Every finding on record at Homestead Hospice of Charleston, LLC

Observed in Record Review. In 1 of 2 patient records reviewed, for live discharges, it was noted by the surveyor that for RRDC#1 the Notice of Medicare Non-Coverage (NOMNC) was not provided to or signed by the patient’s Power of Attorney as required prior to discharging the patient for an extended prognosis. Finding was verified by the Branch Director.

Observed in Record Review. In 4 of 10 patient records reviewed, for active patients, it was noted by the nurse surveyor that the bereavement risk assessment was not completed as part of the comprehensive assessment. For RRNHV#1, RRNHV#3, and RRNHV#7 the bereavement risk assessment was not completed at all. For RRNHV#5, the initial bereavement assessment was completed almost two months late. Finding was confirmed by the Vice President of Operations, the Regional Clinical Specialist, and the Branch Manager.

Observed in Record Review. In 10 of 10 patient records reviewed, for active hospice patients the nurse surveyor noted that the goals were not consistently measurable. For example, “Patient/Caregiver will verbalize and demonstrate understanding of skin breakdown,” and “Pain currently managed at level acceptable to patient”. There were no short-term goals at start of care to address issues of immediate needs such as understanding medication management, symptom management, pain management, or safety, most time frames for completion were at end of certification period or did not have a timeframe. Finding was confirmed by the Vice President of Operations, the Regional Clinical Specialist, and the Branch Manager.

Observed in Patient Home. In 3 of 3 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned per policy “Hand Hygiene/Special Considerations” During RRHV#1 the skilled nurse washed her hands in the patient’s sink with soap and water prior to providing care. She then took the patient’s vital signs, documenting at intervals during the assessment, however, she did not hand sanitize between touching the patients and documenting per policy. During RRHV#2 the skilled nurse did not hand sanitize between touching the patient and documenting. He donned gloves to clean his equipment after use but, did not hand sanitize prior to donning or doffing his gloves. The skilled nurse then went to the patient’s bathroom to wash his hands with soap and water. He turned the sink off with his bare hands and used the patient's hand towel to dry his hands. During RRHV#3 the hospice aide hand sanitized in the facility hallway, got linens off the linen cart, and touched the door latch upon entering the patient’s room. She then hung up her bag on a hanger, took her computer out of her bag, opened it up and put it on a barrier on a cabinet in the room and then donned gloves without hand sanitizing. She then provided care for the patient, changed gloves once without sanitizing, completed her care, bagged up the garbage and hand sanitized after removing her gloves when her tasks were completed. Findings were verified by the Branch Manager who was present on the home visits. Observed in Patient Home. In 1 of 3 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned per their “Bag Technique Policy IC.60”. For RRHV#2, the skilled nurse put his dirty equipment (blood pressure cuff, thermometer, pulse oximeter, stethoscope) on a barrier. He then cleaned his equipment and put it back on the barrier where the dirty equipment had been to allow it to dry. Finding was verified by the Branch Manager who was present on the home visit. Observed in Patient Home. In 1 of 3 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned per their policy “Bag Technique IC.60”. During RRHV#1, the skilled nurse put a barrier on the floor and put her bag on the barrier. Finding was verified by the Branch Manager who was present on the home visit.

Observed in Record Review. In 3 of 10 patient records reviewed, for active patients, it was noted by the nurse surveyor that the hospice aide care plan did not include all of the information for the hospice aide to effectively provide care. For RRHV#3, the hospice aide care plan did not address what the hospice aide’s responsibility was regarding the patient’s feeding tube, foley catheter, or wound on her coccyx. Additionally, the patient was on oxygen and there were no instructions to indicate if the patient’s oxygen could be removed for her bath. For RRNHV#2, the hospice aide care plan did not address what the hospice aide’s responsibility was regarding the patient’s colostomy, supra pubic catheter, or wounds. For RRNHV#5, the hospice aide care plan did not address what the hospice aide’s responsibility was regarding the patient’s wounds. Findings were confirmed by the Vice President of Operations, the Regional Clinical Specialist, and the Branch Manager.

Observed in Record Review. In 4 of 10 patient records reviewed, for active patients all of which had the hospice aide, it was noted by the nurse surveyor that hospice aide supervisory visits were not documented the required every fourteen days per regulation. For RRHV#2, there were no documented hospice aide supervisory visits since the patient’s admission approximately two months ago. RRHV#3, there were no documented hospice aide supervisory visits for over two months. For RRNHV#3, there were no documented hospice aide supervisory visits since the patient’s admission approximately six weeks ago, and for RRNHV#5, there were no documented hospice aide supervisory visits since the patient’s admission approximately three months ago. Findings were confirmed by the Vice President of Operations, the Regional Clinical Specialist, and the Branch Manager.

Based on chart review and interview, the hospice failed to ensure the patient's Plan of Care (POC) for new wounds was updated for 1 of 2 applicable patients. (Patient #5) The finding included: Patient #5 On 4/6/2022 at 10:46 AM, review of Patient #5 revealed a Skilled Nurse(SN) note dated 2/7/2022 that showed Patient #4 had developed a wound of the gluteal fold 4.0 cm(centimeters) X(times) 1.0 cm x 0.1 cm. Review of Patient #5's POC revealed there was no documentation about the wound and no orders for wound care. The hospice failed to address and meet the patient's needs based on the new findings of a wound. On 4/7/2022 at 10:11 AM, the Administrator verified there was "nothing in the chart for wound care, and no physician orders."

Based on chart review and interview, the hospice failed to ensure the hospice staff followed the patient's Plan of Care (POC) for weight assessments for 2 of 2 applicable patients. (Patient #7 and #11) The findings include: Patient #7 On 4/6/2022 at 9:07 AM, review of Patient #7's chart revealed the patient was admitted to hospice care on 11/1/2021 with a diagnosis of Congestive Heart Failure. Review of the patient's POC for the episode of care dated 1/31/2022 to 4/30/2022 revealed physician orders for "Skilled Nurse (SN): Patient/caregiver monitors patient's weight and weight changes and reports any weight gain to clinician." Review of the hospice's weight flowsheets for the patient's episode dated 1/31/2022 to 4/30/2022 showed no weights were documented. A review of the skilled nursing visits dated 1/31/2022, 2/7/2022, 2/14/2022, 2/21/2022, 3/2/2022, 3/8/2022, 3/14/2022, 3/21/2022 and 3/28/2022 showed no documentation of the patient's weights. On 4/7/2022 at 10:06 AM, the Administrator revealed "There are no weights documented." Patient #11 On 4/6/2022 at 11:48 AM, review of Patient 11's chart revealed the patient was admitted on 1/25/2022 with a diagnosis of Heart Failure. Review of the physician orders revealed an order to "obtain and document weekly weights." Review of the hospice's weight flowsheets for the patient showed no weights had been documented. Review of the skilled nursing visit documentation dated 1/28/2022, 1/31/2022, 2/4/2022, 2/11/2022, 2/14/2022, 2/25/2022, and 3/23/2022 revealed no documentation of the patient's weights. The finding was verified by the Administrator at 12:10 PM on 4/7/2022.

Based on review of the hospice's Quality Assessment and Performance Improvement (QAPI) data and interview, the hospice failed to develop a program that included one of one multiple location in the hospice's QAPI. The finding includes: On 4/7/2022 at 11:50 AM, review of the hospice's QAPI data revealed the hospice's QAPI program did not include the hospice's multiple location. Each location has a separate QAPI program that tracks separate data. On 4/7/2022 at 12:01 PM, Registered Nurse (RN) #1 revealed "Been doing QAPI for about a month. I do the multiple location in Beaufort. This paperwork looks like ours, but it is the Summerville location QAPI."

Based on review of the hospice's Quality Assessment and Performance Improvement (QAPI) program data and interview, the Governing Body failed to ensure the hospice's QAPI program operated as one program addressing the quality of care and patient safety with a holistic action plan for all locations served by the hospice. The finding includes: On 4/7/2022 at 11:50 AM, review of hospice QAPI data revealed the hospice program in the hospice's primary location does not include the QAPI data at the hospice's multiple location in Beaufort. The primary hospice location tracks different data than the hospice's multiple location. On 4/7/2022 at 12:22 PM, the Administrator revealed "We have 85% (percent) on our audit for PIP for aide supervision in the hospice's primary location. We talk about both programs at our meetings." When the surveyor asked the hospice Administrator what percentage(s) the multiple location had for its PIP for aide supervision, the Administrator was unable to report the percentages for the aide supervision audit in the hospice's multiple location.

Based on observations and interview, 2 of 2 Registered Nurses (RN) failed to follow accepted principles for infection control in the provision of patient care. (RN #2 and #3) The findings include: Patient #2 On 4/5/2022 from 2:00 PM to 2:44 PM, observation during a home visit with Patient #2 revealed RN #2 placed the electronic documentation device and equipment on the overbed table without using a barrier, failed to sanitize the stethoscope after patient use, touched his/her eyeglasses 6 times without performing hand hygiene, failed to sanitize electronic device at the end of the visit, and set the nurse equipment bag on the patient's blanket without using a barrier. On 4/5/2022 at 2:45 PM, RN #2 verified the findings. Patient #3 On 4/5/2022 from 11:55 AM to 12:30 PM, observations during a home/facility visit with Patient #3 revealed RN #3 placed the electronic documentation device on the table without a barrier, inserted his/her hands into the uniform pockets to extract clean gloves and equipment 4 times without performing hand hygiene, placed equipment items on the table without a barrier, retracted a tape measure after use and failed to sanitize the tape measure after use, failed to sanitize the stethoscope after use, and knelt on the floor without a barrier. At the end of the visit, RN #3 sanitized the equipment, placed items into his/her uniform pockets, but failed to sanitize the electronic documentation device after use. On 4/5/2022 at 12:30 PM, RN #3 verified the findings.

Based on patient chart reviews and interview, the hospice failed to ensure its Skilled Nursing staff provided patient specific instructions for the Certified Nurse's Aide's (CNA) assignments for 9 of 9 applicable patients receiving CNA services. (Patient #1, #3, #4, #5, #6 #7, #8, #9, and #11) The findings include: Patient #3 On 4/6/2022 at 12:25 PM, review of Patient #3's CNA assignment form had no written care instructions for frequency of tasks assigned. The CNA assignment revealed "give SSE (soap suds enema) as directed by RN each visit." SSE treatment is not part of the CNA scope of practice. On 4/7/2022 at 9:11 AM. the Administrator reported, "They don't give enemas. That is a mistake." Patient #4 On 4/6/2022 at 10:46 AM, review of Patient #4's CNA assignment form revealed it had no written care instructions for frequency of tasks assigned. The CNA assignment form reads, "Give SSE (soap suds enema) as directed by RN each visit." SSE treatment is not part of the CNA scope of practice. On 4/7/2022 at 10:25 AM, the Administrator verified the finding. Patient #5 On 4/6/2022 at 10:46 AM, review of Patient #5's CNA assignment form revealed it had no written care instructions for frequency of tasks assigned. The CNA assignment form reads, "give SSE (soap suds enema) as directed by RN each visit." SSE treatment is not part of the CNA scope of practice. On 4/7/2022 at 10:11 AM, the Administrator verified the finding. Patient #7 On 4/6/2022 at 9:07 AM, review of Patient #7's CNA assignment form revealed the CNA assignment form had no written care instructions related to frequency of tasks assigned. On 4/7/2022 at 10:06 AM, the Administrator verified the findings. Patient #9 On 4/6/2022 at 2:32 PM, review of Patient #9's chart revealed the CNA assignment form had no written care instructions related to frequency of tasks assigned. On 4/7/2022 at 9:22 AM, the Administrator verified the finding. Patient # 1 On 4/5/2022 at 2:16 PM, review of Patient #1's chart revealed the Aide assignment form had no frequencies for the tasks. The finding was verified by the Administrator at 11:54 AM on 4/7/2022. Patient #11 On 4/6/2022 at 11:48 AM, review of Patient 11's chart revealed the Aide assignment form had no frequencies for the tasks. The finding was verified by the Administrator at 12:10 PM on 4/7/2022. Patient # 8 On 4/6/2022 at 2:46 PM, review of Patient #8's chart revealed the Aide assignment form had no frequencies for the tasks. The finding was verified by the Administrator at 12:08 PM on 4/7/2022. Patient #6 On 4/6/2022 at 3:31 PM, review of Patient #6's chart revealed the Aide assignment form had no frequencies for the tasks. The finding was verified by the Administrator at 11:43 AM on 4/7/2022.