Every finding on record at Hannibal Regional Healthcare System, Inc.

Based on Patients Bill of Rights, policy review, record review, and interview, the provider failed to promote and protect the following patient right: - To receive effective pain management and symptom control from the hospice for conditions related to the terminal illness (L512). The cumulative effect of this deficient practice has the potential to affect all patients served by the provider.

Based on Patients Bill of Rights, policy review, record review, and interview, the provider failed to manage the patients symptoms of shortness of breath and changes in behavior related to his/her terminal illness resulting in the patient going to the local emergency room (ER) for symptom management and revoking his/her hospice benefits, in one of two clinical records reviewed for revocation (Record/Patient #8). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the Patients Bill of Rights (provided to each patient upon admission to hospice), dated as revised 03/2022, showed in part:- All hospice patients are entitled to receive information regarding their rights and be informed of the hospices responsibility to protect and promote the patient in exercising their rights; and- Receive effective pain management and symptom control for conditions related to terminal illness. Review of the providers policy titled, ";Nursing Services," dated as reviewed 01/10/2022, showed in part:- Policy: Nursing care and services are provided to hospice patients by or under supervision of a registered nurse; and- The hospice registered nurse (RN) reports the condition of the patient and/or family to the interdisciplinary team and/or the attending physician. Review of the providers policy titled, ";Physician Communication," dated as reviewed 01/20/2009, showed in part:- Policy: Hospice will establish and maintain communication with the attending physician to ensure safe and appropriate care for the patient; - Hospice will contact the patients attending physician: * When there are changes in the patients condition; * When changes occur in the patients expected response to treatment and/or medications; and- Hospice will notify the Hospice Medical Director when the patients attending physician is not available and concerns necessitate medical consultation or intervention. This contact is made: With noted changes in the condition of the patient. Review of the providers policy titled, ";On-Call Services," dated as reviewed 01/20/2009, showed in part:- Policy: Hospice of Northeast Missouri ensures that there will be twenty-four hour a day, seven days week coverage for the patients and caregivers needing nursing consultation or service during non-business hours;- The on-call guidelines that include problems that may require a nursing visit for the hospice nurse: * Respiratory difficulty; * Increased anxiety and/or confusion; and * Patient, family or caregiver perceives a problem and requests a visit. RECORD/PATIENT #8:Review of the comprehensive assessment, dated 04/05/2023, showed in part:- Diagnosis: Malignant neoplasm of unspecified part of unspecified bronchus or lung (cancer of the bronchus or lung);-Additional Diagnosis/Comorbidities: Chronic obstructive pulmonary disease (COPD; final stage of lung disease that blocks airflow and makes it difficult to breathe) and congestive heart failure (CHF; a decrease in the ability of the heart to pump blood);- The patient lived with caregiver;- Family adaptation- issues: Daughter tearful and afraid the patient would suffer. Educated on comfort medications used at end of life. Granddaughter voiced concerns related to comfort meds as he/she was a certified nurse assistant (CNA) and felt the medications were used to hasten (speed up) death. Education provided on the use of the medications for comfort and dosage being appropriate for comfort;- Pain status: Medication not always taken as directed;- Pain site: * Location/label: Hips; * Pain frequency: Frequent; * Current pain value: ";9" on a scale of 0 (very low pain intensity) to 10 (very high pain intensity); * Best pain value: ";4"; * Acceptable/Goal, pain value: ";2";- Pain issues: * Issue: Pain not controlled with current medication/methods; * Issue description: As evidenced by the patient not taking currently prescribed medications as directed and voices unwillingness to take specific medications, including: fentanyl (narcotic opioid used for pain) patch, morphine (narcotic opioid used for pain), lorazepam (sedative), and liquid oxycodone (narcotic opioid used for pain); * Visit note: The patient tearful in pain, granddaughter administered oxycodone-APAP (narcotic opioid used for pain) one tablet. Discussed with the patient options, he/she adamantly refused to try fentanyl patch or any pain patch, morphine, lorazepam, or liquid oxycodone. Goal was to see if appropriate use of the current medications would control the pain and discuss additional medications as the patient progressed; * Goal: The patient would maintain pain controlled at an acceptable level (which was a 2) for patient/caregiver;- Cardiopulmonary: * Respiratory rate: 20 (normal = 12 to 20 breaths per minute); * Circulatory conditions: Other- cyanosis across face and ears; * Right lung sounds: Diminished; wheezing (breathing a whistling or rattling sound in the chest); * Left lung sounds: Diminished; wheezing; * Cough: none; * Dyspnea: ";7" on a scale of 10 (severe) to 0 (none); * Exertion level causing dyspnea: At rest; with mild exertion; with speech; * Oxygen use: Nasal cannula; * Oxygen liters per minute (L/m): 3.5; * Oxygen saturation (on oxygen): 98 %;- Cardiopulmonary Issues: * Issues: Patient had shortness of breath/dyspnea related to terminal illness and end of life (EOL) process; * Issue description: As evidenced by observed the patient become short of breath with speech, at rest, and with exertion related to diagnosis of COPD and CHF; * Visit note: The patient became short of breath easily. Cyanosis observed around the mouth, across the chin, and in bilateral ears; * Goal: The patient would maintain an effective breathing pattern as evidenced by relaxed breathing at a normal rate, rhythm, and depth with absence of dyspnea through EOL process; * Intervention: The hospice nurse would provide patient/caregiver with rescue medications for dyspnea when appropriate (morphine, anti-anxiety agents, nebulized bronchodilators, secretion control agents); * Intervention: The hospice nurse would seek medication adjustment to better control the patients dyspnea as needed (PRN); -Summary: * Teaching done: Yes; * Summary of Visit: Comprehensive skilled nurse visit. The care plans were initiated for symptom management. The patient was outside on bench upon arrival to the home and he/she remained outside for a bit. The patient was alert and oriented times three. He/she was able to state the year, place, and date of birth. The hospice nurse entered the home and reviewed medications with the daughter. The patient ambulated into his/her room and laid down on the bed and remained there for the duration of the visit. The daughter was tearful at the discussion of mother suffering, education provided on goal of comfort. The granddaughter verbalized fear that medications given for comfort would hasten the patients death. Educated that the medications were provided to give the patient comfort during death and that amounts prescribed were safe and appropriate dosages. Upon entering the patients room, he/she reported a current pain level of ";8" out of 10, was tearful regarding hip pain. The last pain medication was given last night, the granddaughter gave the patient an oxycodone-APAP 10 milligram (mg)/325 mg during the visit. The patient had not been taking the prescribed medications on a regular basis. The patient did agree to allow nursing staff to set up medication planner. The patient became very upset at the mention of morphine, lorazepam, or pain patch and stated loudly ";NO". Educated the family that the provider would attempt to use the current prescribed medications to control pain. Medications would need to be taken consistently as ordered to evaluate the effectiveness. The patient agreed and the granddaughter verbalized an understanding. The patient wore oxygen at 3.5 L/NC. Skin around mouth, chin, and ears cyanotic. Very short of breath with mild exertion. No edema observed. Second day visit scheduled for next day. Educated to use number provided for any questions or concerns. No further needs noted; and-The note failed to mention any non-pharmacological interventions for pain or breathing and it failed to mention if the patient or caregiver was asked about any breathing treatments. Review of the admission medications, dated 04/05/2023, failed to show any bronchodilators, inhalers, or nebulizers for terminal illness or for conditions related to terminal illness. Review of the clinical record failed to show any documentation notifying the attending physician and/or the medical director regarding the unacceptable level of pain and that the patient failed to have any orders for bronchodilators, inhalers, or nebulizers for conditions related to terminal illness. Review of the Medical Director Certification of Terminal Illness, signed and dated 04/06/2023, showed in part:- Certification period dates: 04/05/2023 to 07/03/2023;- Diagnosis: Malignant neoplasm of unspecified part of unspecified bronchus or lung; and- Physician narrative: Patient with squamous cell carcinoma of the lung (lung cancer), end stage COPD, and CHF. Symptoms: severe dyspnea (difficult or labored breathing)cyanosis (bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood) of hands, face, and neck, oxygen saturation (the level of oxygen in the blood stream) 86% (normal = 95% or higher), moist cough, increase use of oxygen from 2.5 liters to 4 liters per nasal cannula, multiple trips to ER for dyspnea since December 2022 with antibiotics and steroid dosages. Refuses to be admitted to hospital and now refuses to go to ER from doctor appointments. Lung mass has increased in size and not a candidate for further treatment. There are no curative treatment options. Patient refuses any additional pain medications to what he/she already has in the home. Review of Nurse Progress Note Routine Visit, dated 04/06/2023, showed in part:- Family Adaptation Issues: * Visit note: The patients daughter was getting ready for work, so unable to provide education to him/her other than informing him/her that the medication organizer had been filled for the patient; * Intervention: Education to patient and caregiver related to the usage of comfort medications; * Visit note: Education given to patient, but caregiver unavailable during visit;- Pain: * Pain status: Pain not controlled by current medication(s)/other methods; * Pain interferes with: Energy, mood, activity, and sleep; * Non-verbal pain symptoms: Grimacing and restlessness; * PRN doses since last visit: None;- Pain Site: * Location/label: Hips; * Pain frequency: Constant; * Current pain level: ";6" on scale of 0 to 10; * Best pain value: ";4"; * Acceptable/Goal, pain level: ";2";-Pain issues: * Issues: Pain not controlled with current medication/methods; * Issue description: As evidenced by patient not taking currently prescribed medications as directed and voiced unwillingness to take specific medications, including fentanyl patch or any pain patch, morphine, lorazepam, or liquid oxycodone; * Goal: The patient would maintain pain controlled at an acceptable level for patient/caregiver; * Goal progress: Not progressing; * Visit note: The patient rated bilateral hip and thigh pain as a ";6" during visit; * Intervention: Assess/monitor medication effectiveness/side-effects; * Visit note: The patient agreed to take Methadone (narcotic opioid used for pain) times two and naproxen (non-steroidal anti-inflammatory) during visit, but refused oxycodone-APAP; * Intervention: Instruct patient/caregiver in principles of pain management; * Visit note: RN discussed with the patient that to achieve adequate pain management, he/she was going to have to take his/her pain medications as ordered. Informed the patient that the RN would put routine medications in the pill planner/organizer. Asked the patient if he/she would take medications regularly form the organizer and he/she stated that he/she would do so. RN informed the patient that he/she still had pain medications that he/she could take as needed if he/she would notify his/her daughter when he/she needed it;-Cardiopulmonary: * Respiratory rate: 20; * Color: Cyanotic around mouth and on both sides of his/her face, including ears; * Circulatory conditions: Extremities cool; * Respiratory condition: Labored; * Right lung sounds: Clear; * Left lung sounds: Clear; * Dyspnea: ";5"; * Exertion level causing dyspnea: At rest, with mild exertion, and with speech; * Oxygen use: Nasal cannula; continuous; * Oxygen (L/m): 4; * Oxygen saturation: 95%;-Cardiopulmonary issues: * Issue: The patient had shortness of breath/dyspnea related to terminal illness/EOL process; * Issue description: As evidenced by observed the patient become short of breath with speech, at rest, and with exertion related to diagnosis of COPD and CHF; * Goal: The patient would maintain an effective breathing pattern as evidenced by relaxed breathing at a normal rate, rhythm, and depth with absence of dyspnea through EOL process; * Goal progress: Not progressing; * Intervention: Hospice nurse would assess respiratory status at each skilled nursing visit; * Visit note: Respirations even and moderately labored. Lungs clear to auscultation bilateral (LCTAB). The patient reported shortness of breath ";like normal" and stated that it did worsen with exertion. The patient was cyanotic around mouth and on both sides of face, including ears; * Intervention: Hospice nurse would provide patient/caregiver with rescue medications for dyspnea when appropriate (morphine, anti-anxiety agents, nebulized bronchodilators, secretion control agents); * Visit note: The patient refused to use morphine or lorazepam for dyspnea, but did use inhalers at times (no inhalers were on admission medication orders); *Intervention: Hospice nurse will seek medication adjustment to better control the patients dyspnea PRN;-Summary: * Teaching done: Yes; * Summary of visit: Routine skilled nurse visit. All interventions listed in care plans were in place for symptom management. The patient was seated in chair in his/her bedroom with oxygen on at 4 L/m per NC. The patient rated bilateral hip and thigh pain as a ";6" out of 10. The RN discussed with the patient that to achieve adequate pain management, he/she was going to have to take his/her pain medications as ordered. Informed the patient that the RN would put routine medications in pill organizer. Asked the patient if he/she would take the medications regularly from the organizer, and she stated that he/she would do so. Informed him/her that he/she still had pain medication he/she could take as needed as well if he/she would notify his/her daughter when he/she needed it. The patient agreed to take Methadone times two and naproxen during the visit, but refused the oxycodone-APAP. Respirations were even and moderately labored. LCTAB. The patient reported shortness of breath ";like normal" and stated that it worsened with exertion. The patient was cyanotic around his/her mouth and on both sides of face, including ears. The patient was incontinent of bowel that morning, which was unusual for him/her. The patient was only oriented to self, which was a change from yesterdays visit. The patient rose from the chair and laid on the floor during the visit, assisted to sit back in the chair, then the patient was up and down out of chair one to two times during the visit. The patient continued to refuse to utilize lorazepam for restlessness and to improve effectiveness of pain medication. Medications placed in organizer per RN and the patient agreed to take as ordered from the organizer. The patients daughter and granddaughter were both in the house during the visit, but only had brief contact with each of them during the visit. No further needs at that time; and- The note failed to mention any non-pharmacological interventions for pain or breathing. Review of the clinical record failed to show any documentation notifying the attending physician and/or the medical director regarding the unacceptable level of pain, the new onset of bowel incontinence, the change in orientation, or that the patient was not progressing with effective breathing goal. Review of physician orders/medication profile, showed on 04/07/2023, the following medications were ordered:- Albuterol sulfate (short-acting bronchodilator) 2.5 mg/3 milliliter (ml) solution for nebulization- inhale one vial per nebulizer four times a day as needed for shortness of breath;- Ipratropium (bronchodilator) 0.5 mg/albuterol 3 mg/3 ml nebulization solution- inhale one vial per nebulizer four times daily for COPD;- Stiolto Respimat (combination drug that includes a long-acting bronchodilator and an anticholinergic, used to reduce flare-ups in adults with COPD) 2.5 microgram (mcg)-2.5 mcg/actuation solution for inhalation- inhale two puffs in the morning daily for COPD; and- Combivent Respimat (combination drug that is a bronchodilator) 20 mcg-100 mcg/actuation solution for inhalation- inhale three puffs per inhaler one time a day for COPD. Review of Nurse Progress Note Routine Visit, dated 04/10/2023, showed in part:- Family adaptation: * Patient and family/caregiver interaction: Difficult- the patients daughter/caregiver stated the patient had been ";really grouchy" that day;- Family adaptation issues: * Visit note: RN educated the patients daughter/caregiver regarding calling hospice if any concerns/questions arise. Discussed with the patient and caregiver that the goal of care was patient comfort, but that the patient had the right to refuse care if desired;- Pain: * Pain status: Pain not controlled by current medication(s)/other methods; * Non-verbal pain symptoms: Restlessness;-Pain site: * Location/label: Hips and thighs bilateral; * Pain frequency: Constant; * Current pain level: ";8"; * Best pain value: ";4"; * Worst pain value: ";10"; * Acceptable/Goal, pain value: ";2";-Pain issues: * Issue: Pain not controlled with current medication/methods; * Issue description: As evidenced by the patient not taking currently prescribed medications as directed and voiced unwillingness to take specific medications, including fentanyl patch or any pain patch, morphine, lorazepam, or liquid oxycodone; * Goal: Patient would maintain pain controlled at an acceptable level for patient/caregiver; * Goal progress: Not progressing; * Visit note: Patient rated bilateral hip and thigh pain at ";8". Patient was given Lyrica (nerve pain medication) and oxycodone-APAP during visit. The patient reported a decrease in pain by the end of the visit, ";6";-Cardiopulmonary: * Respiratory rate: 20; * Color: Cyanotic around mouth and on both sides of face, including ears; * Circulatory conditions: Extremities cool; * Respiratory conditions: Labored; * Right lung sounds: Clear; * Left lung sounds: Clear; * Dyspnea: ";7"; * Exertion level causing dyspnea: With mild exertion and with speech; * Oxygen use: Nasal cannula; continuous; * Oxygen (L/m): 4; * Oxygen saturation (on oxygen): 97%;-Cardiopulmonary issues: * Issue: Patient had shortness of breath/dyspnea related to terminal illness/EOL process; * Issue description: As evidenced by observed the patient become short of breath with speech, at rest, and with exertion related to diagnosis of COPD and CHF; * Goal: Patient would maintain an effective breathing pattern as evidenced by relaxed breathing at a normal rate, rhythm, and depth with absence of dyspnea through EOL process; * Goal progress: Not progressing; * Intervention: Hospice nurse will seek medication adjustment to better control the patients dyspnea PRN;- The note failed to mention any non-pharmacological interventions for pain or breathing. Review of the clinical record failed to show any documentation notifying the attending physician and/or the medical director regarding the unacceptable level of pain or that the patient was not progressing with effective breathing goal. Review of Interdisciplinary Note, dated 04/11/2023, showed the following:- Start time: 04/11/2023 at 11:00 AM;- End time: 04/11/2023 at 11:05 AM;- Note: Telephone call from the patients daughter/caregiver, reporting that the patient was acting ";weird." Stated that the patient tried to light a ";candle" but it was a piece of paper, the patient also had tried to fix eggs in the microwave, but cracked the eggs directly onto the microwave plate. RN informed the patients daughter/caregiver that the patients attending physician would be contacted regarding a change in the patients behavior. Review of the clinical record failed to show any documentation the patients attending or the hospice medical director was notified regarding the 04/11/2023 telephone call. Review of the clinical record failed to show any documentation a visit occurred on 04/11/2023 to assess the patient. Review of Interdisciplinary Note, dated 04/12/2023, showed the following:- Start time: 04/12/2023 at 7:00 AM;- Note: The patient was taken by ambulance to the local ER. Upon arrival to the hospital, found the patient in the cardiac room, the ER nurse reported a ";full workup" had been done. The ER physician wanted to know the plan of care and stated that he/she planned on doing a CT (computed tomography scan is an imaging test) and a probable blood transfusion. The patient was found to be unresponsive in the ER room, with dried blood on face, and audible gurgling with breathing. There was no family present in the ER. The daughter/caregiver was contacted and would sign revocation papers. Drove to the patients home where the daughter met the nurse in the street to sign papers, tearful and stated ";I dont understand" regarding the fast decline. Review of the ERs order sheet, dated 04/12/2023, showed the following:- Arrival date: 04/12/2023 at 7:19 AM; and- Arterial blood gas (ABG; a test to measure the amount of oxygen and carbon dioxide in the blood) stat (at once); * Received results: 04/12/2023 at 7:43 AM; and * Interpretation: PH 7.100 (normal = 7.35 to 7.45, pH under 7.35 indicates acidosis) PC02 88.0 (normal = 35 to 45, above 45 indicates presence of respiratory acidosis). Review of Transfer/Discharge/Death Summary, dated 04/12/2023, showed in part:- Patient Discharged/Transferred due to: Other- revocation;- Patient status/condition at discharge: Patient taken to local ER by ambulance;- Notifications: Notified patient and/or caregiver of discharge date; revocation/transfer signed by patient or representative; and- Comment: Daughter called ambulance for the patients respiratory issues and notified hospice. Revocation papers signed by the daughter. During an interview on 10/19/2023 at 12:50 PM RN B, stated he/she was the nurse that took the call from the patients daughter on 04/11/2023 and was driving, so did not get the patients attending physician called. He/she did not make a visit that day either to assess the patient. He/she thought the increased confusion was probable from ";hypoxia" (an absence of enough oxygen in the tissues to sustain bodily function). During an interview on 10/19/2023 at 12:55 PM, the patients attending physician stated he/she could not recall if the hospice provider called him/her on 04/11/2023 and did not find a note in the patients chart regarding a call on 04/11/2023. He/she did have a note dated 04/12/2023 that showed the patient had went to the ER and was no longer on hospice services. During an interview on 10/19/2023 at 3:05 PM, the administrator stated he/she did not know why or recall why the patient was not seen on 04/11/2023. He/she would have expected the physician to have been notified or a visit made that day.

Based on policy review, clinical record review and interview, the provider failed to ensure that each patient received an individualized initial or revised plan of care (POC) in, but not limited to, two of five full records reviewed (Records/Patients #1 and #4). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the providers policy titled, "Interdisciplinary Team Plan of Care" dated revised 05/05/2021, showed, in part:-";The admitting nurse will collaborate with the IDT (interdisciplinary team) to develop an initial Plan of Care based on problems and needs identified in the initial assessment."; and - ";The individualized plan of care must reflect patient and family goals and interventions based on problems identified in the initial, comprehensive, and updated assessments and include all necessary for the palliation and management of the terminal illness and related conditions." RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 06/20/2023 with a diagnosis of malignant neoplasm of overlapping sites of the brain (brain cancer causing difficulties with thought process, speech and activities of daily living). The patient lived at home with family. Review of the hospice plan of care (POC) revised on 10/12/2023, showed in part:-";Access Port-a-cath (a surgically implanted catheter used for the administration of intravenous (IV) medications and fluids as order by the physician) with sterile technique (an essential patient safety principle that reduces the risk of microbial transmission to patients during surgery or a procedure) and flush with 10mL of normal saline (fluid that is given in the vein to ensure there is no blockages or concerns) and 5 mL of Hep-Lock (a medication used to prevent blood for clotting inside of the Port-a-cath) every month"; - ";Change Port-a-cath Huber needle and tubing, flush with 10 mL normal saline and 5mL Hep-lock every week when accessed";-The POC failed to be individualized to include education to the patient/caregiver regarding signs and symptoms of infection to watch for at the port-a-cath site; and-The POC failed to be individualized and include the date of the last port-a-cath flush (so staff would know when to flush again). During an interview on 10/19/2023 at 2:55 PM, Registered Nurse (RN) A stated that the monthly flush is a standing order for patients with Port-a-cath. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice on 09/29/2023, with a diagnosis of chronic combined systolic and diastolic heart failure (a decrease in the ability of the heart to pump blood). The patient lived alone with intermittent help from family. Review of the Hospice Initial POC and medication list dated 09/29/2023 showed:- The patient had been prescribed clopidogrel (a medication that prevents blood from clotting to reduce risks for heart attack or stroke), 75 milligram (mg) take one tablet, once a day for anticoagulation; - The POC failed to include increased risk for bleeding as a problem for this patient; and - The POC failed to include interventions or outcomes related to the patients increased risk for bleeding. During an interview on 10/19/2023 at 2:50 PM, the administrator stated that he/she ";would expect for that to be a part of safety on the plan of care."

Based on policy review, employee orientation checklist review, home visit observation, and interview, the provider failed to ensure that accepted standards of practice to prevent the transmission of infections and communicable diseases was followed in one of four home visits observed (Record/Patient#3). This deficient practice has the potential to adversely affect all patients served by the provider. --- Findings included: Review of the providers undated policy titled, ";Bag Technique Procedure", showed in part: - As necessary, when the bag is required to be placed in the home, the following procedure will be followed: * Upon entering the home, place the bag on a clean surface at waist high or above, not on the floor; and * A poly-backed towel or some paper towels will be used to create a clean area for the bag. Review of the hospice aides orientation checklist showed infection control in hospice care, at home and facilities initialed by the hospice aide and the hospice RN (registered nurse) coordinator and dated 11/03/2022. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 06/12/2023 with a primary diagnosis of malignant neoplasm of the colon, unspecified (cancer of the colon (bowel). Observation on 10/18/2023, beginning at 10:05 AM, during the patients home visit showed the hospice aide placed his/her nursing supply bag directly on the floor without a barrier upon entering the patients home. During an interview on 10/18/2023 at 10:19 AM the hospice aide stated that he/she: - Did not remember going over bag technique when hired; and - Did not know if he/she was supposed to put the bag on the floor or not. During an interview on 10/19/2023 at 3:00 PM the administrator stated that: - The bag should be placed on a barrier; and - The bag should not be placed on the floor.

Based on policy review, record review and interview, the provider failed to ensure the hospice aide supervisory visits included all the required components in, but not limited to, one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients that receive aide services. --- Findings included: Review of the providers policy titled, ";Hospice Aide Supervision", with a revised date of 05/21/2023 showed, in part, the following: - Hospice aides are supervised by a registered nurse (RN) in a manner and frequency that assures safety of patients and the quality of aide services provided; - A RN makes an on-site visit to the patients home no less frequently that every fourteen days to ensure that the services ordered by the IDT (interdisciplinary team) and provided by the aide are meeting the patients needs; and - The supervising nurse assesses and documents an aides ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include, but is not limited to: * Following the patients plan of care for completion of tasks assigned to the hospice aide by the RN; * Creating successful interpersonal relationships with the patient and family; * Demonstrating competency with assigned tasks; * Complying with infection control policies and procedures; and * Reporting changes in patients condition. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted 08/22/2023 with a primary diagnosis of Parkinsons disease (a neurological disorder that causes unintended or uncontrollable movements or stiffness). Review of the aide supervisory notes from 08/22/2023 to 09/26/2023 failed to address: - Creating successful interpersonal relationships with the patient and family; - Demonstrating competency with assigned tasks; - Complying with infection control policies and procedures; and - Reporting changes in patients condition. During an interview on 10/19/2023 at 3:00 PM the administrator stated that his/her expectations regarding aide supervisory visits were: - Are they (the patient) happy; - If they need changes made to the plan of care (POC) or additional needs added; and - Compliance with infection control policies and procedures, and if there are concerns with infection control, that they would be addressed and education provided.

Based on policy review, clinical record review, and interview the hospice provider failed to: - Ensure that all clinical record documentation was documented in a timely matter (L679);- Document the discharge summary was sent to the attending physician for patient revocation or discharge (L684); and- Ensure clinical records were readily available on request by an appropriate authority (L685). This cumulative effect of these deficient practices have the potential to affect all patients served by the provider.

Based on policy review, record review, and interview, the provider failed to ensure documentation was accurate and timely in five of five full records reviewed and one focused record reviewed (Records/Patients #1, #2, #3, #4, #5 and #8). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the providers policy titled, "Entries into the Clinical Record," revised 05/05/2021, showed in part:- ";Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided"; and-";Late entries will be documented and include: * The date the entry is made; * The date and documentation that was originally omitted; and* The signature and title of Hospice personnel making the late entry." RECORD/PATIENT #1: Review of the clinical record showed:- The patient was admitted to hospice services on 06/20/2023 with a diagnosis of malignant neoplasm of overlapping sites of the brain (brain cancer causing difficulties with thought process, speech and activities of daily living); - Skilled nurse visit (SNV) performed on 8/22/2023, was electronically signed on 9/10/2023 (19 days later); - SNV performed on 08/25/2023, was electronically signed on 08/29/2023 (4 days later); - SNV performed on 08/29/2023, was electronically signed on 09/05/2023 (7 days later); - SNV performed on 09/05/2023, was electronically signed on 10/06/2023 (31 days later); - SNV performed on 09/07/2023, was electronically signed on 10/18/2023 (41 days later); - SNV performed on 09/19/2023, was electronically signed on 10/02/2023 (14 days later); - SNV performed on 09/26/2023, was electronically signed on 10/04/2023 (8 days later); - SNV performed on 10/03/2023, was electronically signed on 10/17/2023 (14 days later); - SNV performed on 10/06/2023, was electronically signed on 10/17/2023 (11 days later); - SNV performed on 10/10/2023, was electronically signed on 10/17/2023 (7 days later); - SNV performed on 10/13/2023, was electronically signed on 10/17/2023 (4 days later); - Aide assignment care plan was created 06/20/2023, was electronically signed on 06/28/2023 (8 days later); - Aide visit performed on 08/25/2023, was electronically signed on 08/28/2023 (3 days later); - Aide visit performed on 09/11/2023, was electronically signed on 09/27/2023 (16 days later); - Aide visit performed on 09/14/2023, was electronically signed on 09/22/2023 (8 days later); - Aide visit performed on 09/18/2023, was electronically signed on 09/23/2023 (5 days later);- Aide visit performed on 09/25/2023, was electronically signed on 10/06/2023 (11 days later); - Aide visit performed on 09/28/2023, was electronically signed on 10/06/2023 (7 days later); and - An interdisciplinary team note was created on 09/08/2023, was electronically signed on 10/02/2023 (24 days later). RECORD/PATIENT #2: Review of the clinical record showed: - The patient was admitted 08/22/2023 with a primary diagnosis of Parkinsons disease (a neurological disorder that causes unintended or uncontrollable movements or stiffness);- SNV performed on 08/22/2023, was electronically signed on 09/03/2023 (12 days later); - SNV performed on 08/24/2023, was electronically signed on 09/02/2023 (9 days later); - SNV performed on 08/29/2023, was electronically signed on 09/04/2023 (6 days later); - SNV performed on 08/31/2023, was electronically signed on 09/04/2023 (4 days later); - SNV performed on 09/05/2023, was electronically signed on 09/24/2023 (19 days later); - SNV performed on 09/07/2023, was electronically signed on 09/16/2023 (9 days later); - SNV performed on 09/12/2023, was electronically signed on 09/24/2023 (12 days later); - SNV performed on 09/14/2023, was electronically signed on 09/24/2023 (10 days later); - SNV performed on 09/26/2023, was electronically signed on 10/04/2023 (9 days later); - SNV performed on 10/10/2023, was electronically signed on 10/18/2023 (8 days later); - Aide visit performed on 09/13/2023, was electronically signed on 10/01/2023 (27 days later); - Aide visit performed on 09/18/2023, was electronically signed on 09/23/2023 (5 days later); - Aide visit performed on 09/22/2023, was electronically signed on 10/01/2023 (8 days later); - Aide visit performed on 09/26/2023, was electronically signed on 10/06/2023 (10 days later); - Aide visit performed on 09/27/2023, was electronically signed on 10/06/2023 (9 days later); - Aide visit performed on 09/29/2023, was electronically signed on 10/09/2023 (10 days later); - Aide visit performed on 10/06/2023, was electronically signed on 10/10/2023 (4 days later); - Medical social worker visit performed on 09/20/2023, was electronically signed on 09/25/2023 (5 days later); - Spiritual counselor visit performed on 09/13/2032, was electronically signed on 09/18/2023 (5 days later); and- Spiritual counselor visit performed on 09/28/2032, was electronically signed on 10/02/2023 (4 days later). RECORD/PATIENT #3 Review of the clinical record showed: - The patient was admitted to hospice services on 06/12/2023 with a primary diagnosis of malignant neoplasm of the colon, unspecified (cancer of the colon (bowel);- SNV performed on 09/11/2023, was electronically signed on 09/25/2023 (14 days later); - SNV performed on 09/15/2023, was electronically signed on 10/04/2023 (19 days later); - SNV performed on 09/19/2023, was electronically signed on 10/04/2023 (15 days later); - SNV performed on 09/22/2023, was electronically signed on 10/04/2023 (12 days later); - SNV performed on 09/29/2023, was electronically signed on 10/04/2023 (5 days later); - SNV performed on 10/03/2023, was electronically signed on 10/18/2023 (16 days later); - SNV performed on 10/06/2023, was electronically signed on 10/18/2023 (13 days later); - SNV performed on 10/10/2023, was electronically signed on 10/18/2023 (8 days later); - SNV performed on 10/12/2023, was electronically signed on 10/18/2023 (6 days later); - SNV performed on 10/13/2023, was electronically signed on 10/18/2023 (5 days later); - Homemaker visit performed on 09/13/2023, was electronically signed on 10/01/2023 (18 days later); - Homemaker visit performed on 09/20/2023, was electronically signed on 10/01/2023 (11 days later); - Homemaker visit performed on 09/27/2023, was electronically signed on 10/09/2023 (12 days later); - Homemaker visit performed on 10/11/2023, was electronically signed on 10/19/2023 (8 days later); - Medical social worker visit performed on 09/28/2023, was electronically signed on 10/19/2023 (21 days later); and- Medical social worker visit performed on 09/20/2023, was electronically signed on 10/09/2023 (19 days later). RECORD/PATIENT #4: Review of the clinical record showed: - The patient was admitted to hospice on 09/29/2023, with a diagnosis of chronic combined systolic and diastolic heart failure (a decrease in the ability of the heart to pump blood); - SNV performed on 09/29/2023, was electronically signed on 10/04/2023 (5 days later); - SNV performed on 09/30/2023, was electronically signed on 10/05/2023 (5 days later); - SNV performed on 10/05/2023, was electronically signed on 10/18/2023 (13 days later); - SNV performed on 10/09/2023, was electronically signed on 10/18/2023 (9 days later); - SNV performed on 10/12/2023, was electronically signed on 10/18/2023 (6 days later); and- Spiritual counselor visit performed 10/04/2023, was electronically signed on 10/11/2023 (7 days later). RECORD/PATIENT #5 Review of the clinical record showed: - The patient was admitted to hospice on 10/03/2023, with a diagnosis of dilated cardiomyopathy (a decrease in the ability of the heart to pump blood); - SNV performed on 09/08/2023, was electronically signed on 09/16/2023 (8 days later); - SNV performed on 09/09/2023, was electronically signed on 09/17/2023 (6 days later); - SNV performed on 09/10/2023, was electronically signed on 09/17/2023 (7 days later);- SNV performed on 09/11/2023, was electronically signed on 09/25/2023 (14 days later); - SNV performed on 09/12/2023, was electronically signed on 09/29/2023 (17 days later); - SNV performed on 09/18/2023, was electronically signed on 10/04/2023 (16 days later); - SNV performed on 09/19/2023, was electronically signed on 10/04/2023 (15 days later); - SNV performed on 09/22/2023, was electronically signed on 10/04/2023 (12 days later); - SNV performed on 09/26/2023, was electronically signed on 10/06/2023 (11 days later); - SNV performed on 09/27/2023, was electronically signed on 10/07/2023 (8 days later); - SNV performed on 10/03/2023, was electronically signed on 10/18/2023 (15 days later); - SNV performed on 10/06/2023, was electronically signed on 10/18/2023 (12 days later); - SNV performed on 10/10/2023, was electronically signed on 10/18/2023 (8 days later); - SNV performed on 10/13/2023, was electronically signed on 10/18/2023 (5 days later); - Medical social worker visit performed on 09/13/2023, was electronically signed on 09/17/2023 (4 days late); - Medical social worker visit performed on 10/04/2023, was electronically signed on 10/18/2023 (14 days late); - Spiritual counselor visit performed 09/08/2023, was electronically signed on 09/13/2023 (5 days later); and- Spiritual counselor visit performed 09/20/2023, was electronically signed on 09/25/2023 (5 days later). RECORD/PATIENT #8 Review of the clinical record showed: - The patient was admitted on 04/05/2023 with a diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung (cancer of the bronchus or lung);- SNV performed on 04/06/2023, was electronically signed on 05/01/2023 (25 days later); and- SNV performed on 04/10/2023, was electronically signed on 05/01/2023 (21 days later). During an interview on 10/19/2023 at 2:47 PM with the administrator stated that he/she would expect documentation to be completed within 24-72 hours under normal circumstances.

Based on record review and interview, the provider failed to document a complete discharge summary containing all the components required by this regulation in, but not limited to, one of three applicable records reviewed (Record/Patient #9). This deficient practice has the potential to adversely affect the discharge care of all the patients served by the provider. --- Findings included: RECORD/PATIENT #9: Review of the clinical record showed the patient was admitted 06/15/2023 with a diagnosis of myotonic muscular dystrophy (a genetic condition that causes progressive muscle weakness and wasting). Review of a discharge summary form dated 09/12/2023, with faxed stamped and dated as 09/14/2023, showed, in part: - No longer determined to be terminally ill was check marked; - Discharge was discussed with the IDT (interdisciplinary team) prior to discharge was check marked; - Discharge was discussed with the patient and/or caregiver was check marked; and - The following information was faxed to the attending physician and facility, as appropriate: Summary of the patients stay including treatments, symptoms, and pain management, current POC (plan of care), latest physician orders, any other documentation that will assist with the post-discharge continuity of care that is requested by the attending physician failed to be check marked. (The discharge summary form failed to contain this information). During an interview on 10/19/2023 at 10:00 AM, the administrator stated that: - They (the provider) had no way of showing what was sent to who, or how many pages were faxed; and - They (the provider) did not have a fax confirmation.

Based on policy review, record review and interview, the provider failed to ensure that the clinical records, whether in hard copy or in electronic form, were made readily available on request when documentation from staff failed to be completed in a timely manner in four of five full records reviewed (Records/Patients #1, #3, #4 and #5). This deficient practice has the potential to affect accurate documentation for all the providers patients. --- Findings included: Review of the providers policy titled, "Entries into the Clinical Record," revised 05/05/2021, showed in part ";Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided". A request of the clinical documentation of the five full clinical records was made before 1:00 PM on 10/17/2023. Records #1, #3, #4, and #5 were not received in completion until 11:00 AM on 10/19/2023 (46 hours later). Due to the late entry of documentation, there was a delay in receiving patient records, in order to review for the survey process. RECORD/PATIENT #1 During clinical record review on 10/17/2023 at 7:00 PM the provider failed to provide, on initial request, the following documentation:- Skilled nurse visit (SNV) performed on 09/07/2023, was electronically signed on 10/18/2023, provided on 10/19/2023;- SNV performed on 10/03/2023, was electronically signed on 10/17/2023, provided on 10/19/2023;- SNV performed on 10/06/2023, was electronically signed on 10/17/2023, provided on 10/19/2023; - SNV performed on 10/10/2023, was electronically signed on 10/17/2023, provided on 10/19/2023; and- SNV performed on 10/13/2023, was electronically signed on 10/17/2023, provided on 10/19/2023. RECORD/PATIENT #3 During clinical record review on 10/18/2023 at 7:00 PM the provider failed to provide, on initial request, the following documentation:- SNV performed on 10/03/2023, was electronically signed on 10/18/2023, provided on 10/19/2023; - SNV performed on 10/06/2023, was electronically signed on 10/18/2023, provided on 10/19/2023; - SNV performed on 10/10/2023, was electronically signed on 10/18/2023, provided on 10/19/2023;- SNV performed on 10/12/2023, was electronically signed on 10/18/2023, provided on 10/19/2023;- SNV performed on 10/13/2023, was electronically signed on 10/18/2023, provided on 10/19/2023;- Homemaker visit performed on 10/11/2023, was electronically signed on 10/19/2023, provided on 10/19/2023; and - Medical social worker visit performed on 09/28/2023, was electronically signed on 10/19/2023, provided on 10/19/2023. RECORD/PATIENT #4 During clinical record review on 10/18/2023 at 7:00 PM the provider failed to provide, on initial request, the following documentation:- SNV performed on 10/05/2023, was electronically signed on 10/18/2023, provided on 10/19/2023; - SNV performed on 10/09/2023, was electronically signed on 10/18/2023, provided on 10/19/2023; and- SNV performed on 10/12/2023, was electronically signed on 10/18/2023, provided on 10/19/2023. RECORD/PATIENT #5 During clinical record review on 10/18/2023 at 7:00 PM the provider failed to provide, on initial request, the following documentation:- SNV performed on 10/03/2023, was electronically signed on 10/18/2023, provided on 10/19/2023; - SNV performed on 10/06/2023, was electronically signed on 10/18/2023, provided on 10/19/2023; - SNV performed on 10/10/2023, was electronically signed on 10/18/2023, provided on 10/19/2023; - SNV performed on 10/13/2023, was electronically signed on 10/18/2023, provided on 10/19/2023; and- Medical social worker visit performed on 10/04/2023, was electronically signed on 10/18/2023, provided on 10/19/2023. During an interview on 10/18/2023 at 2:45 PM, the administrator stated that there was several notes that had not been documented in the system yet due to switching to the new electronic medical record (EMR) system. He/she stated the staff are using their paper notes in the field to then later chart in the EMR. He/she stated that an increase in the providers census increased from 15 to 32 the month before so the provider was behind before the EMR change. During an interview on 10/19/2023 at 2:47 PM, the administrator stated that he/she would expect documentation to be completed within 24-72 hours under normal circumstances.