Every finding on record at Hospice of Palm Beach County, Inc.

Observed in Record Review. In 1 of 14 patient records reviewed, the hospice RN did not follow it's pain assessment policy #17A titled -Comfort Care. A review of a RN visit note for RR#10 reflected that patient had a pain level of 3. This visit note also indicated that there was no further need for a pain assessment. There were no further descriptors for pain detailed on this visit note. This observation was discussed with the manager.

Observed in Record Review. In 4 of 4 patient records reviewed, During the record review for HV 1,2,3 and 4; the hospice surveyor noted that the care plan goals were not individualized. For example, the goal for pain was pain is managed at a level acceptable to the patient but no specific number was indicated that could be measured. This was validated in a discussion with and observation by the Director of Patient Care. Observed in Record Review. In 1 of 14 patient records reviewed, the goals were not individualized. RR#14 NHV had issues with pain and the care plan goal reflected the following- patient will have acceptable level of pain. There was no further qualification of this goal. This observation was discussed with the RN

Observed in Record Review. In 1 of 14 patient records reviewed, the comprehensive care plan did not include all the interventions required based on the patient assessment. RR#13 NHV had a Foley, and the comprehensive care plan/485 did not include the size of the foley or the balloon size, the frequency of change or who was responsible for changing the Foley. Additionally, for the same patient, the nursing care plan reflected port flushes monthly however this order was not reflected on the 485/comprehensive care plan. This observation was discussed with the RN.

Observed in Record Review. In 2 of 14 patient records reviewed, that had aide service. Based on a review of the record and confirmed by discussions with the RN, RR#13 NHV had seizures and the hospice aide care plan did not reflect seizure precautions. Similarly, the aide care plan of RR#11 did not reflect oxygen precautions. This patient utilized oxygen prn. This observation was discussed with the RN.

Observed in Individual Tracer. During HV1 the hospice surveyor noted that the medication profile in the record was not updated. Amlodipine 5mg was still on the medication profile even though the patient had discontinued the medication right after the order date. This was validated in a discussion with and observation by the Director of Patient Care.

Observed in Record Review. In 3 of 14 patient records reviewed, did not have an accurate medication profile. The medication profile for RR#13 NHV reflected that patient was receiving the same doe, frequency, and schedule of methadone twice daily. Per discussions with the RN there was a disconnect between the profile electronically displayed on the computer terminal versus what was displayed on the RN's device and subsequently provided to the patient. Similarly, the medication administration records (MAR) in the nursing home of RR#6 HV and RR#11 did not match the hospice medication profile. Specifically, the hospice medication profile reflected that the patient should be on lorazepam and Pyridium and these medications were not on the nursing home MAR. Finally, the MAR for RR#5 did not include Lasix, Hyoscyamine, Jardiance, and Lorazepam which appeared on the hospice medication profile. This observation was discussed with the RN.

Observed in Record Review. In 2 of 2 home visits conducted, the organization did not assess and reassess its patients. In HV#5, the initial assessment indicated that the patient has a surgical wound to his neck. the Registered Nurse failed to assessed the wound weekly as required by the organization policy. Additionally, in RR#8 , the initial assessment also indicated that the patient had a wound on the coccyx, however, the wound was only measured once. The patient was visited by a Registered Nurse weekly but failed to assess the wound. The wound assessment policy required the wound to be measured weekly.This was confirmed by Patient care Manager.

Observed in Patient Home. In 1 of 2 home visits conducted, During HV#4 the Hospice surveyor noted that the agency's medication list did not reflect the medications that were in the facility's system. For example, during medication review the agency electronic medical record had Oxycontin, Piper/ Tazoba and oxycod/ Apap as active medication but according to the skilled Nursing Facility nurse these had discontinued on 1/16/2022. This was also observed by Patient Care Manager.

Observed in Record Review. In 8 of 8 patient records reviewed, the agency failed to document an initial bereavement assessment at admission as part of the comprehensive assessment. There was no documentation of an initial bereavement assessment completed for RR# 9, RR# 10, RR# 11, RR# 12, RR#13, RR#14, HV#3, and HV # 5. This was validated with the Patient Care Manager

Observed in Tracer Activities. during the Interdisciplinary Group meeting document review, the Surveyor noted that the Interdisciplinary Group failed to document decline, revisions to plans of care and goals. This was confirmed by the Chief Nurse Officer.

Observed in Individual Tracer. In 18 of 20 patient records reviewed, The hospice nurse surveyor noted (HV#1) that the plan of care dis not include any goals that had measurable outcomes or time frames for achieving outcomes. The surveyor noted that there were no goals for the problems identified in the nursing assessment including: dysphagia with aspiration and vomiting, constipation and care of an indwelling Foley catheter. Also, there were no goals for managing a wound to the sacrum described in the initial assessment. Also, the surveyor noted that there were no goals (HV#2) to manage the patient's symptom of dyspnea. The surveyor noted that the patient plan of care included only interventions for managing the oxygen. It also, did not include oxygen safety with risk for open flames identified on the assessment. Also, in (HV#2) and ( DRR#2-7), the surveyor noted that none of the care plans included measurable outcomes and time frames for achieve outcomes. This was confirmed with the nurse reviewer. Observed in Record Review. In 10 of 20 patient records reviewed, During record review for RR # 8-14 and HV# 3-5, the surveyor observed that patient goals were not always measurable and did not have designated time frames. For example, in RR # 8 , patient goals were fall risk will be minimized, HV # 5 optimal respiratory functions, and RR# 14 optimal nutrition. None of the goals were measurable or had time frames. This was verified with the Patient Care Manager.

Observed in Individual Tracer. The hospice nurse surveyor noted(HV#1) that the plan of care visit frequency orders were not followed. The plan of care orders were for SN visits every week; however a visit was not completed for the third week in January. The surveyor noted that the visits the week before and after that week were telehealth visits, as requested by the patient, so the patient was not visited by the registered nurse for a period of one month. This was confirmed with the nurse reviewer.

Observed in Individual Tracer. In 2 of 20 patient records reviewed, The hospice nurse surveyor noted(HV#1) that the plan of care did not include treatment orders for managing the patient's Foley catheter. The initial assessment indicated that the patient had an indwelling catheter when admitted. Also, on (HV#2) the surveyor noted that the patient was ordered continuous oxygen; however the orders were unclear. There were no oxygen orders on the plan of care and the medication list indicated 2LPM continuous via NC. The patient's concentrator was set at 2.5 LPM as observed on the visit, and the last face-to-face nurse practitioner's note indicated it was 3LPM. This was confirmed with the nurse reviewer.

Observed in Tracer Activities. In 6 of 8 patient records reviewed, The organization utilized the Interdisciplinary group meeting as part of the process to update the care plan. In RR # 8-10and HV # 3-5, no progress toward outcomes or goals were found in any of the IDT documentation. The care plan did not include measurable goals and no plans for the next few weeks. This observation applies to all disciplines. This was acknowledged by the Chief Clinical Officer. Observed in Individual Tracer. In 6 of 8 patient records reviewed for updates, The hospice nurse surveyor noted (HV#1) the plan of care was not updated with goals and interventions. The surveyor noted that the plan of care had only one goal patient/caregiver will understand symptoms of agitation that was not measurable and the interdisciplinary care plan updates did not indicate the progress for managing the patient's agitation. The surveyor also noted that the current plan of care still had old interventions (no goals) for wound care for a wound that healed months ago. The plan of care was never updated to include indwelling catheter management or dysphagia prevention since the patient was admitted almost a year ago. The surveyor noted that the same goals interventions were on the plan of care, since admission and additional goals were never added since 10 months ago. Also, (HV#2) the surveyor noted that the plan of care was not updated since the patient was admitted 18 months ago to include goals and interventions to manage her dyspnea and oxygen safety. The only goal was patient/caregiver will understand affects of anxiety/agitation and available treatments that remained on the care plan since admission. This was confirmed with the nurse reviewer.

Observed in Individual Tracer. In 1 of 5 home visits conducted, The hospice nurse surveyor noted (HV#2) that the chaplain placed her bag directly on the kitchen counter in the patient's home. The surveyor noted that the hospice policy required that the bag be placed on a barrier. This was confirmed with leadership. Observed in Patient Home. In 1 of 5 home visits conducted, During HV#4 the nurse surveyor observe the Registered Nurse pouring hand sanitizer on a paper towel to clean her stethoscope both before and after use. Additionally, the Registered nurse did not clean the blood pressure machine prior to or after use. The hospice policy required that equipment be clean with an approved organization disinfectant. This was also observed by patient care manager.

Observed in Patient Home. In 1 of 3 resident records reviewed, the registered nurse did not provide written patient care instructions to the hospice aide. For example, in HV #5 the surveyor noted that the aide removed the patient neck collar during bed bath, but the aide plan of care did not address whether the collar could be removed for bath. This was observed by the Patient Care Director.

Observed in Patient Home. In 1 of 2 home visits conducted, the patient record did not contain information that reflected it's care, treatment, or services. During medication review the agency electronic medical record had Oxycontin, Piper/ Tazoba and oxycod/ Apap as active medications. According to the Skilled Nursing Facility nurse these medications were discontinued on 1/16/2022. This was also observed by Patient Care Manager.

Observed in Record Review. In 2 of 2 transfer/discharge summaries, The hospice nurse surveyor noted (DRR#6 and DRR#7) that the transfer summary and discharge summaries did not include progress toward goals and therefore reflect the patient's status. The surveyor noted that the summaries populate form goals identified in the plan of care; however the plan of care did not include goals with outcome measures and time frame. This was confirmed with the nurse reviewer.

Observed in Data Session. In 3 of 3 years, hospice surveyor noted the contracts for DME, Inpatient services, SNF and pharmacy did not have criteria established to evaluate the contracted services in there QAPI. There was no evidence that the organization had a plan to monitor there contracted services. There was no data to show that the organization evaluated these services in relation to the organization expectation in the past 3 years. This was confirmed by the Chief Compliance Officer.

Observed in Building Tour. In 1 of 5 inpatient units, The hospice nurse surveyor noted during the building tour of the (G-IPU), that there were several bags of linens/pillows stored within 6-12 inches of the ceiling in the linen room. This was confirmed with the facilities manager and corrected on site. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. The hospice nurse surveyor noted during the building tour of the (G-IPU), that the escutcheon plate was missing from around a sprinkler head in patient room 303. This was confirmed with the facilities manager. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.

Observed in Building Tour. The hospice nurse surveyor noted during the building tour of the (G-IPU), that there were five containers of soup and several packages of confectioner sugar that had expired and stored in the kitchen pantry. This was corrected on site and packages removed by the dietary manager.

Observed in Patient Home. In 1 of 2 home visits conducted, the organization failed to discussed the organization plan of care with the skilled Nursing Facility ( SNF )representatives. For example, the SNF added Ferrous sulfate to their plan of care and Oxycontin, Piper/ Tazoba and oxycod/ Apap were discontinued. The organization plan of care did not reflect these changes. This was observed by Patient Care Manager.