Every finding on record at Homestead Hospice of Greenville, LLC

Observed in Record Review. In 8 of 19 patient records reviewed, where the interdisciplinary group met two or more times, the organization did not document changes that occurred since the initial assessment. Interdisciplinary notes did not consistently document patient decline. RRHV#1, RRHV#2, RRNHV#3, RRNHV#4, RRNHV#6, RRNHV#8, RRNHV#9, RRNHV#10. This RFI was reviewed with the Regional Director of Operations and Branch Managers.

Observed in Record Review. In 2 of 19 patient records reviewed, the organization did not ensure that patient records were complete and accurate. For example, in the record of RRNHV#3 an RN documented that the patient had an indwelling catheter in the initial assessment but did not note the size, balloon capacity and date of insertion. And in the record of RRNHV#7 an RN documented in the initial assessment that the patient had ascites causing discomfort and requiring weekly paracenteses but did not address this problem in any further documentation. This RFI was reviewed with the Regional Director of Operations and Branch Managers.

Observed in Record Review. In 19 of 19 patient records reviewed, the organization did not develop plans of care that were based on patient’s goals and the time frames, settings, and services required to meet those goals. In all records reviewed most goals were not specific, measurable, and did not identify targeted dates for completion. For example: Patient/caregiver verbalizes/demonstrates understanding of proper safety measure related to fall prevention; patient demonstrates adequate use of positive coping mechanisms in dealing with hopelessness; patient exhibits reduction/relief of any cardiopulmonary symptom; pain will be maintained at an optimal level. This problem was already identified, and the organization is working with EMR developers to rectify the problem. This RFI was reviewed with the Regional Director of Operations and Branch Managers.

Observed in Record Review. In 6 of 19 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. For example, in the record of RRNHV#2 an RN documented that the patient had an indwelling catheter. In the record of RRHV#3, RRNHV#4, RRNHV#8, and RRNHV#10 RNs documented that the patients were using oxygen. In the record of RRNHV#7 an RN documented that the patient was getting weekly paracentesis. In the record of RRNHV#10 an RN documented that the patient was receiving tube feedings. There were no orders written for these treatments. This RFI was reviewed with the Regional Director of Operations and Branch Managers.

Observed in Patient Home. In 1 of 4 home visits conducted, care was not provided according to the plan of care. During home visit RRHV#4 a CNA shaved the patient’s chin even though it was not part of the aide’s care plan. This RFI was reviewed with the Regional Director of Operations and Branch Managers.

Observed in Patient Home. In 1 of 4 home visits conducted, a CNA did not remove the gloves she wore while giving a bed bath, nor perform hand hygiene before reaching into the clean section of her visit bag during home visit RRHV#4, as required by standard precautions and the Infection Control policy. This RFI was reviewed with the Regional Director of Operations and Branch Managers. Observed in Patient Home. In 1 of 4 home visits conducted, the organization did not implement its infection prevention and control activities. During home visit RRHV#2 a registered nurse used Saniwipes to disinfect a stethoscope, sphygmomanometer, thermometer, and pulse oximeter but did not follow the manufacturer's guidelines for use requiring dwell time of two minutes. This was confirmed by the Branch Manager.. Observed in Patient Home. In 1 of 4 home visits conducted, the organization did not ensure that staff were compliant with standard precautions, regulation or organizational policy. At home visit RRHV#4 the nails of a CNA were observed to be longer than a quarter inch, had overlays, were studded with rhinestones, and did not comply with Hand Hygiene policy IC-15. This RFI was reviewed with the Regional Director of Operations and Branch Managers.

Based on chart reviews, review of the hospice's Emergency Preparedness Program and interview, the hospice failed to identify and assign disaster risk levels at the patient's Notice of Election for the hospice benefit (NOE) for 10 of 11 patient charts reviewed. (Patient #1, #3, #4, #5, #6, #7, #8, #9, #10 and #11) The findings are: Patient #1 On 5/16/2022 from 9:20 AM to 3:50 PM, review of the hospice's Emergency Preparedness Program (EPP) and chart reviews for Patient #1, #3, #4, #5, #6, #7, #8, #9, #10 and #11 revealed there was no documentation for an assessment of the disaster triage level at NOE for Patient #1, #3, #4, #5, #6, #7, #8, #9, #10 and #11 on 9/15/2021. On 5/18/2022 at 2:06 PM, the Administrator verified the findings.

Based on review of the hospice's Emergency Preparedness Program (EPP) and interview, the hospice failed to provide documentation of contact information for staff, physicians, vendors, and other hospice facilities for use in emergency situations. The Finding includes: On 5/18/2022 at 1:33 PM, review of hospice's EPP revealed there was no documentation of contact information for staff, physicians, vendors and other hospices. On 5/19/2022 at 12:25 PM, the Administrator and Regional Director verified the findings.

Based on review of hospice's Emergency Preparedness Program (EPP) and interview, the hospice failed to provide documentation for emergency officials in each county where the hospice is licensed. The findings are: On 5/18/2022 at 1:33 PM, review of the hospice's EPP revealed there was no documentation for emergency official contact in an emergency. The hospice is licensed for every county of the state. On 5/19/2022 at 12:25 PM, the Administrator and Regional Director verified the finding.

Based on chart reviews and interview, the hospice failed to provide evidence of an initial comprehensive assessment completed within 5 days of the patient's notice of election for hospice benefits for 3 of 10 patient charts reviewed for care and services. (Patient #1, #5 and #11). The findings are: Patient #1 On 5/16/2022 at 11:59 AM, review of Patient #1's chart revealed the patient's Notice of Election(NOE) for the hospice benefit was 9/15/2021, and the Registered Nurse's (RN) initial assessment visit was 9/15/2021, Chaplin visit for the initial assessment 9/17/2021, first Interdisciplinary Team (IDT) meeting was dated 9/22/2021, and the Licensed Medical Social Worker's (LMSW)initial assessment visit was 10/7/2021. There was no documentation in the patient's chart of the core members performing an initial comprehensive assessment to determine the patient's/family's needs within 5 days of the patient's NOE, and no documentation that the patient declined visits from the LMSW at NOE. On 5/18/2022 at 2:06 PM, the Administrator verified the finding. Patient #5 On 5/16/2022 at 10:09 AM, review of Patient #5's chart revealed the patient's NOE was 10/28/2021, RN initial assessment visit was 10/28/2021, Chaplin visit for initial assessment was 11/1/2021, first IDT meeting was 11/4/2021, and the LMSW declined. There was no documentation in the patient's chart of the core members performing an initial comprehensive assessment to determine the patient and family needs within 5 days. On 5/18/2022 at 3:08 PM, the Administrator verified the finding. Patient #11 On 5/16/2022 at 2:03 PM, review of Patient #11's chart revealed the patient's NOE was 1/12/2022, RN initial assessment visit was 1/12/2022, Chaplin telephone visit for initial assessment was 1/13/2022, first IDT meeting was 1/19/2022, and the LMSW initial assessment visit was 2/5/2022. There was no documentation in the patient's chart of the core members performing an initial comprehensive assessment to determine patient and family needs within 5 days of the NOE. On 5/19/2022 at 11:20 AM, the Administrator verified the findings.

Based on chart reviews and interview, 1 of 2 applicable (Patient #6) deceased patient record had no documentation that the hospice offered/provided bereavement counseling reflecting the identified needs of the bereaved. 1 of 11 patient records reviewed had no documentation of an initial bereavement risk assessment. (Patient #8) The findings are: Patient #6 On 5/17/2022 at 1:19 PM, review of Patient #6's chart revealed there was no documentation for a post death bereavement assessment or initiation of a bereavement Plan of Care (POC). Patient #6 expired on 9/10/2022. On 5/18/2022 at 1019 AM, the Bereavement Coordinator verified the finding. Patient #8 On 5/17/2022 at 2:52 PM, review of Patient #8's chart revealed there was no documentation an initial bereavement risk assessment for the patient/family. On 5/19/2022 at 9:39 AM, the Administrator verified the finding.

Based on review of the patient charts, review of the hospice Interdisciplinary Team (IDT) sign in data, and interview, the hospice failed to ensure its core members were present at IDT meetings to contribute to the patient's ongoing assessments and care planning process for 5 of 10 patient charts. (Patient #1, #7, #8, #9 and #11) The findings are: Patient #1 On 5/16/2022 at 11:59 AM, review of Patient #1's chart revealed the patient's Plan of Care (POC) for episode 3/14/2022 to 5/12/2022 showed LMSW(Licensed Medical Social Worker) visit schedule was one visit every month for 3 months with 2 Pr Re Nata (PRN) visits. Review of the IDT meeting dated 4/6/2022 revealed there was no documentation that the Licensed Medical Social Worker (LMSW) was present. On 5/18/2022 at 2:06 PM, the Administrator verified the finding. Patient #7 On 5/17/2022 at 1:47 PM, review of Patient #7's POC for episode 8/25/2021 to 10/23/2021, and IDT meetings dated 9/1/2021 and 9/15/2021 revealed there was no evidence the LMSW or Chaplin attended the IDT meetings dated 9/1/2021 and 9/15/2021. On 5/18/2022 at 3:29 PM, the Administrator verified the finding. Patient #8 On 5/17/2022 at 2:52 PM, review of Patient #8's chart revealed for POC for episode 11/25/2021 to 12/17/2021 (revocation) revealed there was no evidence that the Chaplin attended the IDT meeting dated 12/8/2021. On 5/19/2022 at 9:39 AM, the Administrator verified the finding. Patient #9 On 5/17/2022 at 3:26 PM, review of Patient #9's chart revealed the patient's POC for episode 1/26/2022-4/25/2022 revealed there was no evidence that the LMSW attended the IDT meeting dated 1/26/2022. On 5/19/2022 at 11:00 AM, the Administrator verified the finding. Patient #11 On 5/16/2022 at 2:03 PM, review of Patient #11's chart revealed the patient's POC for episode 4/12/2022-7/10/2022 revealed there was no evidence the hospice's Medical Director attended the IDT meeting dated 4/13/2022. On 5/19/2022 at 11:20 AM, the Administrator verified the finding.

Based on review of patient charts and interview, the hospice staff failed to update, revise, and/or maintain an accurate Plan of Care (POC) for 7 of 9 applicable patients. (Patient #1, #2, #3, #5, #9, #10 and #11) The findings are: Patient #1 On 5/16/2022 at 11:59 AM, review of Patient #1's chart revealed the patient's POC for the episode dated 5/13/2022-7/11/2022 revealed the Skilled Nurse (SN) developed goals for Optimal cardiac status, symptom control, identify and avoid stress and fatigue, nutritional needs and adequate hydration with target date 1/16/2022, developed Aide goals for skin integrity and personal care with target date 1/16/2022, and the Interdisciplinary Team (IDT) meeting dated 4/6/2022 revealed IDT goals to provide the patient/family with resources to meet the needs of the patient and maintain appropriate psychological functioning with target date of 1/18/2022. The hospice's staff did not update the patient's POC. On 5/18/2022 at 2:06 PM, the Administrator verified the findings. Patient #2 On 5/16/2022 at 12:31 PM, review of Patient #2's chart revealed the patient's POC for episode 4/21/2022-6/19/2022 had SN goals for nutritional needs, pain free or acceptable level of pain and free from serious fall with target date 12/22/2021. Listed Aide goals for personal care with target date 12/20/2021. IDT meeting dated 4/6/2022 had IDT goals to maintain optimal coping with target date 1/18/2022. On 5/18/2022 at 2:27 PM, the Administrator verified the findings. Patient #3 On 5/16/2022 at 11:25 AM, review of Patient #3's chart revealed the patient's POC for episode 4/15/2022-6/13/2022 had SN goals listed to demonstrate ability to care for dependent patient, demonstrate safe use of home oxygen, and understand fall/injury prevention with target date 4/14/2022. Listed Aide goals were for maintain clean environment, promote healthful environment, promote skin integrity, safe personal care and hygiene, and personal care needs met with target date 11/19/2021. MSW(Master Social Worker) goals to connect with helpful resources target date 1/18/2022. On 5/18/2022 at 2:37 PM, the Administrator verified the findings. Patient #5 On 5/16/2022 at 10:09 AM, review of Patient #5's chart revealed the patient's POC for episode 4/26/2022-6/24/2022 had listed the SN goals comply with lifestyle changes, recognize energy limitations, adapt to lifestyle changes and maintain energy conservation with target date 4/23/2022. The Aide goals listed personal care needs met and neat and clean after aide visit with target date 4/23//2022. On 5/18/2022 at 3:08 PM, the Administrator verified the findings. Patient #9 On 5/17/2022 at 3:26 PM, review of Patient #9's chart revealed the patient's POC for episode 1/26/2022-4/25/2022 had listed SN goals for avoid personal contact, demonstrate proper hand washing, demonstrate ways-maintain airway/breathing pattern and improve/maintain participation in activities with target date 2/4/2022. On 5/19/2022 at 11:00 AM, the Administrator verified the findings. Patient #10 On 5/17/2022 at 3:50 PM, review of Patient #10's chart revealed the patient's POC for episode 4/27/2022-7/25/2022 had no interventions or goals for the SN. The IDT meeting note dated 4/27/2022 had no goals or interventions for the SN. The SN visit schedule beginning week of 4/27/2022 showed 2 visits per week for 14 weeks with 3 visits Pro Re Nata (PRN). On 5/19/2022 at 11:06 AM, the Administrator verified the finding. Patient #11 On 5/16/2022 at 2:03 PM, review of Patient #11's chart revealed the patient's POC for episode 4/12/2022-7/10/2022 showed: Aide goals for personal care needs met and promote safe personal care with target date 4/11/2022. There were no interventions or goals for the SN. Review IDT meeting notes dated 4/27/2022 showed no goals or interventions for SN. SN visit schedule beginning week of 4/12/2022 was 1 visit weekly for 13 weeks with 3 PRN visits. On 5/19/2022 at 11:20 AM, the Administrator verified the finding.

Based on review of the hospice's Quality Assessment and Performance Improvement (QAPI) minutes and interview, the hospice failed to have regular meetings and failed to coordinate QAPI activities in the primary location and the multiple location. The findings included: On 5/19/2022 at 11:33 AM, review of the hospice's QAPI minutes and other data revealed the hospice showed the hospice primary location and multiple location held independent QAPI meetings and data collection separately without coordination of the data holistically. On 5/19/2022 at 1:20 PM, the Administrator revealed "I took over as Administrator in January 2022. We have not had a QAPI meeting since I started as Administrator." When the Administrator was asked about the hospice's Performance Improvement Projects in progress, the Administrator replied, " We don't have any right now. I'm going to get one started for signing paperwork in timely manner."

Based on observation and interview, 2 of 2 Registered Nurses and 1 of 1 Certified Nurse Assistant failed to follow accepted principles of infection control for sanitizing equipment used between patients for 3 of 3 applicable patients. (Patient #1 and #2) 1 of 1 Certified Nurse Assistant (CNA) failed to use accepted principles for infection control for personal care/hygiene for 1 of 1 applicable patient. (Patient #3) The findings included: Patient #1 On 5/17/2022 from 9:50 AM to 10:28 AM, a home observation visit to Patient #1's home was conducted with RN #1. Observations revealed RN #1 used a retractable tape measure to measure the patient's upper arm circumference and then retracted the tape without sanitizing the tape. RN #1 charted on the electronic recording device while holding the electronic device under his/her arm against his/her uniform without sanitizing the electronic device. On 5/17/2022 at 10:24 AM, RN #1 reported confirmed the findings. Patient #2 On 5/17/2022 from 8:40 AM to 9:23 AM, a home visit was conducted to Patient #2's home with RN #2. Observations showed RN #2 used a retractable tape measure to measure the patient's upper arm circumference and retracted the tape without sanitizing the tape. RN #2 failed to sanitize the electronic charting device at the end of the visit. On 5/17/2022 at 9:18 AM, RN #2 verified the finding. Patient #3 On 5/17/2022 between 11:01 AM to 12:09 PM, a home visit to Patient #3's home revealed CNA #1 performing a bed bath for the patient. CNA #1 removed the patient's incontinence briefs and cleaned the patient's perineum area. Then, CNA #1 washed the patient's body except for the patient's face using the same water and washcloth. CNA #1 failed to sanitize the electronic charting device at the end of the visit. On 5/17/2022 at 12:04 PM, when CNA #1 was asked why the patient's bed bath started with patient's perineum area and not the patient's face, CNA #1 replied "Force of habit. go from the dirtiest to the cleanest." On 5/18/2022 at 2:37 PM, the Administrator reported, " I know the RN#1 didn't check him/her(CNA #1) off for that. You go from cleanest to dirtiest."

Based on the hospice's personnel file review and interview, the hospice failed to provide the Bereavement Coordinator(BC) with training specific to grief and loss. The findings include: On 5/18/2022 at 10:19 AM, the Bereavement Counselor revealed he/she started working in the hospice in March 2022. The BC Counselor reported "No one ever told me what to do." On 5/19/2022 at 8:40 AM, review of the BC's personnel file revealed the BC had received no training specific to grief or loss.

Based on chart review and interview, the hospice failed to ensure its Registered Nurses(RN) prepared written patient specific care instructions for the Certified Nurse Assistant (CNA) for 8 of 10 applicable patients. (Patient #1, #2, #3, #4, #5, #8, #10 and #11) The findings included: Patient #1 On 5/16/2022 at 11:59 AM, review of Patient #1's chart revealed there was no specific frequency for CNA tasks. The interventions under "Elimination' required the CNA to "give SSE (soap suds enema) as directed by RN". CNA scope of practice does not allow CNAs to perform enemas. On 5/18/2022 at 2:06 PM, the Administrator reported "No, CNAs do not do enemas". Patient #2 On 5/16/2022 at 12:31 PM, review of Patient #2's chart revealed there was no specific frequency for CNA tasks. On 5/18/2022 at 2:27 PM, the Administrator reported "Should be scheduled for each visit or what the patient or facility wants." Patient #3 On 5/16/2022 at 11:25 AM, review of Patient #3's chart revealed there was no specific frequency for CNA tasks. The interventions under "Elimination" instructed the CNA to "give SSE (soap suds enema) as directed by RN." CNA scope of practice does not allow CNAs to perform enemas. On 5/18/2022 at 2:37 PM, the Administrator verified the finding. Patient #4 On 5/16/2022 at 9:20 AM, review of Patient #4's chart revealed there was no specific frequency for CNA tasks. On 5/18/2022 at 2:57 PM, the Administrator verified the finding. Patient #5 On 5/16/2022 at 10:09 AM, review of Patient #5's chart revealed there was no specific frequency for CNA tasks. On 5/18/2022 at 3:08 PM, the Administrator verified the finding. Patient #8 On 5/17/2022 at 2:52 PM, review of Patient #8's chart revealed there was no specific frequency for CNA tasks. Interventions listed under "Elimination" instructed the CNA to "give SSE (soap suds enema) as directed by RN." CNA scope of practice does not allow CNAs to perform enemas. On 5/19/2022 at 9:39 AM, the Administrator verified the finding. Patient #10 On 5/17/2022 at 3:50 PM, review of Patient #10's chart revealed interventions under "Elimination" instructed the CNA to "give SSE (soap suds enema) as directed by RN each visit." CNA scope of practice does not allow CNAs to perform enemas. On 5/19/2022 at 11:06 AM, the Administrator reported "Each visit!... they do not do enemas." Patient #11 On 5/16/2022 at 2:03 PM, review of Patient #11's chart revealed under "Elimination" interventions that instructed the CNA to "give SSE (soap suds enema) as directed by RN each visit." CNA scope of practice does not allow CNAs to perform enemas. On 5/19/2022 at 11:20 AM, the Administrator verified the finding.

Based on chart review and interview, the hospice failed to assess the family's need for a volunteer for 3 of 9 patient charts reviewed. (Patient #4, #10 and #11) The findings include: Patient #4 On 5/16/2022 at 9:20 AM, review of Patient #4's chart revealed there was no documentation the patient and family were initially assessed for volunteer services. On 5/18/2022 at 2:57 PM at interview, the Administrator reported "I can't find it in the chart" and verified the finding. Patient #10 On 5/17/2022 at 3:50 PM, review of Patient #10's chart revealed there was no documentation the patient and family were initially assessed for volunteer services. On 5/19/2022 at 11:06 AM at interview, the Administrator reported "I can't find it in the chart" and verified the finding. Patient #11 On 5/16/2022 at 2:03 PM, review of Patient #11's chart revealed there was no documentation the patient and family were initially assessed for volunteer services. On 5/19/2022 at 11:20 AM at interview, the Administrator reported "I can't find it in the chart" and verified the finding.

Based on chart review and interview, the hospice failed to provide evidence of advanced directives in the clinical records for 3 out of 11 patients (Patient #3, #4 and #10). The Finding includes: Patient #3 On 5/16/2022 at 11:25 AM, review of Patient #3's chart revealed no documentation for either a Do Not Resuscitate (DNR) or Advanced Directives for hospice staff to follow the patient's individualized choice. On 5/18/2022 at 2:37 PM, the Administrator reported "I can't find a copy in the chart" and verified the finding. Patient #4 On 5/16/2022 at 9:20 AM, review of Patient #4's chart revealed no documentation for either a Do Not Resuscitate (DNR) or Advanced Directives for hospice staff to follow the patient's individualized choice. On 5/18/2022 at 2:57 PM, the Administrator reported "I can't find a copy in the chart" and verified the finding. Patient #10 On 5/17/2022 at 3:50 PM, review of Patient #10's chart revealed no documentation for either a Do Not Resuscitate (DNR) or Advanced Directives for hospice staff to follow the patient's individualized choice. On 5/19/2022 at 11:06 AM, the Administrator reported "I can't find a copy in the chart" and verified the finding.