Every finding on record at Idaho Home Health and Hospice, Inc

Based on review of medical records, policies, State Operations Manual Chapter 2, and staff interview it was determined the hospice failed to properly document a discharge for 1 of 3 patients (Patient #12) who were documented as a revocations or live discharges and whose records were reviewed. This caused a patient to be improperly documented as a revocation when they should have been discharged from hospice which had the potential for a misunderstanding of ability to access services and lead to unmet need. Findings include: --- State Operation Manual Chapter 2 §2081 defined a revocation as, ";a voluntary action taken by the patient or representative. The election of the hospice benefit is the beneficiarys choice rather than the hospices choice, and the hospice cannot revoke the beneficiarys election." State Operations Manual Chapter 2 §2082 states a discharge may occur when, ";the hospice determines that the patient is no longer terminally ill." These guidelines were not followed. An undated hospice policy titled ";Live Discharge/Transfer of the Hospice Patient" stated, ";Patient will be discharged from services as follows ... The patient moves out of the hospice agency geographic service area. ... Another example would be when a hospice patient is receiving treatment for a condition unrelated to the terminal prognosis ... in a facility with which the hospice does not have a contract. ... This entry into a non-contracted facility should not be considered as an absolute requirement to discharge the patient from hospice services. ... When a patient is discharged, transferred or referred to another agency, relevant information for discharge is document in the medical record, typically in the form of a discharge summary, Documentation sent to the patient physician and receiving agency may include: a) Reason for transfer or discharge and date of transfer or discharge" among other documentation. The policy did not include revocation processes. This policy was not followed. An example includes: Patient #12 was an 81-year-old male admitted to hospice on 5/28/24 with the terminal diagnosis of heart failure. Patient #12 had secondary diagnosis of dementia, atrial fibrillation and hypertension among others and received SN, HHA, MSW, and Chaplain services. His record for the certification period of 5/28/24 to 8/25/24 was reviewed. Patient #12s medical record included an SN visit dated 9/12/24. The SN visit note stated, ";Patient continued to complain of pain and nausea. ... POA requested transfer to the ER. Aware of pain and son stated he had a history of bowel obstruction." Patient #12s medical record included an SN visit dated 9/13/24. The SN visit note stated, ";Reason for discharge Moved out of Hospice Service Area." An undated Client Coordination Note Report stated, ";Discharge from hospice due to PT transferring out of hospice area/ability to provide hospice care and follow hospice POC as patient has an extensive HX of bowel issues to include a bowel obstruction." Regional Vice President of the agency was interviewed on 10/16/24 at 1:30 PM and confirmed that if a patient went to the hospital for additional care it would be a revocation not a discharge. The RVP confirmed Patient #12 should have been documented as a revocation and not discharge, and appropriate discharge steps should have been taken according to policy. The hospice failed to properly discharge Patient #12.

Based on review of medical records and staff interview, it was determined the agency failed to ensure documentation of coordination of patient care between disciplines for 1 of 11 patients (Patient #10) whose records were reviewed. This resulted in a lack of clarity as to the course of care and whether physicians or other hospice care staff had been contacted related to care that required practitioner input. Findings include: 1. Patient #10 was a 78 year old female admitted to the agency on 8/01/21, with a terminal diagnosis of coronary artery disease. She received SN, MSW, and chaplain services. Her record, including the POC, for certification period 8/01/21 to 10/29/21, was reviewed. Patient #10's record included a chaplain visit note, dated 9/29/21. The chaplain documented Patient #10 had visited a hospital emergency room the night before for abdominal pain, and was still experiencing discomfort. Patient #10's record did not include a communication note documenting whether her physician or RN Case Manager had been notified of her ER visit and abdominal pain issues. Her record documented she was seen on 10/04/21, 5 days later, by an agency RN who documented ondansetron was ordered and Patient #10's aspirin was changed to enteric coated to address her abdominal discomfort. Patient #10's record included a physician's order, dated 10/04/21, for her new medications. Surveyors requested agency policies related to the procedure for communication of a patient's change in condition to the interdisciplinary team. The ED stated there were none. The branch ED was interviewed by telephone on 11/05/21, beginning at 9:25 AM. She confirmed Patient #10's record did not include documentation her chaplain notified her RN Case Manager of her ER visit or abdominal issues. The branch ED stated agency staff were expected to immediately communicate any patient changes to the RN Case Manager, and document it in the medical record. The agency failed to ensure Patient #10's care was coordinated between disciplines to meet her needs.

Based on review of medical records, incident reports, policies, and staff interviews, it was determined the hospice failed to ensure adverse events were tracked and analyzed for 2 of 11 patients (#4 and #6) whose records were reviewed, and had the potential to affect all hospice patients. This prevented the hospice from recognizing all incidents and adverse events and implementing measures to decrease the likelihood of repeat incidents. Findings include: The agency's policy, "INCIDENT/EVENT REPORTING," stated, "Any employee who discovers an occurrence involving a patient, contractor, affiliate, or visitor is responsible for completing an incident report in and notifying his/her supervisor regarding the incident ... All incidents should be entered into the online incident reporting system within 72 hours of the incident or the identification of the incident." This policy was not followed. Examples include: 1. Patient #6 was a 97 year old male admitted to the agency on 11/03/20 with a terminal diagnosis of pulmonary embolis. Patient #6's medical record was reviewed. a. Patient #6's medical record included a skilled nurse visit note dated 5/07/21, signed by the nurse. It included a description of an event which occurred on 5/06/21 which precipitated a documented call to APS. The agency's incident reports for the previous 12 months were reviewed. Patient #6's event on 5/06/21 and reported APS call was not captured as an adverse event. An interview was conducted with the ED on 11/05/21, beginning at 9:15 AM. She confirmed that APS involvement should have been captured as an incident. b. Patient #6's medical record included a skilled nurse visit note dated 8/28/21, signed by the nurse. It included in the narrative section: "Nurse received a message ... that patient had fallen in the middle of the night ... " The agency's incident reports for the past 12 months were reviewed. Patient #6's reported fall on 8/28/21 was not captured in the incident reports. An interview was conducted with the ED on 11/05/21, beginning at 9:15 AM. She confirmed Patient #6's fall on 8/28/21 was not captured as an incident. c. Patient #6's medical record included a skilled nurse "Fall Notification" note dated 10/18/21. It stated, "... [son] found his dad laying on the floor next to his bed. Patient had gotten the bed rail down to the bed and have [sic] attempted to get out of bed on his own and had fallen." The agency's incident reports for the past 12 months were reviewed. Patient #6's reported fall on 10/18/21 was not captured in the incident reports. An interview was conducted with the ED on 11/05/21, beginning at 9:15 AM. She confirmed Patient #6's fall on 10/18/21 was not captured as an incident. The agency failed to track all patient adverse events. 2. Patient #4 was a 76 year old male admitted to the agency on 10/01/21, with a terminal diagnosis of interstitial pulmonary disease. He received SN and chaplain services. His record, including the POC, for the certification period 10/01/21 to the present, was reviewed. a. Patient #4's medical record included an SN visit note dated 10/20/21, signed by an RN. The RN documented, "PATIENT HAS A YELLOWISH GREEN BRUISE ON HIS RIGHT FOREHEAD. FACILITY STAFF REPORT THAT AFTER NURSE LEFT LAST VISIT THAT PATIENT WAS BANGING HIS HEAD ON THE TABLE DURING LUNCH TIME ATTEMPTING TO SOLVE HIS NECK PAIN." The agency's incident report log for the previous 12 months was requested and reviewed. The log did not include Patient #4's injury. b. Patient #4's medical record included an SN visit note dated 10/27/21, signed by the RN. The RN documented, "FACILITY STAFF REPORT THAT PATIENT HAS A NEW SKIN TEAR ON HIS RIGHT FOREARM. ON 10/21/21 PATIENT WAS SEATED IN THE RECLINER IN THE COMMON AREA WHEN THE REMOTE FELL BETWEEN THE CHAIR AND THE END TABLE. PATIENT LEANED OVER AND PUT HIS ARM BETWEEN THE CHAIR AND THE END TABLE CAUSING A SKIN TEAR. PATIENT ALSO HAS AN ABRASION ON THE LEFT SIDE OF HIS FOREHEAD. FACILITY STAFF REPORT THAT ON 10/25/21 AROUND 9:40 P.M. PATIENT WAS WALKING WITH A STAFF MEMBER TO HIS ROOM. PATIENT WAS APPROXIMATELY 2 FEET FROM HIS BED WHEN ALL OF THE SUDDEN HE STARTED TO LEAN SIDEWAYS AND FELL. PATIENT SUSTAINED AN ABRASION ON HIS LEFT FOREHEAD FROM HIS HEAD RUBBING AGAINST THE CARPET." The agency's incident report log for the previous 12 months was requested and reviewed. The log did not include Patient #4's injury on 10/21/21 or his fall on 10/25/21. The ED and PCM were interviewed together on 11/05/21 beginning at 9:40 AM, and Patient #4's medical record was reviewed in their presence. They confirmed Patient #4's injuries on 10/13/21 and 10/21/21, and his fall on 10/25/21 should have been reported as incidents and were not included in the incident reports. The agency failed to track all patient adverse events.

Based on record review, infection reports, and staff interview, it was determined the agency failed to ensure identification of patient infections for inclusion in the agency's QAPI program for 1 of 3 patients (patient #7) whose records were reviewed and noted to have infections. This had the potential to interfere with analysis and prevention of infections. Findings include: Patient #7 was an 85 year old male admitted to the agency on 1/15/21 with a terminal diagnosis of COPD and comorbidities of urinary retention with long time use of urinary device (foley catheter). He received SN, MSW and aide services. His record documented a CAUTI on 2/12/21, treated with antibiotics. There was no incident report completed related to Patient #7's infection on 2/12/21. The ED was interviewed on 11/05/21, beginning at 9:15 AM. She confirmed no incident report was completed for Patient #7's CAUTI on 2/12/21. Infections were not accurately captured and reported to QAPI.