Every finding on record at Honest Health Care, Inc.

Observed in Record Review. In 1 of 5 patient records reviewed, During RR# 2's patient record it was noted the organization had not ensured the nurse followed organization policy Wound Care Policy that included the admitting clinician to document each wound status to include measurement of length, width, and depth. This was reviewed, discussed, and validated with the Administrator/DPCS.

Observed in Record Review. In 10 of 10 patient records reviewed, the organization failed to ensure the patient right to participate in decisions about their care, treatment, or services was respected. On review of all active patient records there was no documentation that the patient or caregiver was informed of the Patient Notification of Hospice Non-Covered Items, Services, and Drugs as this information could not be located on the record. The Administrator Designee was able to present the addendum form and review the process yet there was no indication the patients were given the information as required.

Observed in Record Review. In 5 of 10 patient records reviewed, the organization failed to ensure the comprehensive assessment was completed no later than 5 calendar days after the election of hospice care. On review of RRHV#1 the patient elected hospice in April and there was no psychosocial assessment documented at time of survey. There was documentation of a spiritual care assessment visit within 5 days yet no documentation of the assessment completed. In RRHV#2, and RRHV#3 there was no documentation of a psychosocial or spiritual assessment. The RN initial comprehensive assessment noted a psychosocial and spiritual screening and documented that a MSW and Spiritual visit was needed yet later orders noted services declined without a psychosocial/spiritual assessment documented. In RRNHV#4, and RRNHV#5 there was no documentation of a psychosocial assessment. These observations were reviewed with the Administrator Designee and the Administrator/DON.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to ensure that a patient specific comprehensive assessment that identified the patient's need for hospice care and services to include severity of symptoms was conducted. On review of RRHV#2 the patient record documentation noted multiple wounds to the heels, ankle, and buttocks. There was no documentation of a comprehensive wound assessment to include details such as size, color, drainage, odor, surrounding skin as required. In RRHV#3 the initial comprehensive assessment noted the patient was uncomfortable because of pain yet there was no comprehensive assessment conducted to assess details such as: type, location, frequency, character, and tolerable level. In RRNHV#5 and RRNHV#9 the patient indicated there was pain yet the pain was not assessed per policy to include highest level, lowest level and patient pain goal as required by policy. In RRNHV#7 there was documentation the patient had a wound yet no comprehensive assessment of the wound as required. In RRNHV#10 the patient was diabetic yet the initial comprehensive assessment the endocrine system assessment was left blank. Further, the plan of care noted orders for daily blood glucose monitoring yet the blood glucose monitoring assessment was not documented by nursing during May. These observations were reviewed with the Administrator Designee and the Administrator/DON.

Observed in Record Review. In 3 of 10 patient records reviewed, the organization failed to conduct and document a patient specific comprehensive assessment that identified the patient’s need for hospice care and services to include bereavement needs. In review of RRHV#1 there was no documentation of an initial bereavement risk assessment being conducted. There was also no documentation of an initial bereavement risk assessment noted in RRHV#2, and RRHV#3. These observations were reviewed with the Administrator Designee, and Administrator/DON.

Observed in Record Review. In 8 of 10 patient records reviewed, the organization failed to ensure the update of the comprehensive assessment was accomplished by the interdisciplinary group as frequently as the condition of the patient required but no less frequently that every 15 days. On review of RRHV#1 and RRHV#2 each IDG meeting every 15 days the updated to the comprehensive assessment was noted to be nearly identical verbiage each update and did not address patient's progress toward desired outcomes nor reassessment of the patient's response to care. In RRNHV#4, RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#9, RRNHV#10 the most recent IDG meeting was incomplete as there was no update to the comprehensive assessment documented. On discussion with Administrator Designee it was noted the meeting was started but delay and would not be completed until Friday after survey leaving a 17 day gap in update to the comprehensive assessment. In RRNHV#9 there was a 42 day gap in documentation of RN visits from March to May. These observations were reviewed with the Administrator Designee, and the Administrator/DON.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to ensure the patient record contain all information to reflect the patient's care treatment and services. On review of RRHV#1 there was documentation of visits by the RN being made with a date and time in and time out conducted in April and other visits conducted in May, per the leadership, but not yet entered into the system. The Initial spiritual assessment by the Chaplain there was visit note with a time in and time out yet the note was blank with no documentation of the assessment. In RRHV#2 the RN documentation for April and May were incomplete as notes had not been entered into the system at time of survey. Per the Administrator Designee the policy is that visit notes must be entered into the record within 72 hours of the visit. These observations were reviewed with the Administrator Designee and the Administrator/DON.

Observed in Record Review. In 8 of 10 patient records reviewed, the organization failed to ensure the individualized written plan of care is based on goals that are specific, measurable, and time bound. On review of RRHV#3 there were goals that were noted to not be specific and measurable such as: Pt will report BP within acceptable range. In RRNHV#4 an example was Promote rest status for pt/family/PCG and Blood sugar management for patient comfort. Further all goals were noted to have a target/achieve by date of the end of the certification period. In RRNHV#5 an example was Pt/Family/PCG will verbalize understanding that symptom is a part of the disease process and the limitations of treatments and Reduce discomfort with improved bowel elimination status. Further examples can be seen in RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#9, and RRNHV#10. These observations were reviewed with the Administrator Designee and Administrator/DON.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to ensure the patient/primary caregiver receive education and training as appropriate to their responsibilities for the care and services identified in the plan of care. On review of RRNHV#5 there was a pain medication Norco added yet there was no documentation in the record that the patient/caregiver was educated on the medication to include indication, dosage, frequency, route, and potential side effects. On review of RRNHV#9 the patient was prescribed Lactulose and Norco that were documented in a communication note yet there was no documentation that the patient/family was educated on the new medications. In RRNHV#10 the patient was diabetic and there were orders for blood glucose monitoring yet no documentation the patient was educated on diabetes, hypo and hyperglycemia or on blood glucose monitoring to include return demonstration. These observations were reviewed with the Administrator Designee and the Administrator/DON.

Observed in Record Review. In 4 of 10 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRNHV#5, and RRNHV#6 the patient was being seen by the MSW yet there was no psychosocial care plan established to guide the care. In RRNHV#7 and RRNHV#8 the Chaplain was visiting the patient but no spiritual care plan had been established. These observations were reviewed with the Administrator Designee.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRNHV#4 the patient was getting aide services yet there was no order for aide services as part of the plan of care. This observation was reviewed with the Administrator Designee.

Observed in Record Review. In 5 of 10 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRHV#1 the nursing document noted that the patient was taking Acetaminophen 500mg for pain however there were no physicians orders for the medication noted on the patient's plan of care. Further in RRHV#1 home observation there was a pressure dressing to the patient's right antecubital space and when questioned the caregiver noted it was for a lab draw for a Divalproex level yet there were no physicians order nor was the lab indicated on the plan of care. In RRNHV#7 there was an order for wound care that was incomplete as it had no location indicated. Further, there was an order for diclofenac gel that did not have a dosage of location or where to apply the gel. In RRNHV#8 the patient was diabetic, and nursing was documenting blood glucose monitoring yet there were no orders on the plan of care for the monitoring. In RRNHV#9 there were multiple pain medications ordered as needed (Naproxen, Ibuprofen, and Norco) yet there were no specific instructions to guide the patient on when to use which medication. In RRNHV#10 the patient was ordered oxygen 2-5 lts as needed but no specific instruction of how to choose the liter flow. These observations were reviewed with the Administrator Designee and the Administrator/DON.

Observed in Record Review. In 4 of 10 patient records reviewed, the organization failed to ensure the care and services were provided in accordance with the plan of care. On review of RRHV#1 the skilled nurse was order 1 time a week per the plan of care yet there was no visit documented on week 4 of April. In RRNHV#7, RRNHV#8, and RRNHV#9 the Chaplain was ordered a frequency of monthly yet there were no visits documented in May. These observations were reviewed with the Administrator Designee and Administrator/DON.

Observed in Record Review. In 3 of 10 patient records reviewed, the organization failed to ensure the ongoing sharing of information between all disciplines. In review of RRNHV#4 there was documentation in the record that the patient barely slept, and became loud and aggressive yet there was no documentation that the change in patient condition was reported to the physician. In RRNHV#5 on admission the documentation noted the patients pain 10/10 and indicated the current pain medication was not working yet there was no documentation the physician was informed of the patient's pain. In RRNHV#8 the documentation from the RN noted a blood glucose of 356 but no documentation that the physician was informed of the issue. These observations were reviewed with the Administrator Designee.

Observed in Tracer Activities. the organization failed to routinely provide substantially all core services directly by hospice employees. On review of the organizations W2's it was noted that hospice had 3 contracted 1099 registered nurses, and 2 contracted 1099 Licensed Vocational Nurses that were providing patient care. There was no documentation of any extraordinary circumstances or other nonroutine circumstances. This observation was reviewed with the Administrator Designee and the Administrator/DON.

Observed in Record Review. In 2 of 2 bereavement records reviewed, the organization failed to develop a bereavement plan of care that noted the kind of bereavement services to be offered and frequency of service delivery. On review of RRBR#1 and RRBR#2 there was no bereavement plan of care that noted the services to be offered and the frequency of service delivery. This observation was reviewed with the Bereavement Coordinator.

Observed in Patient Home. In 1 of 1 home visits conducted, with the spiritual counselor, the organization failed to ensure the patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. On home observation with the spiritual counselor (SC) at RRHV#3 the visit was the SC's first visit and was to conduct an initial spiritual assessment. On observation the SC provided prayer only and did not inquire with the caregiver to assess for any spiritual needs. This observation was reviewed with the Spiritual Counselor and the Administrator/DON.

Observed in HR File Review. In 1 of 1 HR files reviewed, for the hospice aide, the organization failed to ensure the hospice aide receive at least 12 hours of in-service training each 12 month period. On review of HR#9 for the hospice aide there was only documentation of 9 hours of in-service training over the last 12 months. This observation was reviewed with the Administrator/DON and the Administrator Designee.

Observed in Record Review. In 1 of 1 patient records reviewed, receiving aide services, the organization failed to ensure the registered nurse prepare written patient care instructions for the hospice aide. On review of RRNHV#4 the aide had documented 2 patient visits conducted yet on the aide plan of care there were no tasks assigned except to report pain to RN. This observation was reviewed with the Administrator Designee and the Administrator/DON.

Observed in Record Review. In 1 of 1 patient records reviewed with hospice aide services, the organization failed to ensure the registered nurse supervises the hospice aide during an on-site visit to the patient’s home no less frequently than every 14 days. In review of RRNHV#4 there was no documentation of an aide supervisory visit. There was a gap of 15 days from the first aide visit to the date of survey. This observation was reviewed with the Administrator Designee.

Observed in Tracer Activities. Upon review of all tracer activities, it was noted that there was a pattern of staff failing to follow established organization policy and the governing body/leadership did not ensure that the Conditions of Participation for 418.100, 418.104, 418.116, 418.64, 418.54, and 418.56, were met per policy as determined through observations, documentation, and staff interviews.

Observed in Record Review. In 5 of 10 patient records reviewed, the organization failed to ensure the medical director review the clinical information for each hospice patient and provide written certification. On review of RRHV#3 the Initial Certification of Terminal Illness (CTI) had not been completed with a written narrative to certify the patient's life expectancy is six months or less if the illness runs its normal course. In RRNHV#6 the Initial CTI physician's narrative lacked all required elements as it read Based on the MD Face to Face encounter and RN assessment, patient meets the LCD guidelines for hospice services and is appropriate for hospice services. Further decline is anticipated due to poor prognosis. Continue with the plan of care. Similar narratives that lacked required elements were seen in RRNHV#7, and RRNHV#10. In RRNHV#9 the physicians narrative read like a nursing note that noted services needed but lacked required elements to establish eligibility. These observations were reviewed with the Administrator Designee.

Observed in Patient Home. In 2 of 3 home visits conducted, where medication reconciliation was conducted, the organization failed to ensure the patient record contain all information to reflect the patient's care, treatment, and services. On home observation of the medication reconciliation for RRHV#1 the medication profile did not match the profile and physicians orders per the hospice plan of care. In the plan of care the patient was taking Divalproex 125 mg daily, yet in the home and on home profile the patient was getting 2 tabs daily (1 in the AM and 1 in the PM). Quetiapine 50 mg was ordered daily at bedtime yet in the home the patient was getting 1/2 tab in the AM and 1 1/2 tab in the PM. In RRHV#3 during medication reconciliation there were medications that were being administered by the caregiver differently than that of the Plan of care. The caregiver noted the patient was no longer taking Calcium + D, and was taking Losartan 1 tab as opposed to 1/2 listed in the record. She also stated the Memantine was given 2 times a day and not daily as ordered. She noted the changes took place approximately 2 months ago. These observations were reviewed with the Administrator Designee, and The Administrator/DON.

Observed in Record Review. In 10 of 10 patient records reviewed, the organization failed to ensure that all entries in the patient record were legible, clear, complete, and appropriately authenticated and dated in accordance with the organization’s policy and currently accepted standards of practice. In all active patient records reviewed it was noted that most all entries were in various stages of submission status and therefore not completed and were not electronically signed and dated as part of the record. In RRNHV#4 it was noted that the election of Benefits was signed by the patient representative and hospice representative yet was not dated. These observations were reviewed with the Administrator Designee.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to maintain complete and accurate patient records. On review of RRHV#3 the patient record noted the patient was a full code yet there was a signed POLST stating the patient was a DNR. In RRNHV#4 there was RN documentation that appeared nearly identical to the initial assessment documentation to include stating that the consents were signed during the visit however the visit took place 2 weeks after the admission start of care visit. These observations were reviewed with the Administrator Designee.

Observed in Record Review. In 1 of 1 patient records reviewed, for extended prognosis the organization failed to operate and furnish service in compliance with all applicable Federal, States, and local laws and regulations. On review of RRDC#1 the patient was discharged for extended prognosis and there was no Notice of Medicare Non-Coverage (NOMNC) form noted on the patient record. On discussion with the Administrator Designee the organization was not aware of the requirement to provide the NOMNC.

Observed in Infection Control Tracer. On review of the written infection control plan it was found that the hospice had identified 3 priority risks , COVID, Flu, and wound infections, however, they had not established, in writing, goals for these risks. This was confirmed by the Administrator/DON

Observed in Individual Tracer. In 1 of 4 patient records reviewed, it was found that orders could not be validated for the wound care. For example, the nurse on one visit of seven home visits from July 2022 to the middle of August 2022 , had not documented the specific wound care provided. The RN had documented wound treatment done. There was no further documentation found that identified the exact wound treatment that had been provided, and orders had been followed. The patient was seen weekly by nursing. This was validated by the LVN reviewing the record with the surveyor.

Observed in Tracer Activities. During a review of the Emergency Management Plan, the surveyor noted the Hazard Vulnerability Analysis (HVA) presented was identified as a generic 'tool' with a list of possible hazards that would require disaster planning. The organization had not individualized the HVA to represent an assessment of the population and community based needs they might encounter. The organization had also not prioritized any risks into an emergency plan. This was validated by the Administrator and Director of Patient Care Services.

Observed in Tracer Activities. During a review of the Emergency Management Plan, the surveyor noted the agency had not conducted an annual disaster drill as required by their emergency plan to evaluate the effectiveness of the plan's objectives, scope and performance. The last completed drill was documented in 2020. This was validated by the Administrator and Director of Patient Care Services.

Observed in Record Review. In 2 of 8 patient records reviewed, the orders had been incomplete. for example, in HV RR #1, there had been an order for Gentamicin 0.1% ointment Apply to affected area every other day with dressing changes. The order did not specify who was to apply the ointment, and the specific area. The same record had wound care orders which did not specify who was to change the dressings. This was validated with the Administrator and Director of Patient Care Services.

Observed in Patient Home. The surveyor observed the Licensed Vocational Nurse (LVN) perform wound care that had not followed the most current physician orders. For example, during HV #1, physician order for wound care to L trochanter- place a silicone bordered foam over the closed wound. The LVN did not perform any care to the area and left the wound open to air. The care to the right lateral foot and L great toe was ordered: Cleanse wound with sterile wound cleanser, put dry calcium alginate and medihoney, ABD pad, roll gauze. The LVN was observed to cleanse the wound with sterile normal saline, applied gentamicin ointment, then placed Alginate, ABD pad, and covered with roll gauze. Of note, the plan of care wound care orders were also inaccurate related to the most current orders; however, the LVN had not followed these orders either. This was validated with the Director of Nursing present for the visit.

Observed in Tracer Activities. The surveyor was unable to identify evidence of the Governing Board (GB) involvement and oversite of the QAPI program. The GB had not approved the overall QAPI program, and there were no GB meeting minutes to validate the GB was involved in the QAPI program. The QAPI program approval and all meeting minutes were signed by the only by the person performing the QAPI activities. This was validated by the Administrator and Director Of Patient Care Services.

Observed in Tracer Activities. The organization had not developed a data driven performance improvement program, hence leadership had not set priorities for data collection. The organization had not identified any performance improvement projects for the current calendar year, other than monitoring for falls and adverse medication events. The data collection for the two monitored items had not been documented on a regular basis to reflect ongoing QAPI evaluation and intervention. This was validated by the Administrator and Director of Patient Care Services.

Observed in Patient Home. In 2 of 3 home visits conducted, the clinicians had not followed CDC guidelines and agency Hand Hygiene policy No. 9-009.2. During HV#1, the clinician had been observed to don and doff procedure gloves without hand decontamination 4 times. The same clinician completed wound care to 4 different wound sites (1 on left hip, 2 on right foot, and 1 on left foot), touched the patient’s skin around coccyx and then moved to a clean body site, all without changing gloves or disinfecting hands. During the same visit, the clinician utilized a cellular phone (3 times) to photograph the wounds, touching the phone with dirty gloves and returning it to his pocket without disinfecting the phone. During HV #3, the clinician had not disinfected his hands before and after removing procedure gloves. This was validated with the Director of Nursing present during the visit. Observed in Patient Home. The Home Health Surveyor observed the organization had not implemented the infection prevention and control activities it had planned according to Bag Technique Policy No. 9-014.1. During HV #1, the clinician was observed reaching into the clinical bag five times without first disinfecting his hands. This was validated with the Nursing Director onsite during the visit.

Observed in Tracer Activities. The hospice nurse surveyor noted the organization had an infection risk assessment that had no elements specific to the agency, including: name, date completed nor specific infection risks identified related to the population and community they serve. The document was identified as a guidance tool only. This was validated by the Administrator and Director of Patient Care Services.

Observed in Record Review. the surveyor noted the Hospice Aide orders for RR #5 were for a shower; however, the patient was documented as bedbound and there had been no orders to get patient out of bed nor method of transfer. This was validated by the Administrator and Director of Patient Care Services.

Observed in Tracer Activities. During a review of the agency Governing Board (GB) Meetings, the surveyor noted the organization had not completed GB meeting minutes and could not validate GB meeting agendas and dates. There had been intermittent sign in sheets dated back 2 years ago; however, there was no supporting minutes. There had been no available documentation the GB had appointed the administrator who was responsible for all day-to-day operations of the organization, the Director of Patient Care Services, the Policy and Procedure manual, Infection Control plan, Emergency Management plan, and QAPI plan. This was validated by the Administrator and Director of Patient Care Services. Observed in Tracer Activities. The agency had multiple Condition Level Findings which requires leadership involvement and oversite. The findings are: LD.03.07.01 EP5 COP: 418.58 L560; RC.02.01.01 EP2 COP(s): 418.104 (a)(3) L670 and L 674; EM.01.01.01 EP3 COP(s): 418.113 (a) (2) E-006, 418.113 (b)(1) E-0011, 418.113 (d)(3)(iii) E0039; and IC.02.01.01 EP2 COP(s):418.60 L577.

Observed in Patient Home. In 2 of 3 home visits conducted, the clinical record had not contained a complete list of the medications. For example during HV #2, the medication profile was missing the medications actively used by the patient: Alieve Ointment, Melatonin 5mg, Alka-Seltzer for pain and gas, Diclofenac 75 mg 1 tab 2 times per day for back pain, Dulcolax pink, Amlodipine 10 mg 1 tab once a day, Phillips laxative caps (magnesium 500mg), Leg and Back pain relief cream (containing Belladonna). Observed in Record Review. In 5 of 8 patient records reviewed, The surveyor noted the documentation in the patient record of care had not been updated or had been inaccurate. For example during HV RR#1, the clinician had documented weights for the patient; however, the patient was contracted and bed bound. HV RR #3 multiple notes include supervisory visits completed for hospice aide care, but the patient did not have a hospice aide, and the record documented family refusal of hospice aide services. HV RR #3 and RR #5 Interdisciplinary Group notes (IDG) for the Spiritual, Psychosocial and Other/Physician were all duplicate for 6-9 consecutive meetings. RR #4, the most recent IDG had orders to provide wound care; however the RN who saw the patient 2 days prior to the IDG documented 'no open areas'. RR #5 the surveyor noted the Hospice Aide documented that the patient had been given a shower; however, the patient was documented as being bedbound. This was validated by the Administrator and Director of Patient Care Services.

Observed in Record Review. In 2 of 3 patient records reviewed, of patients receiving wound care, the surveyor had not been able to validate whether wound care orders were followed as the clinician had not documented the actual wound care provided to the patient. For example, in HV #1 and RR #4 The clinicians only documented “Wound care treatment as follows” on each patient visit. This was validated with the Director of Nursing.

Observed in Record Review. The surveyor noted during RR #6, the patient had been discharged and a follow up treatment plan had not been identified or communicated to the physician who would be continuing to provide patients care. This was validated with the Administrator.

Observed in Patient Home. In 3 of 3 home visits conducted, the admission folder in the patients home had not been completed to support the development of an individualized emergency and safety plan. During HV #1, HV #2, and HV #3, the admission folder had no information about an emergency plan available to the patient and caregiver. For example, patients for HV #1, and HV #2 were both bedbound and contracted which might hinder a safe and rapid response to an emergency, and yet the emergency plan for safe evacuation had not been completed, including what to do in the event of an emergency/ power loss. This was validated by the Administrator and Director of Patient Care Services.