Every finding on record at Ipr Healthcare Systems, Inc.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to conduct and document a patient-specific comprehensive assessment and reassessment that identified the patient’s need for hospice care and services. On review of HosRRNHV#5 the patient was diabetic with orders for Insulin and two oral hypoglycemics, yet there was no documentation of an endocrine system review on admission or elsewhere in the record. In HosRRNHV#10 the initial nursing assessment documentation noted there was a wound, however there was no wound assessment noted in the documentation. These observations were reviewed with the ADON.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to update the comprehensive assessment. On review of HosRRHV#2 the IDG meeting failed to update the comprehensive assessment. In the documentation for the most recent IDG meeting there was no mention that the patient had a foley catheter added since last IDG meeting. The IDG documentation stated no lines, tubes, or devices in place yet a foley catheter had been placed since the last IDG. In review of HosRRNHV#6 the patient had a change in level of care as they went respite, yet the changes were not discussed in the update to the comprehensive assessment during the IDG meeting. These observations were reviewed with the DON and ADON.

Observed in Record Review. In 8 of 10 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. In HosRRHV#1 the documentation and conversation with the patient's husband noted that anxiety/agitation was an ongoing issue for the patient. There was documentation of the use of ABH cream and increase in the Haldol dosage yet no care plan related to the anxiety/agitation open to guide the care. In HosRRHV#2 the documentation noted the patient had a seizure that required a PRN visit and use of Lorazepam yet there were no seizure precautions noted on the plan of care nor was seizure risk addressed on the care plan. In HosRRHV#3 there was documentation of swelling in the patient's neck prompting a PRN visit and ongoing monitoring yet there was no care plan opened to address the issue. In HosRRNHV#5 the patient was diabetic with insulin and multiple oral hypoglycemics, yet the issue was not addressed in the care plan. In HosRRNHV#6 the patient had a change in level of care to respite and back for caregiver relief, but the changes were not reflected in the plan of care. Further, the documentation noted poor appetite with increased protein needs but no care plan to guide the care. In HosRRNHV#7 the documentation noted issues with anxiety utilizing ABH cream and Haldol, and issues with pain requiring Fentanyl but no care plans to address the issues. The patient had multiple UTI's with antibiotic orders yet the care plan for urinary was not updated to reflect the changes. In HosRRNHV#8 the patient had an ear infection and increased agitation requiring changes in Seroquel dosage, yet the issues were not reflected in the care plans. In HosRRNHV#10 the patient's terminal diagnosis was End Stage Heart Disease yet there was no cardiovascular care plan to guide the care. These observations were reviewed with the ADON.

Observed in Record Review. In 10 of 10 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of HosRRHV#3 the patient's wife noted they were using Thickener to honey consistency related to swallowing difficulties yet there were no orders for the thickener noted on the plan of care. There were two orders for Carafate, one liquid and one tablets yet there were no specific instructions to guide the user when to use each one. In HosRRHV#1 there were range orders for Morphine Concentrate and Lorazepam yet no specific instructions to guide the user in when to use what dosage. Such as Morphine Concentrate 100mg/5ml give 0.25ml - 1ml Q1H as needed for pain and shortness of breath, and Lorazepam 0.5 mg give 1-2 tabs as needed for anxiety/shortness of breath. Range orders for Morphine and/or Lorazepam could be seen in all records reviewed as the orders were part of the comfort kit orders. In HosRRNHV#5 the documentation noted skin tears with treatment provided yet no wound care orders noted on the plan of care. In HosRRNHV#9 there were multiple orders for PRN anxiety medication two for Lorazepam and one for Alprazolam yet no specific instructions to guide the user as to which one to choose for what situations. These observations were reviewed with the ADON.

Observed in Record Review. In 6 of 10 patient records reviewed, the organization failed to ensure plan of care revisions were based on information from updates to the patient's comprehensive assessment and address the patient's progress toward goals and outcomes. On review of HosRRNHV#4 there were goals that had not been updated based on the comprehensive assessment. The goals had target dates that were past without update, such as: Patient will report a decrease in pain score from 5/10 to 1/10 on a numerical rating scale by (date in Feb). Examples of goals without update past the achieve by/target dates that were: In HosRRNHV#6 Patient will rate the pain scale lower than the initial rate at a level that is acceptable to them or 0/10 by (date in April). In HosRRNHV#7 an example was Patient will achieve a normal elimination pattern free from frequency and urgency by ( date in June of 2025). In HosRRNHV#8 an example was Patient will report averaging 7-9 hours of restful sleep per night by (date January). Further examples could be seen in HosRRHV#3, and HosRRNHV#9. These observations were reviewed with the ADON.

Observed in Record Review. In 3 of 10 patient records reviewed, the organization failed to ensure the care and services were provided in accordance with the plan of care. On review of HosRRNHV#7 the Spiritual Counselor (SC) was order a frequency of 1 x month but there were no documented visits in July, October, or November, nor any documentation as to why the visits were not made. In HosRRNHV#8 the SC was also ordered 1 x month but there were no documented visits in January, February or March. In HosRRHV#3 the SC was also ordered 1 x month yet visits were not documented monthly as early documentation noted services were declined but the frequency remained active on the plan of care. These observations were reviewed with the ADON.

Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement records, the organization failed to develop a bereavement plan of care that noted the type of bereavement services to be offered and the frequency of service delivery. On discussion with the bereavement coordinators and review of HosRRBR#1 and HosRRBR#2 it was noted that there was no written bereavement plan of care to indicate the services to be delivered and frequency of delivery documented on the record. This observation was reviewed with the Bereavement Coordinators, and the DON.

Observed in Record Review. In 2 of 9 patient records reviewed, where hospice aide services were provided, the organization failed to ensure written patient care instructions for the hospice aide were prepared by the registered nurse. On review of HosRRHV#2 the patient had a foley catheter, yet the catheter was not noted on the aide assignment nor was foley care assigned as a task for the aide. In HosRRNHV#9 there was documentation the patient had a wound with wound treatment. There was no instructions for the aide on how to handle the wound while providing care. This observation was reviewed with the DON and ADON.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to supervise the aide effectively. On review of HosRRNHV#4 the aide was seeing the patient weekly starting in February. The 1st aide supervisory was in March, after the required 14 days, on day 16. There was no further documentation of an aide supervisory visit since the March visit to date of survey. This observation was reviewed with the ADON.

Observed in HR File Review. In 1 of 1 HR files reviewed, for hospice aide, the organization failed to document annual on-site visits to the location where a patient is receiving care in order to observe and assess each aide while preforming care. In HR#2 for the hospice aide there was only documentation of a visit in 2023 and 2026. This observation was reviewed with the HR Coordinator.

Observed in Tracer Activities. on review of the volunteer program it was noted the organization failed to provide day-to-day administrative or direct patient care in an amount that equals 5% of the total patient care hours of all paid hospice employees and contract staff. The hospice volunteer time documented was consistently less than 5% of the total patient care hours. Volunteer time was 1.9% for 2024 and 0.9% for 2025. This observation was reviewed with the Volunteer Coordinator, DON and ADON.

Observed in Tracer Activities. 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 3 home visits conducted, the organization failed to ensure the patient record contain all information to reflect the patient's care, treatment, and services. On home observation of medication reconciliation the medication profile as part of the medical record did not match the medications noted in the home. In HosRRHV#2 there was an order for oxygen yet the patient's wife stated they did not have oxygen in the home. Mirtazapine was ordered and the patient had not been taking for a while and Dexamethasone had been stopped per the wife a week or two ago. Further, the wife noted she had been giving Ibuprofen yet Tylenol was ordered. She stated she did not have Tylenol in the home. In HosRRHV#3 the medications scopolamine, Claritin, Flonase, Ammonium Lactate lotion, Magic Mouthwash and Lorazepam were ordered in the record yet the caregiver noted the patient was not taking the medications and they were not in the home. There was Cetirizine liquid in the home the patient was using for allergy symptoms but not included in the ordered medications. These observations were reviewed with the RN and ADON.

Observed in Record Review. In 1 of 2 patient records reviewed, the organization failed to ensure a copy of the discharge summary was provided to the receiving facility when the patient is transferred to another Medicare/Medicaid certified facility. On review of HosRRDC#1 the patient was transferred to the hospital seeking aggressive treatment yet there was no documentation the transfer summary was sent to the receiving facility. This observation was reviewed with the DON and ADON.

Observed in Record Review. In 2 of 2 patient records reviewed, the organization failed to provide the patient's attending physician with a copy of the hospice discharge summary when a patient revoked or was discharged from hospice care. On review of HosRRDC#1, HosRRDC#2 there was no documentation the attending physician was provided with a copy of the discharge summary. This observation was reviewed with the DON and ADON.

Observed in Record Review. In 2 of 4 patient records reviewed, For hospices that elect to use The Joint Commission deemed status option: The plan of care did not include all services needed for the palliation and management of the terminal illness and related condition. During review of patient records, it was noted that in records 3 and 4 the record did not contain all problems identified in the comprehensive assessment. For example in records 3 and 4 the patient's were assess as having anxiety but anxiety was not addressed in the plans of care. This was confirmed by the Hospice Manager.

Observed in Emergency Management Session. During review of the emergency plan and discussion with agency leaders, the surveyor determined that the organization had not completed a Hazard Vulnerability Assessment (HVA) prioritizing the potential emergencies that could affect its ability to provide services specific to Home Health and Hospice. This was verified with the Chief Operations Officer.

Observed in Emergency Management Session. the organization did not have a delegation of authority plan for home health and hospice that described the decisions and policies that could be implemented by authorized successors during an emergency and criteria or triggers that would initiate this delegation. This was verified with the Chief Operations Officer.

Observed in Emergency Management Session. The Emergency Operations Plan did not accurately describe how staff will be notified that emergency response procedures have been initiated. The call tree for home health and hospice did not reflect the actual process that occurred. This was verified with the Chief Operations Officer.

Observed in Emergency Management Session. The organization did not establish backup procedures in the event that communications failed during an emergency for its home health and hospice programs. The emergency management plan did not include the alternate means for communication. This was verified with the Chief Operations Officer.

Observed in Individual Tracer. In 2 of 2 patient records reviewed, The hospice bereavement coordinator did not conduct a post death bereavement risk assessment which is required by the agency's program policy on Bereavement. There was no post death assessment for the bereaved on BR#1 and BR#2. This was verified with the Bereavement Coordinator.

Observed in Individual Tracer. In 6 of 11 patient records reviewed, The hospice did not develop specific measurable goals with specific time frames. For example in HSRR#1, HSRR#2, HSRR#3, HSRR#4, HSRR#6, and HSRR#8 time frames were written as during cert period, throughout cert period, within 1 cert period. Goals were not measurable such as, goals for coping, pain, debility and insomnia will be improved or will be decreased or will be controlled or will be managed. This was verified with the Director of Nursing. Observed in Individual Tracer. In 5 of 11 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: - Measurable outcomes anticipated from implementing and coordinating the plan of care. During the home visit HSHV#1 for a patient with End stage Heart Failure the surveyor noted the patient had significant edema of bilateral lower extremities. The record reflected that edema ranged for +2 to +4. HSRR#5 care plan was not created at admission, there was no care plan for 13 days, patient had following problems cardiac, edema, pain, wound, and dyspnea. HSRR#6 problems of fall risk, UTI and wound was not care planned. HSRR#7 fall risk not care planned. HSRR#8 the following problems were not care planned: abdominal distention with Pleurex drain, measuring abdominal girth, difficulty urinating, swelling upper arm, and lower extremity edema. This was confirmed by the Director of Nursing.

Observed in Individual Tracer. In 5 of 11 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: - Interventions to manage pain and symptoms . During the home visit HSHV#1 for a patient with End stage Heart Failure the surveyor noted the patient had significant edema of bilateral lower extremities. The record reflected that edema ranged for +2 to +4. There was no care plan, including interventions, to address edema management. HSRR#5 care plan was not created at admission, there was no care plan for 13 days, patient had following problems cardiac, edema, pain, wound, and dyspnea. HSRR#6 problems of fall risk, UTI and wound was not care planned. HSRR#7 fall risk not care planned. HSRR#8 the following problems were not care planned: abdominal distention with Pleurex drain, measuring abdominal girth, difficulty urinating, swelling upper arm, and lower extremity edema. This was confirmed by the Director of Nursing.

Observed in Individual Tracer. In 4 of 11 patient records reviewed, the hospice organization prescribed more than one medication for managing symptoms but did not specify which medication to use first. For example, there were three medications prescribed for pain for the HSHV#2 patient: Tylenol, Norco, and Morphine. There was no specification of which medication to use first or for what level of pain. Additional examples include HSRR#1 with multiple medications for pain: Fentanyl, Hydromorphone and morphine; HSRR#7 multiple medications for pain: Tramadol and Tylenol and three medications for constipation :Senna, Bisacodul and MiraLAX; and HSRR#8 with multiple medications for pain: Tramadol and Morphine. The organization did have physician ordered protocol to direct administration. This was verified with the Director of Nursing.

Observed in Individual Tracer. In 2 of 11 patient records reviewed, The organization did not revise the plan of care based on information from updates to the patient’s comprehensive assessment and did not address the patient’s progress toward goals and outcomes as evidenced by 1) HSRR#6 the care plan was not updated by 2/9 when the problem related to funeral plans was resolved 2/2 and oxygen was not added to the care plan 2/8 when the patient was started on oxygen 2) HSRR#8 the care plan not revised when the patient developed a new skin tear 3/20. This was verified by the Director of Nursing.

Observed in Individual Tracer. In 2 of 2 patient records reviewed, The hospice did not develop a bereavement plan of care following the post death bereavement assessment for HSBR#1 and HSBR#2. A plan of care for bereavement services had been developed prior to the patient's death based on the pre bereavement assessment. This was verified with the Bereavement Coordinator.

Observed in Individual Tracer. In 2 of 11 patient records reviewed, the organization did not ensure documentation in the clinical record reflected the patient care as evidenced by 1) HSRR#1 the patient's Fentanyl dose was increased to 100 mcg on February 8, however, all visit notes dated 2/10, 2/13, 2/15, 2/17 stated patient started on Fentanyl 50mcg today. 2) HSRR#5 was receiving oxygen via trach and was on five liters, however, the plan of care stated the oxygen was delivered via nasal cannula and was two-three liters. This care plan was corrected three months after admission. This was verified with the Director of Nursing.

Observed in Individual Tracer. In 11 of 11 patient records reviewed, the surveyor noted that hospice records did not include RN updates to IDG. The Director of Nursing stated she entered notes on each patient after each IDG meeting to reflect patient updates and changes to the plan of care. The Director of Nursing had verified that the information was present in the record after the last IDG meeting. The RN updates and some social worker updates were missing from multiple records for multiple dates. The agency contacted the clinical software company for restoration of data. The company validated that the software company was responsible for the missing data. This was verified with the Director of Nursing.