Every finding on record at Illuminate Hospice Care, Inc.

Observed in Tracer Activities. In 2 of 7 HR files reviewed, the organization failed to document emergency management training at least annually per policy. During EM tracer activities, the Hospice Nurse Surveyor observed HR#2 ( HHA) and HR#3 (Chap/ VC/BC) did not have documentation of EM training at least annually as evidenced by the organization was unable to provide this information during survey. This was discussed and reviewed with the DPCS/ Owner.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to assess and reassess its patient's. During record review for all patients, the Hospice Nurse Surveyor observed the comprehensive assessment did not include measurable progress towards goals or revisions to the plan of care when needed. For example in HOSRRNHV#7, the comprehensive assessment stated that the pain teachings goal was completed but the Plan of Care was not updated to reflect that. Upon conversation with the DPCS, she stated that the progress being documented was just continuous teaching and not measurable progress towards specific goals. This was discussed and reviewed with the DPCS/ Owner.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to plan the patient's care. During record review for HOSRRHV#1, HOSRRNHV#1, HOSRRDC#1, HOSRRDC#2, HOSRRHV#2, HOSRRNHV#2, HOSRRHV#3, HOSRRNHV#3, HOSRRNHV#4, the Hospice Nurse Surveyor observed the plan of care not based on the patient's goals, and time frames, settings and services to meet those goals. In HOSRRHV#1, the patient had a goal of pain will be controlled within 24-48 hrs of initial assessment with no indication of what controlled meant. The patient also had a goal of patients agitation at manageable level during care which was not measurable and had no individualized timeframe. In HOSRRNHV#1, the patients goal timeframes were not individualized to meet their needs. The patient had a goal of Pain will be managed throughout care and PCG will verbalize understanding of medication and treatment during care. There were no measurable timeframes to meet those needs. In HOSRRDC#1, the patient had a goal of pain will be managed throughout care. This was not individualized or measurable. In HOSRRDC#2, the patient had a goal of nausea and vomiting will be controlled during care. This goal did not include an individualized timeframe to achieve the goal and the goal was not measurable. In HOSRRHV#2, the patient had a goal of PCG will verbalize understanding of medications and treatment during care. This goal did not have an individualized timeframe to achieve the goal. In HOSRRNHV#2, the patient had a stage 4 pressure ulcer but there were no goals related to wound healing. The only goal was to maintain skin integrity. The interventions did reflect current wound care orders. In HOSRRHV#3, the patient had a goal of pt pain will remain at a comfortable level but there had been multiple medication changes related to pain management but the goal was not updated. The patient also had a goal of patient will maintain skin integrity during care but had stage II pressure ulcer and the goal did not address wound healing. In HOSRRNHV#3, the patient had a goal of patient will maintain skin integrity during care but had an active wound to left hand. In HOSRRNHV#4, the patient had a goal of CG will demonstrate ability to cope with patients altered mental status during care with no goal timeframe and the goal had been in place 1 year prior to survey.In HOSRRNHV#5, the patient developed insomnia 5 days prior to survey and had new orders but this was not addressed on the plan of care. In HOSRRNHV#6, the patient had a goal for functional mobility stating the patient was chair bound but the patient was recently noted to be bed bound with new orders and this was not updated on the plan of care. In HOSRRNHV#7, the patient had a goal of patient will be free from infection related to Covid and Flu which had been in place for 8 months but the patient did not have issues with Covid or Flu and there was no timeframe for the goal to be achieved. This was discussed and reviewed with the DPCS/ Owner.

Observed in Record Review. In 8 of 14 patient records reviewed, the organization failed to plan the patient's care. During record review for HOSRRHV#1, HOSRRDC#1, HOSRRDC#2, HOSRRHV#2, HOSRRNHV#2, HOSRRHV#3, HOSRRNHV#5, HOSRRNHV#7, the Hospice Nurse Surveyor observed not all necessary items were included on the Plan of Care. In HOSRRHV#1, HOSRRDC#1, HOSRRDC#2, HOSRRHV#2, HOSRRNHV#2, HOSRRHV#3, HOSRRNHV#5, and HOSRRNHV#7, the patients had orders for PRN nursing visits with no indication as to use. This was discussed and reviewed with the Hospice DPCS/ Owner.

Observed in Record Review. In 9 of 14 patient records reviewed, the organization failed to plan the patient's care. During record review for HOSRRHV#1, HOSRRHV#3, HOSRRNHV#1, HOSRRDC#1, HOSRRDC#2, HOSRRNHV#2, HOSRRNHV#4, HOSRRNHV#5, and HOSRRNHV#7, the Hospice Nurse Surveyor observed not all necessary items were included on the Plan of Care. For example in HOSRRHV#1, the patient had Advil and Hydromorphone PRN for pain with no indication on the Plan of care of when to take which medication. In HOSRRNHV#1,HOSRRDC#1, HOSRRHV#2, and HOSRRNHV#2, HOSRRNHV#4, HOSRRNHV#5, and HOSRRNHV#7, the patient had orders for Roxanol and Tylenol PRN for pain with no indication of when to take which medication. For HOSRRDC#2, the patient had orders for tramadol PRN every 6, Roxanol every 6 prn and ,Tylenol every 4 PRN for pain with no indication when to take which drug. In HOSRRHV#3, the patient had orders for PRN Tylenol, tramadol, and Roxanol for pain with no indication when to use which one. This was discussed and reviewed with the Hospice DPCS/ Owner.

Observed in Record Review. In 2 of 2 patient records reviewed, the organization failed to plan the patient's care. During record review for HOSRRBR#1 and HOSRRBR#2, the Hospice Nurse Surveyor observed the organization failed to document a specific bereavement care plan. For example, in both records the bereavement coordinator documented a risk level but did not document how often outreach would be based on that risk. The documentation did not include the services to be offered or the frequency of services. During conversation with the DPCS it was noted that the org keeps a log of all of the needed letters but there was no documented individualized bereavement care plan for each patient. This was discussed and reviewed with the DPCS/ Owner.

Observed in Tracer Activities. In 1 of 1 HR files reviewed, the organization failed to document on-going education and training. During HR tracer activities, the Hospice Nurse Surveyor observed HR#2 (HHA) did not have 12 hours of in-service training during the previous 12 month period, she only had 10 hours of training. This was discussed and reviewed with the DPCS/ Owner.

Observed in Record Review. In 8 of 8 patient records reviewed, with aide services ordered, the organization failed to plan the patient's care. During record review for HOSRRDC#1, HOSRRDC#2, HOSRRHV#2, HOSRRNHV#2, HOSRRHV#3, HOSRRNHV#3, and HOSRRNHV#4, the aide plan of care was not complete. For example in HOSRRDC#1, the patient was a high risk of fall, was on PRN oxygen, and had aspiration precautions but these were not addressed on the aide plan of care. In HOSRRDC#2, the patient was a high risk for fall and was on PRN oxygen but this was not addressed on the aide plan of care. In HOSRRHV#2, the patient was a high risk for fall and was on PRN oxygen but it was not addressed on the aide plan of care. In HOSRRNHV#2, the aide care plan did not contain precautions for oxygen, fall or thickened liquid diet. In HOSRRHV#3, the patient had a recent fall but did not have fall precautions on the aide care plan. In HOSRRNHV#3, the patient was a high risk of fall and had oxygen PRN but neither were addressed on the aide plan of care. In HOSRRNHV#4, the patient was a bleeding and fall risk but it was not addressed on the aide plan of care. In HOSRRNHV#7, the patient was a high risk of fall and had oxygen but it was not addressed on the aide plan of care. This was discussed and reviewed with the DPCS/ Owner.

Observed in Tracer Activities. In 1 of 7 HR files reviewed, the organization failed to document verification of staff qualifications. During HR tracer activities, the Hospice Nurse Surveyor observed HR#2 (aide) was hired 2 1/2 years prior to survey and there was no documentation of a background check. The background check was completed before the surveyor left. This was discussed and reviewed with the DPCS/ Owner.

Observed in Record Review. In 6 of 11 patient records reviewed, the organization failed to effectively screen and assess the patient's pain. For example: in review of RR#4 the patient had uncontrolled pain in the first weeks of hospice care. During the initial comprehensive assessment the patient's pain was not assessed per policy as it only addressed the severity and lacked location, character, exacerbating and relieving factors, quality. Further, a comprehensive pain assessment was also not documented in subsequent skilled nursing visits. Example 2: In RR#11 the comprehensive pain assessment in the initial assessment was also only addressed the pain severity. Similar observations were noted in RR#3, RR#5, RR#10, and RR#7. This observation was reviewed with the Owner/DPCS.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to conduct a comprehensive assessment that identified the patient and family need for bereavement services. For example: in RR#5 and RR#4 there was no initial bereavement risk assessment conducted as the patient's had declined MSW and spiritual care services. This observation was reviewed with the Owner/DPCS.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to ensure the patient and caregiver receive education and training for the care and services identified. For example: in review of RR#4 the patient had multiple medication changes for uncontrolled pain. There was no indication in the record that the patient and/or caregiver had any education or training on pain medication, the medication changes, or pain management. Example 2: In review of HV#1 the patient was noted to have been ordered trazadone with further trazadone dosage adjustment. There was no indication in the record that the patient and /or caregiver was educated on the medication or the dosage adjustments. These observations were reviewed with Owner/DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, The organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. For example: in review of RR#4 the patient had uncontrolled pain after admission with multiple medications changes, however the patient's skilled nurse frequency remained 1 time a week without additional visits to evaluate the patient's response to changes in the medication regimen. This observation was reviewed with the Owner/DPCS.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization failed to conduct the hospice interdisciplinary group meeting to review, revise and document the individualized plan of care no less frequently that every 15 days. After discussion with the Owner/DPCS the organization was conducting IDG meetings monthly and not every 15 days.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization failed to ensure the revised plan of care included information from the patient 's updated comprehensive assessment and document the patient's progress toward outcomes and goals. For example: throughout all records reviewed there was no noted updates to the plan of care nor progress toward goals noted. The plans of care goals and interventions remained unchanged IDG to IDG with only revisions of dates each benefit period. This observation was reviewed with the Owner/DPCS.

Observed in HR File Review. In 4 of 7 HR files reviewed, the organization failed to document annual competency assessment completed for the chaplain, DPCS designee, DPCS, and LVN as required by organization policy 1-008.1. This observation was reviewed with the QA nurse.

Observed in Record Review. In 6 of 7 patient records reviewed, where hospice aide services were provided, the organization failed to effectively supervise the aide to assess the quality of care and services provided. For example: Throughout the clinical record where hospice aide services were provided there was no documentation of aide supervisory visits. The RN comprehensive assessment had a check box that stated CHHA Supervisory Visit, yet there was no documentation of the questions asked nor the outcome of the supervisory visit. This observation was reviewed with Owner/DPCS.

Observed in HR File Review. In 3 of 7 HR files reviewed, the organization failed to document completed initial competency during orientation as required by organization policy 1-008.1 for the Hospice Aide, LVN and DPCS Designee. Upon review of the HR Files it was noted that the LVN and Hospice Aide files contained a skill and experience inventory completed by the clinician but did not have documentation of an initial skills competency assessed. The DPCS designee had a skills competency started but the form was not completed nor signed. These observation were reviewed with the QA nurse.

Observed in Record Review. In 5 of 11 patient records reviewed, the organization failed to ensure the clinical record contained information that reflected the patient's care and treatment. For example: upon review of RR#5, RR#8, and HV#2 the nursing documentation failed to include an detailed description of the patient wound to include wound care measurements weekly as required by policy. Example 2: upon review of RR#4, RR#9 and HV#1 many of the RN visits were documented as being accomplished via telehealth, however the documentation lacked platform used and consent of the patient/caregiver as required per organization policy. These observations were reviewed with Owner/DPCS. Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to document responses to medications, symptom management, treatments, and services in the clinical record. For example: In RR#4 there were multiple orders for pain medication changes outside of the dates of the skilled nursing visits, yet there was no indication in the record, such as a communication log, of how the symptoms were assessed, any communication between the hospice and the patient and/or caregiver, nor any follow up or response to the orders. Similar issues with the trazadone changes were noted in HV#1. Orders were noted in the record, yet there was no indication of how the symptoms were assessed, communication between the clinician and the family, nor any follow up to assess response to the orders. These observations were reviewed with the Owner/DPCS.