Every finding on record at Kumar Lifecare Hospice Inc.

Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the POC did not include frequency of services necessary to meet the specific patient and family needs. For example, in record RRHV#3 there were 2 documented IDGs including the POC and no frequency for nursing visits was included in the documentation. The nurses had been documenting nursing visits were completed 1 time a week. This was confirmed with the DPCS present.

Observed in Patient Home. In 2 of 4 home visits conducted, it was noted that the staff failed to perform hand hygiene consistent with policy. For example, during home visit RRHV#1 the aide did not perform hand hygiene prior to entering the bag greater than 5 times. The organization's Bag Technique policy stated that hand hygiene was to be performed prior to entering bag. During PCRRHV#1 the MSW did not perform hand hygiene during the visit, no hand hygiene upon entering or leaving the home. This was discussed with the Administrator and DPCS present.

Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement care it was noted that the bereavement care plans did not include specific, individualized goals or interventions, and the timing and frequency of interventions was the same for both patients. For example in records RRBR#1 and RRBR#2 the goal in the bereavement POC was not individualized, To ensure support for appropriate grief response. Also the interventions were not individualized, all of them were check marked for both patients and the area that could be free texted/individualized was left blank. This was confirmed and discussed with the DPCS and Administrator present.

Observed in Record Review. In 1 of 1 home visits conducted, with an aide, it was noted that the Aide Care Plan did not include all service that the aide provided. For example, during visit RRHV#1 the aide performed hair washing in the bed and the aide POC hair section was blank with no direction for performing hair washing. This was confirmed with the DPCS and Administrator.

Observed in Record Review. In 3 of 10 patient records reviewed, it was noted that there was incomplete documentation. For example in records RRHV#1 and RRHV#2 the Individual Emergency Management Plan oxygen area was checked, but the Flow Rate, Hours of Use and Delivery Service were left blank. During visit RRHV#1 with the aide it was noted that the aide performed hair washing, upon review of the documentation the hair washing was not documented. I record RRHV#3 the IDG documentation had written comment from the medical director and nurse, on 2 occasions however there was no signature on the documents. Also in RRHV#3 there was a new pain goal documented and a new order for a pain medication the same day, however there was no visit note, communication note or any documentation of why the goal and medication had been put in place. This was confirmed with the DPCS and Administrator.

Observed in Record Review. In 4 of 5 patient records reviewed, the update of the comprehensive assessment was not based on changes that had taken place since the initial assessment and did not include information about the patient’s progress toward desired outcomes nor a reassessment of the patient’s response to care. In the charts for RR#1,RR#2 and RR#5, there was no documented progress toward goals for Spiritual Care nor MSW in the IDT meeting/POC update documents as confirmed with the DPCS. In the chart for RR#4, a SC goal was Pt/ Family/PCG will freely verbalize spiritual needs and concerns within 14 days and will update on next IDT the only Input at the subsequent IDT was that SC would perform the initial evaluation to provide spiritual support to patient and family. (which had already occurred. This was discussed with the DPCS. Observed in Record Review. In 1 of 5 patient records reviewed, the hospice’s interdisciplinary group had not updated the comprehensive assessment in collaboration with the patient’s attending physician, as frequently as the patient’s condition requires, but no less than every 15 days. In the chart for RR#2, the MSW and SCC notes in the IDT were identical two meetings in a row, yet the patient had moved from a private residence to a SNF between IDT meetings. This was discussed with the DPCS.

Observed in Record Review. In 5 of 5 patient records reviewed, plan of care 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#1 and RR#2, the POC had not been updated after the assessments by the Chaplain and MSW to include their interventions and goals which were outlined in the assessment documents. In the chart for RR#3, the MSW interventions and goals from the assessment had not been added to the hospice POC. In the chart for RR#4, the MSW did not update POC with interventions/goals post initial assessment related to identified problems such as a need for caregiver support, psychosocial stimulation for the patient. In the chart for RR#5, the Spiritual Care, Social work interventions/goals were not updated after the initial assessment. Additionally, the patient was using oxygen. The SN discovered during a visit that the patient was still smoking. The POC was not updated to include oxygen safety interventions and goals. This was discussed with the DPCS.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization had not provided the patient with care, treatment, or services according to the patient's individualized plan of care. In the chart for RR#2, the aide visits were ordered 3/weekly. In weeks 3 and 4 of the benefit period, 4 visits were made as discussed with the DPCS.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: - §418.54, §418.56.

Based on observation, interview, and record review, the facility failed to ensure privacy was maintained during care for Patient 6. This failure resulted in Patient 6's dignity not being respected. Findings: During a review of Resident 6's "Personal Information", (PI), dated 5/5/22, the "PI" indicated, Patient 6's diagnosis was Alzheimer's disease (a brain disorder in which the memory loss and other cognitive abilities interfere with daily life). During an observation on 7/18/22, at 3:22 PM, in Patient 6's bedroom, nursing care was being provided to Patient 6. During perineal care (the area between the genitals and anus) for Patient 6, the bedroom door was left open. During a concurrent observation looking out Patient 6's bedroom door, Patient 12 was observed to be looking towards Patient 6's bedroom. During an interview on 7/18/22, at 3:53, PM, with Registered Nurse (RN 1), indicated the bedroom door should be closed during patient care. During a review of RN 1"s, facility's Job Descriptions", (JD), dated 5/7/22, the "JD" indicated "...Essential Job Functions/Responsibilities... Provides privacy during patients care..."

Based on interview and record review, the facility failed to ensure it met and tracked the five percent requirement for the volume of care provided by volunteers on two consecutive years, 2021 and 2022. The Volunteer's (VT) timesheet hours for the month of July 2022 were incorrect. These failures resulted in noncompliance with the facility's policies and procedures on tracking and meeting the volume of care provided by volunteers. Findings: A review of the report titled, "Hospice-MD Volunteer Savings Report," indicated the following: *From 1/1/22 to 7/19/22, the total patient care hours for all paid hospice employees and contract staff were 5,409.2 hours. The total volunteer hours were zero hours. The total percentage of volunteer services were 0% percent for 2022. *From 1/1/21 to 12/31/21, the total patient care hours for all paid hospice employees and contract staff were 15,014.3 hours. The total volunteer hours were one hour. The total percentage of volunteer services were 1% percent for 2021. An interview was conducted with the Volunteer Coordinator (VC) on 7/19/22 at 12:02 PM and at 1:41 PM. VC confirmed, the hospice agency did not meet the minimum five percent requirement for 2021 and 2022, because the volunteer percentage amount was one percent from 1/1/21 to 12/31/21 and zero percent from 1/1/22 to 7/19/22. VC stated, it was her mistake because she had not gotten the chance to track and document the volunteer hours on the 2021 and 2022 reports. VC stated, she had been busy but should have done this. VC confirmed, the reports for 2021 and 2022, were the only one's available at the time requested by the surveyor. VC stated, it was the responsibility of the volunteer coordinator to track and document volunteer patient care and administrative hours on the volunteer cost savings report. A concurrent interview and record review was conducted with the Volunteer (VT) on 7/20/22 at 10:36 AM, the timesheet record indicated VT had worked from 9 AM to 5 PM, with a 30-minute lunch break from 1 PM to 1:30 PM. This equal eight hours per day, 7/5/22 through 7/8/22 and 7/11/22 through 7/15/22. The timesheet record indicated the total hours documented by VT for the above dates added up to 72 hours total. *This surveyor calculated the timesheet hours and the total hours added up to 67.5 hours. VT confirmed, the above findings. A review of the facility's policy titled, "Volunteer Services," revised 4/2021, indicated, "The volunteer coordinator will track the use of volunteers, cost savings achieved, and the hours of volunteer services exceed 5% of the total day-to-day administrative or direct patient care hours of paid and contracted hospice personnel." A review of the facility's policy titled, "Documentation of Volunteer Utilization," revised 4/2021, indicated, "The Volunteer Coordinator will compile and analyze the data monthly. The Volunteer Coordinator will document the following: A. The continuing level of volunteer activity and the expansion of care and services achieved through the use of volunteers; B. Volunteer service hours to show that volunteer hours equal at least 5% of the total day-to-day administrative or direct patient care hours of all paid hospice and contract staff."

Observed in Record Review. In 3 of 3 patient records reviewed, the comprehensive assessment was not updated every 15 days as required. Upon review of RR#1 and RR#2, it was noted the last interdisciplinary group (IDG) note documented as completed was 26 days ago. On review of RR#1, it was noted the patient was changed from general inpatient (GIP) level of care to routine level of care; however, on review of IDG documentation and updates to the comprehensive assessment, this change was not addressed. On review of RR#2, it was noted the patient was started on colchicine for gout due to redness and swelling of the right hand; however, on review of IDG documentation and updates to the comprehensive assessment, this change was not addressed. On review of RR#3, it was noted nursing documentation for several IDG notes was identical and was not updated to reflect the patient’s current status. This was reviewed and validated with the Hospice Administrator. Observed in Record Review. In 3 of 3 patient records reviewed, the update of the comprehensive assessment did not include specific information about the patient's progress toward desired outcomes. Upon review of interdisciplinary group (IDG) documentation for RR#1, RR#2, and RR#3, it was noted the social worker and spiritual counselor documentation was the same for each IDG meeting and did not reflect progress, or lack thereof, towards goals. The documentation was as follows, “No psychosocial and/or spiritual needs at this time. Will continue to follow up once a month to provide support to the patient/family”. On review of nursing IDG documentation, changes to medications were documented; however, there was no documentation to reflect progress, or lack thereof, towards goals. This was reviewed and validated with the Hospice Administrator.

Observed in Record Review. In 3 of 3 patient records reviewed, the plan of care did not include spiritual care interventions and/or psychosocial interventions. Upon review of RR#1 and RR#3, it was noted the psychosocial and spiritual assessments indicated ongoing support was to be provided; however, on review of the plan of care, there were no interventions established. On review of RR#2, the social worker assessment indicated, “Caregivers require teachings and psychoeducation related to death and dying”; however, on review of the plan of care, there were no interventions established related to education. This was reviewed and validated with the Hospice Administrator. Observed in Record Review. In 2 of 3 patient records reviewed, the plan of care did not include all interventions to meet the patient's needs. Upon review of RR#1, it was noted the patient had medications for constipation ordered on start of care; however, on review of the plan of care, there were no interventions established related to bowel management. The patient was on Remeron for depression and lorazepam for anxiety; however, on review of the plan of care, there were no interventions established related to these diagnoses. Upon review of RR#3, it was noted the patient had medications for constipation ordered on start of care; however, on review of the plan of care, there were no interventions established related to bowel management. This was reviewed and validated with the Hospice Administrator.

Observed in Record Review. In 2 of 3 patient records reviewed, the plan of care did not include the frequency of visits based on needs identified in the comprehensive assessment. Upon review of RR#1, it was noted the social worker assessment indicated monthly visits would be conducted for psychosocial support; however, on review of the plan of care, the visit frequency for the social worker indicated one visit per certification period and as needed. On review of RR#2, it was noted the spiritual counselor assessment indicated continuing support would be provided; however, on review of the plan of care, no visit frequencies were established. This was reviewed and validated with the Hospice Administrator.

Observed in Record Review. In 1 of 1 patient records reviewed with wound care, wound care orders were not included on the plan of care. Upon review of RR#1, it was noted the patient had a stage II pressure ulcer to their sacrum and nursing documentation indicated, “Advised to cleanse site daily and as needed when soiled with wound cleanser. Apply thin layer of calmoseptine on wound. Cover with bordered dressing.” On review of the plan of care and physician orders, there was no documentation to validate wound care orders were obtained. This was reviewed and validated with the Hospice Administrator.

Observed in Record Review. In 2 of 3 patient records reviewed, the plan of care was not updated based on changes to the comprehensive assessment. Upon review of RR#1, it was noted the patient was on general inpatient level (GIP) of care on start of care and 3 days later the level of care was changed to routine. On review of the plan of care, the GIP care plan was listed as active and had not been resolved. On review of nursing notes, the documentation indicated the patient’s edema had resolved; however, on review of the plan of care, the cardiac care plan related to edema was listed as active and had not been resolved. On review of nursing notes, the documentation indicated the patient’s bowel medications had changed with new orders for Senna and Colace to begin; however, on review of the plan of care, these changes were not addressed. On review of nursing notes, the documentation indicated the patient had developed cellulitis to their bilateral lower extremities; however, on review of the plan of care, this change was not addressed. On review of RR#2, it was noted the patient developed gout with redness and swelling to their right hand; however, on review of the plan of care, this change was not addressed. This was reviewed and validated with the Hospice Administrator.

Observed in Record Review. In 1 of 3 patient records reviewed, spiritual care was provided without an ordered visit frequency. Upon review of RR#2, it was noted the spiritual counselor was making monthly visits; however, on review of the plan of care, there were no visit frequencies established for spiritual care services. This was reviewed and validated with the Hospice Administrator.

Observed in Record Review. In 1 of 1 patient records reviewed with a change in level of care, care was not provided based on the patient’s needs identified in the comprehensive assessment. Upon review of RR#1, it was noted the patient was started on general inpatient (GIP) level of care due to shortness of breath. On review of the nursing note on the third day of GIP level of care, the documentation indicated the following: the patient had shortness of breath noted at rest with a respiratory rate of 28 breaths/minute; the patient was on oxygen at 3 liters per minute (LPM) due to a Covid19 infection; diminished breath sounds noted on auscultation with productive cough and desaturates on room air; mouth breathing noted intermittently; patient with Promethazine/codeine to start today for cough. On review of the plan of care, the level of care was changed following this visit to routine and there was no documentation to validate the change in level of care was discussed with the physician. This was reviewed and validated with the Hospice Administrator.

Observed in Record Review. In 1 of 3 patient records reviewed, collaboration between nursing and the hospice physician did not occur. Upon review of RR#1, it was noted the level of care was changed from general inpatient to routine; however, there was no documentation to validate the change in level of care was discussed with the physician. Nursing documentation indicated the patient developed cellulitis to their bilateral lower extremities; however, there was no documentation to validate this change in the patient's condition had been communicated to the hospice physician. This was reviewed and validated with the Hospice Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed with aide services, the hospice aide did not provide care as ordered by the interdisciplinary group (IDG). Upon review of RR#1, it was noted the aide was assigned to provide a bed bath for the patient; however, on review of aide documentation for 1 of 16 aide visits completed, the documentation indicated a shower was given. This was reviewed and validated with the Hospice Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed with aide services, hospice aide supervision did not confirm the aide was following the patient's plan of care as assigned. Upon review of RR#1, it was noted aide visit documentation reflected the aide was not following the plan of care; however, the supervisory visit documentation completed during the time frame in which the visit was made did not address that bathing services were not provided according to the plan of care. This was reviewed and validated with the Hospice Administrator.

Observed in Record Review. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: - §418.54, §418.56, §418.100, and §418.104.

Observed in Record Review. In 3 of 3 patient records reviewed, the record contained inaccurate information. Upon review of RR#1, it was noted the patient was admitted with a terminal diagnosis of Alzheimer’s disease and on review of the physician’s narrative on the Certification of Terminal Illness (CTI), the documentation indicated a Palliative Performance Scale (PPS) of 40% and a 7D on the Functional Assessment Staging Tool (FAST) scale; however, the nursing narrative on the CTI indicated a PPS score of 30% and a FAST score of 7A. On review of the comprehensive assessment, nursing documentation indicated the patient was not on oxygen therapy; however, on review of the plan of care, oxygen was documented as ordered. On review of nursing notes, the documentation indicated the patient had no pressure ulcers; however, on review of the wound assessment, a stage II to the sacrum was listed as an active wound. On review of all Interdisciplinary Group (IDG) notes, the spiritual update to the comprehensive assessment indicated, “MSW will continue to follow up”. On review of nursing documentation, the narrative indicated it was the patient's last day of General Inpatient Level of Care; however, the care level identified on the nursing note indicated routine level of care. Upon review of RR#2, it was noted the patient’s terminal diagnosis was a cerebral infarction; however, the Local Coverage Determination (LCD) documentation was completed for heart disease. On review of all Interdisciplinary Group (IDG) notes, the spiritual update to the comprehensive assessment indicated, “MSW will continue to follow up”. On review of the plan of care, documentation indicated spiritual care services were declined; however, on review of the spiritual assessment and visit notes, care was being provided. On review of RR#3, it was noted the physician’s narrative on the CTI indicated the terminal diagnosis was cerebrovascular disease; however, the nursing narrative on the CTI indicated the terminal diagnosis was heart disease. On review of all Interdisciplinary Group (IDG) notes, the spiritual update to the comprehensive assessment indicated, “MSW will continue to follow up”. This was reviewed and validated with the Hospice Administrator.

Observed in Record Review. In 2 of 3 patient records reviewed, the medication/treatment profile was inaccurate. Upon review of RR#1, it was noted the medication/treatment profile had two active orders for oxygen therapy listed as follows: continuous oxygen at 2 liters per minute (LPM) via nasal cannula for shortness of breath (SOB)/respiratory distress and oxygen concentrator 2 LPM via concentrator via nasal cannula as needed for shortness of breath. On review of RR#3, it was noted the medication/treatment profile had two active orders for oxygen therapy listed as follows: oxygen at 2 LPM via nasal cannula as needed for SOB/respiratory distress and oxygen concentrator 2 LPM - 5 LPM via nasal cannula as needed for shortness of breath. This was reviewed and validated with the Hospice Administrator. Observed in Record Review. In 1 of 1 patient records reviewed with wound care, the record did not contain documentation of care provided. Upon review of RR#1, nursing documentation indicated treatment was provided as ordered to the patient's heel and sacrum; however, there was no documentation of the actual treatment provided. This was reviewed and validated with the Hospice Administrator.

Observed in Record Review. In 3 of 11 patient records reviewed, it was noted that the comprehensive assessment was not updated as evidenced by the RN not visiting the patient at least every two weeks prior to the IDG meeting. This was noted in record review for home visit #2. In record review #1 it was noted that there was no documentation of IDG note since 9/15/21. In review of record #3 it was noted that the RN did not visit at least every two weeks for the comprehensive assessment as evidenced by no RN visit between 8/31 and 9/17. This was discussed with the DPCS.

Observed in Record Review. In 4 of 11 patient records reviewed, it was noted that the care plan goals did not always contain time frames, settings or services to meet the goals. For example, in record review #1 the following goal was stated, Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects. And will have no shortness of breath related to CHF. In another example, in record review #2 the following goal was stated, Patient will remain comfortable within the next 2 weeks as evidenced by absence of physical signs/symptoms of pain will be re-evaluated during the next IDT meeting. Another example in record review #1 reduce discomfort as evidenced by less or absence of acid reflux. Another example in home visit #1 record was Pain will remain in comfortable level during care. This was discussed with the DPCS.

Observed in Record Review. In 5 of 11 patient records reviewed, it was noted that orders for the MSW and SC visits included PRN visits that were not quantified or qualified. This was discussed with the DPCS.

Observed in Record Review. In 3 of 11 patient records reviewed, it was noted that there were no orders for treatments. For example, in record review #2 there was documentation in the nursing notes of wound care with cleansing with normal saline and applying triple antibiotic ointment however there was no order for this treatment. In another example, in record review #3 it was noted that there was documentation in the nursing notes for a stage one coccyx ulcer to cleanse with normal saline and apply calmoseptine however there was no order for this treatment. Additionally in this record in review of record #3 it was noted that there was no order to discontinue a referral for ST as the patient was now NPO. In another example, it was noted that there was no indication for use for an ointment on the medication sheet. For example, in home visit #1 record review the medication sheet stated, apply mupirocin ointment topical daily, prophylaxis for skin infection. Discussion with the caregiver revealed that the ointment was being applied to the meatus to prevent UTI. This was discussed with the DPCS and administrator. This was discussed with the DPCS.

Observed in Record Review. In 3 of 11 patient records reviewed, it was noted that the plan of care was not revised to include new issues based on the patient's needs. For example, in review of record for home visit #3 on 8/30/21 new orders were received for a new issue of diarrhea and skin breakdown however the care plan was not updated with these new problems to include interventions or goals. In another example, in review of record #1 it was noted that the patient developed new onset of pain and was ordered Norco pain medication but the care plan was not updated to include any pain issues. In another example, it was noted that in record review #2 the patient developed new skin breakdown however the plan of care was not revised to reflect the new issue or orders. This was confirmed by the DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, it was noted that the care was not provided according to the plan of care. For example, in review of record for home visit #2 it was noted that an extra SC visit was provided in July without a PRN need documented. This was discussed with the DPCS.

Observed in Record Review. In 2 of 11 patient records reviewed, it was noted that supervisory visits for the CHHA were not done at least every 14 days. For example, in review of record for home visit #2 there were two periods where this was noted in the past two months. One period was 15 days between supervisory visits and the other was 22 days between supervisory visits. In another example, in record review #3 it was noted that there were 17 days between supervisory visits. This was confirmed by the DPCS.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation and staff interviews: 418.56, 418.100, 418.104.

Observed in Record Review. In 6 of 11 patient records reviewed, it was noted that the medication sheet did not contain all of the medications the patient was using. For example, in review of record for home visit #1 the caregiver stated she was applying proctozol foam to the patient's hemorrhoids. This medication was not on the list. In another example, in review of record for home visit #2 it was noted that Morphine Sulfate was not on the medication list and that Acetaminophen was listed twice on the list and was duplicative. In record review #1 it was noted that the aide documented that she gave the patient a bed bath due to his refusal of shower, however she still documented shower was given but then recanted this information and said she did give the patient a shower as he later agreed. In record review #2 it was noted that in three of three RN visit notes there was no documentation of wound care. In review of record #3 it was noted that the RN did not document in nursing notes the assessment of the peg tube site. In another example, in review of record #8 it was noted that there was no documented plan of care for this patient who was on services for 17 days. In another example, record review #7 it was noted that the death report was blank and there was no documentation for disposal of medications. This was discussed with the DPCS and administrator.

Observed in Record Review. In 3 of 11 patient records reviewed, it was noted that on the consent form the area indicating whether or not the patient had an advance directive was blank. This was noted in record review for home visit #1. In another example, in review of record for home visit #2 it was noted that a communication note documented on 8/30/21 was not relevant to this patient and was actually referring to another patient. In another example, in record review #1 it was noted that the initial nursing assessment narrative was not for the patient whose record it was. For example, the narrative described edema and that the daughter signed the consent, however there was no edema and there were no family members and the patient signed his own consents. This was confirmed by the DPCS and the administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, it was noted that in review of record for home visit #1 white out stripe was used on the POLST to correct the patient's date of birth. Review of agency policy stated that the appropriate practice for corrections is to draw a line through the error. This was discussed with the DPCS and administrator.

Observed in Record Review. In 2 of 11 patient records reviewed, for those patient's who were in SNF it was noted that there was no process currently in place for a care plan that identified which provider would be responsible for what functions in the plan of care. This was noted in record review #1 and #5 and was confirmed by the DPCS.