Every finding on record at Lakeview Medical Center Inc of Rice Lake

Observed in Record Review. On 1 of 2 active hospice records reviewed, the organization failed to ensure the staff conduct and document a patient-specific comprehensive assessment that identifies the patient's need for hospice care and services. On HSRRNHV #1, it was noted that patient started oxygen and no oxygen assessment and teaching was completed prior to starting services. On review of the organizations policy, their assessment policy did not contain information on oxygen assessment requirements. This observation was reviewed with the Administrator and clinical supervisor.

Observed in Record Review. In 2 of 2 active hospice patient records reviewed. the organization did not updated the plan of care based on information from update to the patients comprehensive assessment. On HSRRNHV #1, it was noted on the most recent recert assessment that patient had change in nutrition and this was not reflected in the current Plan of Care. On HSRRNHV #2, it was noted that the patient has had a teaching goal for CHF for over a year with no update to that plan. These observations were reviewed with the Clinical Supervisor.

Observed in Record Review. In 1 of 2 Hospice patient records reviewed, education was not provided based on the needs of the patient. On HSRRNHV #1, it was noted that the patient had need for oxygen, however, before starting oxygen education on the care and treatment of the equipment was not provided. There was a note that the caregiver stated she knew how to administer oxygen but there is no documentation on the storage, handling and access of oxygen. This finding was reviewed with the clinical supervisor.

Observed in Record Review. In 1 of 1 patient records reviewed, for live discharge for extended prognosis, the organization failed to respect the patient's right to participate in decisions about their care, treatment, and services. On review of HosRRDC#2 there was no documentation that the Notice of Medicare Non-Coverage was signed by the patient/caregiver/POA two days prior to discharge as required. There was documentation that the POA was informed vis phone of the planned discharge and that NOMNC was mailed yet there was no documentation that the POA was informed of their right to appeal the decision nor was the document returned signed. This observation was reviewed with the Clinical Supervisor.

Observed in Tracer Activities. the organization failed to provide a written definition of data and information to be collected during the comprehensive assessment that included the patient’s physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the patient’s well-being, comfort, and dignity throughout the dying process - The nature of the condition causing the patient’s admission to the hospice program, including the presence or absence of objective data and subjective complaints - Complications and risk factors that affect care planning - Functional status, including the patient’s ability to understand and participate in their care - Imminence of death. On review of the organizations policy for initial assessment filed to include the required elements only specifying time frames that the assessment was to be accomplished yet not defining the elements of the assessment. This observation was review with the Director of Home Care/Hospice and Clinical Supervisor.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to ensure and document a patient specific comprehensive assessment and reassessment that identified the patient's need for hospice and services. On review of HosRRNHV#14 the patient had a diagnosis of Alcoholic Cirrhosis with ascites yet there was no documentation of the severity of the ascites such as appearance, size, palpation, and presence of fluid wave. This observation was reviewed with the Clinical Supervisor. Observed in Patient Home. In 1 of 4 home visits conducted, the organization failed to ensure the staff conduct and document a patient-specific comprehensive assessment and reassessment that identifies the patient's need for hospice care and services. On home observation for HosRRHV#2 the RN was observed to perform an incomplete patient assessment. There was no observation of assessment of lung sounds, heart sounds, respirations, or bowel sounds. The RN observed the skin on the feet and elbows yet failed to observe any other portions of the skin such as the sacrum or perineum. There were no vital signs taken as part of the assessment. This observation was reviewed with the Manager/Administrator of Home Health and Hospice.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to maintain complete and accurate patient records. On review of HosRRHV#2 in review of the documentation of each IDG meeting to review and update the comprehensive assessment, it was noted that the physician's documentation was specific to a patient with a diagnosis of intrahepatic cholangiocarcinoma with metastasis to the lung along with related history and physical yet all documentation from the rest of the IDG team and the Certificate of Terminal Illness was noted the patient with a terminal diagnosis of Alzheimer's disease. The discrepancy was throughout all IDG documentation from admission in January to the current IDG meeting. This observation was reviewed with the Clinical Supervisor.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to ensure the plan of care reflect patient and family goals that were specific, measurable, and time-bound. Throughout all records reviewed there was noted a lack of goals that were specific, measurable and /or time-bound. In HosRRHV#1 examples of goals that were not individualized, measurable, and time-bound were Patient will receive massage therapy for comfort by the end of the certification and Spiritual trust has been restored with no achieve by date. Similar goals that were not measurable were noted throughout all records reviewed. Throughout the records reviewed all goals established were noted not to be individualized and were set an achieve by date of the end of the certification period. These observations were reviewed with the Clinical Supervisor.

Observed in Record Review. In 1 of 2 patient records reviewed, for live discharge, the organization failed to ensure the patient/caregiver receive education and training by the hospice as appropriate to their responsibilities for care and services as identified in the plan of care. On review of HosRRDC#2 for extended prognosis there was no documentation of discharge instructions for the caregiver that was to care the patient post discharge. This observation was reviewed with the Clinical Supervisor.

Observed in Record Review. In 14 of 14 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#1 the documentation noted the patient with difficulty swallowing, poor appetite with the use of ensure as supplement, and high fall risk yet there were no care plans for nutrition or fall safety. There were orders to taper medications related to over sedation yet the issue was not reflected in the plan of care. In HosRRHV#2 the patient had a terminal diagnosis of Alzheimer's yet the only clinical care plan was for skin integrity. There was documentation of weight loss, poor appetite and PRN visit for cough yet no care plans related to the issues established to guide the care. In HosRRHV#3 the patient was on bleeding precautions, there was documentation of a yeast infection, complaints of dizziness and an episode of COVID yet the issues were not reflected in the plan of care. Throughout records reviewed there was a pattern noted of issues documented in the record yet not reflected in the plan of care. Further examples of issues documented yet not reflected were: In HosRRHV#4 tube feedings, and dysphagia/aspiration precautions. In HosRRNHV#5 the use of oxygen and respiratory/shortness of breath. In HosRRNHV#6 issues with pain, nausea were not reflected. Fall safety had a goal but no interventions. In HosRRNHV#7 the patient was diabetic with orders for blood glucose monitoring yet no endocrine plan, and documented confusion related to an encephalopathy diagnoses yet no care plan to address established. In HosRRNHV#8 the terminal diagnosis was Parkinson's that required medication adjustment with tapering doses yet no care plan to guide. In HosRRNHV#9 the patient had issues with CHF and COPD with oxygen use yet to cardiopulmonary care plan established. Additional examples of issues that were noted in the documentation yet were not reflected in the plan of care were noted in HosRRNHV#9, HosRRNHV#10, HosRRNHV#11, HosRRNHV#12, HosRRNHV#13 and HosRRNHV#14. These observations were reviewed with the Clinical Supervisor.

Observed in Record Review. In 3 of 14 patient records reviewed, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. On home observation and record review for HosRRHV#4 the patient had a G- Tube and the RN provided G Tube site care yet there were no orders for the care noted on the plan of care. In HosRRHV#3 there were orders noted on the plan of care for oxycodone as needed for pain, and oxycodone with acetaminophen as needed for pain yet there were no specific instructions to guide the patient/caregiver as to when to use which medication. Further, there were as needed orders for acetaminophen oral for pain/fever and per suppository for pain/fever along with the oxycodone with acetaminophen order but no specific instructions on when to choose which medication, nor any parameters for max dose of acetaminophen per day. In HosRRNHV#5 the order for oxygen read 1-6 liters per nasal cannula yet there were no specific instructions to guide the user as to which liter flow to choose. In HosRRNHV#14 there was an order for Oxygen 1-4 liters without any instruction as to what liter flow to choose. These observations were reviewed with the RN and Manager/Administrator for Home Health/Hospice.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to ensure the plan of care revisions were based on information from update to the patients comprehensive assessment and address the patient's progress toward goals and outcomes. Throughout all clinical records reviewed there was a lack of updates to the plan of care as the care plans were noted to remain unchanged IDG to IDG without revisions based on changes in patient status and updates to the comprehensive assessment. There was no evidence noted in the record of progress toward goals. These observations were reviewed with the Clinical Supervisor.

Observed in Record Review. In 2 of 14 patient records reviewed, the organization failed to ensure the care and services were provided in accordance with the plan of care. On review of HosRRHV#2 the social worker was order a frequency of every other week yet there was no visit documented on the 2nd week of February leaving a 3 week gap in social worker contact. In HosRRNHV#12 the Chaplain frequency was ordered 12 visits in 86 days yet in the allotted period only 10 visits were documented. These observations were reviewed with the Clinical Supervisor.

Observed in Record Review. In 2 of 14 patient records reviewed, the organization failed to ensure all disciplines that provide care, treatment or services collaborate in the care of the patient and coordinate their efforts to support the goals outlined in the plan of care. On review of HosRRHV#2 there was documentation of a PRN skilled nursing visit made to assess the patient for a cough, yet there was no documentation that the physician was informed of the change in the patient status. In HosRRHV#3 during home observation the hospice aide was unable to perform the patient bath because the patient complaint of dizziness. The aide noted that patient frequently complained of dizziness and refused services yet there was no documentation noted in the clinical record that the dizziness had been reported to RN case manager. These observations were reviewed with the Clinical Supervisor.

Observed in Tracer Activities. The organization failed to compile and analyze data. During tracer activities for Data Management for Home Care and Hospice, the surveyor observed the HCO collected data on complaints however did not document that the data was analyzed to identify trends or variances. Upon conversation with the Home Care and Hospice Director he stated that he was investigation all complaints but there was no data to say how many complaints had been received in the last 3 years or if there were any trends related to those complaints. This was discussed and reviewed with the Home Care and Hospice Director.

Observed in Tracer Activities. The organization failed to document an infection prevention control program that was organizational wide and was an integral part of the organization's quality assessment and performance improvement program. During tracer activities for Data Management, the surveyor observed the organization failed to document an infection control plan for the current year and the previous two years. Upon discussion with the Home Care and Hospice Director, the organization had been collecting data on catheter related urinary tract infections but did not have prioritization of infections, or analysis of what infections affected their patients. There was no documentation of an overall infection control plan. This was discussed and reviewed with the Home Care and Hospice Director. Observed in Tracer Activities. The organization failed to implement activities for the prevention and control of infections and communicable disease. During tracer activities for Hospice, the surveyor observed the organization had only been collecting data on Catheter Associated Urinary Tract Infections and no other infections. Upon conversation with the Home Care and Hospice Director he stated that he wasn't sure why they were collecting that. And he was unable to produce documentation of the data that was collected or any other infection data. This was discussed and reviewed with the Home Care and Hospice Director.

Observed in HR File Review. During a review of two home health aid education records, for the required 12 total hours per year required specifically for home-health aids. the hospice e pharmacy surveyor noted that one of the home health aids had a training sheet on file, but no hours assigned to the education provided. The second home health aid had been employed for 11 months and still had no training record. However, they still had one more month to meet this requirement. Also, in talking with one of the clinical nurse managers, the employee was not aware that this 12-hour education was required for all home health aides. This omission was validated with the director and clinical manager at the time of the survey.

Observed in Record Review. In 3 of 12 patient records reviewed, the organization failed to ensure the quality of care and services provided by the hospice aide to ensure that services ordered meet the patient need were assessed by the RN no less frequently than every 14 days. On review of HosRRHV#1 there was a 15 day gap in aide supervisory visits in February. In HosRRHV#2 there was a 27 day gap from January to February in the RN aide supervisory visit. In HosRRNHV#5 the last aide supervisory visit documented was mid February leaving a 16 day gap to present day of survey. These observations were reviewed with the Clinical Supervisor.

Observed in Tracer Activities. During a review of the organization's volunteer recruitment and retention activities, the hospice pharmacist surveyor noted that retention activities were completed and documented; however although the volunteer coordinator indicated that recruitment activities were being completed, no documentation of this effort was available at the time of the survey, This omission was validated with the volunteer coordinator.

Observed in Tracer Activities. The hospice pharmacist surveyor noted that the organization had not documented the estimated cost savings for 2024 that the hospice would have incurred if paid employes had occupied the positions identified as volunteer positions for the same number of hours as the volunteers provided. The hospice must maintain these cost records on the use of volunteers for patient care and administrative services. The validation of this information was reviewed with the volunteer coordinator and director at the time of the survey

Observed in Leadership Session. 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, 418.54, and 418.56, were met per policy as determined through observations, documentation, and staff interviews.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to ensure the patient record contain all information to reflect the patient's care, treatment, and services. On review of HosRRNHV#5 the patient had orders for wound treatments that were to be performed on each nursing visit yet in visits in the end of January, and early February there was no documentation of the dressing change performed nor the patient's reaction to the treatment. This observation was reviewed with the Clinical Supervisor.

Observed in Patient Home. In 2 of 2 home visits conducted, where medication reconciliation was conducted, the organization failed to ensure the patient record contain all information to reflect the patient's care, treatment, and services. For example: on home observation of medication reconciliation for HosRRHV#1 the patient's plan of care had orders for cholecalciferol (Vit D3) 25 mcg/1000units 1 daily yet the medication was not included in the facility medication records. On HosRRHV#4 during the observation for medication reconciliation the patient medication profile as part of the plan of care noted hydrocodone 5mg/acetaminophen 325 mg as needed for pain yet the patient's wife stated the patient was not taking the medication and had not taken for a couple of months (prior to hospice admission). For the loperamide 2 mg order noted take 1 tab every 4 hours as needed, yet the patient wife noted he was taking 1/2 tab daily. These observations were reviewed with the RN and Manager/Administrator HH and Hospice.

Observed in Record Review. In 1 of 2 patient records reviewed, for live discharge, the organization failed to provide the receiving facility with a copy of the hospice discharge summary. On review of HosRRDC#1 the patient revoked hospice services when enter the ED of the hospital yet there was no documentation of a discharge summary created or sent to the Medicare/Medicaid certified facility. This observation was reviewed with the Clinical Supervisor.

Observed in Record Review. In 1 of 2 patient records reviewed, for live discharge, the organization failed to provided the patient's attending physician with a copy of the hospice discharge summary and if requested the patient's clinical record. On review of HosRRDC#1 there was no documentation that a discharge summary was created therefore not provided to the patient's attending physician. This observation was reviewed with the Clinical Supervisor.

Observed in Record Review. In 1 of 2 patient records reviewed, for live discharge, the organization failed to ensure that when the patient was discharged or transferred the discharge summary included all of the required elements. On review of HosRRDC#1 the patient revoked the hospice benefit to go the hospital yet there is no documentation in the record that a discharge summary was created. This observation was reviewed with the Clinical Supervisor.

Observed in HR File Review. In 6 of 7 HR files reviewed, the organization had not provided emergency preparedness training to staff at least every two years as required. For example in review the personnel files for HS-Aide, HS-RN 1, HS-BCC, HS-Vol, HS-MT and HS-Adm there was no documentation or evidence that emergency preparedness training. This was validated with the Home Care & Hospice Manager.

Observed in Emergency Management Session. the organization had not conducted an exercise to test the emergency plan at least annually. This was confirmed with the Hospice/Home Health Manager.

Observed in Record Review. In 2 of 13 patient records reviewed, the hospice’s interdisciplinary group, in consultation with the patient’s attending physician, if any, did not complete the comprehensive assessment no later than five calendar days after the election of hospice care. In the chart for HSRR#3, the patient who had accepted Chaplain services, did not have a Spiritual Care evaluation completed until 12 days post admission. There was no indication that the IDG was aware of the delay nor why the delay happened as confirmed with the Hospice Supervisor. In the chart for HSRR#4, the patient accepted SC services as documented by the SN and SW, however no SC assessment was completed; telephone contacts only were documented for spiritual care services as confirmed with the Hospice Supervisor.

Observed in Record Review. In 1 of 13 patient records reviewed, the hospice’s interdisciplinary group had not updated the comprehensive assessment in collaboration with the patient’s attending physician, if any, as frequently as the patient’s condition requires, but no less than every 15 days. In the chart for HSRR#3, the initial IDG meeting did not include any input from SN, SW or SC as confirmed with the Hospice Supervisor. The only input documented was from the physician and volunteer.

Observed in Record Review. In 3 of 13 patient records reviewed, the hospice 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. During HSHV#2, the RN discussed with the patient and the patient's spouse interventions that were in place to prevent falls, including using the call light to request help from the SNF staff, use of the hoyer lift for transfers. The bed was in the lowest position and two siderails were up on the bed. These interventions were not included on the POC as confirmed with the Hospice Supervisor. Additionally, the order for Lorazepam prn was missing the indication for administration. In the chart for HSHV#3, the patient was also at risk for falls, however the POC did not include specific fall prevention interventions, but did include a goal related to fall safety. In the chart for HSRR#4, the dressing for a subcutaneous infusion did not include the type of dressing to be applied with the order for dressing changes. These findings were confirmed with the Hospice Manager.

Observed in Record Review. In 3 of 13 patient records reviewed, the plan of care was not revised to reflect the patient's progress toward goals and outcomes. In the chart for HSHV#2, the patient had a wound upon admission with dressing changes ordered. During the home visit, the patient had not dressing and no open area, simply redness not requiring a dressing. The hospice plan of care/orders still included orders for a dressing change to the coccyx as confirmed with the Hospice Supervisor. In the charts for HSRR#7 and HSRR#8, the updated POC at the time of the recertification included goals that had anticipated achievement dates which were prior to the beginning of the new benefit period. This was also discussed with the Hospice Supervisor.

Observed in Record Review. In 2 of 13 patient records reviewed, the organization had not provided services according to the hospice POC. In the chart for HSRR#6, the Massage Therapist had not provided visits at the frequency included on the POC. It was confirmed by the Hospice Supervisor with the therapist, that the patient census load had increased and she had been unable to fulfill the required visits. In the record for HSRR#7, the Chaplain visits were ordered every other week, the Chaplain was visiting weekly as confirmed with the Supervisor

Observed in Data Session. although the organization was collecting data the frequency was not approved by the governing body. The system Quality Director validated that there was no evidence that the governing board approved the QAPI plans for the hospice program.

Observed in Record Review. In 1 of 13 patient records reviewed, the RN had not prepared clear written instructions for the hospice aide. During HSHV#1, the aide performed wound care. However, the aide care plan had two different instructions for the same wound for the patient. This was discussed with the Hospice Manager.

Observed in Record Review. In 1 of 13 patient records reviewed, the supervising nurse had not assessed the aide’s ability to demonstrate continued satisfactory performance in the following: Complying with infection control policies and procedures. In the chart for HSHV#1, the Aide supervisory note within the SN assessment did not include assessment of the aides compliance with infection control policies and procedures. This was the note used by the SN in many supervisory visits for this patient; a separate document which is available to the staff to choose as confirmed with the Hospice Supervisor.

Observed in Competency Session. In 6 of 7 HR files reviewed, the hospice had not provided orientation about the hospice philosophy to all employees and contracted staff who have patient and family contact. This topic was not included in any of the orientation materials for any hospice employee file with the exception of the volunteer as discussed with the Hospice Manager.

Observed in Record Review. In 5 of 13 patient records reviewed, the patient record was not complete and accurate. In the chart for HSHV#1, the wound care order included application of Silvadene. This medication was not included in the SN documentation of wound care provided. In discussion with the Hospice Supervisor, it was determined that this was incomplete documentation. Additionally for this patient, within one SN note the documentation was inconsistent with the wound care provided as discussed with the Hospice Supervisor. One aide supervisory note indicated that the aide's communication was ineffective, yet no indication as to what the problem was, nor resolution was. The Hospice Supervisor verified that this was inaccurate documentation. In the chart for HSRR#2, the aide care plan wound care assignment did not match the physician ordered wound care on the hospice POC. In the chart for HSRR#3, the RN confirmed that a ST evaluation was performed prior to transfer from hospice to outpatient rehabilitation, however there was no documentation of this evaluation in the patient record. In the chart for HSRR#4, the RN wrote an order for Fentanyl 75mcg patch - take 50mcg every 72 hours transdermal which was an incorrect order. In the chart for RR#7, there were inconsistencies within the record regarding the patient's oxygen. The order was 3.5 lpm; the physician note stated 4lpm, the aide care plan stated 2.5-4lpm. Additionally, the Hospice election date was incorrect on the Plan of Care. This was discussed with the Hospice Supervisor.

Observed in Record Review. In 1 of 1 patient records reviewed, when the care of the patient was transferred to another Medicare/Medicaid-certified facility, the hospice had not provided the receiving facility with a copy of the hospice discharge summary and, if requested, a copy of the patient’s clinical record. In the chart for HSRR#4, the patient moved into a skilled facility and transferred hospice organizations. There was no documentation in the chart that a discharge summary was provided to the receiving facility; there was no discharge summary in the chart as confirmed with the Hospice Supervisor. Observed in Record Review. In 2 of 13 patient records reviewed, the organization had not completed a discharge summary, so it was not available to the physician. In the chart for HSRR#1, the patient who was discharged due to no longer meeting terminal illness criteria, there was no discharge summary present as confirmed with the Hospice Supervisor. There was no discharge summary in the record for HSRR#3, the patient who revoked the hospice benefit. The organization did not have a process for creating a discharge summary for hospice patients.

Observed in Record Review. In 1 of 13 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 HSRR#4, the SN documented that she received telephone orders from the hospice physician for changes to the patient's subcutaneous Hydromorphone in relation to unrelieved pain. The note clearly documented the phone call, order, implementation of the order as well as the realization that it was a tubing malfunction rather than a need to change the dosage, so subsequent new orders were received to return to the original dosing. No verbal orders were documented and sent to the physician as confirmed with the Hospice Supervisor.

Observed in Document Review. In 2 of 4 contracts reviewed, the written agreement with an outside agency providing contracted services for the hospice did not include the following: The manner in which contracted services will be coordinated, supervised, and evaluated by the hospice; The delineation of the role of the hospice and contractor in the admission process, patient/family assessment, and the interdisciplinary group conferences. These stipulations were missing in the contracts for DME and pharmacy services as discussed with the Hospice Manager. The written agreement with the pharmacy was missing a stipulation that the contracted entity will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This was also discussed with the Hospice Manager.