Every finding on record at Hospice Care of America, LLC

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, and safe handling of soiled items in the patient’s care environment. This standard was not met as evidenced by a review of clinical records, document reviews, interviews, and observations. Agency policy, “Procedure: C_11G Bag Technique and Standard Precautions” “Hand Hygiene,” stated in part, “Hand hygiene is divided into two (2) aspects: a. hand washing using soap and water-Scrub your hands for at least 20 seconds, b. use of alcohol-based hand gel (sanitizer) when soap and water are not available or feasible for use. “When to use Hand Gel (sanitizer): 1. Before direct patient contact and after direct patient contact, 2: Before donning gloves and after removing gloves, 6. Moving between clean and contaminated body surfaces/sites, 7. After contact with inanimate objects in the patient’s environment.” 1 of 3 (33%) home visits observed, the hospice did not ensure the adherence to agency infection control policies and procedures for hand hygiene. During observation of Home Visit #3 on 11/10/2022, the Registered Nurse (RN) (Staff #6) washed his hands for 12 seconds using the blue liquid from a used food container on the kitchen counter. The RN donned gloves, removed a saturated wound dressing from the left lower extremity, removed the dirty gloves and placed them in a clear disposable bag, washed hands for 10 seconds using the blue liquid, donned clean gloves, and completed wound care. The RN placed multiple pairs of used (dirty) gloves in a clear disposable bag with an open package of gauze, wound cleanser, and tape. The RN washed his hands for 12 seconds using the blue liquid and then typed information into an electronic tablet. Before departing the visit, the RN reached into the dirty bag with the used gloves, removed the open package of gauze, wound cleanser and tape then placed them on the shelf in the patient’s home for patient/family use in wound care. The RN was not observed washing hands in the soap for at least 20 seconds. The RN was not observed using hand gel sanitizer before donning gloves, after removing gloves, or after contact with an inanimate object in the patient’s environment. The RN was not observed washing his hands before reaching into the dirty bag to remove the wound supplies he left in the patient’s home to be used for wound care for a stage 3 wound. The Director of Clinical Services was interviewed on 11/10/2022 and agreed, the staff did not follow the infection control policy on hand hygiene and safe handling of soiled items in the patient’s care environment. Agency policy, “Procedure: C_11G Bag Technique and Standard Precautions” “Hand Hygiene,” stated in part, “Hand hygiene is divided into two (2) aspects: a. hand washing using soap and water-Scrub your hands for at least 20 seconds, b. use of alcohol-based hand gel (sanitizer) when soap and water are not available or feasible for use. “When to use Hand Gel (sanitizer): 1. Before direct patient contact and after direct patient contact, 2: Before donning gloves and after removing gloves, 6. Moving between clean and contaminated body surfaces/sites, 7. After contact with inanimate objects in the patient’s environment.” During observation of Home Visit #3 on 11/10/2022 at 9:00am, the Registered Nurse (RN) (Staff #6) washed his hands for 12 seconds using blue liquid from a used food container on the kitchen counter. The RN donned gloves, removed a saturated wound dressing from the left lower extremity, removed the dirty gloves and placed them in a clear disposable bag, washed hands for 10 seconds using the blue liquid, donned clean gloves, and completed wound care. The RN placed multiple pair of used (dirty) gloves in a clear disposable bag with an open package of gauze, wound cleanser, and tape. The RN washed his hands for 12 seconds using the blue liquid then typed information in an electronic tablet. Before departing the visit, the RN reached into the dirty bag with the used gloves, removed the open package of gauze, wound cleanser and tape then placed them on the shelf in the patient’s home for patient/family use in wound care. The RN was not observed washing hands in soap for at least 20 seconds. The RN was not observed using hand gel sanitizer before donning gloves, after removing gloves, or after contact with an inanimate object in the patient’s environment. The RN was not observed washing his hands before reaching into the dirty bag to remove the wound supplies he left in the patient’s home to be used for wound care to a stage 3 wound. The Director of Clinical Services was interviewed on 11/10/2022 and agreed, the staff did not follow the infection control policy on hand hygiene and safe handling of soiled items in the patient’s care environment.

It is required that nursing care and services are provided by or under the supervision of a Registered Nurse and per the patient's 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 a review of clinical records, document reviews, interviews, and observations. Agency policy, “Procedure: C_15B 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.” 1 of 3 (33%) clinical records reviewed with a wound identified, the hospice did not ensure the Registered Nurse measured wounds at least one time weekly. Record 3: The patient’s date of the election was 9/21/2022. The Registered Nurse documentation on 9/21/2022 identified a stage 3 pressure ulcer wound to the left posterior calf. The wound record report and nursing visit documentation were reviewed for 9/25/2022-11/5/2022. During observation of Home Visit #3 on 11/10/2022, the Registered Nurse (RN) (Staff #6) was not observed completing wound measurements. The Registered Nurse was interviewed on 11/10/2022 and stated, “I measure about every 14 days or more if needed.” There was no documented evidence of wound measurements between 9/25/2022-11/5/2022. The Regional Director of Quality Outcomes was interviewed on 11/10/2022 and agreed, there was no documented evidence of wound measurements in the records identified. The Director of Clinical Services was interviewed on 11/10/2022 and stated, “they should be measured at least one time a week per policy.” Agency policy, “Procedure: C_15B 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.” Record 3: The patient’s date of election was 9/21/2022. The registered nurse documentation on 9/21/2022 identified a stage 3 pressure ulcer wound to the left posterior calf. The wound record report and nursing visit documentation was reviewed for 9/25/2022-11/5/2022. During observation of Home Visit #3 on 11/10/2022 at 9:00am, the Registered Nurse (RN) (Staff #6) was not observed completing wound measurements. The Registered Nurse was interviewed on 11/10/2022 and stated, “I measure about every 14 days or more if needed.” There was no documented evidence of wound measurements between 9/25/2022-11/5/2022. The Regional Director of Quality Outcomes was interviewed on 11/10/2022 and agreed, there was no documented evidence of wound measurements in the records identified. The Director of Clinical Services was interviewed on 11/10/2022 and stated, “they should be measured at least one time a week per policy.”

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 3 of 11 (27%) clinical records reviewed with a hospice aide ordered, the hospice did not ensure the hospice aide followed the plan of care as ordered. Record 2: The patient’s date of the election was 5/25/2022. The Initial Plan of Care (IPOC) dated 5/25/2022 ordered a hospice aide 1wk1, 2wk12, 1wk12. During the week of 5/25/2022-5/28/2022, there was no documented evidence of a hospice aide visit or documented reason for the missed visit. During the week of 6/5/2022-6/11/2022, there was a hospice aide visit on 6/10/2022. There was no documented evidence of a second hospice aide visit or documented reason for the missed visit. During the week of 7/17/2022-7/23/2022, there was no documented evidence of a hospice aide visit or documented reason for the missed visits. During the week of 7/24/2022-7/30/2022, there was a hospice aide visit on 7/29/2022. There was no documented evidence of a second hospice aide visit or documented reason for the missed visit. Record 4: The patient’s date of the election was 5/20/2022. The IPOC dated 5/20/2022 ordered a hospice aide 2wk8 effective 5/22/2022. During the week of 6/5/2022-6/11/2022, there was a hospice aide visit on 6/10/2022. There was no documented evidence of a second hospice aide visit or documented reason for the missed visit. Record 6: The patient’s date of the election was 6/25/2021. The Plan of Care (POC) dated 12/14/2021 ordered a hospice aide 1wk1 2wk8 effective 12/22/2021. During the week of 2/13/2022-2/19/2022, there was a hospice aide visit on 2/15/2022. There was no documented evidence of a second hospice aide visit or documented reason for the missed visit. The Regional Director of Quality Outcomes was interviewed on 11/10/2022 and agreed, there was no documented evidence the missing hospice aide visits were completed and there were no documented reasons for the missed visits. The Director of Clinical Services was interviewed on 11/10/2022 and agreed, the hospice aide did not follow the plan of care as ordered. Record 2: The patient’s date of election was 5/25/2022. The Initial Plan of Care (IPOC) dated 5/25/2022 ordered a hospice aide 1wk1, 2wk12, 1wk12. During the week 5/25/2022-5/28/2022, there was no documented evidence of a hospice aide visit or documented reason for the missed visit. During the week 6/5/2022-6/11/2022, there was a hospice aide visit on 6/10/2022. There was no documented evidence of a second hospice aide visit or documented reason for the missed visit. During the week 7/17/2022-7/23/2022, there was no documented evidence of a hospice aide visit or documented reason for the missed visits. During the week 7/24/2022-7/30/2022, there was a hospice aide visit on 7/29/2022. There was no documented evidence of a second hospice aide visit or documented reason for the missed visit. Record 4: The patient’s date of election was 5/20/2022. The IPOC dated 5/20/2022 ordered a hospice aide 2wk8 effective 5/22/2022. During the week 6/5/2022-6/11/2022, there was a hospice aide visit on 6/10/2022. There was no documented evidence of a second hospice aide visit or documented reason for the missed visit. Record 6: The patient’s date of election was 6/25/2021. The Plan of Care (POC) dated 12/14/2021 ordered a hospice aide 1wk1 2wk8 effective 12/22/2021. During the week 2/13/2022-2/19/2022, there was a hospice aide visit on 2/15/2022. There was no documented evidence of a second hospice aide visit or documented reason for the missed visit. The Regional Director of Quality Outcomes was interviewed on 11/10/2022 and agreed, there was no documented evidence the missing hospice aide visits were completed and there were no documented reasons for the missed visits. The Director of Clinical Services was interviewed on 11/10/2022 and agreed, the hospice aide did not follow the plan of care as ordered.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 11 (18%) clinical records reviewed, the hospice did not ensure the notification of hospice non-covered items was completed and provided to the patients within 5 days of the request upon admission. Record 3: The patient’s date of the election was 9/21/2022 with a primary diagnosis of atherosclerosis heart disease of the native coronary artery without angina pectoris. The hospice election statement and initial comprehensive assessment were reviewed and identified the patient requested the addendum on 9/21/2022. The medication profile was reviewed and revealed a start date of 9/21/2022 for: Abacavir, reason HIV, financial responsibility patient; Prezcobix, reason HIV, financial responsibility patient; Tivicay, reason HIV, financial responsibility patient. The Patient Notification of Hospice Non-Covered Items, Services, and Drugs, signed by the patient and hospice representative on 9/21/2022 did not identify related diagnoses, unrelated diagnoses, non-covered items, services, and drugs, and reason for non-coverage; these sections were blank. Record 10: The patient’s date of the election was 7/20/2022 with a primary diagnosis of atherosclerosis of the aorta. The hospice election statement and initial comprehensive assessment were reviewed and identified the patient/representative requested the addendum on 7/20/2022. The medication profile was reviewed and revealed a start date of 7/20/2022 for: Finasteride, reason BPH, financial responsibility patient; Glipizide, reason DM2, financial responsibility patient; Latanoprost, reason Glaucoma, financial responsibility patient; Januvia, reason DM2, financial responsibility patient; Metformin, reason DM2, financial responsibility patient; Tamsulosin, reason BPH, financial responsibility patient. The Patient Notification of Hospice Non-Covered Items, Services, and Drugs, signed by the patient/representative and hospice representative on 7/20/2022 did not identify related diagnoses, unrelated diagnoses, non-covered items, services and drugs, and reason for non-coverage; these sections were blank. The Director of Clinical Services was interviewed on 11/10/2022 and agreed, the patient notification of hospice non-covered items, services, and drugs was not provided to the patients identified within 5 days of their request at the time of admission. The Director of Clinical Services stated, “these are blank and were not completed properly.” Record 3: The patient’s date of election was 9/21/2022 with a primary diagnosis atherosclerosis heart disease of native coronary artery without angina pectoris. The hospice election statement and initial comprehensive assessment were reviewed and identified the patient requested the addendum on 9/21/2022. The medication profile was reviewed and revealed a start date 9/21/2022 for: Abacavir, reason HIV, financial responsibility patient; Prezcobix, reason HIV, financial responsibility patient; Tivicay, reason HIV, financial responsibility patient. The Patient Notification of Hospice Non-Covered Items, Services, and Drugs, signed by the patient and hospice representative on 9/21/2022 did not identify related diagnoses, unrelated diagnoses, non-covered items, services and drugs, and reason for non-coverage; these sections were blank. Record 10: The patient’s date of election was 7/20/2022 with a primary diagnosis atherosclerosis of aorta. The hospice election statement and initial comprehensive assessment were reviewed and identified the patient/representative requested the addendum on 7/20/2022. The medication profile was reviewed and revealed a start date 7/20/2022 for: Finasteride, reason BPH, financial responsibility patient; Glipizide, reason DM2, financial responsibility patient; Latanoprost, reason Glaucoma, financial responsibility patient; Januvia, reason DM2, financial responsibility patient; Metformin, reason DM2, financial responsibility patient; Tamsulosin, reason BPH, financial responsibility patient. The Patient Notification of Hospice Non-Covered Items, Services, and Drugs, signed by the patient/representative and hospice representative on 7/20/2022 did not identify related diagnoses, unrelated diagnoses, non-covered items, services and drugs, and reason for non-coverage; these sections were blank. The Director of Clinical Services was interviewed on 11/10/2022 and agreed, the patient notification of hospice non-covered items, services, and drugs was not provided to the patients identified within 5 days of their request at the time of admission. The Director of Clinical Services stated, “these are blank and were not completed properly.”

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 2 (100%) clinical records reviewed with a discharge from hospice, the hospice did not ensure that the discharge summary provided to the attending included a summary of the patient’s stay or the current plan of care. Record 10: The patient’s date of the election was 7/20/2022. The discharge was reviewed and revealed the patient was discharged for an extended prognosis on 10/14/2022. There was no documented evidence the discharge summary sent to the attending included a summary of the patient’s stay or the current plan of care. Record 11: The patient’s date of the election was 6/15/2022. The discharge was reviewed and revealed the patient was discharged for revocation seeking aggressive treatment on 7/23/2022. There was no documented evidence the discharge summary sent to the attending included a summary of the patient’s stay or the current plan of care. The Regional Director of Quality Outcomes was interviewed on 11/10/2022 and agreed, there was no documented evidence the discharge information sent to the attending included a summary of the patient’s stay or the current plan of care. Record 10: The patient’s date of election was 7/20/2022. The discharge was reviewed and revealed the patient was discharged for extended prognosis on 10/14/2022. There was no documented evidence the discharge summary sent to the attending included a summary of the patient’s stay or the current plan of care. Record 11: The patient’s date of election was 6/15/2022. The discharge was reviewed and revealed the patient was discharged for revocation seeking aggressive treatment on 7/23/2022. There was no documented evidence the discharge summary sent to the attending included a summary of the patient’s stay or the current plan of care. The Regional Director of Quality Outcomes was interviewed on 11/10/2022 and agreed, there was no documented evidence the discharge information sent to the attending included a summary of the patient’s stay or the current plan of care.