Every finding on record at Hospice by the Sea

Based on interview and record review, the agency failed to have a log to track patient complaints. As a result, there was the risk of the agency not addressing patient complaints. Findings: On 7/13/22 at 2:23 P.M., a telephone interview was conducted with the DPCS. The DPCS stated, the agency was unable to find their grievance log. On 7/14/22 at 9:15 A.M., a telephone interview was conducted with the DPCS. The DPCS stated, a grievance log was needed to track patient concerns. Per the agency's undated policy, titled Complaint Resolution, " ...Appropriate personnel conduct and document an investigation of all written or verbal complaints received by the hospice ...9. Complaints are tracked and regularly reviewed to identify patterns or trends and performance improvement opportunities ..."

Based on interview and record review, the facility failed to complete home visits per the plan of care for five of eleven sampled patients (1, 2, 4, 6, and 10). As a result, the patients did not receive the number of visits ordered by the physician in order to address patient care needs. Findings: 1. Per the agency's Plan of Care for certification period from 4/24/22 through 6/22/22, Patient 1 was admitted to the agency on 6/28/21 with a diagnosis of Parkinson's disease (a movement disorder). Patient 1 had an order for one CHHA visit per week for nine weeks. On 7/12/22 at 2:48 P.M., a concurrent interview and record review was conducted with the OM. The OM stated, on 6/1/22, a CHHA visit was documented as refused for Patient 1. The OM further stated, there was no documentation to indicate the physician was notified. On 7/13/22 at 1:35 P.M., a telephone interview was conducted with CM 1. CM 1 stated, when a CHHA was not able to complete a visit, the CHHA notified him some of the time, but he did not document anything. On 7/13/22 at 2:23 P.M., a telephone interview was conducted with the DPCS. The DPCS stated, when a CHHA visit was refused, the CHHA should have notified the CM, the CM should have notified the physician of the missed visit, then the CM should have documented a communication note explaining why the visit was missed, and that the physician was notified. The DPCS further stated, the agency did not have a policy on missed visits. 2. Per the agency's Plan of Care for certification period from 5/11/22 through 7/9/22, Patient 2 was admitted to the agency on 11/17/20 with a diagnosis of atrial fibrillation (a heart disorder). Patient 2 had an order for 1-2 SW visits per month. On 5/25/22 an order was written for SW 4 to follow up with Patient 2 in June 2022. On 7/12/22 at 2:48 P.M., a concurrent interview and record review was conducted with the OM. The OM stated, there was no documentation in Patient 2's medical record to explain why the SW visit was not completed in June 2022. On 7/13/22 at 2:23 P.M., a telephone interview was conducted with the DPCS. The DPCS stated, SW 4 should have entered a communication note to explain why the visit was missed in June 2022, and the CM should have documented that the physician was notified of the missed visit. The DPCS further stated, the agency did not have a policy on missed visits. 3. Per the agency's Plan of Care for certification period from 5/5/22 through 8/2/22, Patient 4 was admitted to the agency on 2/4/22 with a diagnosis of heart disease. Patient 4 had an order for two visits per week for twelve weeks, starting on the week of 5/8/22. On 7/12/22 at 2:48 P.M., a concurrent interview and record review was conducted with the OM. The OM stated, on 5/30/22, a CHHA visit was documented as refused for Patient 4. The OM further stated, there was no documentation to indicate the physician was notified. On 7/13/22 at 1:35 P.M., a telephone interview was conducted with CM 1. CM 1 stated, when a CHHA was not able to complete a visit, the CHHA notified him some of the time, but he did not document anything when that happened. On 7/13/22 at 2:23 P.M., a telephone interview was conducted with the DPCS. The DPCS stated, when a CHHA visit was refused, the CHHA should have notified the CM, the CM should have notified the physician of the missed visit, then the CM should have documented a communication note explaining why the visit was missed, and that the physician was notified. The DPCS further stated, the agency did not have a policy on missed visits. 4. Per the agency's Plan of Care (POC) for the certification period from 4/18/22 through 7/16/22, Patient 6 was admitted to the agency on 4/18/22 with diagnoses which included protein-calorie malnutrition. Per the POC, the Certified Home Health Aide (CHHA) was to visit the patient twice a week for 13 weeks. A review of Patient 6's clinical record was conducted. The CHHA visited Patient 6 one time the week of 6/19/22 through 6/25/22, and the CHHA did not visit Patient 6 the week of 6/26/22 through 7/1/22. There was no documented evidence that the physician was aware of the missed visit. On 7/11/22 at 8:45 A.M., an interview was conducted with CHHA 1. CHHA 1 stated she did not see Patient 6 for two weeks, and the agency was aware that she could not complete the POC. On 7/13/22 at 2:10 P.M., a joint interview and record review was conducted with Case Manager (CM) 2. CM 2 stated the assigned CM should have notified the physician when visits were not provided to the patient per the POC. CM 2 said she did not inform the physician of the missed visit and should have been, so the physician could have modified the POC. 5. Per the agency's Plan of Care (POC) for the certification period from 5/12/22 through 8/9/22, Patient 10 was admitted to the agency on 5/12/22 with diagnoses which included nonrheumatic aortic stenosis (heart valve disease). Per the POC, the Medical Social Worker (MSW) was to visit the patient once to twice a month. A review of Patient 10's clinical record was conducted. There was no documented evidence that the MSW visited Patient 10 in June. On 7/14/22 at 9:30 A.M., an interview was conducted with the Director of Patient Care Services (DPCS). The DPCS stated the MSW did not visit Patient 10. The DPCS further said the MSW should have entered a communication note to explain why the visit was missed in June 2022, and the CM should have documented that the physician was notified of the missed visit. The DPCS further stated, the agency did not have a policy on missed visits.

Based on interview and record review, the agency failed to ensure the Licensed Vocational Nurses (LVN) were supervised by the Registered Nurse (RN) at least bi-monthly per the agency's policy for 2 of 11 sampled patients, Patient 6 and Patient 9. As a result, the agency could not ensure the LVN followed the patient's plan of care. Findings: 1. Per the agency's Plan of Care for certification period from 4/18/22 through 7/16/22, Patient 6 was admitted to the agency on 4/18/22 with diagnoses which included protein-calorie malnutrition. The Skilled Nurse (SN) was to visit the patient at least twice a week for 13 weeks. A review of Patient 6's clinical record was conducted. Patient 6 was seen by the LVN on 4/20/22, 4/29/22, 5/3/22, 5/12/22, 5/17/22, 5/26/22, 5/31/22, 6/9/22, 6/23/22, and 6/29/22. There was no documented evidence the RN completed a supervisory note. 2. Per the agency's Plan of Care for certification period from 6/28/22 through 8/26/22, Patient 9 was admitted to the agency on 12/30/21 with diagnoses which included atrial fibrillation (irregular heartbeat). The Skilled Nurse (SN) was to visit the patient at least twice a week for nine weeks. A review of Patient 9's clinical record was conducted. Patient 9 was seen by the LVN on 3/29/22, 4/12/22, and 4/26/22. There was no documented evidence the RN completed a supervisory note. On 7/13/22 at 2:30 P.M., an interview was conducted with the Case Manager (CM) 2. CM 2 stated the LVN provided care for Patients 6 and 9, and there was no RN supervisory note. CM 2 said it was important for the RN to supervise the LVN to ensure the LVN followed the POC. On 7/14/22 at 9:30 A.M., an interview was conducted with the Director of Patient Care Services (DPCS). The DPCS stated the RNs did not complete the LVN supervisory note and this should have been done to ensure the LVN's followed the patient's POC and scope of practice. Per the agency's undated policy and procedure, titled Nursing Services, "...the RN makes at least bi-monthly home visits (once every two weeks) and documents that the LPN/LVN is routinely providing nursing services in accordance with the patient's plan of care and the LPN's/LVN's scope of practice."

Based on interview and record review, the agency failed to develop policies and procedures to ensure all staff were vaccinated for covid-19. As a result, the agency did not have a plan to ensure all staff were vaccinated for covid-19. Findings: On 7/13/22 at 2:23 P.M., an interview was conducted with the Director of Patient Care Services (DPCS). The DPCS stated, their agency required all staff to be vaccinated for covid-19 or have an exemption, but did not have a written policy on staff vaccination for covid-19. On 7/13/22 a review was conducted of the agency's infection control binder. There was not a policy which required all staff to be vaccinated for covid-19.