Every finding on record at Intra Care Hospice, Inc.

Observed in Record Review. In 3 of 10 records reviewed, surveyor noted that the organization failed to write a plan of care based on the patient’s goals and the time frames, settings, and services required to meet those goals. For example, in HOSRRHV#1, for the problem of difficulty swallowing, the goal stated to ensure and effective swallowing maintaining adequate nutrition and hydration while preventing complications like aspiration pneumonia. In HOSRRHV#3, for the problem of weakness, the goal stated Increase strength/energy for functional activities. In HOSRRNHV#7, for the problem of pain, the goal stated Family/PCG will verbalize understanding of non-verbal signs of pain. -Keep pain below SIT level for comfort. This was reviewed with the Director of Patient Care Services.

Observed in Patient Home. In 3 of 3 home visits, surveyor noted that the organization failed to provide the patient with care, treatment, or services according to the patient's individualized plan of care. For example, In HOSHV#1, HOSHV#2, and HOSHV#3, the nurse did not perform a skin assessment, to be performed each nursing visit per the organization's policy, increasing the risk for skin breakdown on patient's with compromised skin integrity related to disease processes and impaired mobility. This was reviewed with the Director of Patient Care Services.

Observed in HR File Review. During the HR session, surveyor noted in 6 of 12 records reviewed, that the organization failed to ensure staff are competent to perform their responsibilities. For example, in HR#4 (Administrator), HR#5 (LVN), HR#6 DPCS-Designee), HR#8 Chaplain), HR#10 (SW), HR#12 (Medical Director) had not had a competency assessment documented annually per the organization's policy. This was reviewed with the Director of Patient Care Services Designee.

Observed in Record Review. in 1 of 10 records reviewed, surveyor noted that the organization failed to ensure that a registered made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered meet the patient’s needs. For example, in HOSRRHV#1, the surveyor noted that the registered nurse went 28 days without performing an on-site aide supervisory visit. This was reviewed with the Director of Patient Care Services.

Observed in HR File Review. During the HR session, the surveyor noted in 1 of 12 records reviewed, that the organization failed to ensure staff were competent to perform their responsibilities. For example In HR#9, the Volunteer Coordinator's initial competency assessment was not documented per the organization's policy. This was reviewed with the Director of Patient Care Services Designee.

Observed in HR File Review. During the HR session, surveyor noted that the organization failed to ensure that when the medical director was not available, a physician designated by the hospice assumes the same responsibilities as the medical director. The organization did not have a backup medical director under contract or directly employed by the organization. This was reviewed with the Director of Patient Care Services Designee.

Observed in Record Review. In 5 of 10 records reviewed, surveyor noted that the organization failed to ensure that patients' records contained information that reflects the patient's care, treatment, or services per the organization's policy. For example, in HOSRRHV#1, HOSRRHV#2, HOSRRHV#3, HOSRRNHV#1, and HOSRRNHV#5 the social worker entered a narrative statement indicating that a visit was made, however, the social worker did not complete the comprehensive assessment documentation; the assessment form for each patient was blank. This was reviewed with the Director of Patient Care Services.

Observed in Document Review. During the review of contracted service agreements, surveyor noted that the organization failed to evaluate contracted services as defined in their policy. There was no documentation present to validate that contracted services are being evaluated to ensure services are being provided safely and effectively. This was reviewed with the Director of Patient Care Services Designee.

Observed in Tracer Activities. During the review of contracted service agreements, surveyor noted that the organization failed to include provision stating that the hospice will report all mistreatment, neglect, or verbal, mental, sexual, and physical abuse to the SNF, NF, or ICF/IID administrator within 24 hours of the hospice becoming aware of the alleged violation, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice. This was reviewed with the Director of Patient Care Services.

Observed in HR File Review. In 1 of 6 HR files reviewed, the organization had not provided emergency preparedness training to staff at least every 2 years. There was no documentation of training on the emergency operations plan in the file for the physician since hire in 2018. The QA Nurse confirmed that the organization does not include any staff except for nurses and aides in their annual EM education. The process had been to assume that the annual EM drill would account for education of staff.

Observed in Record Review. In 2 of 2 patient records reviewed, in which the hospice discharged the patient alive, the organization had not involved the patient/patient surrogate in making decisions about their care, treatment, or services. In the charts for RR#4 and RR#6 the patients were discharged due to extended prognosis. The NOMNC was provided, however, the phone number provided for the QIO, Livanta was incorrect. This was discussed with the Alternate Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization had not conducted and documented a patient-specific comprehensive assessment that identified the patient's need for hospice care and services, specifically survivor risk factors, such as the nature of the relationship with the patient, circumstances surrounding the death, behaviors before and after the death, availability of coping mechanisms, and potential for pathological grief reactions. In the chart for HV#1, there was no initial bereavement risk assessment completed upon admission. This was discussed with the Alternate DPCS.

Observed in Record Review. In 2 of 11 patient records reviewed, the written plan of care (POC) was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the charts for RR#2 and RR#3, the patients were at high risk for development of pressure ulcers. The POC's did not include any goals re: pressure ulcer prevention. This was confirmed with the Alternate DPCS.

Observed in Record Review. In 4 of 11 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: Medications and treatment necessary to meet the patient’s needs. In the chart for RR#2, the patient was at high risk for pressure ulcer development and orders for treatment of skin breakdown were obtained during the admission visit. The POC did not include any of the interventions that the RN instructed on during the admission visit such as frequent repositioning, keeping the patient's skin clean and dry, etc. During HV#1, it was confirmed that the patient uses Triamcinalone cream for her eczema which is a long-standing medication. Additionally, the patient indicated that she uses CPAP at night. These treatments were not included on the hospice plan of care as confirmed with the LVN during the visit. In the chart for RR#3, the patient was assessed to be at high risk for pressure ulcer development, yet there were no interventions regarding this risk on the POC. Additionally, the insulin order was incomplete and read Regular Insulin 1-6 units SQ as needed before meals and at bedtime per sliding scale. There was no scale included in the order. In the chart for RR#7, the patient had four wounds on admission. the orders for wounds 2 and 3 were missing the frequency of the dressing change. Additionally, the POC did not indicate who was to provide care on the days that the SN was not visiting the patient. SN was ordered weekly, the wound care for which there was an ordered frequency was three times/week. This was discussed with the Alternate DPCS.

Observed in Record Review. In 3 of 11 patient records reviewed, plan of care (POC) revisions were not based on information from updates to the patient’s comprehensive assessment and did not address the patient’s progress toward goals and outcomes. In the charts for RR#3 and RR#6, the frequency of visits had not been updated for the MSW nor the Chaplain. The current POC's stated initial evaluation only for these disciplines. The MSW was seeing the patients every benefit period; the Chaplain was seeing the patients monthly. In the chart for RR#7, the RN documented that aide services were discontinued per family request and discussion with the physician. The service frequency was not removed from the POC. This was discussed with the Alternate DPCS.

Observed in Patient Home. In 1 of 2 patient records reviewed, the organization had not provided the patient with care, treatment, or services according to the patient's individualized plan of care. During HV#2, the aide removed the patient's oxygen for the sponge bath as there was not enough tubing to reach into the bathroom. The patient's caregiver present at the visit indicated to this surveyor that all of the aide supplied by the hospice remove the oxygen to bathe the patient. The aide assignment indicated that the oxygen is continuous and does not address that the oxygen may be removed for the bath. This was discussed with the Alternate DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, all disciplines that provide care, treatment or services to the patient did not collaborate in the care of the patient and coordinate their efforts to support the goals outlined in the plan of care. In the chart for RR#9, upon admission the patient's self-identified goal for pain management was 8. During SN visit 2, the RN documented Patient able to report decrease in pain 5/10, mostly in BL hips, but when questioned further admits pain `everywhere`. Spouse admin all pain meds on schedule but feels not very helpful as patient in constant pain with approx 4 hrs sleep qhs, then just awake until dawn when he falls into/out of sleep another 4 hrs. There was no documentation the physician was made aware of the patient's pain. During SN visit 3, the RN documented Patient states has abdominal pain in addition to generalized 10/10 pain. Instruct should perform passive/active LE ROM exercises while in bed to assist with possible ileus from opioid meds. The physician was contacted for orders related to bowel management and treatment ensued. There was no reassessment of the patient's pain after the treatment. During SN visit 4, the RN documented Spouse states concerns with not being able to manage patients pain effectively with current meds, states pain pump is not possible because of multiple fractures in his spine and IV is impossible due to terrible veins but wants to discuss IM medications that could be safely administered at home. States will reach out to pain mgmt doctors this coming week. Pain rated 5/10. The patient also developed a new pressure ulcer, in addition to the one which was present at admission. The RN implemented wound care utilizing wound care orders that were present upon admission for the first wound and indicated to the spouse that she would contact the physician for a referral to a wound specialist. That contact was not documented until 4 days later and orders for treatment of this wound were received. This was discussed with the Alternate DPCS.

Observed in Patient Home. In 2 of 2 home visits conducted, the organization had not implemented infection prevention and control activities when doing the following: Cleaning and performing disinfection of medical supplies and devices. During HV#1, the LVN cleaned all of her patient care equipment used during the visit with wipes she purchased herself which contained ammonium chloride. Per the organization's Infection Control Program Addendum, stethoscopes and BP cuffs are to be cleaned with ammonium chloride; Thermometers are to be cleaned with alcohol wipes. During HV#2, the CHHA put her used gloves into the outside pocket of her clinical bag to take home with her and dispose of which she indicated is her routine practice. The organization's Infection Control Program Addendum indicated that any piece of disposable equipment which has been in contact with blood/body fluids or moist body substances must be disposed of in a plastic bag. Place the plastic bag in the patient's covered trash receptacle. This was discussed with the Alternate DPCS.

Observed in Record Review. In 2 of 2 patient records reviewed, the hospice had not developed a bereavement plan of care that specified the type of bereavement services to be offered and the frequency of service delivery. In the charts for BR#1 and BR#2, the patient's had some interventions documented within the post-death bereavement assessment, however, there was no frequency of contacts documented. For example, in the chart for BR#1, the bereaved party was receiving the routine mailings that the organization prepared, however these mailings were not addressed in the post-death assessment/care planning document as interventions. The plan on the post-death bereavement assessment indicated Provide on going emotional counseling and outreach calls with no further detail. This was discussed with the Alternate Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, the patient record did not contain the following clinical information: specific notes on care, treatment, or services. In the chart for RR#7, during the admission visit, the RN documented in regard to wounds Wound care provided to all. without specifying what the actual care provided entailed. This was discussed with the Alternate DPCS.

Observed in Record Review. In 2 of 11 patient records reviewed, the patient record was not complete, promptly and accurately documented, readily accessible, and systematically organized to facilitate retrieval. In the charts for HV#1 and HV#2, the aide was to see the patients twice weekly. There were no aide notes in the charts since the last of the previous month, almost 3 weeks into the current month. Organizational policy Entries into the Clinical Record required that All documentation will be turned into the office no later than 7 days after the visit is made. This was discussed with the Alternate Administrator.

Observed in Record Review. In 2 of 11 patient records reviewed, when a verbal order for medication was received, the individual who received it did not record and sign it immediately and did not have the prescriber sign it in accordance with state and federal regulations. In the chart for RR#2, the admission RN noted that verbal orders were received to remove the patient's Foley catheter per the patient's request. This order was not documented in the patient's chart. In the chart for RR#7, the RN documented that she received an order from the physician to discontinue aide services per family request. No order was written in the patient chart. This was confirmed with the Alternate DPCS.

Observed in Tracer Activities. For hospice care provided to residents of a Skilled Nursing Facility (SNF), Nursing Facility (NF), or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), the written agreement did not include the following: A provision stating that the hospice will report all mistreatment, neglect, or verbal, mental, sexual, and physical abuse to the SNF, NF, or ICF/IID administrator within 24 hours of the hospice becoming aware of the alleged violation, including injuries of unknown source. This provision was missing in the contract for Respite and GIP services as discussed with the Alternate Administrator.

Observed in HR File Review. In 4 of 5 HR files reviewed, the organization had not verified and documented the following: Credentials of care providers using the primary source when licensure, certification, or registration is required by law and regulation to practice their profession. This was not done at the time of hire and at the time credentials are renewed. In the file for the DPCS/Administrator, the license renewal verification was dated 3 weeks post expiration date. The renewals for the Medical Director and LVN were both documented 6 months or longer past the previous expiration date. There was no date on the verification of registration for the CHHA. This was discussed with the Alternate Administrator.