Every finding on record at Hope & Peace Hospice

Observed in Record Review. In 1 of 14 patient records reviewed, During HV#1 record review it was noted a completed individualized disaster form in the patient home, however the medical record lacked a copy of the document. This was discussed with the QAPI Coordinator.

Observed in Record Review. In 4 of 14 patient records reviewed, During HV#3 record review it was noted lack of interventions on the POC related to the primary terminal diagnosis of Alzheimer's disease. In addition there were lack of interventions added to the POC for the visit frequency established for the MSW and SC. During RR#2 it was noted lack of interventions on the POC for the MSW and the SC. During RR#4 it was noted on the POC respiratory section an intervention to educate Pt/Family/PCG on safety measures re: oxygen use, storage/placement of fire extinguishers related to oxygen use. The POC lacked an order for oxygen therapy. During RR#7 it was noted lack of interventions on the POC related to the primary terminal diagnosis of Parkinson's disease This was discussed with the QAPI Coordinator. Observed in Record Review. In 2 of 14 patient records reviewed, During HV#2 record review it was noted the patient was prescribed Pradaxa 150 mg twice a day without interventions added to the POC related to S/S bleeding and bleeding precautions. In addition the patient had a suprapubic urinary catheter in place, however the POC lacked interventions related to the patient GU clinical findings. During RR#6 it was noted lack of interventions established on the POC for the SN for an admission 17 days prior. This was discussed with the QAPI Coordinator and the DPCS.

Observed in Record Review. In 7 of 14 patient records reviewed, During HV#1, HV#3, RR#4 and RR#5 record reviews it was noted the following frequency of visits for the MSW and Spiritual Counselor (SC): one time then PRN without the number or reason for PRN visits. During Live D/CRR#1 it was noted the MSW and SC did not follow the ordered frequency of visits of once a month. From February 2023 to December 2023 the MSW missed visits in October and November 2023. The SC missed visits in May 2023, August 2023, and October 2023. There was lack of documentation in the MR of the reason for the missed visits. During Live D/CRR#2 it was noted the frequency of visits was not followed by the SC of a visit once a month. There was one visit documented after the initial SC encounter in May 2023-November 2023. During RR#2 it was noted the MSW frequency was; As needed and Recert and SC: per Month + 1 PRN Visits. The orders lacked the number of RPN visits for the MSW and the reason and the SC lacked the reason for the PRN visits. There was lack of SC visits monthly after the initial visit from September 2023-August 2024. This was discussed with the QAPI Coordinator.

Observed in Record Review. In 1 of 14 patient records reviewed, During RR#5 it was noted the medication profile listed 2 medications for moderate to severe pain without an indication which to take first. Oxycodone/acetaminophen 5mg/325mg every 6 hours as needed for moderate to severe pain and oxycodone/acetaminophen 10mg/325 mg every 6 hours for moderate to severe pain. This was discussed with the QAPI Coordinator and the DPCS.

Observed in Record Review. In 5 of 14 patient records reviewed, During BR#1RR, it was noted the MSW and spiritual counselor (SC) had interventions entered on the POC that were established by the RN at the time of the initial evaluation visit. There was lack of documentation that the RN coordinated with the SC or MSW to establish the interventions on the POC. During BR#2RR, it was noted the SC and MSW disciplines were declined by the patient/family during phone calls. The RN entered SC and MSW interventions to the POC without documentation of collaboration with the MSW or SC. During Live D/C#1 it was noted the RN added MSW and SC interventions to the POC during the initial evaluation. There was lack of documentation of collaboration with the MSW or the SC by the RN when establishing the interventions. During RR#3 it was noted MSW and SC visits were declined. The POC had interventions and goals related to psychosocial/emotional issues and spiritual issues that were documented by the RN at the initial RN assessment. There was lack of documentation of MSW and SC collaboration with the RN on established interventions. During HV#1 record review it was noted clinical findings documented on a comm note the beginning of July 2024 that the patient had developed diarrhea, potential dehydration and need to increase blood glucose monitoring (BGM) to twice a day were not updated on the POC. This was discussed with the QAPI Coordinator and the DPCS.

Observed in Record Review. In 2 of 14 patient records reviewed, During RR#3 it was noted an order for aide services twice a week for one month in August of 2023. There was an aide visit documented the beginning of June 2024 without an order. During RR#6 it was noted lack of clinical nursing interventions and goals on the POC however there were 2 SN visits provided to date without an IDG POC established. This was discussed with the QAPI Coordiantor.

Observed in Leadership Session. It was noted during the survey lack of evidence that the governing body and leadership had established processes to support patient care treatment and services through sustained compliance as evidenced by conditional deficiencies scored at 418.56 and 418.100. This was discussed with the organization leadership.

Observed in Document Review. During review of the therapy contract it was noted it included physical therapy services, however it lacked occupational therapy (OT) and speech therapy (ST) services. This was discussed with the QAPI Coordinator.

Observed in Document Review. During review of the contract for physical therapy, it was noted since it was a contract for home health therapy services, it lacked the stipulation that the care would be delivered in accordance with the hospice POC. This was discussed with the QAPI Coordiantor.

Observed in Patient Home. In 2 of 14 patient records reviewed, During HV#2 it was noted some of the medications on the medication profile did not match the medication bottle labels reviewed. This included Amlodipine 5 mg on the medication profile, and the med bottle directions were 10 mg, carbamazepine 200mg, 2 tabs twice a day on the med profile and 2 tabs 3x/day on the med bottle, Ibuprofen 200mg, 1 tab every 4-6 hours PRN mild pain on the profile and 1-2 tabs every 4-6 hours on the med label, Levetiracetam (Keppra) 1000mg tabs, take 1/2 tab twice a day, the med label was take 500mg, 3 tabs twice a day, and stool softener 100mg 2 caps once a day as needed on the label and 100mg 1 cap, 2-4 every day as needed on the medication profile. In discussion with the SN during the visit the RCFE caregiver administers the medications according to the bottle labels. The medication profile in the EMR was corrected during the survey. During RR#6 it was noted the medication profile in the medical record was blank, 15 days after the initial RN assessment. In discussion with the RN, it was stated the patient had medications ordered and medications in the home. This was corrected during the survey. This was discussed with the QAPI Coordiantor.

Observed in Record Review. In 1 of 1 patient records reviewed, for a patient discharged due to hospitalization, it was noted in RR#2 the patient was transferred to the hospital as a full code for treatment. There was lack of documentation that the inpatient facility was provided with a discharge summary that included the reason for the patient’s discharge or transfer, and a summary of care, treatment, or services it provided to the patient. This was discussed with the QAPI Coordinator and DPCS.

Observed in Emergency Management Session. In 4 of 14 patient records reviewed, During review of the organization emergency management plan it was noted the HVA for 2024 identified the following natural disasters: earthquakes, wild fires, drought and heat wave in the geographic areas served. The admission packet education section lacked patient education on drought, heat wave and wild fire mitigation and preparedness strategies. During HV#2 it was noted lack of an individualized disaster form in the home or in the medical record. During HV#3 it was noted the individualized disaster form was blank except for the patient name and allergies. During RR#6 it was noted the disaster preparedness form was blank except for name, allergies and one contact number.This was discussed with the QAPI Coordinator.

Observed in Document Review. During reivew of the physical therapy contract it was noted it lacked a stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This was discussed with the QAPI Coordiantor.