Every finding on record at Ivy Hospice Care, Inc.

Observed in Record Review. In 1 of 3 patient records reviewed, The organization failed to established individualized measurable goals based on the needs of the patient. During RR#1 it was noted 3 of 6 goals lacked outcome measure time frames to assess goal progress as follows: Pt needs will be met on a day to day basis as communicated. Pt will remain free of injury. Pain will remain in comfortable level during care within 48 hours and will update on next IDT meeting. This was discussed with the Administrator.

Observed in Record Review. In 1 of 3 patient records reviewed, During RR#1 it was noted on the RN initial assessment the patient was at a high risk for skin breakdown. The POC lacked interventions related to the integument system. This was discussed with the Administrator.

Observed in Record Review. In 1 of 3 patient records reviewed, During RR#1 it was noted an order for oxygen therapy 2-5 L/min PRN SOB. The order lacked the titration of the oxygen flow to relieve respiratory distress. This was discussed with the Administrator.

Observed in Record Review. In 1 of 3 patient records reviewed, During RR#2 it was noted the patient was prescribed Eliquis 5mg twice a day. Bleeding precautions were not added to the hospice aide personal care assignment form. This was discussed with the Administrator.

Observed in Emergency Management Session. The organization failed to review the after action reports to identify opportunities of improvement and make recommendations to improve the emergency management program. For example, during an emergency alert issued regarding brush fires in the area, it was identified that the communication methods, staff structure, and availability to assist the patient with evacuation was delayed. The organization had not developed a plan to improve the process for 5 months after the event occurred. This was validated and reviewed with the Administrator and the Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to perform a medication reconciliation. For example, in RRHV #2, the Skilled Nurse failed to perform a medication reconciliation to ensure the facility's medications matched the current medication list for the organization. This was validated and reviewed with the Director of Patient Care Services and the Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to make a Skilled Nurse visit as required by the organization's policy. For example, in RRDC #2, there was a call from the facility indicating the patient was experiencing not being able to obtain a blood pressure, patient guarding the chest area with indications of chest pain, decreased heart rate, and shortness of breath. The Skilled Nurse did not visit the patient for 2 days or contact the facility as requested by the facility Nurse. The patient expired 2 days after the facility call and the organization did not make a death or bereavement visit to the patient at the time of death. This was validated and reviewed with the Administrator and the Director of Patient Services.

Observed in Record Review. In 1 of 2 patient records reviewed, the organization failed to provide the patient/patient's caregiver with discharge instructions. For example, in RRDC #1, the Skilled Nurse visited the patient's caregiver to have the revocation form signed but there is no documentation to support the patient/patient's caregiver were given discharge instructions to include medications, follow up appointments. This was validated with the Director of Patient Services.

Observed in Record Review. In 2 of 14 patient records reviewed, the organization failed to established individualized goals based on the needs of the patient. For example, in RRHV #1, 2, and 3 the goals include, ADL needs are met to an optimal level during this 60 day benefit period (re-eval and continue for the following benefit period if applicable. All patient's had private caregivers who stated, ADL care is provided without difficulty. In RRHV 2 and 3 the patient's are in facilities which provide ADL care to the patients. The goal was established during benefit period 1 and continued throughout all benefit periods although the patient's private caregivers and the facility staff were not in need of ADL teaching/education. This was validated with the Administrator and the Director of Patient Care Services.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to establish frequencies for the skilled clinicians to include duration and the number of as needed visits. For example, in RRHV #1, the Skilled Nurse (SN) frequencies are as follows: SN follow up visit within 48 hours, then 1 week and as needed for fall or change in condition, the Medical Social Worker, 1 every certification and as needed for psychosocial support, Chaplain frequency, 1 in every certification and as needed for spiritual support, and the certified Home Health Aide, 2 per week. There are similar findings in RRHV #2, #3, RRNHV 1 through 7, RRDC #1 and #2, and Bereavement records 1 and 2. This was validated and reviewed with the Administrator and the Director of Patient Care Services. Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to establish frequencies based on the needs of the patients. For example, in RRHV #1, 2, and 3, RRDC 1 and 2, RRNHV 1 through 7, and Bereavement 1 and 2, the Skilled Nurse frequencies, the Medical Social Worker frequencies, the Chaplain frequencies were not established based on the needs of the patient as evidenced by documentation in several clinical records by the Chaplain and MSW, the patient/family/PCG were open to services but no frequencies were established to visit throughout the benefit periods. This was validated and reviewed with the Administrator and the Director of Patient Care Services.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to update the plan of care. For example in RRHV #1 in benefit period 1, 2, and 3 the goals: ADL needs are met to an optimal level during this 90 day benefit period (re eval and continue for the following benefit period if applicable), goal: Bereavement: Family/PCH acknowledges available services to support them in their grieving process, Cardiovascular: Goal: patient will maintain BP within individually acceptable range and will have no symptoms during this benefit period (re-eval and continue for the next benefit period if applicable) are the same throughout all benefit periods. There are similar findings in RRHV 2, 3, RRNHV 1 to 7, RRDC #1 and 2, and Bereavement 1 and 2. This was validated and reviewed with the Administrator and the Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to follow the Physician's order. For example, in RRHV #2, the Skilled Nurse (SN) order indicated, cleanse area with soap and water, pat dry, leave open to air once a day x 21 days. The SN did not perform woundcare as ordered during the visit with the Surveyor and there is no documentation to support the facility performed the woundcare. This was validated with the Administrator and the Director of Patient Care Services. Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to follow the hospice frequency in the hospice plan of care. For example, in RRHV #2 the SN frequency order for wound care was daily x 21 days but the SN continued only once a week visits. This was validated and reviewed with the Director of Patient Care Services. Observed in Record Review. In 1 of 2 patient records reviewed, the organization failed to follow the post bereavement plan of care. For example, in RRDC #2, the plan of care indicated a sympathy card will be sent to the bereaved. There is no documented evidence that the sympathy card was mailed to the bereaved. This was validated with the Administrator and the Director of Patient Care Services.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to address the needs of the patient according to the present symptoms. For example, in RRNHV #1, the patient's family reported an episode of urinary retention. The Skilled Nurse (SN) obtained an order hold Lasix and KCL due to episodes of unable to urinate as reported by family until seen on next week SN visit. The SN decided to visit the patient the same day the order was obtained and in a documented assessment noted no urinary retention, dysuria, and or foul smelling urine but failed to contact the Physician to provide an updated report. The SN documented in the visit notes, the patient developed bilateral pedal edema ranging from +1 to +3 over the next 2 months, There is no indication the SN contacted the Physician with an updated report until 2 months later in which there was a new order given for Lasix. The Lasix refill was still not provided to the patient for 39 days after the restart order date. This was validated and reviewed with the Administrator and the Director of Patient Care Services.

Observed in Leadership Session. The organization failed to compile and analyze the data for performance improvement measures. For example, the organization had a performance improvement plan for safety culture. During the Leadership session the Leaders indicated, the safety culture was evaluated using surveys and all surveys were returned with either a strongly agree or an agree which would indicate a score above the 70% target goal indicated on the performance improvement plan. In review of the actual performance improvement plan, the data showed a score 61.90% for 2024. Another example, the organization had performance improvements for hand hygiene and hand washing. The organization's data showed 5 Certified Home Health Assistances (CHHA) and 1 Licensed Vocational Nurse (LVN) but the actual hand hygiene and bag technique tools which were paper forms used to collect the data showed that only 3 CHHAs were evaluated and 1 LVN resulting in inaccurate data collection. This was validated and reviewed with the Administrator and the Director of Patient Services.

Observed in Record Review. In 2 of 14 patient records reviewed, the organization failed to follow the plan of care. For example, in RRHV #2, the Certified Home Health Aide's (CHHA) indicated, RN instruction: heart rate is 101 and above or 59 and below-notify the RN Case Manager, Hospice Office and Charge Nurse/Facility Staff. The patient's heart rate per the CHHA documentation was 56 in benefit period 8. In RRNHV #1 benefit period 5 and 6: indicated, if patient is experiencing pain/change in condition notify RN. There is no documentation to support the RN was notified of the heart rate and no documentation to support the patient being asked about the pain level. This was validated and reviewed with the Director of Patient Care Services.

Observed in Leadership Session. The organization failed to implement policies and procedures to support patient care, treatment, and services which resulted in condition level deficiencies in care planning and assessment of patients. This was validated and reviewed with the Administrator and the Director of Patient Care Services.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to document accurate information in the clinical record. For example, in RRHV #2 the wound care order states daily woundcare and in the intervention documentation the Skilled Nurse documented the woundcare as, as needed. This was validated and reviewed with the Administrator and the Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to discontinue medications on the medication list. For example, in RRHV #1 docusate sodium 100 mg 1 tablet by mouth daily was changed to docusate sodium 100 mg 1 tablet by mouth two times a day (hold for loose stool) 5 months prior to the survey. The docusate daily dose was not discontinued. Medihoney wound gel 1.5 oz 1 application topical daily x 21 day wound care to the mid back was not discontinued but remained on the medication list at the time of the survey for at least 3 months after the stop date. This was validated and reviewed with the Director of Patient Care Services and the Administrator.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization failed to assess and reassess its patient's. For all records reviewed, the hospice nurse surveyor observed the interdisciplinary group notes did not document decline or revisions to the plan of care. Consistently, Social Work and Chaplain entered goals at the start of care but did not update them. Nursing updated timeframe dates to extend to the next certification period at each recertification but did not document progress towards goals. The IDG meeting minutes were visit notes pulled over into the IDG. This was discussed and reviewed with the Administrator.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization failed to plan the patient's care. In all records reviewed, the hospice nurse surveyor observed the written plan of care did not contain all goals or measurable timeframes to meet those goals. For example: in HV#1 the patient had continued to have issues with pain but it was not addressed on the POC. In RR#1 skin integrity/ wound care was entered on 2/14 with a goal of will resolve in next 30 days but as of survey date patient still had an active wound with new orders but the POC had not been updated. And in RR#3 the patient had an increase in SOB with no update to the POC. For all records reviewed, timeframes to reach goals were entered for the last day of the certification period no matter the goal to be achieved or the discipline entering that goal. No individualization was noted. This was discussed and reviewed with the Administrator.

Observed in Tracer Activities. The organization failed to provide services to meet all of the patient's needs. During tracer activities for the Volunteer program, the hospice nurse surveyor observed there was no current volunteers and no current activities for recruitment. The agency office staff were monitoring an online site for Volunteer matches but nothing further. No activities had been completed since the beginning of the Pandemic. The hospice team had been utilizing a past employee as a volunteer who also is part owner. Education was provided. The Hospice team did state they understood the requirement. This was discussed and reviewed with the Administrator.