Every finding on record at Horizon Hospice, LLC

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. This standard was not met as evidenced by clinical record review, document review, and interview. In 4 of 19 (21%) clinical records reviewed, the agency did not ensure the initial bereavement assessment was completed as stated by agency policy. Agency policy #C_19A "Bereavement Risk Assessment" in part stated, "The Social Worker completes the initial bereavement risk assessment during the social worker's comprehensive assessment conducted within 5 days of the hospice election." Clinical Record 8: The patient elected hospice care on 06/05/2023. The Medical Social Worker (MSW) completed the MSW comprehensive assessment on 06/09/2023. A clinical record review revealed no documented evidence an initial bereavement assessment was completed. Clinical Record 10: The patient elected hospice care on 03/08/2023. The MSW completed the comprehensive assessment on 03/09/2023. A clinical record review revealed no documented evidence an initial bereavement assessment was completed. Clinical Record 11: The patient elected hospice care on 04/17/2023. The MSW completed the comprehensive assessment on 04/18/2023. A clinical record review revealed no documented evidence an initial bereavement assessment was completed. Clinical Record 17: The patient elected hospice care on 09/08/2022. The MSW completed the comprehensive assessment on 09/12/2022. A clinical record review revealed no documented evidence an initial bereavement assessment was completed. During an interview and a joint review of the records, the Area Executive of Clinical Operations (ACO) contacted the MSW regarding completing the Bereavement Risk Assessment (BRA). The ACO confirmed the bereavement risk assessments had not been completed on Records 8,10,11, and 17.

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes; reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires; [and] no less frequently than every 15 days. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the Registered Nurse (RN) notified the physician of changes in the patient's condition. Clinical Record 1: The patient elected hospice care on 10/07/2022. A physician order dated 11/30/2022 read in part, "Order for emergent PRN visit; purpose of visit catheter hurting patient." The skilled nurse pro re nata (PRN) visit dated 11/30/2023 documented, "Patient requested catheter be removed and no new catheter put in..." There was no evidence of communication with the attending physician regarding removing the Foley catheter without a replacement. Clinical Record 3/Home Visit 3: During the home visit observation on 08/09/2023 with the Medical Social Worker, the patient's caregiver stated, "I called the hospice the other night because my son's feeding tube had blood in it. The nurse told me it would be a couple hours before she could get here and not to feed him until she could check the tube. When she got here, she told me there was nothing she could do, that I should take him to the emergency." A review of the on-call skilled nurse note dated 08/07/2023 stated, "Received a call from mother to report that patient was having blood in feeding tube. Instructed to hold feedings until patient could be assessed. Upon arrival, patient was in bathroom. Upon returning to bed with mother's assist, patient expressed he was tired. Refused vital signs at this time. Encouraged to allow staff to see Peg tube. Visible blood noted in tubing as well as on gauze around tubing, dark red in color. Small amount noted approx. quarter size diameter. Mother encouraged to send to ER to ensure Peg tube placement as well as function with verbal understanding. Reports she would call daughter, who was a nurse, and notify hospice if pt went to ER. Hospice notified to follow-up in am." There was no documented evidence the on-call registered nurse contacted the medical director to inform him of the blood in the feeding tube. A follow-up skilled nurse visit dated 08/08/2023 documented, " Reports incident of blood clots in PEG tube, her granddaughter who is a nurse flushed with coke then warm water. Line is clear this morning. Pt was given 1/2 can of feeding. Tolerated well." There was no documented evidence the skilled nurse notified the physician the patient had blood clots in the PEG tube. During an interview and a joint record review, the Area Executive of Clinical Operations (ACO) confirmed the physician was not notified.

It is required that each patient’s individualized written plan of care includes medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (16%) clinical records reviewed, the agency did not ensure that medical supplies and appliances necessary to meet the patient's needs were included in the plan of care. Clinical Record 17: The patient elected hospice care on 09/08/2022. The initial comprehensive assessment completed by the Registered Nurse (RN) dated 09/08/2022 documented the patient was using Oxygen at 2-4L/NC. The plan of care (POC) dated 09/08/2022 through 12/6/2022 documented "Durable Medical Equipment (DME) and Supplies.. none." The POC did not document oxygen and oxygen supplies with DME and supplies. Clinical Record 18: The patient elected hospice care on 06/22/2023. The initial comprehensive assessment completed by the RN dated 06/22/2023 documented, "the patient had a Foley catheter 16Fr/10cc." The POC dated 06/22/2023 through 09/19/2023 documented "DME and Supplies... none." The POC did not document Foley catheter and catheter supplies with DME and supplies. During an interview on 08/09/2023, the Area Executive of Clinical Operations (ACO) confirmed DME and supplies were not included in the POC.

It is required that each patient’s individualized written plan of care includes the Interdisciplinary Group’s documentation of the patient’s or representative’s level of understanding, involvement, and agreement with the POC. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the patient's or representative's level of understanding, involvement, and agreement with the Plan of Care (POC) was included in the Interdisciplinary Group's documentation. Clinical Record 2: The patient elected hospice care on 10/07/2022. The plan of care (POC) dated 10/07/2022 through 11/16/2022 did not include the Interdisciplinary Group's documentation of the patient's or representative's level of understanding, involvement, and agreement with the POC. The Area Executive of Clinical Operations (ACO) confirmed the finding during a joint review of the clinical record and an interview.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview, and observation. Agency policy "Bag Technique and Standard Precautions" stated in part, "rinse hands well under clean, running water. Dry your hands using a clean towel or air dry them. In 1 of 4 (25%) home visit observations, the agency did not ensure the agency policy on hand hygiene was followed. Home Visit 4: During the home visit observation with the Registered Nurse (RN) [Personnel Record 5] on 08/09/2023, the RN washed their hands using soap and water, then proceeded to dry hands on a towel hanging in the bathroom. The RN did not ask if the towel hanging in the bathroom was clean or used prior to drying hands. During an interview and a review of the home visit, the Area Executive of Clinical Operations (ACO) confirmed the RN did not follow the agency policy.

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review, document review, and interview. Agency procedure, "Wound Management," stated in part, " At each nursing visit...Visualize any known wounds at least 1x/week and more often if required for wound management a. Size-length x width x depth in centimeters. In 1 of 19 (11%) clinical records reviewed, the agency did not ensure that nursing care and services were provided per the patient's plan of care and the agency's wound management procedure. Clinical Record 8: The initial comprehensive assessment dated 06/05/2023 documented the patient had two wounds on the right leg. No wound measurements were documented for the weeks of 06/11/2023, 06/20/2023, and 06/282023 per the agency's wound management procedure. The Area Executive of Clinical Operations (ACO) confirmed the finding during an interview and a joint record review.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the patient's record included an accurate initial plan of care reflective of the patient's comprehensive assessment. Clinical Record 2: The patient was admitted to hospice care on 10/07/2022. The POC dated 10/07/2022 through 11/16/2022 ordered: "SN 1w1,2w5,1w1; HHA effective 10/09/2022 3w5,2w1; CH 1M2." The POC documented: "Orders for Discipline and treatments: Admit to GIP Level of Care... Implement daily hospice staff visits to support the level of care oversight and management... Goals: Patient's physical, psychosocial, and spiritual needs will be assessed and managed through hospice interdisciplinary team care in order to transition patient from GIP Level of Care as soon as symptoms are managed." The attending physician signed the orders electronically on 10/29/2022, and the Hospice physician electronically signed on 10/10/2022. There was no documented evidence that the interventions in the plan of care were based on problems identified in the comprehensive assessment. A clinical record review revealed the patient was to receive routine home care as of the election of hospice care on 10/07/2022. There was no evidence the patient was admitted to the inpatient unit during hospice care. During the joint record review and an interview on 08/08/2023, the Area Executive of Clinical Operations (ACO) stated, " I am not sure what happened, but the patient was never admitted to GIP." On 08/10/2023, the ACO reported that a software glitch occurred, and no one could determine what happened. Page 1 of 2 of the Plan of Care The POC dated 10/07/2022-11/16/2022; Diagnosis Other specified malignant neoplasm of anal skin; Unspecified Dementia Essential Primary Hypertension, Osteoarthritis of hip, Vertigo of central origin. SN 1w1,2w5,1w1; HHA effective 10/09/2022 3w5,2w1; CH 1M2. Orders for Discipline and treatments: "Admit to GIP Level of Care for (blank) (whatever the reason for GIP is. Implement daily hospice staff visits to support the level of care oversight and management. Begin discharge planning. Communicate with Hospice physician and patients' attending physician (if different) for any changes in the plan of care related to GIP. The licensed professional whose signature appears in block 23 attest that the physician orders were received on 10/7/2022. Goals: Patient's physical, psychosocial and spiritual needs will be assessed and managed through hospice interdisciplinary team care in order to transition patient from GIP Level of Care as soon as symptoms are managed. DME and Supplies None, Functional Limitations: endurance, Safety measures: universal precautions, Activities no restrictions Nutritional requirements Regular diet, Advance Directive Do No Resuscitate Mental status forgetful. The Attending Physician electronically signed on 10/29/2022 and the Hospice Physician electronically signed on 10/10/2022. Page 2 of 2 listed the patient's medications.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. 3 of 19 (16%) clinical records reviewed, the hospice did not ensure the patient's clinical record included physician orders for services and treatments provided. Clinical Record 1: The patient elected hospice care on 10/07/2022. A physician order dated 11/30/2022 read in part, "Order for emergent PRN visit; purpose of visit catheter hurting patient." The skilled nurse pro re nata (PRN) visit dated 11/30/2023 documented, "Patient requested catheter be removed and no new catheter put in..." The wound care report dated 11/11/2022 documented the patient had a coccyx unstageable deep tissue injury (DTI). There was no evidence of communication with the attending physician regarding the removal of the Foley catheter without replacement or a physician's order. Clinical Record 13: A physician order dated 06/17/2022 stated in part, “Calendar frequency Chaplain effective 06/10/2022 1M1. There was no evidence that the order was sent to the physician for authentication. The Chaplain visit note dated 07/17/2022 stated in part, " Indicate to whom spiritual support was provided…Patient Spouse… Indicate assessment findings found to be outside of within normal limits "no problems identified." Additional physician orders for Chaplain services dated 07/05/2022, 07/29/2022, and 08/31/2022 documented: Hospice Physician order… Calendar frequency 1m1.” There was no evidence that the orders were sent to the physician for authentication. Chaplain visits were completed on 07/05/2023 and 07/29/2023. Clinical Record 16: On 06/30/2023, the physician ordered, "Emergency prn visit wound care request." The Skilled Nurse (SN) visit noted dated 06/30/2023 documented, "Wound care performed to both lower legs, blisters cleansed with normal saline antibiotic applied, 4x4 gauze and wrapped with kerlix and secured with paper tape." A clinical record review revealed no evidence of communication with the physician or order for wound care. During an interview and a joint record review, the Area Executive of Clinical Operations (ACO) stated, "I agree with your findings for these records."

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed of discharged patients, the agency did not ensure that the discharge summary was sent to the attending physician. Clinical Record 15: The patient elected hospice care on 03/01/2023 and was discharged from the hospice on 04/27/2023 due to hospital admission. A clinical record review revealed no documented evidence that a discharge summary was sent to the patient's attending physician. The Area Executive of Clinical Operations (ACO) reviewed the clinical record on 08/10/2023 and agreed that a discharge summary was not sent to the patient's attending physician.