Every finding on record at Hospice of St. Francis, Inc

It is required that each patient’s individualized written plan of care reflects patient and family goals, and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 4 of 20 (20%) active records reviewed, for patients on routine hospice care, it was revealed that the agency did not ensure that each patients individualized plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected the hospice benefit on 07/10/2023 with a diagnosis of Inclusion body myositis. During the initial assessment’ dated 07/10/2023 the Registered Nurse (RN) documented "dysphagia leading to recurrent aspiration and/or inadequate or decreasing oral intake." On an RN note, dated 07/11/2024 the RN documented "difficulty chewing and swallowing, dysphagia. Breads are difficult to swallow as are large food items." The plan of care dated 07/04/2024 to 09/01/2024 included the following diet "regular/thin liquids/as tolerated, difficulty chewing and swallowing. Reason: Dysphasia," but did not have any additional problems, goals, or interventions related to dysphagia or aspiration precautions. Clinical Record 13: The patient elected the hospice benefit on 08/15/2024 with a diagnosis of senile degeneration of the brain. During the initial comprehensive assessment by the RN, it was documented "Increasing dysphagia. Eats 100% x3 meals per day. Increasing episodes of dysphagia, especially over the past month. Daughter states anxiety is not adequately controlled with current medication regimen." The plan of care, dated 08/15/2024 to 11/12/2024, did not include any problems, goals, or interventions related to dysphagia or anxiety. Clinical Record 14: The patient elected the hospice benefit on 07/25/2024 with a diagnosis of Cerebrovascular disease. In the initial comprehensive assessment, dated 07/25/2024, the RN documented, "anxiety reported by patient's family, not adequately controlled, however due to a history of Seroquel making psychosis worse family elects not to make any changes to patient's medications at this time." During review of the medication profile the following orders were identified: Lorazepam 1mg oral tablets. Take 0.5mg for moderate anxiety and 1mg for severe anxiety, every 3 hours as needed for anxiety; Bupropion 150mg every 12 hours; and Mirtazapine 15mg at bedtime for anxiety and depression. The plan of care dated 07/25/2024 to 10/23/2024 did not include any problems, goals, or interventions related to anxiety. Clinical Record 17: The patient elected the hospice benefit on 09/25/2024 with a diagnosis of malignant neoplasm of the rectum. In the initial comprehensive assessment dated 09/25/2024 the RN documented "uncontrolled anxiety and depression, poor sleep as a result of anxiety." Medications listed on the patient's medication profile were Lorazepam 0.5mg for anxiety, Celexa 20mg daily for depression, and Trazadone 50mg at night for sleep. The plan of care, dated 09/25/2024 to 12/24/2024, did not include any problems, goals, or interventions related to anxiety, depression, or sleep disturbances. In an interview and joint review of clinical records with the Chief Clinical Officer (11/15/2024) the plans of care were discussed and what the agency processes were for developing them was. She stated that these plans of care were not complete with all the required information on them. She stated that she agreed the RN should have included the problems identified in the comprehensive assessments in plans of care.

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, use of gloves, mask, eye protection, or face shield depending on anticipated exposure, safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids, safe handling of soiled items in the patient’s care environment, other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, interview and observation. In 2 of 5 (40%) observations of care of patients in the inpatient unit (IPU) it was revealed that the agency did not ensure that accepted standards of practice were followed to prevent the transmission of infections and communicable disease. The agency’s standard operating procedure (SOP) for Infection Control/Hand Hygiene (no date) stated in part, "When to wash hands: before performing a clean/aseptic procedure, immediately after an exposure risk to body fluids, before and after glove removal." Home Visit 8/Clinical Record 29: The patient was admitted to the hospice IPU on 11/06/2024 with a diagnosis of Cardiomyopathy. During the observation, conducted on 11/13/2024, of the Registered Nurse (RN) (Personnel Record 13) performing wound care on the patient’s coccyx wound, the RN removed the soiled dressing with gloved hands. The wound was then cleaned according to the plan of care, and a new dressing was applied. However, the RN did not change her gloves between handling the dirty and clean dressings. Home Visit 9/Clinical Record 30: The patient was admitted the hospice IPU 11/5/2024 with a diagnosis of Merkel cell carcinoma. During observation, conducted on 11/13/2024, of the RN (Personnel Record 13) and Licensed Practical Nurse (LPN) (Personnel Record 14) performing personal care for the patient, the LPN changed a soiled brief with gloved hands, cleaned stool off patient, placed a clean brief on the patient and then replaced the blanket over the patient without changing her gloves. During an interview on 11/13/2024, the agency’s standard operating policy and procedure for Infection Control/Hand Hygiene was reviewed with the Chief Clinical Officer and IPU manager who said these policies were in place and reported education was provided to staff regarding specific hand hygiene and infection control procedures. They both agreed that the RN and LPN did not abide by these policies as evidence by putting on an initial pair of gloves and not changing them between dirty and clean tasks. Both staff members were re-educated immediately and while site visitor was still on site. The agency SOP for infection control/Hand Hygiene states in part, "When to wash hands: before performing a clean/aseptic procedure, immediately after an exposure risk to body fluids, before and after glove removal."

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 5 of 20 (25%) active records reviewed, for patients on routine hospice care and receiving aide services, it was revealed that the agency did not ensure that the Registered Nurse (RN) developed a written plan of care with specific instructions for patient care. Clinical Record 2: The patient elected the hospice benefit on 12/13/2022 with a diagnosis of Cardiomyopathy. The aide plan of care, dated 07/27/2024 to current, was written as follows: Assist with Dressing/Undressing all days “as directed”; Assist with oxygen all days “as directed”; Comb or brush hair all days “as directed”; and Shave (specify electric or disposable razor, patient has both) All days “as directed.” There was no evidence the RN provided the aide instructions for tasks assigned "as directed,” and the aide care plan did not identify a decision maker. Clinical Record 3: The patient elected the hospice benefit on 12/05/2023 with a diagnosis of frontotemporal neurocognitive disorder. The aide plan of care for 09/25/2024 to 11/12/2024 was written as follows: assist with dressing/undressing all days “as directed, as needed”; Brush teeth all days “as directed, as needed”; comb or brush hair all days “as directed as needed”; denture care all days “as directed” in am and pm; and fingernail care all days “as directed, as needed.” There was no evidence the RN provided the aide instructions for tasks assigned "as directed” or “as needed” and the aide care plan did not identify a decision maker. Clinical Record 5: The patient elected the hospice benefit on 03/24/2024 with a diagnosis of Cerebrovascular Disease. The aide plan of care, last updated on 04/04/2024, ordered “apply barrier cream all days, every visit.” There was no written evidence of specific directions on where to place the barrier cream. The aide documented completion of this task on 09/29/2024, 09/30/2024, 10/03/2024, and 10/07/2024 with no documentation of where the barrier cream was needed or applied. Clinical Record 11: The patient elected the hospice benefit on 07/09/2024 with a diagnosis of malignant neoplasm of the left breast. The aide plan of care dated 10/29/2024 included the following relevant tasks: assist with dressing/undressing “as directed and as needed”; and Fingernail care “as directed, as needed” can clean and file nails. There was no evidence the RN provided the aide instructions for tasks assigned "as directed,” and the aide care plan did not identify a decision maker. Clinical Record 17: The patient elected the hospice benefit on 09/25/2024 with a diagnosis of Malignant neoplasm of the rectum. The RN documented that the patient had a colostomy on the right side of abdomen and dressing over a post prostatectomy surgical incision. On the aide plan of care dated 09/30/2024 it was ordered for the aide to give the patient a shower and shampoo every visit. There was no written evidence of notification or specific instructions for aide to abide by in the instance the colostomy was malfunctioning, or the dressing was displaced or soiled. In an interview and joint clinical record review (11/15/2024) with the Chief Clinical Officer she confirmed that the aide plans of care should not contain any “as needed” or “as directed” ordered tasks. She stated that they are doing more education with the nursing staff on this topic currently.

It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code fire drills at varied times on all shifts. This standard was not met as evidenced by document review, observation and interview. The hospice failed to ensure that there were documented and dated reports of the Life Safety code fire drills or documented employee training related to the current fire plan. A tour of the in-patient facility occurred during the site visit on 1/5/2022. There were no documented quarterly fire drills for each shift consistent with facility policy and the 2012 Life Safety Code requirements. There was no documentation of employee training on fire safety related to the current fire plan, permissible under the CMS COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers. Specifically, there was no documentation of employee training on fire safety or fire drills for the third quarters of 2021 and 2020, and the first and second quarters of 2019. During interview on 1/5/2022, the Chief Compliance Officer confirmed the maintenance technician did not conduct fire drills during the third quarters of 2020 and 2021 and that the fire drills for the first and second quarters of 2019 could not be located. The Director of Compliance confirmed that there were two shifts at the inpatient facility, 7am to 7pm and 7pm to 7am. Reference: 2012 Life Safety Code, section 19.7.1.2 for existing health care facilities: "Fire drills shall be conducted quarterly on each shift to familiarize facility personnel with the signals and emergency actions required under varied conditions”. The agency's Inpatient Facility Policy "Fire Safety In the IPU Policy", Policy No. 1114, effective August 2016, included, in part, "A fire drill is held at least quarterly, each shift has a fire drill at least quarterly at varied times, and the fire drill (time, date, and participants) and the evaluation are documented".

It is required that the hospice inpatient facility provides meals to each patient that are palatable, attractive, and served at the proper temperature, and obtained, stored, prepared, distributed and served under sanitary conditions. This standard was not met as evidenced by interview, observation and document review. The hospice failed to ensure that meals served to each patient were provided at the proper temperature consistent with agency policy. A tour of the in-patient facility occurred during the site visit on 1/5/2022. No recorded food temperature logs were maintained at the hospice inpatient house to ensure that foods were served to the patients at the proper temperature and consistent with the hospice inpatient facility policy and procedure. During interview, the Food Services Manager stated that she uses a food thermometer to check the temperature of the food before serving to the patients, however, these temperatures were not recorded and this process could not be validated. During phone interview with the Dietitian on 1/5/2022 she stated the hospice would put together a process for the Food Service Manager to utilize for recording food temperatures. Additionally, there was no evidence that the hospice inpatient facility provided meals to patients that were stored, prepared, distributed, and served under sanitary conditions, and consistent with agency policy. A tour of the in-patient facility occurred during the site visit on 1/5/2022 and the following was observed: The ice machine in the hospice inpatient kitchen was not clean and sanitary. The Food Services Manager confirmed that she had not cleaned the inside of the ice machine and that a contracted service provider comes every quarter for maintenance of the ice machine only. During phone interview, the Dietitian stated that the ice machine should be cleaned and sanitized according to the manufacturer's recommendations or least monthly. In the inpatient kitchen freezer, there was a white plastic container on a shelf filled with bags of food. The plastic container was soiled with food residue which had accumulated on the sides and bottom of the container. After the inspection of the inside of the freezer, the Food Services Manager removed the soiled plastic container from the freezer and stated that she cleans the inside of of the freezer every couple months. During the phone interview, the Dietitian stated the freezer should be cleaned at least monthly. On the inpatient kitchen ceiling there was a vented cover to the air conditioner air return opening that had an accumulation of dust. After observation of the dust accumulation on the ceiling vent cover, the Maintenance Technician stated that the filters are changed by a contracted quarterly maintenance provider. During interview, the Maintenance Technician stated the contracted service provider changed the air conditioner filter from the roof of the inpatient facility and not from the inside of the kitchen. Review of the outside contracted service reports revealed that the air filter to this air conditioner vent location was changed last on 10/8/21. During interview, the Dietitian stated the surface of the vent covering on the ceiling should be cleaned monthly. The oven in the inpatient kitchen that was currently in use for baking and preparing food for patients had a light build-up of grease and food spills on the sides, bottom and inside surface of the door of the oven. The Food Services Manager stated that she "tries to clean up spills when they happen" and that she cleans the oven "every couple months". Additionally, a second convection oven in the inpatient kitchen also had a light build-up of grease and food spills on the inside of the oven. The Food Services Manager stated that she is not currently using this convection oven. During interview, the Dietitian stated the ovens should be cleaned at least weekly. Policy "Dietary Department", Policy No. 1105, effective August 2016, included, in part, "The hospice purchase, stores, prepares and serves food in a manner that prevents foodborne illness", and Policy "Dietary Services", Policy No. 1106, effective August 2016, included, in part, "The hospice furnishes meals to each patient that are palatable, attractive, and served at the proper temperature, and obtained, stored, prepared, distributed, and served under sanitary conditions".