Every finding on record at Hospice of the North Country Inc

Based on clinical record review and staff interview, the hospice failed to ensure an initial bereavement risk assessment was conducted in a timely manner to identify the needs of the family and caregivers in one out of thirteen records reviewed (Patient # 2). Failure to conduct an initial bereavement risk assessment timely has the potential to result in unmet family and caregiver needs and may inhibit the hospice's ability to develop a comprehensive bereavement plan of care. Finding: Patient # 2 (start of care 04/15/2021) has a diagnoses of End Stage Renal Disease and Essential (Primary) Hypertension. The record (reviewed on 01/05/2022) contains an initial bereavement risk assessment that was conducted on 07/19/2021, greater than 3 months after start of care. The finding was confirmed 01/05/2022 at 12:00 PM with the Executive Director and Director of Patient Services; no additional evidence was provided.

Based on clinical record review and staff interview the hospice failed to ensure in nine of thirteen records (Patient # 1, 2, 3, 4, 7, 8, 10, 11 and 12) an individualized and complete physician Plan of Care (POC) was developed to meet the needs of the patient. Failure to develop a patient specific individualized and complete plan of care has the potential to result in unmet patient needs and negative patient outcomes. Findings: Patient # 1 (start of care 10/13/2021) has diagnoses of Malignant Neoplasm of Unspecified Kidney Except Renal Pelvis and Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. The physician's POC for certification period 10/13/2021 through 01/10/2022 contains order for Levothyroxine 50 microgram (mcg) (0.05 milligram) oral tablet (tab); Take 1 tab orally once a day. The order is incomplete as it lacks instruction to administer medication 30 minutes to 1 hour before consuming food. Patient # 2 (start of care 04/15/2021) has a diagnoses of End Stage Renal Disease and Essential (Primary) Hypertension (HTN). The physician's POC for certification period 12/11/2021 through 02/08/2022 contains an order for Aspirin 81 mg, oral. Take one tab once a day. The POC is incomplete as it lacks bleeding precautions. Patient # 3 (start of care 08/16/2021) has a diagnoses of Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung and Tobacco Use. The physician's POC for certification period 11/14/2021 through 02/11/2022 contains orders for: - Fentanyl 50 mcg/hour (Hr) transdermal film, extended release; apply 1 patch transdermal every 72 hours for pain. The order is incomplete as it lacks instruction to rotate patch site. - Levothyroxine 125 mcg, oral tablet; Take 1 tab orally once a day. The order is incomplete as it lacks instruction to administer medication 30 minutes to 1 hour prior to consuming food. Patient # 4 (start of care 10/26/2021) has a diagnoses of Creutzfeldt-Jakob Disease, Unspecified and HTN. The physicians POC for certification period 10/26/2021 through 01/23/2022 contains an order for Eliquis 5 mg tablet, oral. Take one tablet two times a day. The POC is incomplete as it lacks bleeding precautions. Patient # 7 (start of care 12/07/2021) has diagnoses of Senile Degeneration of the Brain not elsewhere Classified and HTN. The physicians POC for certification period 12/07/2021 through 03/06/2022 contains orders for: - Levothyroxine 75 mcg oral tablet; Take 1 tab oral every other day. The order is incomplete as it lacks instruction to administer medication 30 minutes to 1 hour prior to consuming food; Alternate with 50 mcg tablet. - Levothyroxine 50 mcg oral tablet; Take 1 tab oral every other day; Alternate with 75 mcg tablet. The order is incomplete as it lacks instruction to administer medication 30 minutes to 1 hour prior to consuming food. Patient # 8 (start of care 12/15/2021) has diagnoses of Chronic Kidney Disease, Unspecified and Depression, Unspecified. The physicians POC for certification period 12/15/2021 through 03/14/2022 contains orders for: - Fentanyl 25 mcg/hr (hour) transdermal film, extended release; apply 1 film applied topically every 72 hours. The order is incomplete as it lacks instruction to rotate patch site. - Eliquis 5 mg oral tablet. Take one tab orally two times a day. The POC is incomplete as it does not state bleeding precautions. Additionally, the record contains an initial RN (Registered Nurse) assessment (dated 12/15/2021) that specifies the presence of a dialysis catheter located in the patients right upper chest. The physician POC is incomplete as it lacks identification of the dialysis catheter and instructions of any care to be provided to the catheter. Patient # 10 (start of care 04/21/2021) has diagnoses of Chronic Diastolic (Congestive) Heart Failure and Non-rheumatic Aortic (Valve) Stenosis. The physicians POC for certification period 12/17/2021 through 02/14/2022 contains an order for Synthroid 25 mcg oral tablet; Take 1 tab orally once a day. The order is incomplete as it lacks instruction to administer medication 30 minutes to 1 hour prior to consuming food. Patient # 11 (start of care 04/21/2021 and discharged 09/25/2021) has diagnoses of Huntington's Disease and Over Active Bladder. The physicians POC for certification period 09/21/2021 through 11/19/2021 contains an order for Levothyroxine 200 mcg (0.2 milligram) oral tablet; Take 1 tab orally once a day. The order is incomplete as it lacks instruction to administer medication 30 minutes to 1 hour prior to consuming food. Patient # 12 (start of care 04/27/2021, discharged 12/05/2021) has a diagnoses of Malignant Neoplasm of Bladder, Unspecified and Personal History of Nicotine Dependence. The physicians POC for certification period 10/24/2021 through 12/22/2021 contains an order for Aspirin Enteric Coated 81 mg oral, delayed release. Take one tab once a day. The POC is incomplete as it lacks bleeding precautions. The findings were confirmed on 01/05/2022 at 12:00 PM and 01/06/2022 at 10:00 AM, 10:15 AM, 2:45 PM and 3:10 PM with the Executive Director and Director of Patient Services; no additional evidence was provided.

Based on clinical record review and staff interview the hospice failed to ensure in one of thirteen records (Patient # 9,) care and services are provided in accordance to the physician's Plan Of Care (POC). Failure to provide care in accordance with the patient's established plan of care has the potential to result in inappropriate care, unmet patient needs and negative patient outcomes. Finding: Patient # 9 (start of care 12/20/2021) has diagnoses of Alcoholic Cirrhosis of Liver with Ascites and Gastric Varices. The physicians POC for the certification period 12/20/2021 though 03/19/2022 states the Medical Social Worker (MSW) is to conduct one visit a week for four weeks. The record lacks documented evidence the MSW conducted a visit the week of 12/26/2021 and that the physician was notified of the MSW missed visit. The finding was confirmed on 01/06/2022 at 3:10 PM with the Executive Director and Director of Patient Services; no additional evidence was provided.

Based on review of the hospice's infection control policies and procedures, and interview with the Executive Director and Director of Patient Services, evidence is lacking the hospice has ensured the development of a comprehensive infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable disease. Failure to develop a comprehensive infection control program has the potential to place patients and staff at risk for exposure to infectious and/or communicable diseases which may result in negative patient outcomes and adversely affect hospice operations. Finding: The hospice's infection control policies and procedures entitled "Infection Control-Biohazard Waste and Spill Management " (Effective date: 09/15/2020), "Infection Control-Exposure to Blood and Body Fluids" (Effective date: 01/09/2020), "Infection Control-Standard Precautions and Transmission Based Precautions" (Effective date: 03/01/2021) and "Infection Control Program" (Effective 05/18/2021) fail to include specific protocols addressing the prevention of infection related to higher risk patient care issues such as infusion therapy and urinary tract care. The finding was confirmed on 01/05/2022 at 1:30 pm with the Executive Director and the Director of Patient Services; no additional evidence was provided.

Based on clinical record review and staff interview the hospice failed to ensure a comprehensive discharge summary was prepared that contained all required components in one of three records in which the patient was discharged (Patient # 12). Failure to prepare a comprehensive discharge summary places patients at risk for poor coordination of patient services and unmet patient needs upon discharge from the hospice. Finding: Patient # 12 (start of care 04.27.2021, discharged 12/05/2021) has a diagnoses of Malignant Neoplasm of Bladder, Unspecified and Personal History of Nicotine Dependence. The record contains a Discharge Summary (dated 12/05/2021) that is incomplete as it lacks documented evidence of the Durable Medical Equipment the patient utilizes (i.e. grab bars/safety rails, shower chair, and walker). The finding was confirmed on 01/06/2022 at 3:00 PM with the Executive Director and Director of Patient Services; no additional evidence was provided.

Based on an observational home visit at a Skilled Nursing Facility (SNF) (Patient # 10) and staff interview, the hospice failed to ensure orientation was provided to SNF staff furnishing care to Hospice patients regarding the Hospice philosophy, Hospice policies and procedures regarding methods of comfort, pain control, symptom management, principles about death and dying, individual responses to death, patient rights, appropriate forms and record keeping requirements. Failure to ensure SNF staff have received orientation regarding the Hospice philosophy, Hospice policies and procedures regarding methods of comfort, pain control, symptom management, principles about death and dying, individual responses to death, patient rights, appropriate forms and record keeping requirements has the potential to result in the provision of inappropriate care, unmet patient and family needs and negative patient outcomes. Finding: Patient # 10 (start of care 04/21/2021) has diagnoses of Chronic Diastolic (Congestive) Heart Failure and Non-rheumatic Aortic (Valve) Stenosis. During an observation home visit at the SNF conducted on 01/05/2022, the SNF Staff Educator was contacted and acknowledged orientation to SNF staff furnishing care to Hospice patients regarding the Hospice philosophy, Hospice policies and procedures regarding methods of comfort, pain control, symptom management, principles about death and dying, individual responses to death, patient rights, appropriate forms and record keeping requirements was not part of the orientation curriculum. The finding was reviewed on 01/05/2022 at 12:30 PM with the Executive Director and the Director of Patient Services; no additional evidence was provided.