Every finding on record at Lhcg Xli, LLC

Based on interview and record review, the facility failed to follow their policies and procedures on Emergency Preparedness Training and Testing regarding Risk Assessment. --- Findings included: No documentation of a Risk Assessment was provided during the survey, During an interview on 03/14/2024 at 11:00 AM, the Regional Vice President of Operations stated, "We don't have one. It's not filled out." Record Review of the facility's policy titled, "Emergency Preparedness: Operational Guide," dated 06/21/2021, showed that Risks shall be prioritized based on frequency and regional vulnerability. Refer to the Hazard Vulnerability Form.

Based on interview and record review, the facility failed to follow their policies and procedures on Emergency Preparedness Training and Testing regarding Emergency Preparedness (EP) contact numbers for EP officials in all the counties in which the agency is licensed to see patients. --- Findings included: No documentation of Emergency Official contacts for the counties in which the agency is licensed to see patients is found. During an interview on 03/14/2024 at 11:15 AM the Regional Vice President of Operations stated "We don't have it". Record Review of the facility's policy titled, " Emergency Preparedness: Operational Guide," dated 06/21/2021, showed that the agency must maintain contact with local county offices of emergency preparedness. The plan will be forwarded annually to the state/county offices of emergency preparedness in each county the agency provides care in.

Based on interview and record review, the facility failed to follow their policies and procedures on Emergency Preparedness Training and Testing regarding Emergency Prep Training Program. Record Review of the facility's policy titled, " Emergency Preparedness: Operational Guide," dated 06/21/2021, showed that all staff, volunteers and contract workers will receive training in the provisions of the emergency plan upon hire and biennially thereafter. The same policy at 7., the agency shall test their emergency operations plan annually, and 8.d. the plan shall test each exercise drill and documentation of the actual or drill critique (Disaster Review) will be kept on file in the agency. --- Findings included: No documentation could be found for Emergency Preparedness initial training 3 staff members (Physician, Registered Nurse, Chaplin/Bereavement/Volunteer Coordinator). No documentation could be found for Emergency Preparedness initial training for Volunteer #2. This information is confirmed in an interview on 03/14/2024 at 11:35 AM with the Regional Vice President of Operations and the Volunteer Coordinator. No documentation could be found for Emergency Preparedness drills/testing. This information is confirmed in an interview on 03/14/2024 at 11:35 AM with the Regional Vice President of Operations and the Volunteer Coordinator.

Based on observation, interview and record review, the hospice Registered Nurse (RN) failed to follow their policy to ensure that the medications listed on the Medication Administration Record match the medications the patient reports are current for 2 of 2 patients. (Patients #2, #11). Record review of facility's policy titled, "Medication Management," dated 11/01/2017, showed that all nurses participating in the patient's care are responsible to assist in maintenance of accurate patient medication information throughout the tenure of care, to identify and resolve discrepancies. --- Findings included: Observation in Patient #2's home on 3/12/2024 from 2:00 PM to 3:00 PM showed Patient #2's medication discrepancies: Baclofen 10 milligrams ordered daily, patient reports she is taking every 8 hours; Midodrine ordered three times daily is not on the medication list; Zofran 4 milligrams ordered as needed is not on the medication list. Patient reports taking Trazadone 25 milligrams nightly which is not on the medication list. The medication lists Hydroxyzine Hydrocloride 25 milligrams to be taken 3 times a day but the Patient reports taking it only as needed. Oxycodone 5 milligrams ordered as needed is not on the medication list - Note that patient allergies include Oxycodone. RN#1 is present and verifies the finding. Observation in Patient #11s home on 03/12/2024 from 10 AM to 10:35 AM showed Patient #11 no longer taking medications marked as active: Citalopram, Lutein 300, Fish Oil, Melatonin, metoprolol, Multivitamin, Vitamin A, Vitamin C, Vitamin D3 and Vitamin E. Caregiver reports patient has not been taking these medications since November 2023. RN #1 present and verifies the finding.

Based on interview and record review, the hospice failed to ensure an initial bereavement assessment was performed for 3 out of 14 patients (Patient #4, #7 and #8). --- Review of Patient #4 medical record on 3/14/2024 showed no documentation of an initial bereavement assessment. During an interview on 03/14/2024 at 11:00 AM the Regional Vice President of Operations (RVPO) confirmed the finding. Review of Patient #7 medical record on 03/14/2024 showed no documentation of an initial bereavement assessment. During an interview 03/14/2024 at 11:07 AM the RVPO confirmed the finding. Findings included Review of Patient #8s medical record on 03/13/2024 at 10:53 AM showed no documentation of an initial bereavement assessment being completed. During an interview on 03/13/2024 at 12:49 PM with Licensed Medical Social Worker (LMSW), stated the son (caregiver) was not available at the initial visit and no followup was done.

Based on interview and record review, the hospice failed to provide documentation of core members present and Interdisciplinary Team (IDT) meetings for 5 out of 14 patients (Patient #3, #6, #7, #10 and #14). --- Findings included Review of IDT minutes and signature sheets showed no documentation of Chaplin present for IDT meeting dated 03/10/2023. Records showed no documentation of Licensed Medical Social Worker present at IDT meetings dated 06/01/2023, 06/15/2023, 06/29/2023 and 07/13/2023. Patients #3, #6, #7 and #10 were all on service on those dates.During an interview on 03/13/2024 at 1:25 PM, Regional Vice President of Operations (RVPO) stated the recent loss of staff in June/July of 2023 probably affected missing members and missing signature.

Based on observation, interview and record review the hospice staff failed to follow the plan of care regarding visit schedules for 5 of 14 patients. (Patients #3, #4, #5, #6 and #11). --- Review of Patient #6s medical record on 03/13/2024 at 10:20 AM showed SN visit schedule one visit per week for 9 weeks starting 01/24/2024. There is no documentation for a SN visit the week of 01/24/2024. During an interview on 03/13/2024 at 1:30 PM, RVPO stated could not find a visit that week and verified the finding. Review of Patient #11s medical record on 03/13/2024 at 9:27 AM showed SN visit schedule increased to two visits per week starting 02/28/2024. There is no documentation for a second SN visit the week of 03/03/2024. During an interview on 03/13/2024 at 1:45 PM, RVPO stated could not find a visit that week and verified the finding. Review of Patient #3 medical record on 3/13/2024 at 9:40 AM showed Licensed Medical Social Worker (LMSW) to visit once per month effective 06/28/2023. There is no documentation of a visit note for the LMSW from 06/28/2023 through 08/31/2023. During an interview on 03/14/2024 at 11:15, the Regional Vice President of Operations (RVPO) confirmed. Review of Patient #4s medical record on 03/13/2024 at 9:45 AM showed Registered Nurse (RN) visit schedule increased to two visits per week starting 12/18/2023. There is no documentation for a second RN visit the week of 12/24/2024. During an interview on 03/13/2024 at 1:45 PM, RVPO stated could not find a visit that week and verified the finding. Review of Patient #5 medical record on 3/13/2024 at 9:57 showed the Nurse to visit once in week 1, then twice per week for 12 weeks with 4 as needed visits. In week 2, no nurse visits are documented with no missed visit notes. During an interview on 03/14/2024 at 11:16 AM the RVPO it is confirmed.

Based on observation and interview, Facility Registered Nurse (RN) failed to follow standards of care for sanitizing equipment to prevent spread of communicable disease for 2 out of 2 patients (Patient #2 and Patient #11). --- Findings included Observation in Patient #11s home on 03/12/2024 from 10 AM to 10:35 AM showed RN #1 removed stethoscope from around neck, auscultated patient back and abdomen, then replaced the stethoscope around neck without sanitizing. RN#1 charted on electronic device, passes device to patient caregiver to sign the device, then placed the electronic device into supply bag without sanitizing. During an interview on 03/13/2024 at 1:45 PM, Regional Vice President of Operations (RVPO) stated that the hospice does not have a policy on bag technique, but staff should be sanitizing all equipment. Observation in Patient #2s home on 03/12/2024 from 2:00 PM to 3:00 PM showed RN #1 removed stethoscope from around the neck, auscultated patient back and abdomen, then replaced the stethoscope around neck without sanitizing. RN#1 took the blood pressure cuff off the patient and placed it onto the clean paper barrier then later took the blood pressure cuff off the barrier and put it into the clean side of the bag. RN#1 took a wetted washcloth, wiped the patient's face. Without hand sanitizing, RN#1 put gloves on to examine the patient's left ear then the right knee. Moving down, RN#1 checked the Foley catheter while touching the patient's genitals and finally the patient's left heel and blackened toes. RN#1 then disposed of the gloves and hand sanitized. RN#1 charted on the electronic device, passed device to the patient to sign the device, then placed the electronic device into supply bag without sanitizing. This information was confirmed on site at 3:10 PM with RN#1. During an interview on 03/13/2024 at 1:45 PM, Regional Vice President of Operations (RVPO) stated that the hospice does not have a policy on bag technique, but staff should be sanitizing all equipment.

Based on interview and record review, the hospice failed to demonstrate a cost saving of 5% total patient care hours per use of volunteers. --- Findings includes Review of volunteer data on 03/14/2024 at 10:45 AM showed no volunteer work hours since November 2023 and 0.04% in October of 2023. During an interview on 03/14/2024 between 10:50 AM and 11:20 AM, volunteer coordinator stated that loss of volunteers in 2023 affected hours. Volunteer coordinator stated just took the position 11/27/2023 and has been actively working on connections with possible volunteers and organization.