Every finding on record at Hospice Care of America

Based on record review and interview, the hospice failed to ensure the hospice's communication plan contained contact information for the current staff. --- The findings include: Record review of the hospice's Emergency Preparedness Plan on 08/29/23 at 9:21 AM revealed the communication plan for the hospice staff was not current. During an interview on 08/29/23 at 10:45 AM, the Interim Administrator verified the findings.

Based on record review and interview, the hospice failed to ensure contact for Federal, State, tribal, regional, or local emergency preparedness staff was available in the hospice's Emergency Preparedness (EP) book. --- The findings include: Record review of the hospice's Emergency Preparedness Plan (EPP) on 08/29/23 at 9:25 AM revealed the hospice's EPP did not contain information for the licensing and certification agency and/or the office of the State Long-Term Care Ombudsman. During an interview on 08/29/23 at 10:47 AM, the Interim Administrator verified the findings.

Based on record review and interview, the hospice failed to ensure the hospice's Emergency Preparedness Program (EPP) contained documentation of sharing of information on occupancy/needs for the hospice. --- The findings include: Record review of the hospice's EPP plan on 08/29/23 at 9:28 AM revealed the EPP did not contain documentation that the hospice shared information on occupancy and/or needs for the hospice to local EPP staff. During an interview on 08/29/23 at 10:48 AM, the Interim Administrator verified the findings.

Based on record review, interview, and review of hospice policy and procedure, the hospice failed to ensure 1 of 2 patients received wound care per physician orders. (Patient 4) --- The findings include: Record review on 08/28/23 at 3:58 PM for Patient 4 revealed the patient was admitted on 04/06/23 for unspecified severe protein malnutrition. Review of the certification period dated 04/06/23 to 07/04/23 revealed when the Registered Nurse (RN) completed the patient's initial assessment on 04/06/23, the RN documented (1) stage 1, open buttock wound, 1.75 cm (centimeter) x 1 cm; (1) stage 1, open buttock wound, 1.5 cm x 1 cm, (1) open left heel wound, 2 cm x 1 cm and (1) open right heel wound, 3.5 cm x 2.5 cm. Review of the physician standing orders dated 04/06/23 revealed ";Assess wound for location, size, stage, drainage, wound bed and peri-wound care, with weekly measurements. Notify provider of pain, redness, drainage, foul odor, increase size...". Review of nursing assessments for the certification period dated 04/06/23 to 07/04/23 revealed there was no documentation of wound measurements by the RN for the certification period. During an interview on 08/29/23 at 4:06 PM, the Administrator verified the findings. Hospice policy, entitled, ";Wound Care", revealed, ";The skilled nurse will assess the wound and document the wound status at every visit. The wound measurements will be documented at least weekly...".

Based on record review, interview, and review of the hospice's policy and procedure, the hospice failed to ensure the Interdisciplinary Team (IDT) completed a comprehensive assessment within 5 days of the patient's Notice of Election (NOE) for 5 of 14 patient charts reviewed. (Patient 3, 4, 10, 11, and 14) --- Record review on 08/28/23 at 3:04 PM for Patient 3 revealed the patient was admitted on 04/15/22 for Malignant neoplasm of Liver. Review of the patient's chart revealed there was no IDT comprehensive assessment within 5 days of admission. The first IDT meeting for the patient was on 04/28/22 which was 13 days after the NOE. During an interview on 08/29/23 at 4:00 PM, the Administrator verified the findings. Record review on 08/28/23 at 3:58 PM for Patient 4 revealed the patient was admitted on 04/06/23 for unspecified severe protein malnutrition. Review of the patient's chart revealed there was no IDT comprehensive assessment within 5 days of the patient's admission. The first IDT meeting for the patient was on 05/18/23 which was 41 days after the NOE. During an interview on 08/29/23 at 4:06 PM, the Administrator verified the findings. Record review on 08/29/23 at 11:56 AM for Patient 10 revealed the patient was admitted on 02/17/23 for Dementia. Review of the patient's chart revealed there was no IDT comprehensive assessment within 5 days of admission. The first IDT meeting for the patient was on 03/02/23 which was 13 days after the NOE. During an interview on 08/29/23 at 4:56 PM, the Administrator verified the findings. Record review on 08/28/23 at 10:00 PM for Patient 11 revealed the patient was admitted on 08/11/23 for Senile Degeneration of Brain. Review of the patient's chart revealed there was no IDT comprehensive assessment within 5 days of admission. The first IDT meeting for the patient was on 08/23/23 which was 11 days after the NOE. During an interview on 08/29/23 at 4:33 PM, the Administrator verified the findings. Record review on 08/28/23 at 10:20 PM for Patient 14 revealed the patient was admitted on 08/16/23 for Alcoholic Cirrhosis of the Liver. Review of the patient's chart revealed there was no IDT comprehensive assessment within 5 days of admission. The first IDT meeting for the patient was on 08/23/23 which was 6 days after the NOE. During an interview on 08/29/23 at 4:37 PM, the Administrator verified the findings. Hospice policy, entitled, ";Comprehensive Assessment", revealed, ";3. The comprehensive assessment is completed by the interdisciplinary care members, in consultation with the individuals attending physician (if any), no later than five (5) calendar days after the election of the hospice benefit...".

Based on record review, interview, and review of the hospice policy and procedure, the hospice failed to ensure an individualized written plan of care that contained goals and interventions identified in the initial comprehensive assessment by the Registered Nurse (RN) was developed for 1 of 14 patient charts reviewed. (Patient 4) --- The findings included: Record review on 08/28/23 at 3:58 PM for Patient 4 revealed the patient was admitted on 04/06/23 for Unspecified Severe Protein Malnutrition. Review of the initial Registered Nurse (RN) assessment on 04/06/23 revealed (1) stage 1, open buttock wound, 1.75 cm (centimeter) x 1 cm; (1) stage 1, open buttock wound, 1.5 cm x 1 cm, (1) open left heel wound, 2 cm x 1 cm and (1) open right heel wound, 3.5 cm x 2.5 cm. Review of the patient's chart further revealed the patient was not care planned for the wounds identified during the patient's initial comprehensive assessment. During an interview on 08/29/23 at 4:06 PM, the Administrator verified the findings. Hospice policy, entitled, ";Plan of Care", revealed, ";1. The plan of care specifies interventions, care and services necessary to meet the needs of the patient and/or caregiver identified in the comprehensive assessment and ongoing assessments of the patient...3. The interdisciplinary team members are directed toward achieving the desired goals or outcomes in the plan of care...".

Based on record review and interview, the hospice failed to ensure the Registered Nurse (RN) and Aide completed home visits per the ordered frequency on the patient's plan of care for 2 of 14 patient charts reviewed. (Patients 3 and 4) --- The findings include: Record review on 08/28/23 at 3:04 PM for Patient 3 revealed the patient was admitted on 04/15/22 for Malignant Neoplasm of Liver. Review of the patient's certification period dated 06/09/23 to 8/07/23 revealed the RN visit frequency was 1 time a week. Review of Patient 3s visits revealed 1 missed RN visit during the week of 06/09/23. During an interview on 08/29/23 at 4:00 PM, the Administrator verified the findings. Record review on 08/28/23 at 3:58 PM for Patient 4 revealed the patient was admitted on 04/06/23 for Unspecified Severe Protein Malnutrition. Review of the patient's certification period dated 04/06/23 to 07/04/23 revealed the Aide visit frequency was 5 times a week. Review of the patient's visits revealed 5 missed aide visits during the week of 05/14/23, 05/21/23, and 05/28/23. During an interview on 08/29/23 at 4:06 PM, the Administrator verified the findings.

Based on review of the hospice's Quality data, interview, and review of the hospice's policy and procedure, the hospice failed to ensure the Quality Assessment Performance Improvement (QAPI) minutes contained measurable outcomes with indicators related to palliative outcomes and hospice services. --- The findings include: Review of the hospice's Quality Minutes from January 2023 to April 2023 on 08/30/23 at 9:40 AM revealed there was no documentation of measurable outcomes for palliative and/or hospice services. There were no Quality minutes for May 2023, June 2023, and July 2023. During an interview on 08/30/23 at 10:20 AM, the Administrator stated, ";The majority of our QAPI (Quality Assurance Process Improvements) are about PIPS (Performance Improvement Projects)". Hospice policy, entitled, ";Quality Assessment Performance Improvement", revealed, ";2. Processes for measuring, analyzing and tracking quality indicators includes adverse events, and other aspects of performance that are specific to the needs of the hospice and enable the hospice to assess processes of care services and operations included in the QAPI program...".

Based on review of the hospice's quality data and interview, the hospice failed to ensure the Quality Assessment Performance Improvement (QAPI) measured, analyzed, tracked quality indicators for assessing processes of care, hospice services and operations. --- The findings include: Review of the hospice's Quality minutes from January 2023 to April 2023 on 08/30/23 at 9:42 AM revealed no documentation of quality indicators used to assess processes of care, hospice services and operations that was measured, analyzed and/or tracked. There were no Quality minutes for May 2023, June 2023, and July 2023. During an interview on 08/30/23 at 10:20 AM, the Administrator stated, ";The majority of our QAPI (Quality Assessment Performance Improvement) is about PIPS".

Based on review of the hospice's quality data, interview, and review of the hospice's policy and procedure, the hospice failed to ensure the hospice captured and documented its Quality Assessment Performance Improvement (QAPI) data for May 2023, June 2023, and July 2023. --- The findings include: Review of the hospice's Quality minutes on 08/30/23 at 9:44 AM revealed there was no documentation of data collected for May 2023, June 2023, and July 2023. During an interview on 08/30/23 at 10:20 AM, the Administrator stated, ";The majority of our QAPI is about PIPS". Hospice policy, entitled, ";Quality Assessment Performance Improvement". revealed, ";3. Data is collected to examine all facets of the hospice operations and used to monitor the effectiveness and safety of services and quality of care and identify opportunities for improvement...".

Based on review of the hospice data and interview, the hospice failed to ensure the hospice's Quality Assessment Performance Improvement (QAPI) data was obtained and documented for May 2023, June 2023, and July 2023. --- The findings include: Record review of the hospice's Quality minutes revealed the hospice had not captured nor documented quality data for May 2023, June 2023, and July 2023. During an interview on 08/30/23 at 10:20 AM, the Administrator stated, ";The majority of our QAPI is about PIPS".

Based on review of the hospice's quality data, and interview, the hospice's Governing Body failed to ensure that the hospice-wide quality assessment and performance improvement program addressed priorities for improved quality of care and patient safety. --- The findings include: Review of the hospice Quality minutes on 08/30/23 at 9:38 AM revealed no Quality data minutes for May 2023, June 2023, and July 2023. Review of Board Meeting Minutes revealed no documentation of as to the reason for the lack of Quality data for May 2023, June 2023, or July 2023. During an interview on 08/30/23 at 10:20 AM, the Administrator stated, ";We have QAPI sometimes every month or quarterly. If we have a severe incident with the patient, then we will have one due to an adverse event. We know we have to work on our QAPI program".

Based on observations, interviews, record reviews, and review of the hospice's policy and procedure, the hospice failed to ensure the Hospice Aide reported changes in a patients condition to the hospice staff for 1 of 2 home patients observed. (Patient 14) --- The findings include: Record review on 08/28/23 at 10:20 PM for Patient 14 revealed the patient was admitted on 08/16/23 for Alcoholic Cirrhosis of Liver. Home observations on 08/29/23 from 12:57 PM to 1:39 PM revealed Hospice Aide (HA 1) assisted the patient with a shower. Patient 14 commented about a rash located under his/her arm and stated it was not there previously in the same week. HA 1 asked the patient if it hurt. Patient 14 stated, ";No". HA 1 stated he/she would make the nurse aware. Review of HA 1s ";Aide Care Visit" dated 08/29/23 revealed there was no documentation of the concern noted by the patient or acknowledgement of the nurse being informed. During an interview on 08/28/23 at 1:45 PM, HA 1 stated, "I know what care to provide to the patient based on my care plan in my table.t" During an interview on 08/30/23 at 9:26 AM, the Administrator stated, "The Aide is to call the nurse or Administrator and report the issue. The issue can be documented in the communication note. If called, then a communication note should also be put in related to the call. I was not aware of the patients concern and/or the patients RN." Hospice policy, entitled, ";Wound Care", revealed, ";All other disciplines will notify the registered nurse of any observed or caregiver-reported changes in skin integrity...".