Every finding on record at Hospice of Eastern Idaho

Based on observation, medical record review and staff and patient interviews, it was determined the agency failed to ensure the the interventions, measurable outcomes, medications, and goals outlined in the POC were provided for 2 of 10 patients (Patients #1 and #5) whose records were reviewed. This failure resulted in the patients not receiving the care and services outlined in their POCs and had the potential to result in unmet needs and harm to the patient. Findings include: --- Patient #1 was a 61 year old male admitted to the agency on 7/30/24 with a primary diagnosis of Alzheimer's disease with early onset. He received SN and SW services. His medical record, including the POC, was reviewed. A surveyor observational visit was conducted on 8/06/24 with the RN and this patient and his CG. Patient #1's CG stated the patient had not had a BM for 6 days. Medications listed on Patient #1's POC included "Colace 100mg Capsule, 1 cap daily as needed for constipation." There was no colace in the home. RN stated to CG she would order colace for delivery. The RN advised the CG to give Patient #1 a dose of Miralax, 17grams, dissolved in 4 ounces of water beginning tonight. The CG stated she had Miralax in the home and agreed to administer to Patient #1 tonight. The RN stated she would order more Miralax as well. In an interview conducted with the RN on 8/07/24, beginning at 11:40 AM, she confirmed colace was listed on Patient #1's medication profile but was not available in the patient home. Upon review of Patient #1's medical record on 8/07/24, including medication profile, the Miralax had not been added to the medication profile. The DON was interviewed on 8/07/24, beginning at 2:20 PM. She confirmed the Miralax was not on Patient #1's medication profile. Patient #1's medication profile, as part of the POC, was not updated and accurate. Patient #5 was a 91 year old female admitted to the agency on 5/09/24, with a primary diagnosis of age-related cognitive decline. She received SN and SW services. Her medical record, including the POC, since start of care was reviewed. Patient #5's medical record included a POC signed by DON 5/10/24.The POC interventions included "LCSW: 2 per Week + 3PRN." Patient #5 did not receive all interventions ordered in her POC. Findings include: Patient #5's medical contained a note, titled "History of Visit Notes" , listed visits from start of the recertification period through 8/05/24 listed SW visits once a week with visits listed as 5/14/24, 5/21/24, 5/28/24, 5/30/24, 6/04/24, 6/6/24, 6/14/24, 6/18/24, 6/25/24, 7/02/24, 7/05/24, 7/9/24, 7/18/24, 7/23/24, 8/01/24. During the 12 weeks of documented visits, only 3 weeks contained the ordered twice per week SW visits. The DON was interviewed on 8/7/24 at 10:15 AM and Patient #5's medical was reviewed in her presence. The DON confirmed SW visits were ordered for twice a week and were not provided as ordered. Patients #5 and did not receive all interventions outlined in their POCs. This had the potential to result in unmet needs and harm to the patient.

Based on agency policy review, agency admission packet review, and staff interview, it was determined the agency failed to have advanced directive policies regarding implementation of patients' advanced directives. This failure had the potential to violate patient rights for all patients admitted to the agency. An agency policy "Advanced Directives," reviewed on 7/06/18 by the DPS, ED, MD, and the Chairman of the Board of Directors was provided. The policy stated "During the admission interview, and prior to receiving care, the hospice nurse or Social Worker provides written information and instruction on advance directives to the patient ... the written information given to the patient and or legal representative includes: a. the hospice's policies on the implementation of the patient's advance directives including any limitations ... " The agency admission packet was reviewed. There were no instructions or information relating to the agency's policies on the implementation of the patient's advance directives. The ED was interviewed on 10/05/21, beginning at 11:10 AM. She confirmed that agency did not have any other advanced directive policies. The agency failed to ensure patient's right to receive information regarding the agencies policies on implementing advanced directives.

Based on observation, medical record review, agency policy review, and staff interview, it was determined the agency failed to ensure the POC included all necessary drugs to meet patients' needs for 1 of 12 patients (Patient #12) whose records were reviewed. This failure had the potential to result in adverse patient outcomes. Findings include: The agency's policy, "Plan of Care," revised 7/06/18, stated, "The Plan of Care included, but is not limited to ... Drugs and treatment necessary to meet the needs of the patient." 1. Patient #12 was a 79 year old male, admitted to the agency on 9/15/20, with a terminal diagnosis of heart failure. He received SN, aide, MSW, chaplain, and volunteer services. His record, including the POC, for the benefit period 9/07/21 to 11/08/21, was reviewed. A visit was made to Patient #12's home on 10/05/21 at 10:00 AM, to observe an MSW visit. Following the visit, Patient #12's current medications in his home were compared to his current hospice medication list. His home medications included Tamsulosin 0.4mg to be taken once per day. Patient #12 confirmed he was taking the medication once per day. His hospice mediation list documented his Tamsulosin was discontinued on 10/15/20. During an interview on 10/05/21, at 11:45 AM, the DPS, an RN, reviewed Patient #12's medications list and confirmed his Tamsulosin was not listed as current. The agency failed to ensure Patient #12's POC was accurate to include his current medications.

Based on record review and staff interview, it was determined the agency failed to ensure POCs were updated to address changes in patient status and needs for 3 of 12 patients ( #5, #9, #1) whose records were reviewed. This resulted in POCs that were not comprehensive to meet the current needs of the patient. Findings include: 1. Patient #5 was a 79 year old male, admitted to the agency on 6/28/21, with a terminal diagnosis of liver cell carcinoma. He received SN, MSW and aide services. His record, including the POC, and standing orders, was reviewed from the time of admit on 6/28/21 to the time of death on 7/06/21. a. Patient #5's record included an SN visit note dated 7/06/21, signed by the RN. The note stated "Foley cath patent". There was no documentation stating when, how or by whom, the urinary catheter was inserted. Patient #5's POC was not updated to include interventions and goals to address the urinary catheter and care. During an interview on 10/07/21, beginning at 2:20 PM, the DPS reviewed Patient #5's record and confirmed the POC was not updated to address the urinary catheter insertion and care. The agency failed to ensure Patient #5's POC was updated to address the change in condition. b. Patient #5's record included a CNA visit note, dated 6/29/21, signed by the CNA. The note stated that patient reported falling the night before. The CNA note did not mention that the RN was notified. The incident reports were reviewed for Patient #5 and there was no fall reported on 6/29/21. During an interview on 10/07/21, beginning at 2:20 PM, the DPS reviewed Patient #5's record and confirmed the CNA was expected to document notification to the RN of the fall and the RN should have documented the incident. Neither was done. The agency failed to ensure Patient #5's change in condition and updated POC were addressed. c. Patient #5's record included a CNA visit note, dated 7/02/21. The CNA note stated the patient had a skin tear. There was no documentation stating the skin tear was reported to the RN nor was there any update to the POC for skin care. During an interview on 10/07/21, beginning at 2:20 PM, the DPS reviewed Patient #5's record and confirmed the skin tear should have been reported to the RN and the skin care added to the POC. The agency failed to ensure Patient #5's change to skin integrity was noted and the POC was updated. 2. Patient #9 was a 98 year old female, admitted to the agency on 4/22/20, with a terminal diagnosis of Alzheimer's disease. She received SN and MSW services. Her record, including the POC, and standing orders, was reviewed from the time of admit on 4/22/21 to the time of death on 6/29/21. a. Patient #9's record included an SN visit note dated 6/23/21, signed by the RN. The note stated, "yesterday [daughter] had requested, after discussion with this nurse, that a foley be placed. Discussed the pros and cons of foley. Made the visit to place foley." Patient #9's POC was not updated to include interventions and goals to address the urinary catheter and care. During an interview on 10/06/21, beginning at 5:15 PM, the DPS reviewed Patient #9's record and confirmed the POC was not updated to address the urinary catheter insertion and care. The agency failed to ensure Patient #9's POC was updated to address the change in condition. 3. Patient #1 was an 84 year old female, admitted to the agency on 2/21/20, with a terminal diagnosis of Alzheimer's disease. She received SN and aide services. a. A home visit was made on 10/06/21, beginning at 8:30 AM, to observe an aide visit. Patient #1 had a skin tear on her right forearm that was dressed with Tegaderm dressing. The aide stated that the tear had been there on and off for "a couple of weeks." There were no interventions or goals on Patient #1's POC regarding the skin tear on her right forearm. During an interview on 10/06/21, beginning at 5:15 PM, the DPS reviewed Patient #1's record and confirmed the POC was not updated to address Patient #1's skin tear on her right forearm. The agency failed to ensure Patient #1's POC was updated to address the change in condition.

Based on agency policy review, admission packet review, grievance/complaint log review, and agency staff interview, it was determined the agency failed to ensure on call nursing services were available 24 hours a day, 7 days a week. This resulted in lack of on call nursing services to meet patient and caregiver needs. Findings include: 1. An agency policy, "Scope of Services," reviewed on 7/06/18, stated, "Nursing services, physician services, and drugs and biologicals are routinely available on a 24 hour basis 7 days a week and other services on a 24 hour basis when reasonable and necessary to meet the needs of the patient and family." This policy was not followed. 2. An agency admission packet was reviewed. The packet contents included the following instructions to patients/caregivers: - The front cover of the packet stated, "DO NOT CALL "911[sic] or the PARAMEDICS." - An instruction sheet stated, "Call Hospice Nurse First [number] DO NOT CALL "911[sic] or the PARAMEDICS" - A welcome letter stated, "If you have any problems or concerns, an RN is on-call 24 hours a day, and you may reach the RN by calling [number], at any time. We have provided you with a paper listing the 24-on-call [sic] phone number. We ask that you post it near your telephone and remember, always CALL HOSPICE FIRST! If the phone transfers to the voice-mail, please leave your name and number and the nurse will return your call promptly. Alternative number is our office/answering service at [number]." 3. A grievance/complaint log for the previous 12 months was requested. The log included the following grievance filed by family regarding a lengthy on-call response time on 2/17/20: - "Description of Grievance/Complaint: I called gdaughters [sic], [names] 1 day past [patient] passing. In that conversation it was made known to me that when on-call was called of death - phone was not immediately answered. On-call RN responded 3 hrs later and made visit." The ED and DPS were interviewed on 10/07/21, beginning at 3:50 PM. They confirmed agency expectation was for the on-call phone to be answered "immediately." They confirmed only the on call number was provided to patients and caregivers to contact the agency and the "alternative" office number listed in the admission packet was transferred to the on-call phone. They confirmed there was no backup contingency if the on-call phone was not answered in a timely manner or lost/disabled. The agency failed to provide reasonable and necessary on-call services to meet the needs of patients and caregivers.

Based on staff interview and review of personnel information, it was determined the hospice failed to ensure development of written policies and procedures describing a method of assessment of staff competencies. It also failed to ensure assessment of the skills and competencies of 1 of 3 RN staff employees (RN A) who received an annual assessment and whose records were reviewed. This resulted in a lack of validation of current skills and competencies. Findings include: The ED and surveyor reviewed personnel files together on 10/06/21, beginning at 1:30 PM. The personnel files for staff RNs did not document assessment of competencies for 1 of 3 RN's whose files were reviewed. During the review of personnel files, the ED stated she was not sure why this RN's annual competencies had not been assessed. When asked to provide copies of any written policies and procedures describing the hospice's methods of assessment of competencies, she stated the agency did not have any. The hospice did not ensure development of written policies and procedures describing its method of assessment of competencies. It did not ensure all staff RNs were assessed for competencies annually.