Every finding on record at Healthcare Plus Corporation

Observed in Record Review. In 1 of 6 patient records reviewed, the comprehensive assessment was not completed within five days after the election of hospice care. In the chart for HSRRHV#1, the Chaplain did not complete the spiritual care assessment until eleven days after the election. There was no indication that the rest of the team was aware of the delay. This was discussed with the Hospice Clinical Director.

Observed in Record Review. In 1 of 6 patient records reviewed, the update of the comprehensive assessment was based upon changes that took place since the initial assessment, but did not include information about the patient’s progress toward desired outcomes and a reassessment of the patient’s response to care. In the chart for HSRRNHV#5, the MSW documented that the patient refused further MSW visits and would be removed from the plan of care. At the next IDG, the frequency of MSW had been removed, however the note input into the meeting was from 2 months prior to the IDG and there was no information about the patient's desire to stop MSW services nor the progress or lack of progress toward social work goals. This was discussed with the Hospice Clinical Manager.

Observed in Record Review. In 1 of 6 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 HSRRNHV#4, in the most recently completed benefit period, MSW was ordered 1-2 visits/month and 1-2 phone calls/month; only phone calls were made. This was discussed with the Hospice Clinical Director.

Observed in Record Review. In 2 of 3 patient records reviewed, The hospice nurse surveyor noted in (HOSRR#1) that there was no evidence that the nurse assessed the patient's ability to tolerate the enteral nutrition or the patient was receiving the feedings required. In (HOSRR#3) the surveyor noted that the patient was an insulin dependent diabetic and was ordered two daily doses of insulin. There was no evidence in the record that the registered nurse assessed the severity of the patient's diabetes, the compliance and ability to administer insulin and monitor blood glucose levels. There was no information about diabetes in the assessment. This was confirmed with the hospice clinical manager.

Observed in Record Review. In 2 of 3 patient records reviewed, The hospice nurse surveyor noted that there was no evidence in the record (HOSRR#1) that the registered nurse assessed the patient when there was a significant change in the patient condition. The only RN visit was the initial assessment and visit notes entered by the LPN indicated that the family was unable to manage care at home and that the patient's respiratory symptoms were exacerbating, but no RN assessment was completed to manage the progressive symptoms until day 14, when a discharge note was documented. The RN did not complete an assessment at the time of the patient's transfer to another hospice. In (HOSRR#2), there was no evidence in the medical record, that a registered nurse assessed the patient for a period of three weeks. All the weekly visits were conducted by an LPN. This was confirmed with the hospice clinical manager.

Observed in Record Review. In 3 of 3 patient records reviewed, The hospice nurse surveyor noted in (HOSRR#1) that the plan of care and treatment orders did not include diet or nutrition orders for enteral feedings or indicate that the patient was NPO. Also, there were no goals or interventions for the management of N-G tube and the patient nutritional needs due to risk for aspiration. Also, the order for oxygen 2-5 lpm NC prn did not include parameters for dosing the oxygen. The surveyor noted that the first LPN note indicated that she applied the oxygen at 2 lpm and then the second note indicated it was dosed at 5 lpm without indicating the reason or symptoms. Also, in (HOSRR#2) there were no care-plan/orders, goals or interventions to manage the patient's aspiration risk requiring a pureed diet with thickened liquids and there were no parameters for dosing oxygen ordered 2-5 LPM NC as needed. In (HOSRR#3), the assessment indicated that the patient was ordered oxygen and was smoking up to one pack of cigarettes a day; however, the care plan did not include goals or interventions for managing the risk associated with smoking and the use of oxygen. This was confirmed with the hospice clinical manager.

Observed in Record Review. In 1 of 3 patient records reviewed, The hospice nurse surveyor noted that there was no evidence in the record (HOSRR#1) that the organization notified the physician of a change in patient condition. The LPN indicated that the family was unable to manage the care at home and that the patient's respiratory symptoms were exacerbating; however, there was no evidence that the change in condition and inability of the family to manage the care was communicated with the physician. This was confirmed with the hospice clinical manager.

Observed in Record Review. The hospice nurse surveyor noted (HOSRR#1) that the patient was transferred to another hospice; however, there was no evidence that a copy of the discharge summary was sent to the receiving facility. This was confirmed with the clinical manager.

Observed in Emergency Management Session. The organization had not complied with their policy Emergency Preparedness Plan Policy which stated an annual review of the Hazard Vulnerability Analysis (HVA) would be performed. Although the Administrator reported that the HVA was reviewed each year in review of the organization's Emergency Management Plan there was no evidence of documentation of an HVA for the past three years.

Observed in Record Review. In 1 of 3 home visits conducted, The hospice failed to assess for the need for volunteer services to offer support or respite to the patient, family, or other caregivers on admission to hospice services. In review of the medical record for RRHV #1 there was no evidence in the medical record that the admitting RN or MSW or others from the Hospice Team assessed for the need for volunteer services. In discussion with the daughter who was the primary caregiver she stated that no one from the Hospice had discussed Volunteer Services with her.

Observed in Record Review. In 2 of 10 patient records reviewed, the comprehensive assessment was not completed no later than five calendar days after the election of hospice care and the organization did not comply with their policy no. 2 - 036.1 Spiritual Assessment, which stated the hospice chaplain will contact the patient/family by a home visit or telephone call based on the patient's and family's needs and acceptance of these services and if the patient and family/caregiver refuse these services, the refusal will be documented. In review of the medical record for RRDC #2 the spiritual assessment had not been completed until the 8th day following the election of the hospice benefit and in review of the medical record for RRNHV #7 the spiritual assessment had not been completed until the 37th day following the election of the hospice benefit. This was validated with the Clinical Manager of Hospice.

Observed in Record Review. In 1 of 12 patient records reviewed, in review of the medical record for RRHV #1 who had a history of four falls, the target date was documented as two weeks on the initial plan of care and all subsequent plans of care reviewed by the IDG team with no documentation of progress towards goals.

Observed in Record Review. In 12 of 12 patient records reviewed, the hospice did not follow their policy no. 2-044.1 Plan of Care that the plan of care will include individualized interventions and measurable outcomes anticipated from implementing and coordinating the plan of care. The hospice surveyor noted during review of the organization's medical records that the hospice was using generalized goals and interventions and the written plan of care for each patient failed to document specific interventions to meet goals and progress towards goals. For example, in review of the medical record for RRHV #1 who had a history of four falls in the week prior to election of the hospice benefit the care plan included a problem of risk for falls with a goal of reduced risk for falls however interventions were general including; assess degree of physical mobility, balance, and gait, assess caregiver’s knowledge and ability to assist client with mobility to prevent falls and were not patient specific such as providing a commode to prevent falls in the bathroom. Additionally, in review of the plan of care for RRHV #2 who resided in a skilled nursing facility the problem of risk for falls with a goal of reduced risk for falls and the same general interventions including assess degree of physical mobility, balance, and gait, assess caregiver’s knowledge and ability to assist client with mobility to prevent falls and were not patient specific including such things as providing a low bed, floor mats or bed and chair alarms. This was also observed in ten (10) other records reviewed. This was validated by the Clinical Manager of Hospice.

Observed in Patient Home. In 1 of 3 home visits conducted, The organization did not assess medication-related problems. For example, for RRHV #1 the medication list included Prochlorperazine Maleate 5mg tablets take every 6 hours as needed for nausea and vomiting and Prochlorperazine Maleate 10 mg tablets take every 6 hours as needed for nausea and vomiting however, there was no instruction on when to take the different doses of the medications. The RN explained that the patient was taking both medications at the same time which was not included in the medication orders or Plan of Care. This was validated with the Clinical Manager of Hospice.

Observed in Record Review. In 1 of 10 patient records reviewed, the hospice did not provide care, treatment, or services according to the patient's individualized plan of care. In review of the medical record for RRHV #3 who had elected the hospice benefit 13 days ago the frequency of nursing visits on the hospice plan of care was 1x per week however the nursing visit for the second week of service did not occur until the 8th day. This was validated with the Clinical Manager of Hospice.

Observed in Data Session. The hospice program had collected data on falls, hand hygiene, infection rates and more however the data was collected by each quarter and not compiled in a manner that could be analyzed or used to identify performance trends or variances This was validated with the Clinical Manager of Hospice.

Observed in Data Session. Although the organization was collecting data on types of infections and hand hygiene observations of staff the Hospice Program had provided and had a written annual report on infection rates there was no evidence of an Infection Control Plan. The organization had not documented and described in writing an Infection Control Plan which could be integrated into its quality assessment and performance improvement (QAPI) program. This was validated with the Clinical Manager of Hospice.

Observed in Patient Home. In 1 of 3 home visits conducted, Staff failed to perform hand hygiene consistent with CDC guidelines and the organization's hand hygiene policy which requires hand hygiene before donning gloves and after removal of gloves. For RRHV #1 the RN performed hand hygiene, gloved and performed the patient assessment and then upon completion of the patient assessment removed her gloves, however failed to perform hand hygiene before moving on to the next activity of cleaning her equipment used in patient care and placing back in her clinical bag. This was validated with the Clinical Manager of Hospice.

Observed in Data Session. the hospice surveyor noted during the data management session that although the organization had a hand hygiene policy in place and was assessing competency with hand hygiene they had not established a hand hygiene program, or determined what their baseline was for hand hygiene compliance and had not set goals for improving compliance with hand hygiene guidelines for 2023, 2022, or 2021. This was validated with the Administrator and Clinical Manager of Hospice Observed in Data Session. The hospice surveyor observed that hand washing compliance did not show improvement and data was not compiled and evaluated for 2022, 2021 or 2020.

Observed in Record Review. In 4 of 10 patient records reviewed, the comprehensive assessment was not completed. In review of the medical record for RRHV #3, RRNHV #1, RRNHV #5, RRNHV #6 there was no evidence of a spiritual assessment or documentation of refusal of chaplain services.

Observed in Tracer Activities. The hospice had not documented the cost savings achieved through the use of volunteers. In discussion with the Volunteer Coordinator and Hospice Clinical Manager they reported they had not had any volunteers in the past two years due to COVID, therefore have not documented cost savings. The Administrator and Hospice Clinical Manager reported they had implemented the CMS waiver by implementing their Emergency Management Plan (EM) however the EM Plan describes the procedures for staff education and reporting suspected COVID cases but does not address suspension of their volunteer program or tracking of volunteer hours.

Observed in Tracer Activities. The hospice had not documented the level of volunteer activity, the type of volunteer services and time worked. In discussion with the Volunteer Coordinator and Hospice Clinical Manager they reported they had not had any volunteers in the past two years and therefore have not documented cost savings. The Administrator and Hospice Clinical Manager reported they had implemented the CMS waiver by implementing their Emergency Management Plan (EM) however the EM Plan describes the procedures for staff education and reporting suspected COVID cases but does not address suspension of their volunteer program or tracking of volunteer hours.

Observed in Data Session. The hospice surveyor noted there was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by a condition level finding at 484.60 as significant issues with policies & procedures were not developed, and or implemented, maintained and compliance established. For example, the Hospice Program did not have a documented Infection Control Plan or Hand Hygiene Program in place.

Observed in Record Review. In 10 of 12 patient records reviewed, of hospice patients the surveyor noted that organization did not have the ability to provide volunteer services as they have advertised and documented on their website and hospice materials including the hospice book given to patients and families on admission as part of their hospice program. For example, during the home visit for RRHV #1 the daughter who was the primary caregiver verbalized that a hospice volunteer may be helpful for her mother however the hospice program has not had any volunteers for the past two years and is unable to provide the service. Also, in review of the medical record for RRHV #2, RRHV #3 and nine (9) additional medical records the documentation stated that volunteer services had been offered and declined by the patient/family however the hospice program did not have the ability to provide volunteer services. This was validated with the Clinical Manager of Hospice.

Observed in HR File Review. In 2 of 10 HR files reviewed, the hospice had not provided initial orientation on relevant policies and procedures, key safety content about the hospice philosophy to all employees and contracted staff who have patient and family contact. In review of the personnel files for the Medical Director HR #9, and Alternate Medical Director HR #10 documentation of orientation was missing and/or the form had not been completed. This was validated with the Clinical Manager of Hospice.

Observed in Patient Home. In 1 of 3 home visits conducted, the patient record did not contain an accurate medication list. In review of the medical record for RRHV #1 the medication list included Prochlorperazine Maleate 5mg tablets and Prochlorperazine Maleate 10 mg tablets take every 6 hours as needed for nausea and vomiting take every 6 hours as needed for nausea and vomiting however the medications had been discontinued but remained on medication list. This was validated with the Clinical Manager of Hospice.

Observed in Document Review. In 3 of 4 contracts reviewed, the written agreement with the contracted provider of services for the hospice did not include all required elements. In review of the contracts for general inpatient care, respite care and the pharmacy contract there was no language stipulating that services may be provided only with the authorization of the hospice and a stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This was validated with the Clinical Manager of Hospice and the Administrator.