Every finding on record at Innerjoy Hospice Care Incorporated

Observed in Record Review. In 4 of 4 active patient records reviewed, the organization failed to perform the comprehensive assessment. The surveyor noted in record HORR#4 there was also no initial comprehensive psychosocial assessment.

Observed in Record Review. In 4 of 4 active patient records reviewed, the organization failed to ensure that the written plan of care was based on individualized patient goals that were specific, measurable, and time bound. None of the goals had been revised for two patients admitted prior to the triennial survey six weeks ago. Goals for two patients admitted since that survey were similar. Written targets for completion were 1 to 2 weeks, or 12 days and onward, or 17 days and onward, but the identified target date coincided with the date of the next interdisciplinary meeting. And the status for every goal was identified as “controlled”. This RFI was reviewed with the Administrator/DPCS Designee.

Observed in Record Review. In 2 of 4 active patient records reviewed, the organization failed to ensure that the plan of care included all needed services. In record HORR#3 the RN documented that the patient was pocketing food, however, the plan of care was not revised. This RFI was reviewed with the Administrator/DPCS Designee.

Observed in Record Review. In 4 of 4 active patient records reviewed, the organization failed to ensure that the plan of care was revised based on information from comprehensive re-assessments. Entries in the interdisciplinary meeting notes by spiritual care and psychosocial disciplines documented only that there were no changes. This RFI was reviewed with the Administrator/DPCS Designee.

Observed in Record Review. In 1 of 4 active patient records reviewed, In record HORR#2 the family requested local clergy to visit the patient. There was not documentation as of this date that it was done. This RFI was reviewed with the Administrator/DPCS Designee. Observed in Record Review. In 2 of 4 active patient records reviewed, the organization failed to ensure that care and services were provided in accordance with the plan of care. In record HORR#1 an HHA visit was missed last week. In HORR#2 comprehensive nursing re-assessment was not documented in the last 4 weeks. In addition, there were no documented visits by an LVN in more than 2 weeks. In record HORR#3 there was no initial comprehensive psychosocial assessment, nor monthly visits by spiritual care and psychosocial disciplines as ordered. This RFI was reviewed with the Administrator/DPCS Designee.

Observed in Tracer Activities. Leaders did not manage implementation of patient care policies and procedures governing the provision of care as evidenced by a continued condition level finding at §418.56. This RFI was reviewed with the Administrator/DPCS Designee.

Observed in Record Review. In 2 of 7 patient records reviewed, the organization failed to ensure it respect the patient right to participate in decisions about their care, treatment, and services. On review of RRHV#2 the patient on admission elected to receive the Medicare Notification of Non-Covered items, Drugs, Supplies yet there was no documentation that the document was presented to the patient within 5 days as required. In RRNHV#4 there was no documentation that patient either elected or declined the Notification of non-Covered Items nor was there documentation the addendum was presented to the patient. There was an incomplete form noted on the record with no signature or date. This observation was reviewed with the Director of Nursing and Designee.

Observed in Record Review. In 2 of 7 patient records reviewed, the organization failed to ensure the update of the comprehensive assessment was accomplished by the hospice interdisciplinary group (IDG) considering any changes that took place since the initial assessment as frequently as the condition requires but no less frequently than every 15 days. In review of RRHV#2 there was documentation that there were significant changes in the patient cognitive and mobility status prompting the request to discontinue all routine medications yet the changes were not mentioned in the update to the comprehensive assessment in the next IDG meeting. In RRNHV#4 the latest IDG meeting in October there was no documentation of an update to the comprehensive assessment as the nursing portion on the IDG meeting update was left blank. The patient had documentation of medication changes for pain during the IDG period but was not addressed in the comprehensive assessment update. In RRNHV#7 in the early October IDG meeting the IDG discussion for update to the comprehensive assessment in the nursing clinical portion there was a spiritual counselor visit note that did not address the clinical update or discussion. These observations were reviewed with the Director of Nursing and Designee.

Observed in Record Review. In 6 of 7 patient records reviewed, for active patients, the organization failed to ensure the written plan of care was based on the patient's goals that are individualized, specific, measurable and time bound, and the time frames, settings, and services required to meet those goals. In review of RRHV#1 there were goals established that were not specific, measurable, and timebound such as: Maintain mobility and independence. -Minimize complications due impaired mobility and Pain will remain in comfortable level during care. In RRHV#2 examples were In 1-2 weeks Pt needs will be met on a day to day basis as communicated and Patient's allergies will be managed in the next 2 weeks using medication ad will re-evaluate in the next IDG meeting. In RRHV#3 examples were Facilitate bowel elimination and comfort in 14 days and Promote rest status for Pt in 14 days In RRNHV#4 a goal read Assess Pt. status for on-going care. Blood sugar management for pt. comfort. Similar examples can be seen in RRNHV#6 and RRNHV#7. These observations were reviewed with the Director of Nursing and Administrator.

Observed in Record Review. In 1 of 7 patient records reviewed, the organization failed to ensure the patient and/or primary caregiver receive education and training by the hospice as appropriate to their responsibilities for care and services as identified in the plan of care. On review of RRNHV#4 an order to start Gabapentin and to discontinue Dexamethasone were noted on the record, however there was no documentation noted that the patient and/or primary caregiver were educated on the new medication such as the indication, dosage, route, frequency, and potential side effects. There was also no documentation that the patient/caregiver was educated on discontinuing the Dexamethasone. These observations were reviewed with the Director of Nursing and Designee.

Observed in Record Review. In 7 of 7 patient records reviewed, for active patients, the organization failed to ensure the plan of care (POC) include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#1 there was documentation for referral to podiatry for nail trimming yet the was no care plan established to guide the care. Further, the patient was being seen by the social worker and chaplain yet there were no care plans established for psychosocial and spiritual. In RRHV#2 there was documentation of increased agitation and request to discontinue all routine medications yet the issues were not reflected in the plan of care. RRHV#2 was also being seen by the social worker and chaplain yet no psychosocial or spiritual care plans established. In RRHV#3 there were no psychosocial or spiritual care plans even though the disciplines were seeing the patient. Further there was documentation that there was concern the patient was not eating in a communication note yet the issue was not reflected in the plan of care. In RRNHV#4 there was an order for physical therapy but the plan of care did not reflect the addition of PT services. In RRNHV#5 there were orders for a podiatry consult yet was not reflected on the POC. In RRNHV#6 the MSW was seeing the patient yet there was no psychosocial care plan. In RRNHV#7 there were no psychosocial or spiritual care plans established to guide the care. Further, there was documentation of the patient having a poor appetite and education provided on to increase intake yet no nutritional care plan. These observations were reviewed with the Director of Nursing and Administrator.

Observed in Record Review. In 3 of 7 patient records reviewed, for active patients, the organization failed to ensure the plan of care include all drugs and treatment necessary to meet the needs of the patient. For example: on review of RRHV#2 there was an order in October that stated Discontinue routine meds except for comfort meds and seroquel and oral care. The order was incomplete as it did not specify which medications were to be discontinued as all medications remained as active on the medication profile. In RRNHV#5 there was a goal established that indicated parameters that stated Within the next 2-3 weeks, the patient’s blood sugar levels will be maintained as close to the normal range of 90 to 110 mg/dL as possible, without experiencing significant highs or lows, throughout the certification period yet there were no orders for blood glucose monitoring noted on the record. In RRNHV#6 there was an order for wound treatment that noted the dressing to be changed 3 days a week with reinforcement between dressing changes yet that was incomplete as it failed to specify who was to provide wound care and wound dressing reinforcement if needed. These observations were reviewed with the Director of Nursing and Designee.

Observed in Record Review. In 4 of 7 patient records reviewed, for active patient records, the organization failed to ensure the plan of care was revised based on information from updates to the patient's comprehensive assessment and address progress toward goals. For example: on review of RRHV#2 there was no updates to the plan of care nor progress toward goals noted as the care plans remained the same IDG to IDG. There were goals noting they would be reviewed at IDG for example Manage symptoms with current interventions within the next 2 weeks then will evaluate in the next IDG meeting, yet there was no indication the goals were reevaluated during the IDG meeting. In RRHV#3 many of the goals noted to be accomplished within 14 days yet continued IDG to IDG without revision such as Pt will have adequate food and fluids as tolerated or desired in 14 days and Promote rest status for Pt in 14 days. In RRNHV#6 there were multiple care plans active for skin integrity yet the wounds had been documented as healed months prior. There were also goals that noted they were to be reevaluated in the next IDG yet continued without revision IDG to IDG. In RRNHV#7 also contained examples of care plans established on admission with goals such as Pt will have optimum level of oxygen in 14 days yet the care plans remained without revision based on the updates to the comprehensive assessment IDG to IDG for over 6 months. These observations were reviewed with the Director of Nursing and Designee.

Observed in Record Review. In 4 of 7 patient records reviewed, for active patients, the organization failed to ensure the care and services were provided in accordance with the plan of care (POC). On review of RRHV#1 the hospice aide was ordered per the plan of care for 1 time a week however the aide was documenting seeing the patient 2 times a week. In RRHV#2 the Chaplain frequency per the plan of care was declined but was seeing the patient monthly. The MSW was ordered as PRN and certification yet was seeing the patient monthly. In RRHV#3 the order per the POC for MSW and Chaplain was initial only yet the spiritual and psychosocial services were being provided monthly. In RRNHV#6 the RN was ordered a frequency of once every 2 weeks yet in the 3rd week of September and 1st week of October there were 2 RN visits documented. The LVN was ordered 2 times a week yet in the 4th week of October there were 3 LVN visits documented and only 1 LVN visit documented in the 1st and 2nd week of October. There were 3 LVN visits documented the 3rd week of September. These observations were reviewed with the Director of Nursing and Administrator.

Observed in Record Review. In 1 of 6 patient records reviewed, where hospice aide services were provided, the organization failed to ensure the Registered Nurse supervise the hospice aide to assess the quality of care and services provided and ensure the ordered services meet the patient's needs. In review of RRNHV#5 there was no aide supervisory visit documented until 34 days after the initial hospice aide visit. This observation was reviewed with the Director of Nursing.

Observed in HR File Review. In 1 of 8 HR files reviewed, the organization failed to ensure the hospice maintain, document and provide volunteer orientation and training that is consistent with hospice industry standards. On review of HR#8 for the hospice volunteer, there was no documentation that the volunteer was oriented to hospice philosophy and the role and responsibilities of the hospice volunteer consistent with industry standards. This observation was reviewed with the Director of Nursing and Volunteer Coordinator.

Observed in Record Review. Upon review of all tracer activities, it was noted that there was a pattern of staff failing to follow established organization policy and the governing body/leadership did not ensure that the Conditions of Participation for 418.100, and 418.56, were met per policy as determined through observations, documentation, and staff interviews.

Observed in Patient Home. In 2 of 7 patient records reviewed, the organization failed to ensure the patient record contain information to reflect the patient's care, treatment, and services. For example: on review of RRHV#3 on the review of the medication profile there was noted an order for Glucophage 750 mg and an additional order for the generic version of the drug Metformin 750 mg. During medication reconciliation in the home observation the MedTech of the ALF verified that only the Metformin was being given to the patient and not both forms of the drug. In review of RRNHV#4 there were orders noted on the record to start Gabapentin and discontinue Dexamethasone, however there was no documentation noted in the record to explain the circumstances leading to the changes in medications. These observations were reviewed with the Director of Nursing.

Observed in Record Review. In 1 of 4 patient records reviewed, for live discharge, the organization failed to ensure the patient record was complete, promptly, and accurately documented.. For example: on review of RRDC#1 the patient was discharged for extended prognosis and a skilled nurse visit was documented on the day of discharge yet the documentation did not reflect that the patient/caregiver was given accurate information regarding the patient discharge that day. The note stated “PCG was instructed to inform hospice if the current pain regimen becomes ineffective. All immediate concerns were addressed during the visit, with ongoing monitoring recommended. Staff were reminded to contact Inner Joy Hospice at any time for updates on the patient’s condition. Ongoing care will be provided under hospice care.” This observation was reviewed with the Director of Nursing. Observed in Record Review. In 3 of 7 patient records reviewed, for active patients, the organization failed to ensure the patient record was complete, promptly, and accurately documented. For example: on review of RRHV#2 the LVN documented a follow up to admission visit an hour prior to the RN documentation of beginning the admission visit. Further, the RN documented in September and October on each aide supervisory visit that the aide was present at the time of supervisory yet there was no documented aide visit on the day and/or time of the RN visit. In review of RRNHV#4 the spiritual counselor's documentation noted spiritual services were declined, yet the plan of care noted spiritual services to be monthly. In RRNHV#5 the MSW documented a frequency of monthly yet the plan of care orders MSW as PRN. These observations were reviewed with the Director of Nursing and Designee.

Observed in Record Review. In 6 of 11 patient records reviewed, the plan of care did not identify all services necessary to address all the needs identified in the comprehensive assessment. In HV#1 the MSW initial assessment identified that the primary caregiver, the daughter, was overwhelmed and there were no funeral arrangements in place. The plan of care stated that the MSW would assist with facilitating funeral arrangements but there was visit frequency set that would allow the MSW to deliver these services. In addition there was no mention in the plan of care of the daughter's sense of being overwhelmed. In HV#2 there were no interventions in the plan of care to prevent falls, even though the patient had been assessed to be high risk. In addition the MSW identified that there were no funeral arrangements in place and there was no MSW frequency established and there was no mention of assisting with funeral arrangements in the plan of care. In RR#2 and RR#3 the patient was assessed to be at high risk for falls but fall prevention was not addressed in the plan of care. In RR#4 the plan of care did not address a high fall risk and a high risk for skin breakdown. In RR#5 there was no psychosocial care planning from the MSW thus no mention of lack of advanced directives or of funeral arrangements. This was validated with the alternate DPCS.

Observed in Patient Home. In 1 of 3 home visits conducted, the staff failed to perform hand hygiene consistent with CDC guidelines. In HV#3 the aide used a 62% liquid alcohol solution to wash her hands. She went to the sink, wet her hands with the alcohol solution, put her hands under running water, rubbed and then dried her hands with a paper towel. The CDC guidelines call for using soap in this manner or to use alcohol gel that is then rubbed until dry.

Observed in Record Review. In 8 of 9 patient records reviewed, for patients who had oxygen the agency failed to document education on the safe use of the equipment. Specifically the agency failed to address the issues identified in the oxygen safety assessment. In HV#1, HV#2, RR#1, RR#4, RR#5, the oxygen safety assessment identified a risk related to open flames. Multiple of these charts had documented taught against every assessed risk but there was no documented targeted education for the identified risk of open flames. RR#6, RR#7, and RR#8 documented all oxygen risk factors as facility managed thus there was no targeted education for identified risks. This was validated with the alternate DPCS.