaluation note/order. This was discussed with the DPCS.

Observed in Record Review. In 1 of 14 patient records reviewed, all entries in the patient record were not dated. In the chart for RRHV#1, the POLST order was not dated by the physician. This was discussed with the DPCS.

Observed in Document Review. In 2 of 3 contracts reviewed, the written agreement with an outside agency providing contracted services for the hospice did not include the following: A stipulation that all contracted entities obtain criminal background checks on contracted employees who have direct patient contact or access to patient records. This stipulation was missing in the contracts for SNF and pharmacy services as confirmed with the Administrator.

Observed in HR File Review. In 1 of 7 HR files reviewed, the organization had not obtained a criminal background check within three months of the date of employment. In the file for HR#3 there was no criminal background check in the files for the employees hired more than one year ago. This was corrected on site during the survey. This was discussed with the DPCS.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization had not provided information in a manner tailored to the patient's language and ability to understand. For example, for HOS 1 the patient/daughter's preferred language was Spanish however written materials including education in the home folder as well as the consent/service agreement and Hospice Election forms were all in English. This was validated with the COO and DPCS.

Observed in HR File Review. In 1 of 2 HR files reviewed, the organization had not verified and documented the credentials of licensed staff using the primary source at the time credentials were renewed. For example, in review of the personnel file for HR 2, the registered nursing license had expired more than 6 months ago and there was no evidence in the personnel file that the organization had verified the renewal of the license with the board of nursing. The primary source of the license renewal was verified during the survey. This was validated with the COO and DPCS.