Every finding on record at Houston Hospice

It is required that each patient’s individualized written plan of care: 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 1 of 30 (3%) records reviewed revealed the agency did not ensure the plan of care was individualized with specific interventions to meet the needs of the patient. Clinical Record 13: Elected hospice benefit on 05/16/2023 with a diagnosis of cerebrovascular disease. The nursing comprehensive assessment (dated 01/11/2024) documented, "Has had increase in hallucinations/confusion." During the nursing assessment on 01/29/2024 the RN documented, "aroused for visit but is very confused, almost anxious but did calm down." The interdisciplinary team meeting notes from 02/08/2024 reported, "when she is up for meals she gets anxious, will start crying and will calm once she is back in her bed...is confused continuously, often hallucinating, but redirects easily." The plan of care, effective for the current benefit period (01/11/2024 to 03/10/2024) did not contain any problems, goals, or interventions related to the anxiety or hallucinations. Personnel Record 2: On 02/23/2024 the VP of Patient Services confirmed that the plan of care did not include any interventions for the anxiety or hallucinations and agreed that it should have.

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 23 (22%) records reviewed, in which aide services were accepted, revealed the agency did not ensure that the RN provided specific written instructions for the hospice aide to perform assigned personal care tasks. Clinical Record 4: Elected hospice benefit on 02/07/2024 with a diagnosis of heart failure. The initial nursing comprehensive assessment (02/07/2024) documented the patient had a tracheostomy in place with oxygen being administered via a mask over the trach. From 02/07/2024 to 02/14/2024 the patient resided in the inpatient unit and was discharged home on 02/14/2024. Documentation for the review date (02/22/2024) reported, "patient has a 7.5 French Shirley trach with 4 liters oxygen continuous via trach mask in place." The hospice aide care plan, effective from 02/14/2024 to current, instructed the aide to provide a bed bath and assist with dressing and undressing with every visit. The aide care plan did not alert the aide that the patient had the tracheostomy with oxygen and what, if any, precautions or directions they needed to follow. Clinical Record 8: The initial nursing comprehensive assessment (12/01/2023) documented the terminal diagnosis of malignant neoplasm of the pancreas and reported the patient had a PEG (percutaneous endoscopic gastrostomy) tube and biliary drain in place, both sites covered with dressings. An RN visit dated, 02/15/2024, documented that the PEG tube and biliary drain were still present. The hospice aide visits orders, effective 01/28/2024, were for visits one time a week with the following relevant tasks: bed bath and skin care. The hospice aide care plan did not alert the aide that the patient had a PEG tube (with dressing) or biliary drain (with dressing) present nor did it provide directions on what the aide should do if the dressings were not present or became wet. Clinical Record 12: Elected hospice benefit on 02/19/2021 with a diagnosis of cerebrovascular disease. The aide care plan, effective for current benefit period (02/15/2024 to 04/14/2024) instructed the aide to perform oral care with each visit (five times per week) and stated, "patient uses Oral B electric toothbrush." The nursing visit from 02/15/2024 documented the patient was on high flow oxygen at fifteen (15) liters with an oxygen saturation of 84%. The aide care plan did not instruct the aide if they could or could not remove the oxygen for cares or instruct the aide not to use the electric toothbrush when the patient had the oxygen on. The aide care plan did not include oxygen precautions. Clinical Record 18: Elected hospice benefit on 06/02/2023 with a diagnosis of malignant neoplasm of cerebrum. Plan of care effective for current benefit period (01/28/2024 to 03/27/2024) documented that the patient had dysphagia/aspiration risk with interventions to raise the head of the bed to 45 degrees and required thickened liquids. The aide care plan, effective as of 01/28/2024, included the following relevant task, "prepare patient for mealtime" but did not instruct the aide that the patient required aspiration precautions, an elevated head of the bed, or thickened liquids. Clinical Record 19: Elected hospice benefit on 02/08/2024 with a diagnosis of Parkinson's disease with dyskinesia. Per the initial nursing assessment (02/08/2024) the patient was admitted with a PEG (percutaneous endoscopic gastrostomy) tube in place, as well as wounds with dressing to left heel and right calf. On 02/21/2024 the RN documented, "Patient has developed pressure injuries between almost every finger and thumbs. Patients' right pinky (finger) was digging into her palm. Patient's left thumb appears to have cellulitis due to the stage 2 wound caused by her index finger pressing on the thumb. Patient is contracted and moving her fingers causes significant discomfort. RN used wound cleansing spray and gauze between all fingers, thumbs and palms to provide protection and cushioning." The aide care plan, effective from 02/08/2024 ordered three visits per week with the following relevant tasks, bed bath and dressing with each visit. The care plan did not alert the aide that the patient had a PEG tube or wound dressings in place. The aide care plan was not updated on 02/21/2024 to alert the aide that the patient had gauze in place between fingers, thumbs, and palm of both hands. Personnel Record 2: On 02/23/2024 the VP of Patient Services reviewed the records and confirmed that the aide care plans did not contain the above-mentioned information. Furthermore, it was reported that "there is a patient alert area on the aide care plans that the RN's should have used for this type of information."

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by clinical record review, document review and interview. In 5 of 15 (33%) direct care personnel records reviewed revealed the agency did not ensure that skills and competencies assessments were completed in adherence with agency policies and procedures. Document 5: Titled: Clinical Staff Competency 2.120 (last reviewed 06/17/2021) stated in relevant part, "(agency name) will provide for competency assessments by qualified individuals on hire and annually to assess direct care staff's basic skill levels for all staff providing care, including paraprofessionals and professionals." Personnel Record 8: Record revealed the employee was a registered nurse (RN) with a date of hire of 05/05/2014. The last documented skills competency was on 02/11/2022. Personnel Record 14: Record revealed the employee was a licensed vocational nurse (LVN) with a date of hire of 08/29/2022. The last documented skills competency was dated 12/19/2022. Personnel Record 16: Record revealed the employee was a licensed vocational nurse (LVN) with a date of hire of 10/02/2017. The last documented nursing skills competency was dated 10/10/2022. Personnel Record 17: Record revealed the employee was a licensed vocational nurse (LVN) with a date of hire of 02/07/2022. The last documented nursing skills competency was completed on 10/06/2022. Personnel Record 21: Record revealed the employee was a registered nurse (RN) with a date of hire of 10/07/2013. The last documented nursing skill competency was on 10/07/2022. Personnel Record 2: During an interview with the VP of Patient Services, on 02/22/2024, it was confirmed that the employees identified were all direct care employees and should have had annual skills competency assessments. It was reported that "there were changes in clinical managers which created a breakdown in the process."

It is required that a hospice-operated inpatient care facility complies with all applicable federal, state and local health and safety codes, including: the applicable provisions of the Life Safety Code (LSC) of the National Fire Protection Association NFPA 101, Life Safety Code 2012 edition. This standard was not met as evidenced by interview and observation. An observation of the in-patient unit was conducted which revealed the agency did not ensure the fire extinguishers were properly inspected per NFPA regulations. (NFPA 107.2.1 Portable fire extinguishers are required to be visually inspected when initially placed in service and at least monthly at a minimum of 30-day intervals thereafter.) Observation 1: During a LSC inspection of the in-patient unit on 02/20/2024 it was observed that seven (7) fire extinguishers did not have evidence of monthly inspections. The inspection tags affixed to all 7 fire extinguishers revealed initials indicating that in January of 2024 an inspection was completed. The tag also revealed that the annual inspection was completed in June 2023, but all sections between June 2023 and December 2023 were blank. The facility manager (personnel record 20) confirmed this during the joint observation tour and said the "old tags were removed at the end of year." The facility manager reported the facility technician had removed them. In an interview with the facility technician (02/21/2024), he indicated that he had completed the monthly inspections and initialled on each tag. He reported that he was asked to remove the tags at the end of 2023 and replace them with new tags for 2024, he doesn't know what happened to them after that. The tags for July through December 2023 could not be located to provide evidence of the previous inspections. The VP of Patient Services (personnel record 2) reported that the tags should have been left on the fire extinguishers until the next annual inspection (June 2024) and as of the exit conference (02/23/2024) reported there was not additional documentation to present. An observation of the in-patient unit was conducted which revealed the agency did not ensure the fire extinguishers were properly inspected per NFPA regulations. (NFPA 107.2.1 Portable fire extinguishers are required to be visually inspected when initially placed in service and at least monthly at a minimum of 30-day intervals thereafter.)

Based on record review and interview, the agency failed maintain a communication system in its written policies to designate coordinating, and supervising the care and services provided to 1 of 3 patients (Patient #1) whose records were reviewed, in that: The RN failed to coordinate with the hospice aide regarding individualized care instructions for patient #1. This failure resulted in inability to minimize trauma when performing ADL(s) and placed Patient #1 at risk of receiving suboptimal care. --- Findings Patient #1 Review of Patient #1's CR revealed IDT or Hospice Team Care Plan (HTCP) with the SOC dated 01/29/2023 and period reviewed from 01/29/2023 to 04/25/2023 that Malignant neoplasm of liver, primary, unspecified, Metastasis to lung, Metastasis to bone, Diabetes mellitus and depression as the diagnosis. Review of SN visit note dated 01/29/2023 revealed that patient had pathologic right hip fracture on 01/23/2023 and had hip hemiarthroplasty (partial hip replacement) on 01/25/2023. The SN visit note revealed that Patient #1 had left upper arm fracture from moving in bed. The SN visit note revealed that Patient #1 was admitted to hospice IPU on 01/29/2023 with staples present at patient #1s right hip. Record revealed that Patient #1 was bed bound and total care with ADLs. Review of CR revealed that the Patient #1 was transferred from the agency IPU to SNF routine home care on 02/09/2023. Review of HTCP dated 01/29/2023 revealed hospice Aide frequency of 3 times a week for 13 weeks and SN once a week for 13 weeks. Review of HTCP did not include order to pre-medicate patient #1 prior to hospice Aide services. Review of the HTCP revealed section titled ";Care Plan HHA1: Hospice Aide Task List with the goals that ";personal hygiene needs be met" and with the following interventions ";brush/comb hair, standard precautions, bed bath, shampoo, nail care: soak and file weekly, skin care, turn/reposition, empty urinary catheter bag, catheter care, record last bowel movement, change bed linens: weekly and as soiled, straighten bed linens, assist with dressing/undressing, maintain clean, safe environment, observe for bleeding,.. observe for pain/discomfort... RN will review/adjust HHA task list weekly as needed to meet patient needs." The hospice Aide task list failed to include instruction for that patient #1 needed 2 people to perform Aide tasks as outlined in the care plan which included bathing, turning, repositioning, and changing bed linens. Review of RN visit note dated 2/10/2023 revealed Patient #1s skin evaluation of healed surgical incision to left shoulder and staples/sutures that were present at right hip. The RN note revealed ";none" was documented under care coordination with other disciplines, agencies, and vendors. The RN visit note was electronically signed by RNCM. There was no documentation or instruction provided to the CNA(s) regarding needs to pre-medicate Patient #1 prior to performing hospice aide tasks. During telephone interview on 02/27/2023 with CNA #1 at 1:22 p.m., CNA #1 reported that she got to know about patient #1s surgery and level of care needed to safely provide care for the first time she worked with the Patient on 02/13/2023. CNA #1 stated when she touched Patient #1s shoulder to turn her, Patient #1 yelled, and it was Patient #1 that told her she had surgery on her shoulder and had staples on her hip. CNA #1stated that from there on that day, every time she touched Patient #1, she screamed and yelled and that was when she realized she could not perform the assigned tasks by herself and had to called for assistance from the SNF staff. CNA #1 stated she called RNCM and informed RNCM that due to patient #1s hip surgery and inability to assist with tasks, another staff from the hospice will be needed and that was the reason CNA #2 was assigned to accompany her during the subsequent visits. During telephone interview on 02/28/2023 with RNCM at 1:28 p.m., RNCM was asked on how she coordinated Patient #1s care with CNA #1 during initial assignment. RNCM reported that the Aide care plan was plugged into the agency software system for the CNAs to assess. The RNCM stated she did not remember telling the CNAs about Patient #1s left shoulder incision and right hip surgery. The RNCM stated she did not know if there were any specific instruction provided to the CNAs regarding turning and repositioning Patient #1 other than CNAs following normal turning and maintaining safety. The RNCM stated based on her assessment she knew that Patient #1 was a 2-person assists but believed the facility would help when asked. During an interview on 02/28/2023 with the Adm and Alt. Adm at 3:45 p.m., the surveyor reviewed the findings with the agency staff. The Alt. Adm stated that there was a nurse-to-nurse interchange from when Patient #1 was transferred from IPU to the facility but there was no documentation of Nurse to Aide care instructions other than what the tasks/interventions that was stated in the Aide care plan. The Alt. Adm stated that the discussion should have been part of the IDT meeting following the transfer of the Patient to the SNF, but it was not addressed. Policy Review of the agency policy tilled "Coordination of Patient Care and Services." number 6.300 Policy Read in part, "... (IDT) shall provide the care, coordination and maintenance of services safe and effective manner and to ensure the effective exchange of information, reporting and coordination of client services."