Every finding on record at Lakeview Hospice

Observed in Record Review. In 14 of 14 active patient records reviewed,, the hospice nurse surveyor noted that the organization failed to ensure that the written plan of care was developed in accordance with the patient's identified goals that are measurable with defined timeframes for achieving those goals. For example, in records reviewed HOSRRHV#1 the goals in the hospice plan of care were not measurable and had no timeframe such as: to provide education and verify understanding, and alteration in nutritional status. HOSRRHV#2,HOSRRHV#3, HOSRRHV#4, HOSRRNHV#1,HOSRRNHV#2, HOSRRNHV#3, HOSRRNHV#4, HOSRRNHV#5, HOSRRNHV#6, HOSRRNHV#7, HOSRRNHV#8, HOSRRNHV#9, and HOSRRNHV#10 the goal education provided is understood by patient/caregiver and evaluation of understanding in checked through a teach back method for each new intervention implemented had no timeframe.This finding was discussed and validated by the hospice management team.

Observed in Record Review. In 10 of 14 active hospice patient records reviewed, it was noted the organization failed to ensure that the hospice plan of care plan includes all services needed for the palliation and management of the terminal illness and related conditions, including medications necessary to meet the patient’s needs. Upon review of the records, several PRN pain medications ordered to be given for pain without specifying which PRN medication should be administered based on defined parameters. For example, in record review of HOSRRHV#1, HOSRRNHV#5 Acetaminophen 325 mg 2 tablets PO every 6 hours as needed for pain and Morphine 20mg/ml to take 0.25 ml (5mg) PO every 1 hour as needed for pain. HOSRRHV#3,HOSRRHV#4, HOSRRNHV#10 Acetaminophen 500 mg 2 tablets PO 2x a day as needed for pain and Morphine Sublingual 5 mg 1 tablet every 1 hour as needed for pain; Tramadol 50 mg 1/2 tablet PO every 6 hours PRN for pain. HOSRRNHV#1,HOSRRNHV#2, HOSRRNHV#4 Acetaminophen 650 mg 1-2 tablets every 8 hours PRN for pain; Hydromorphone 1 mg PO every 1 hour for pain. HOSRRNHV#3 Acetaminophen 325 mg 2 tablets PO every 6 hours as needed for pain, Morphine 20mg/mo 0.25 ml(5mg) PO every 1 hour as needed for pain and Tramadol 50 mg 1 tablet every 6 hours PRN for pain. HOSRRNHV#6 Acetaminophen 500 mg 2 tablets PO 2x a day as needed for pain and Morphine Sublingual 5 mg 1 tablet every 1 hour as needed for pain; This finding was discussed and validated by the hospice management team.

Observed in Record Review. In 3 of 8 active hospice patient records with home oxygen therapy reviewed, the hospice nurse surveyor noted that the organization failed to ensure that the care and services are provided in accordance with the plan of care. For example during record review of HOSRRHV#1, the patient was supposed to be on 2 LPM of oxygen PRN as per hospice plan of care. however, the patient was on 4 LPM of Oxygen upon arrival in the patient home. Further review of record, there was no evidence documented of any order updated in the plan of care. Another example, in HOSRRNHV#7, the hospice aide was ordered to see patient once during week 1 of benefit period no.1, however, there was no aide visit completed. Lastly, in HOSRRNHV#8, the hospice aide was ordered to visit patient twice during week 2 of benefit period no.1, however, there was no aide visit completed. This finding was discussed and validated by the hospice management team.

Observed in Record Review. In 3 of 8 active patient records with hospice aide services reviewed, the hospice nurse surveyor noted that the organization had failed to ensure that the written patient care instructions for a hospice aide must be prepared by a registered nurse who is responsible for the supervision of a hospice aide. For example, in review of record HOSRRHV#2, it was noted that diabetes precautions were included in the aide care plan as additional instructions; however, during the interview, the aide appeared unfamiliar with what this meant. Another example, in HOSRRNHV#3, the patient had been taking Eliquis as blood thinner, however, the hospice aide care plan did not include instructions on bleeding to watch and report to the registered nurse. Lastly, HOSRRNHV#8, the patient had been taking Eliquis as blood thinner, however, the hospice aide care plan did not include instructions on bleeding to watch and report to the registered nurse. This finding was discussed and validated by the hospice management team.

Observed in Record Review. In 1 of 8 active patient record with hospice aide services, it was noted the organization failed to ensure that the registered nurse supervises the hospice aide during an on-site visit to the patient’s home no less frequently than every 14 days.. During review of record HOSRRNHV#2, an aide supervision documentation showed a gap of 16 days between the 1st week and 3rd week of April of benefit period no. 6. This finding was discussed and validated by the Hospice management team.

Based on interview and document review, the agency failed to have the hospice's governing body approve the frequency and detail of the Quality Assurance and Performance Improvement (QAPI) program. This had the potential to affect all 114 patients currently receiving services by the hospice agency. --- Review of the facility form titled Lakeview Homecare & Hospice 2023 Quality & Performance Improvement Plan, undated, failed to identify the hospice's governing body approval of the frequency and detail of the QAPI plan and program. During interview on 8/30/23 at 8:59 a.m., senior consultant for quality improvement (SCQI)-A and quality compliance supervisor (QCS)-A reviewed with surveyor the agency QAPI plan and program. Executive Director (ED)-A joined the interview and confirmed the agency's governing board had not approved, evaluated or had the details of the QAPI program or the projects they were currently working on. ED-A indicated it was important for the board to approve and evaluate the QAPI program to understand the areas the agency was focusing on for improvement and be able to add their input. During a follow up interview on 8/30/23 at 10:33 a.m., SCQI-A confirmed she was unaware the last time the board approved the agency QAPI program but confirmed it had been greater than 3 years ago. The agency policy titled Improving Organizational Quality & Performance, undated, identified the agency would make recommendations to the governing body regarding individuals responsible for operating the program, the scope of the program, program data and activities, and the frequency and detail of the data collection. The governing body must ensure the program reflected the complexity of the organization and services, focused on indicators related to improved outcomes, took action to demonstrate improvement in performance across the spectrum of care, and maintained documentation of its quality assessment and performance improvements. The policy further identified items the governing body was responsible for, which included evaluating the QAPI program annually, approving the frequency and detail of the collection, and maintaining documentary evidence of the agencys QAPI program.

Based on interview and document review, the hospice governing body failed to ensured the hospice Quality Assurance and Performance Improvement (QAPI) program was implemented, maintained and evaluated annually. This had the potential to affect all 114 patients currently receiving hospice services. --- Review of the facility form titled Lakeview Homecare & Hospice 2023 Quality & Performance Improvement Plan, undated, failed to identify the hospice's governing body had reviewed the QAPI program to ensure it was implemented, maintained, and evaluated annually. During interview on 8/30/23 at 8:59 a.m., senior consultant for quality improvement (SCQI)-A and quality compliance supervisor (QCS)-A reviewed with surveyor the agency QAPI plan and program. Executive Director (ED)-A joined the interview and confirmed the agency's governing board had not approved, evaluated or ensured the agency QAPI program was implemented, maintained and evaluated, annually. ED-A indicated it was important for the board to approve and evaluate the QAPI program to understand the areas the agency was focusing on for improvement and be able to add their input. During a follow up interview on 8/30/23 at 10:33 a.m., SCQI-A confirmed she was unaware the last time the board approved the agency QAPI program but confirmed it had been greater than 3 years ago. The agency policy titled Improving Organizational Quality & Performance, undated, identified the agency would make recommendations to the governing body regarding individuals responsible for operating the program, the scope of the program, program data and activities, and the frequency and detail of the data collection. The governing body must ensure the program reflected the complexity of the organization and services, focused on indicators related to improved outcomes, took action to demonstrate improvement in performance across the spectrum of care, and maintained documentation of its quality assessment and performance improvements. The policy further identified items the governing body was responsible for, which included evaluating the QAPI program annually, approving the frequency and detail of the collection, and maintaining documentary evidence of the agencys QAPI program.

Based on interview and document review, the agency failed to ensure the hospice's governing body designated one or more individuals responsible for operating the quality and performance improvement (QAPI) program. This had the potential to affect all 114 patients currenlty receiving hospice services. --- Review of the facility form titled Lakeview Homecare & Hospice 2023 Quality & Performance Improvement Plan, undated, failed to identify the hospice's governing body had designated one or more individuals responsible for operating the QAPI program. During interview on 8/30/23 at 8:59 a.m., senior consultant for quality improvement (SCQI)-A and quality compliance supervisor (QCS)-A reviewed with surveyor the agency QAPI plan and program. SCQI-A and QCS-A indicated they were unaware if the board had identified QCS-A as the person responsible for operating the QAPI program, but QCS-A indicated she had been in that role for years. Executive Director (ED)-A joined the interview and confirmed the agency's governing board had not approved, or evaluated the agency QAPI program, which would have included identifying the individual(s) responsible for operating the program. During a follow up interview on 8/30/23 at 10:33 a.m., SCQI-A indicated the last governing board documentation related to the agency QAPI program had been at least 3 years prior, but they were unable to locate it. The agency policy titled Improving Organizational Quality & Performance, undated, identified the agency would make recommendations to the governing body regarding individuals responsible for operating the program, the scope of the program, program data and activities, and the frequency and detail of the data collection. The governing body must ensure the program reflected the complexity of the organization and services, focused on indicators related to improved outcomes, took action to demonstrate improvement in performance across the spectrum of care, and maintained documentation of its quality assessment and performance improvements. The policy further identified items the governing body was responsible for, which included evaluating the QAPI program annually, approving the frequency and detail of the collection, and maintaining documentary evidence of the agencys QAPI program.

Based on interview and document review, the agency failed to ensure they had an agency wide infection control program that included investigation and analysis of their patient and employee illness completed to identify trends of illnesses, and implement interventions in timely manner to prevent potential outbreaks, which had the potential to affect all current hospice patients. --- The agency's untitled infection surveillance form identified a listing of hospice patients that had new or existing infections during the months of April, May, June, July and August of 2023. The listing identified patient name, type of infection, whether the patient had a catheter, if the infection was new or existing, the infection diagnosis date, the patient's start of care (SOC) date, place of service and if antibiotic treatment had been ordered. There was no indication if cultures had been obtained, organisms identified and if susceptible to the antibiotic ordered or if the infections had resolved. The agency's Employee Illness and Injury Log identified a listing of employee illness that had occurred during the months of May, June, July and August 2023. The listing identified employee name, date of illness, whether illness was respiratory, gastrointestinal, skin or other, comments and staff initials who logged the information. The log lacked information when or if the infection had resolved. The agency's 2023 Lakeview Homecare and Hospice Report for Infection Prevention and Control, identified Client Surveillance for quarter one and quarter two of 2023. The report identified new and existing client respiratory illness, skin infections, urinary tract infections with and without catheters wound infections and other. Overall total infections were documented as 86 for quarter one and 129 for quarter two. Total new infections had increased by 10 between quarter one and quarter two and exiting infections had increased 33 between quarter one and quarter two. The report did not identify symptoms, culture or causative organisms, or use of antibiotic treatments. The report identified potentially avoidable events of development of urinary tract infections and indicated the agency's percentage had increased from quarter one of 0.53% to 0.86% in quarter two. However, no tracking, trending or analysis of the data was identified. During joint interview on 8/29/23, at 1:00 p.m. with the hospice supervisor (HS) and the quality compliance supervisor (QCS), The HS stated the agency did not have any protocols or procedures to follow regarding symptoms of illness and when to notify the medical provider and request treatment. When patient's resided in skilled nursing facilities, the agency followed the facility guidance, otherwise staff discussed patient symptoms with the patient, family and provider when they occurred. QCS stated medical records regularly pulled the infection control data from patient records on an ongoing basis and recorded the data on a report that was reviewed quarterly during the hospice quality assurance performance improvement (QAPI) meetings. The data was not reviewed or analyzed for tracking or trending and organisms were not tracked. They had just recently had their second quarterly meeting and had discussed the higher rates of infections. They were looking at the data retroactively and not in real-time but they did look at the data quarterly in order develop new interventions when needed, which would help for infection prevention with new patients. QCS stated there was a need for more frequent auditing of patient infections. The agency's undated policy Surveillance, Prevention and Control of Infections Program, indicated responsibilities included to perform comprehensive surveillance for infections and epidemiologically significant organisms, identify and investigate exposures and clusters or outbreaks of infection, analyze procedure and device associated infections, and participate in the antibiotic stewardship program. The practice of surveillance was a continuous process that included the systematic collecting, consolidating, analyzing and interpreting relevant data regarding distribution and determinants of a given disease or event, which would be followed by dissemination of information to those who could improve outcomes. The purpose of surveillance was to differentiate between community acquired and healthcare acquired infections, and to identify infections and communicable diseases in a timely manner so control measures could be implemented for protection of healthcare personnel and patients, reducing potential for spread.