Every finding on record at Hospice of Kona, Inc.

Based on record review and interview, the facility failed to comply with the requirements of subpart I of part 489 regarding advance directives by not having a written policy and procedure. In addition, the facility failed to ensure a written document for advance directive (AD) requirements was completed for 1 of 13 patients (Patient 1) sampled. --- Findings include: A record review (RR) was done on 01/18/23 at 01:00 PM for patient 1(P1). RR revealed no written documentation of advanced directives. Interview and concurrent RR was done on 01/19/23 at 10:00 AM with the administrative assistance (AA1). AA1 stated that there was no record of documentation for advanced directives for P1. On 01/20/23 at 09:44 AM, interview and concurrent RR was done with the Director of Clinical Services (DOS). DOS confirmed that there was no written documentation for P1 advanced directives. Upon request for a policy and procedure for advanced directives, DOS was not able to provide one and stated that they did not have one. This deficient practice has the potential to affect all the residents in the hospice facility. Findings include: 1) On 01/19/23 while conducting record reviews of the electronic health records, inconsistencies were noted where documentation could be found regarding the discussion of AD information. On 01/20/23 at 10:00 AM, during an interview with the Director of Clinical Services (DCS) in the Conference Room, a request was made for a copy of the facility policy on Advance Directives (AD). At 11:30 AM, the DCS returned to the Conference Room and reported that the facility did not have a Policy and Procedure regarding ADs.

Based on record review and interview with staff members, the facility failed to obtain the patients' or representatives' signature to confirm receipt of the notice of rights and responsibilities for 13 of 13 patients (Patients 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 15, and 16) sampled. --- Findings include: Record review during the survey period for Patients (P)2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P13, P15, and P16 found no documentation of patients' or representatives' signature(s) to attest they received written notice of their rights and responsibilities. The survey team requested documentation of patients' or representatives' attestation(s) that the notice of their rights and responsibilities were provided. Interview with the Chief Executive Officer (CEO) on 01/17/23 at 02:25 PM in the Conference Room confirmed that neither the facility's Hospice Election Statement or Notice of Privacy Practices includes a section attesting to the receipt of the patients rights and responsibilities. The CEO stated the facility was not aware that it was not on one of the two forms.

Based on record review and interview, the facility failed to ensure the initial comprehensive assessment was completed by all disciplines of the Interdisciplinary Group (IDG) within five (5) calendar days of the Election of Hospice Care (EOHC) for 2 of 13 patients (Patient [P]2 and P11). This deficient practice does not ensure a thorough and comprehensive evaluation of the patient's status related to their terminal illness and related conditions and can affect the hospice care and services provided. All patients admitted to the facility can be affected by this deficient practice. --- Findings include: 1) Patient (P)2 is a 60-year-old female with an Election of Hospice Care (EOHC) of 09/27/22. On 01/17/23 at 02:05 PM, during a review of P2s medical record, it was noted that the initial assessment by the spiritual coordinator (SC) was finalized on 10/03/22. 2) P11 is a 78-year-old male with an EOHC of 11/30/22. On 01/20/23 at 08:00 AM, during a review of P11s medical record, it was noted that the initial assessments by both the Social Worker (SW) and the SC were finalized on 12/06/22. An interview with the Director of Clinical Services (DCS) on 01/20/23 at 08:57 AM in the Conference Room confirmed that the initial Comprehensive Assessments for both patients were not completed within the required timeframe.

Based on record review and staff interview, the facility failed to ensure all required members were included in the interdisciplinary group (IDG) when reviewing the comprehensive assessment and developing/revising the plan of care for 5 of 13 patients (Patients 2, 6, 10, 11, and 13) in the sample. --- Findings include: 1) Patient (P)2 is a 60-year-old female with an Election of Hospice Care (EOHC) of 09/27/22. On 01/17/23 at 02:05 PM, during a review of P2s medical record, it was noted that the Combined Disciplinary Plan of Care (POC) reviewed by the interdisciplinary group (IDG) on 10/19/22 was not acknowledged or signed by a Registered Nurse (RN). 2) P6 is a 73-year-old female with an EOHC of 11/14/22. On 01/17/23 at 03:30 PM, during a review of P6s medical record, it was noted that the POC reviewed by the IDG on 11/30/22 was not signed by the Spiritual Counselor (SC). An interview with the Director of Clinical Services (DCS) on 01/20/23 at 08:42 AM in the Conference Room confirmed that the SC was on vacation on 11/30/22, and the facility did not have a qualified staff member to act as a replacement SC. 3) P10 is a 91-year-old female with an EOHC of 10/31/22. On 01/19/23 at 09:00 AM, during a review of P10s medical record, it was noted that the POC reviewed by the IDG on 11/30/22 was not signed by the Spiritual Counselor (SC). 4) P11 is a 78-year-old male with an EOHC of 11/30/22. On 01/20/23 at 08:00 AM, during a review of P11s medical record, it was noted that the initial Comprehensive Assessment (CA),which was reviewed by the IDG on 12/06/22, was not signed by the Medical Director or a covering physician. An interview with the DCS on 01/20/23 at 08:57 AM in the Conference Room confirmed that the Medical Directors signature was not present on the document and stated that it should be signed as evidence that the document was finalized. 5) P13 is a 67-year-old male with an EOHC of 12/09/22. On 01/20/23 at 07:50 AM, during a review of P13s medical record, it was noted that the initial CA, reviewed by the IDG on 12/14/22, was not signed by the Medical Director or a covering physician.

Based on interview and record review, the facility failed to ensure that all care and services provided to Patient (P)2 were done in collaboration with the primary caregiver and the patients needs. As a result of this deficient practice, the primary caregiver and family experienced confusion and expressed grief watching P2 decline physically without having adjustments in the plan of care, specifically the frequency of registered nurse (RN) visits, discussed with them. --- Findings include: Patient (P)2 is a 60-year-old female with an Election of Hospice Care (EOHC) of 09/27/22. On 01/17/23 at 02:05 PM, during a review of P2s medical record, it was noted that from 09/27/22 to 10/02/22, RN visits were scheduled once a week. From 10/02/22 to 12/25/22, RN visits changed to twice a week. On 12/25/22, the RN visit order changed to once every two weeks, however, the RN began visiting once a week. On 01/18/23 at 12:19 PM, an interview was done with P2s two adult daughters (Daughter [D]1 and D2), and one daughter-in-law (DIL) during a home visit. All three family members reported a noticeable decline in P2s physical status, stating that in the past month she seemed to be getting weaker, eating less, and drinking less. D1 and DIL reported that coinciding with P2s decline, it seemed that her assigned RN had been coming less frequently. All family members stated that their understanding was that visits usually increase as patient(s) decline, so they were confused why the RN was coming less. D1 and DIL also stated that they wished the RN visited more so they could ask questions about P2s status and be better prepared for what happens next. In particular, D1 and DIL stated that they were unsure how much of her oral pain medication P2 was actually ingesting since she was having trouble swallowing, and expressed a desire to ask the RN for a topical medication for P2s pain. The State Agency (SA) informed the family members that the order for the frequency of RN visits changed on 12/25/22. All family members stated they were unaware exactly when or why it had changed, and were sure that it had not been discussed with any of them. On 01/20/23 at 10:11 AM, an interview was done with the Director of Clinical Services (DCS) in the Conference Room. During a concurrent review of P2s medical record, the DCS stated that given the patients decline she would have expected to see the RN visit frequency to have been maintained at twice a week. The DCS could not explain why the order was changed on 12/25/22.

Based on interview and record review, the facility failed to ensure that care and services were provided in accordance with the patients' plan of care for 3 of 13 patients (Patients 2, 10, and 13) in the active sample. --- Findings include: 1) Patient (P)2 is a 60-year-old female with an Election of Hospice Care (EOHC) of 09/27/22. On 01/17/23 at 02:05 PM, during a review of P2s medical record, it was noted that social worker (SW) services had been ordered once every four weeks plus six as needed visits, while spiritual counseling (SC) visits had been ordered two times every four weeks plus six as needed visits from 09/28/22 to 12/26/22. A review of the SW visit frequency revealed no visit for the month of November 2022. A review of the SC visit frequency revealed only one visit or attempt to visit for the months of October, November, and December. On 01/20/23 at 10:11 AM, during a concurrent interview with the Director of Clinical Services (DCS) and review of P2s medical record in the Conference Room, the DCS confirmed the SW and SC visits had been missed and could find no documentation explaining why. 2) P10 is a 91-year-old female with an EOHC of 10/31/22. On 01/19/23 at 09:00 AM, during a review of P10s medical record, it was noted that Registered Nurse (RN) services had been ordered once a week plus six as needed visits, while SC visits had been ordered two times every four weeks plus six as needed visits. A review of the RN visit frequency revealed no visit for the weeks of 11/06/22 – 11/12/22 and 01/01/23 – 01/07/23. A review of the SC visit frequency revealed only one visit or attempt to visit between the months of November and January. On 01/20/23 at 08:46 AM, during a concurrent interview with the DCS and a review of P10s medical record in the Conference Room, the DCS confirmed that the RN and SC visits were missed. 3) P13 is a 67-year-old male with an EOHC of 12/09/22. On 01/20/23 at 07:50 AM, during a review of P13s medical record, it was noted that SW services had been ordered once every four weeks plus six as needed visits, while SC visits had been ordered once a week plus six as needed visits beginning on 12/30/22. A review of the SW visit frequency revealed no visit since 12/14/22. A review of the SC visit frequency revealed no visit or attempt to visit for the week of 01/01/23 – 01/07/23. On 01/20/23 at 08:56 AM, during a concurrent interview with the DCS and a review of P13s medical record in the Conference Room, the DCS confirmed that the SW and SC visits were missed.

Based on interview and record reviews (RR), the facility failed to obtain an order for a change in prescription from tablet form to liquid form for Patient (P)1, out of 13 patients that were sampled in the survey. --- Findings include: 1) During a record review (RR) on 01/18/23, a progress note written by the RN for pain dated 12/28/22 revealed "patient is given Tylenol for pain. Patient has been switched to liquid Tylenol for ease in administering. Patient is given Tylenol in the morning when caregiver arrives to care for patient to work. Tylenol liquid to be given so it will process quicker and provide faster relief." RR of the routine medication administration record (MAR) dated 01/19/23 revealed the order for Acetaminophen 500 mg tablet. Take 2 tabs crushed, PO Q6 hours and may take last dose at 2400. Further RR indicated a discrepancy in the physician orders that there was no order written for the Tylenol change from tab to liquid. Policy Number: PC.P30 titled physicians orders, procedures reveal: 3.Verbal orders are obtained from the physician in order to provide the following: a. new medication, change in medication or discontinuance of medication. 7. Documentation is maintained of all efforts to obtain signed orders from physicians in a timely manner. In an interview and concurrent record record review with the Director of Clinical Services (DOS) on 01/20/23 at 10:00 AM confirmed that there was no order written for the change of Tylenol from tab form to liquid form. 2) During a RR on 01/19/23 at 02:00 PM for P2, electronic record revealed an order for visit frequency was not signed by the physician. Visit frequency order was for 6 visits dated January 1, 2023 through March 18, 2023. Review of Policy number PC.P30, procedure (7) indicates that documentation is maintained of all efforts to obtain signed orders from physicians in a timely manner. On 01/20/23 at 10:10 AM, interview and concurrent RR with the DOS at 10:10 AM was done. DOS confirmed that the order was not signed and the expectation is to sign the orders in a timely manner. These deficient practices have the potential to affect all residents in the facility.