Every finding on record at Healthkeepers Hospice Inc.

Observed in Record Review. In 1 of 5 patient records reviewed, the Surveyor noted a full clinical assessment had not been completed. The patient in RRHV#1 had a wound on the L ball of foot. The description documented said: 'Pressure Injury II'. There had been no measurements, description of wound bed, surrounding tissue, or drainage. There had also not been any assessment of the pain associated with the wound. This was validated with the Consultant assisting with the Documentation review.

Observed in Record Review. In 7 of 8 patient records reviewed, the Surveyor noted a Bereavement Assessment (BR) had not occurred. In RRHV#1, RRNHV#2, RRNHV#3, RRBR#2 and RRBR#3, there had been no initial BR completed. in RRBR#2 and RRBR #3, there had not been a post death BR assessment completed. Of note, the BR assessments in the records RRNHV#4, RRNHV#5 had been completed by the MSW who had not been documented as qualified to complete. This was validated with the Consultant assisting with the Documentation review.

Observed in Record Review. In 2 of 5 patient records reviewed, the Surveyor observed that not all care required for the patients had been addressed in the Plan of Care (POC) with orders and interventions. For example, in RRHV#1 the clinician had been observed providing wound care to the left ball of foot; however, there had been nothing on the POC to address wound care. In RRNHV#2, the clinician documented the patient had signs and symptoms of a urinary tract infection and provided education on prevention. The clinician also documented that the family had contacted the primary physician (PCP) and a urinalysis had been ordered. The Clinician had not documented communication or order from the PCP in the patient record. This was validated with the Consultant assisting with the Documentation review.

Observed in Tracer Activities. The Surveyor reviewed the QAPI program last updated by the HCO December 2024. There is presence that performance improvement projects had been identified; however, there was no documented data collection available for the surveyor to review. This was validated with the QAPI Coordinator assisting with the Documentation review. Observed in Tracer Activities. The surveyor reviewed the QAPI program with the goals established and monitoring requirements. The HCO had not maintained documentation of the quality assessment and performance improvement program as the Director of Nursing position had been vacant since the middle of November 2024 and the Medical Director now taking responsibility had not documented completion of the tasks. This was validated with the QAPI Coordinator assisting with the documentation review and the Administrator.

Observed in Tracer Activities. Hospice core services were not provided by the organization on a routine basis. The Organization had a period of approximately 3 months where they had been without a Medical Social Worker to provide support to the patients. A new MSW had been hired as of February 2025; however, the period of time prior to this date had been without the needed services. In addition, the organization has been without a Spiritual Care Provider for the past 6 months without providing a replacement for spiritual services. This was validated with the Consultant assisting with the Documentation review and the Administrator.

Observed in Tracer Activities. The Surveyor reviewed 3 Bereavement Records and the program policies in place. At this time, there is no organized bereavement program in place as the Spiritual Care provider position has been vacant since October 2024. This was validated with the Administrator and Consultant. Observed in Tracer Activities. The Surveyor reviewed the Bereavement Program. The Spiritual Care Provider left the HCO employment in October 2024. There had been no one assigned to provide bereavement services since that time. The Medical Social Worker had been trying to assist, but did not have the qualifications according to HCO policy to provide bereavement services. This was validated with the Consultant assisting with the Documentation review.

Observed in Record Review. In 7 of 8 patient records reviewed, the Surveyor noted spiritual needs of the patients had not been evaluated or documented in the patient records. The Spiritual Care provider position had been vacant for 6 months and there had been no clinician qualified to conduct the assessment. This was validated with the Administrator.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by Condition Level observations at 418.54, 418.56, 418.58, 418.64, and 418.100. This was discussed with the Administrator.

Observed in HR File Review. In 2 of 2 HR files reviewed, the Surveyor noted Job duties assigned to employees who had not received documented training to complete. For example, in HR#1, the Medical Social Worker had been assisting with the Bereavement Program; however, she had not received any training to conduct such activities. In HR#2, the Medical Director had been assigned by the Governing Board to oversee the QAPI program. There had been no job description or competency completed with the new assigned duties. This was validated with the Administrator.

Observed in Record Review. In 1 of 5 patient records reviewed, The HCO has not been recording orders unless they are from their medical director. In RRNHV#2, the had a patient with symptoms of a Urinary Tract Infection (UTI). The family had called their PCP for a urinalysis. the clinician documented the signs and symptoms of the UTI and that the family had called their PCP and that a urinalysis had been ordered; however, there was no order to support obtaining the UA and in discussion, the HCO informed the surveyor that there is no process in place to capture orders from the non-hospice MD. They have not been obtaining orders from other MD's.

Observed in Record Review. In 3 of 3 patient records reviewed, it was noted that the organization did not ensure that the plan of care goals included outcome measures for specific care activities. For example, during the review of the medical record for RRNHV#1, it was noted that the problem list included the following areas of concern: Poor appetite, Generalized debility, and Pain. The plan of care did not include goal statements to evaluate care, treatment, and services related to pain, generalized debility, and poor appetite. Example #2: A review of the medical record for RRNHV#2, revealed that the problem list included decreased cognition related to Alzheimer's Dementia. The plan of care did not include a goal statement to evaluate care, treatment, and services related to Alzheimer's Dementia. Example #3: A review of the medical record for RRNHV#3, revealed that the patient's problem list included decreased cognition related to Dementia, nutritional deficit, and safety concerns related to potential for falls. The plan of care did not include goal statements to evaluate care, treatment, and services related to Dementia, nutritional deficit, and risk for falls. This observation was reviewed with agency leadership.

Observed in Record Review. In 1 of 3 patient records reviewed, it was noted that the organization did not ensure that the comprehensive assessment update included all required information. For example, during the review of the medical record for RRNHV#1, it was noted that the nursing assessment identified the patient was experiencing pain. Since the plan of care did not include outcomes and goals related to pain management, the comprehensive assessment update did not document progress towards goals related to pain. This observation was reviewed with agency leadership

Observed in Emergency Management Session. The organization had not documented a hazard vulnerability analysis as confirmed with the Administrator, thus they had not used its prioritized hazards to identify and implement mitigation and preparedness actions to increase the resilience of the organization and help reduce disruption of essential services or functions. Observed in Emergency Management Session. The organization had not documented a hazard vulnerability analysis as confirmed with the Administrator, thus they had not evaluated and prioritized the findings.

Observed in Emergency Management Session. The organization’s 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’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 had not developed a written 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; Use of volunteer staffing, such as staffing agencies, and those deployed as part of the disaster medical assistance teams. This was discussed with the Administrator. 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). This was discussed with the Administrator.

Observed in Emergency Management Session. 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 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. This was discussed with the Administrator.

Observed in Emergency Management Session. The communications plan did not describe how the organization will communicate with and report information about its needs, available occupancy, and ability to provide assistance to relevant authorities. This was discussed with the Administrator.

Observed in Emergency Management Session. The organization's committee had not documented an after action report for the activation of their emergency plan for 2023. This was discussed with the Administrator.

Observed in Record Review. In 1 of 15 patient records reviewed, the hospice had not conducted and documented a patient-specific comprehensive assessment that identified the patient’s need for hospice care and services. The assessment did not include the patient’s need for physical, psychosocial, emotional, and spiritual care, including the following: Factors that alleviate or exacerbate physical symptoms. In the chart for RRNHV#8, the pain assessment in the comprehensive assessment failed to assess for quality of pain, alleviating factors, the patient's pain goal, how the pain impacted his ability to perform ADL's, etc. This was discussed with the Director of Nursing. Observed in Record Review. In 1 of 15 patient records reviewed, the hospice had not conducted and documented a patient-specific comprehensive assessment that identified the patient's need for hospice care and services. In the chart for RRHV#2, there was no documented fall risk assessment. During the home visit, the patient had full bed rails present. This was discussed with the DON.

Observed in Record Review. In 3 of 15 patient records reviewed, the organization had not prepared a written plan of care. In the chart for RRNHV#10, there was no plan of care for the patient admitted one week prior to the survey. In the chart for RRNHV#8, the patient was assessed to be at high risk for pressure ulcers and had a non-pressure stage 3 wound upon admission. The RN documented care to the wound during the admission visit, however there was no order for wound care and no POC, despite the patient having been admitted more than 2 weeks before the survey. In the chart for RRNHV#6, the patient was admitted to the organization thirty-one days prior to the start of the survey, yet the patient did not yet have a plan of care as confirmed with the Director of Nursing.

Observed in Tracer Activities. The hospice team meeting did not include all members of the interdisciplinary team. During the survey, the interdisciplinary meeting consisted of nursing only. The Physician were not in attendance. It was confirmed with the Director of Nursing that this is not an isolated occurrence and she provides report to the physician when he does not attend in person.

Observed in Record Review. In 12 of 12 patient records reviewed, for which a plan of care existed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for RRHV#2, there were no time frames associated with the anticipated achievement of patient goals of care. In the chart for RRHV#1, there were no goals on the current hospice plan of care. The RN created a pressure ulcer care plan with measurable, time based goals upon a change in the patient condition, however the care plan was not included on the hospice plan of care. In the charts for RRHV#3, RRHV#4, RRNHV#5, RRNHV#7, RRNHV#9, RRNHV#11, RRDC#12, RRDC#13, RRBR#14 and RRBR#15 while the care plans had goals, the goals did not have measurable time frames and had not been included on the POC. This was discussed with the DON.

Observed in Record Review. In 2 of 12 patient records reviewed, for which a plan of care existed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: A statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs. In the chart for RRHV#3, the POC did not include the four times weekly aide visits. In the chart for RRDC#12, the aide frequency of visits was not on the plan of care. This was confirmed with the Director of Nursing.

Observed in Record Review. In 9 of 12 patient records reviewed, for which a plan of care existed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: Medications and treatment necessary to meet the patient’s needs. In the chart for RRHV#1, the patient was assessed to be at risk for pressure ulcer development at the admission. The RN did documented education about pressure ulcer prevention and the patient was on pressure relief mattress during the home visit. These interventions however were not on the plan of care. The plan of care was not updated with orders for wound care once the patient developed a wound. The patient was assessed to be on oxygen during the admission assessment. The plan of care did not include any orders for oxygen. During the home visit, it was confirmed with the nursing facility staff that the patient was taking Benzonatate 200mg TID and Donepazil 10mg @HS, which were not on the Hospice POC. In the chart for RRHV#2, there were no orders for the site care to the G-tube provided during the home visit, nor were there orders for the free water that the patient receives daily via the feeding tube as verified with the nurse during the visit. In the chart for RRHV#3, the plan of care included the problem list, but no interventions. The oxygen order which was documented on the initial physician assessment was not on the POC; there was no order for the free water that the patient is receiving 4 times/day via the G-tube. The patient has a pressure reduction mattress, but the other interventions for pressure ulcer prevention do not appear on the POC. In the chart for RRHV#4, the patient was at risk for pressure ulcer development, falls and used oxygen. The care plan interventions for these identified problems/potential safety risks were not included on the POC. Additionally, the order for prn Novolin was incomplete as there was no specific indicator for when the prn dose should be given to the patient. In the chart for RRNHV#5, the physician documented an order for oxygen during his evaluation visit at the time of admission, however that oxygen order was not incorporated into the plan of care and was missing the frequency of administration. Additionally, the patient was as risk for pressure ulcers and a knowledge deficit related to oxygen safety. The interventions related to these treatments/potential problems were not included on the POC. In the chart for RRNHV#9, the there was no order for oxygen, nor interventions related to pressure ulcer risk reduction on the POC. In the chart for RRNHV#11, there were no treatment interventions on the plan of care for the bedbound patient with ALS. In the chart for RRDC#12, the patient was at high risk for pressure ulcer development, yet the interventions taught by the nurse and the physician in the documentation were not included on the POC. This was discussed with the Director of Nursing.

Observed in Record Review. In 2 of 15 patient records reviewed, the interdisciplinary group, in collaboration with the patient’s attending physician, if any, had not reviewed and revised the plan of care as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. No reviews were not documented in the chart for RRNHV#6 who was admitted to the organization approximately 30 days prior to the survey, and did not yet have an individualized plan of care. In the chart for RRNHV#8, the patient had been admitted 19 days before the chart review, yet there had been no review of the plan of care as there was not yet an individualized plan of care developed. This was discussed with the Director of Nursing.

Observed in Record Review. In 1 of 15 patient records reviewed, the organization had not evaluated the patient's progress toward goals. For example, in the chart for RRNHV#5, one problem identified was a knowledge deficit related to safe oxygen use. The problem had been identified upon admission approximately six months prior to the survey, yet the problem remained as an active problem on the Plan of Care. This was discussed with the Director of Nursing.

Observed in Data Session. The organization had not maintained documentation of the quality assessment and performance improvement program and was not able to demonstrate its operation. This was confirmed with the Administrator. Observed in Data Session. The QAPI program did not include all services provided by the organization. There was no data collection related to bereavement or contracted services as confirmed with the Director of Nursing.

Observed in Data Session. The quality assessment and performance improvement program did not demonstrate improvement in the indicators related to improved palliative outcomes and hospice services. There were no documented PI projects over the past year that demonstrated any improvement in palliative measures. This was discussed with the Director of Nursing.

Observed in Data Session. The hospice had not selected performance improvement activities that affect palliative outcomes, patient safety, and the quality of care and that were are based on the prevalence and severity of problems in its high-volume, high-risk, and problem-prone areas. The organization had two active improvement projects active at the time of survey. Both were related to documentation issues. This was discussed with the Director of Nursing.

Observed in Record Review. In 2 of 2 patient records reviewed, the hospice had not developed a bereavement plan of care that specifies the type of bereavement services to be offered and the frequency of service delivery. In the charts for RRBR#14 and RRBR#15, there were no bereavement plans of care. The organization does not have a process to create written bereavement plans of care as confirmed with the bereavement counselor.

Observed in Record Review. In 1 of 2 patient records reviewed, in which aide services were provided, the registered nurse had not supervised the aide during an on-site visit no less frequently than every 14 days. In the chart for RRHV#3, it had been more than 6 weeks since the last documented supervisory visit of the aide as confirmed with the Director of Nursing.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by Condition Level observations at 418.56, 418.58, 418.113, 418.100 and 418.64. This was discussed with the Administrator.

Observed in Document Review. In 4 of 4 contracts reviewed, the written agreement did not include a stipulation that services may be delivered in accordance with the patient's plan of care. This stipulation was missing in the contract for Medical Equipment, Pharmacy and GIP/Repite care. There was no written agreement with the nursing facility. This was discussed with the Administrator.

Observed in Record Review. In 2 of 15 patient records reviewed, before the recertification period, the medical director or physician designee had not reviewed the patient's information. In the chart for RRHV#3, the physician certification of terminal illness for the benefit periods beginning 2 and 4 months prior to the date of the survey still had not been completed by the physician. In the chart for RRNHV#11, the last signed CTI in the chart is from four months prior to the survey. This was discussed with the Director of Nursing.

Observed in Record Review. In 2 of 2 patient records reviewed, when the care of the patient was transferred to another Medicare/Medicaid-certified facility, the hospice had not provided the receiving facility with a copy of the hospice discharge summary and, if requested, a copy of the patient’s clinical record. In the charts for RRDC#12 and RRDC#13 a discharge summary was not provided to the receiving hospital. It was confirmed with the DON that there is not a process to do this when the transfer is initiated by the patient or family.

Observed in Record Review. In 2 of 2 patient records reviewed, in which a live discharge occurred, the hospice discharge summary did not include the following: A summary of the patient’s stay, including treatments, symptoms, and pain management. This was missing in the discharge summary for RRDC#12 and RRDC#13. This was discussed with the DON.

Observed in Record Review. In 1 of 15 patient records reviewed, when a verbal or electronic order was received, the individual who received it did not record and sign it immediately and did not have the prescriber sign it in accordance with state and federal regulations. In the chart for RRHV#1 approximately four months prior to the survey, the RN identified a new pressure ulcer and documented an order was received and care provided, however a verbal order was never documented and sent to the ordering physician. This was discussed with the Director of Nursing.

Observed in Document Review. There was no written agreement that specified the provision of hospice services in the nursing facility. This was confirmed with the Administrator.

Observed in Document Review. In 4 of 4 contracts reviewed, the written agreement did not include 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 stipulation was missing in the contract for Medical Equipment, Pharmacy and GIP/Respite care. There was no written agreement with the nursing facility. This was discussed with the Administrator.

Observed in Record Review. In 5 of 5 patient records reviewed, there were orders for wound care. However, none of the orders included frequencies for cleaning and re-dressing. This was discussed with the Administrator and Director of Nursing.

Observed in Record Review. In 1 of 5 patient records reviewed, the surveyor noted that oxygen was ordered at 3 liters per minute but did not include what type of device to use, nor if it was as needed or continuously in RR#1. This was discussed with the Administrator and Director of Nursing.