Every finding on record at Inspire Hospice LLC

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 6 (17%) records reviewed, it was revealed that the agency did not ensure each patient's individualized plan of care included interventions based on problems identified in the comprehensive assessment. Clinical Record 3: The election of benefit was dated 9/29/23. The initial comprehensive assessment dated 9/29/23, documented the terminal diagnosis of senile degeneration of the brain. The following care plan problems were initiated on 9/30/23: depression; fall risk; Genitourinary; impaired ADL's; impaired mobility; pain; and neurological/memory/confusion. There were identified goals for each problem. However, the care plan did not include planned interventions for these problems. A joint record review was completed with the agency Electronic Medical Record (EMR) Specialist. During an interview on 11/10/23, the EMR Specialist and Director of Nursing confirmed the finding and stated, "The nurse was new when she did this, but the preceptor and IDG (interdisciplinary group) should have caught it."

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 1 of 5 (20%) records reviewed, in which aide services were accepted, it was revealed that the agency did not ensure the registered nurse (RN) provided written care instructions for the hospice aide to follow. Clinical Record 3: Election of benefit was 9/29/23, with a terminal diagnosis of senile degeneration of the brain. RN initial assessment (9/29/23) documented that hospice aide services were requested, and the patient needed assistance with activities of daily living. The plan of care (POC), effective 9/29/23 to date, listed the hospice aide visit frequency order as two times a week, effective 10/1/23. The hospice aide care plan revealed the RN "opened the problem" for aide services on 9/30/23. However, the care plan goal(s) and interventions were blank. Therefore, no written care instructions were prepared for the hospice aide. Hospice aide visits were documented on 10/3/23, 10/5/23, 10/10/23, 10/13/23, 10/19/23, 10/24/23, 10/26/23, 10/31/23, 11/2/23, 11/7/23, and 11/9/23. The hospice aide visits documented the following: 10/3/23, "Coordinated cares with hospice RN and facility staff. Shower given, two persons assist for transfers and cares due to behaviors, oiled skin after shower, transferred to wheelchair and brought to living room"; 10/10/23, "Coordinated with facility staff. no concerns"; and 10/19/23, "Patient refused shower. coordinated with facility staff and case manager." A joint record review was completed with the agency Electronic Medical Record (EMR) Specialist. During an interview on 11/10/23, the EMR Specialist and Director of Nursing confirmed the finding and stated, "The nurse was new when she did this, but the preceptor and IDG (interdisciplinary group) should have caught it."

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by document review, interview and observation. In 2 of 19 (11%) home visit observations with medication reconciliations, it was revealed that the agency did not ensure the patient's medication profiles were current. Document 2: Policy #MM:1, titled Medication Management (no revision date), stated in part, "Agency shall provide medication management information when needed to any personnel. This information shall include but is not limited to the patient's current medications, including prescription, over-the-counter medications, and herbal remedies." In addition, the section titled Procedure stated in part, "During the initial assessment visit, the Registered Nurse generates a list of the patient's current medications, including prescription, over-the-counter (OTC) medications, and herbal remedies. The patient's medications are reviewed and assessed during each skilled visit." Clinical Record 3: A home visit was completed on 7/11/2023 in the presence of the hospice agency Director of Nursing. The election of benefits date was 5/8/2023. The medication profile available in the patient's home stated in part, "Vitamin D3 ten (10) microgram (mcg) tablet/ four hundred (400) units (U). Take one (1) tablet daily." The hospice agency medication profile did not contain the medication, Vitamin D3, ten (10) microgram (mcg) tablet/ four hundred (400) units (U). Take one (1) tablet daily Clinical Record 4: A home visit was completed on 7/11/2023 in the presence of the hospice agency Director of Nursing. The election of benefits date was 8/11/2022. The hospice agency medication profile stated in part, "Cholestyramine 4g/4.8g powder for reconstitution. Four (4) grams mix four (4) grams with a drink of choice once daily for diarrhea. Citalopram twenty (20) milligram (mg) tablet. Take one (1) tablet by mouth once daily for depression. Donepezil ten (10) milligrams (mg). Take one (1) tablet by mouth daily for dementia." The medication profile in the patient's home did not contain the following medications: Cholestyramine 4g/4.8g powder for reconstitution. Four (4) grams mix four (4) grams with a drink of choice once daily for diarrhea. Citalopram twenty (20) milligram (mg) tablet. Take one (1) tablet by mouth once daily for depression. Donepezil ten (10) milligrams (mg). Take one (1) tablet by mouth daily for dementia. A joint record review and interview with the DON on 7/11/2023 confirmed the hospice agency medication profile did not match the medication profile in the patient's home.

It is required that each patient’s individualized written plan of care contain medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, observation, and interview. In 4 of 19 (21%) records reviewed it was revealed that the agency did not ensure that the plan of care contained all supplies necessary to meet the patient's needs. Document 7: Policy #PC:9, titled Care Planning (no revision date), stated in part, "The Plan of Care is appropriate and realistic based on the patient's needs. The healthcare team updates the Plan of Care as necessary." Clinical Record 1: During the home visit on 7/11/2023 with the Director of Nursing (DON), it was verified that the hospice agency was providing the patient wipes, large pull-ups, panty liners, chucks, under-pads, and medium gloves. The DON confirmed that the current Plan of Care did not list the supplies of, wipes, large pull-ups, panty liners, chucks, under-pads, and medium gloves. Clinical Record 3: During the home visit on 7/11/2023 with the DON it was verified that the hospice agency was providing the patient with wound wash, 4X4 gauze pads, wipes, medium gloves, and medium pull-ups. The DON confirmed that the current Plan of Care did not list the supplies of wound wash, 4X4 gauze pads, wipes, medium gloves, and medium pull-ups. Clinical Record 4: During the home visit on 7/11/2023 with the DON, it was verified that the hospice agency was providing the patient medium briefs, wipes, medium gloves, chucks, and underpads. The DON confirmed that the current Plan of Care did not list the supplies of medium briefs, wipes, gloves, chucks, and underpads. Clinical Record 13: The hospice benefit election date was 1/4/2023. The LPN visit note dated 7/5/2023 stated in part, "Incontinent of bladder and bowel. Wears briefs for dignity." The DME and supplies section of the updated plan of care dated 7/6/2023-8/31/2023 stated in part, "Air mattress, bedside table, Broda chair, Hoyer lift." A joint record review and interview with the DON on 7/12/2023 confirmed the Plan of Care dated 7/6/2023-8/31/2023 did not list the briefs provided by the hospice agency to the patient. A joint record review and interview with the Director of Nursing on 7/11/2023 confirmed the hospice agency did not have a solid process to ensure all supplies were listed on the Plan of Care.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions, such as hand hygiene, use of gloves, mask, eye protection, or face shield depending on anticipated exposure, and other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, interview and observation. In 1 of 4 (25%) home visit observations it was revealed that the agency did not ensure its staff adhered to the agency infection control policy and procedures for standard precautions and hand hygiene. Document 4: Policy #IC:8, titled Hand Hygiene (no revision date), stated in part, "All personnel will use the hand hygiene techniques, as set forth in the following procedure: When hands are visibly soiled with blood or body fluids. Agency personnel should wash hands with either non-antimicrobial soap and water or antimicrobial soap. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings." In addition, the sub-section titled Procedure stated in part, "change gloves when moving from a contaminated body site to a clean body site on the same patient." Home Visit 1: The hospice benefit election date was 4/27/2023. During a home visit with the Director of Nursing (DON) and a hospice aide (staff 4) on 7/11/2023, the hospice aide was observed providing personal care to the patient. The hospice aide performed hand hygiene with an alcohol-based sanitizer upon entrance to the home and before donning gloves and beginning a shower. The hospice aide washed the patient's upper body and trunk before cleansing the peri-area. The peri-area was cleansed front to back. Gloves were not changed after cleansing the peri-area. Next, the hospice aide washed the patent's hair with the same soiled gloves worm from cleansing the peri-area. When the shower was completed, the hospice aide did not remove the soiled gloves and perform hand hygiene before drying the patient with a clean towel. The hospice aide wore soiled gloves while drying the patient and dressing the patient with clean clothes. During interview with the DON on 7/11/2023, it was confirmed that the hospice aide did not adhere to standard precautions and proper hand hygiene after performing peri-care and before drying and dressing the patient.

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, document review and interview. In 1 of 19 (5%) records reviewed where hospice aide services were accepted, it was revealed that the agency did not ensure that the Case Manager provided specific written instructions for the aide assignment, thus leaving the aide to make decisions outside the aide's scope of practice. Document 5: Policy #PC:14, titled Interdisciplinary Care Planning (no revision date), stated in part, "The Case Manager is responsible for overseeing the care planning process. The plan is appropriate and realistic based on the patient's needs and clinical status and promotes positive outcomes and avoids duplication of services." Clinical Record 2: A patient with a hospice benefit election date of 4/27/2023 had a care plan for the certification period of 4/27/2023-7/25/2023, in which hospice aide services were accepted. The hospice aide care plan dated 4/27/2023 listed two (2) types of baths to be completed at each hospice aide visit. The hospice aide care plan stated in part, "bed bath/shower per facility directions." The hospice aide performed a visit on 5/2/2023, 5/9/2023, 5/12/2023, 5/16/2023, and 5/19/2023, which the hospice aide documented as "bed bath/shower per facility directions completed." A joint record review and interview with the Director of Nursing (DON) on 7/10/2023 confirmed the hospice aide care plan did not provide specific instructions, as a bed bath and shower were ordered to be completed each hospice aide visit. The DON confirmed the hospice aide documented two types of baths were documented as completed for each visit.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) records reviewed where hospice aide services were accepted, it was revealed that the hospice agency did not ensure that changes in the patient needs were reported to a Registered Nurse (RN). Clinical Record 5: A patient with a hospice benefit election date of 12/26/2023 had an aide care plan dated and signed 6/1/2023 for the benefit period 3/26/2023-6/23/2023, which stated in part, "Shower, skin care apply deodorant, shampoo hair." The hospice aide visit noted dated 6/5/2023 indicated the following refused hospice aide interventions, "shampoo hair was refused, shower was refused, and skin care-apply deodorant was refused." The visit note dated 6/5/2023 contained no evidence that the Registered Nurse was notified of the patient's refusal. The interdisciplinary team (IDT) note dated 6/15/2023 had no documentation that the interdisciplinary team was notified of the refused hospice aide interventions. A joint record review and interview with the Director of Nursing (DON) on 7/10/2023 confirmed the record contained no evidence the RN was informed of the refused hospice aide interventions. In addition, the DON confirmed hospice aides are to notify the RNs of all incomplete tasks on the same day immediately following the hospice aide visit.