Every finding on record at Lifepath Hospice, Inc.

Observed in Patient Home. In 3 of 9 home visits conducted, and records reviewed hospice staff did not identify potential safety risks in a patients’ residence. In the records of RRIPU#2, RRHV#2 and RRHV#4 safety assessments were not documented as part of the initial comprehensive assessment. This RFI was reviewed with hospice leaders at the Vice President, Director and Manager level.

Observed in Record Review. In 4 of 9 home visits conducted, and records reviewed the hospice did not document completion of the initial comprehensive assessment within five days of election of the hospice benefit. In the record of RRIPU#1 spiritual, psychosocial, and bereavement assessments were not documented within the required time frame. The same was true of spiritual assessments in the records of RRIPU#2, RRHV#1, and RRHV#6. This RFI was reviewed with hospice leaders at the Vice President, Director and Manager level

Observed in Record Review. In 1 of 9 home visits conducted, and records reviewed the interdisciplinary team did not update the comprehensive assessment every 15 days or less. In the record of RRIPU#1 the elements required of a comprehensive assessment were not gathered by an RN within the required time. This RFI was reviewed with hospice leaders at the Vice President, Director and Manager level.

Observed in Record Review. In 9 of 14 patient records reviewed, of active patients, the Surveyor noted patient Plan of care goals had not been patient specific or measurable. Examples include: patient will communicate having attained enhanced comfort, patient will have reduced symptoms of agitation, patient will be free and safe from falls and the patient will demonstrate comfortable breathing. Caregiver will report decreased burden, and Skin compromise will be addressed when detected and patients comfort will be maintained. This was evident in each record reviewed and was validated with the Compliance Team present during record reviews. Observed in Record Review. In 18 of 23 patient records reviewed, plan of care goals were not specific or measurable. Examples of patient goals included: comfort will be maintained; pain level will be at an acceptable level; will be oriented to the extent possible at each visit; will remain safe and free from falls for the next 14 days; will maintain nutritional intake via PEG to achieve comfort; skin will be kept intact; dyspnea will be controlled within limits of disease. This RFI was reviewed with hospice leaders at the Vice President, Director and Manager level.

Observed in Record Review. In 1 of 9 home visits conducted, and records reviewed the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. In the record of RRIPU#1 an order did not specify the size for a foley catheter, nor the cubic centimeters volume of the balloon. This RFI was reviewed with hospice leaders at the Vice President, Director and Manager level.

Observed in Record Review. In 8 of 14 patient records reviewed, of active patients, the Surveyor noted therapeutic duplication of as needed medications without clear clinical indications for use. for example, in RRNHV #1 the patient had Lorazepam 0.5 mg every 4 hours as needed for agitation and anxiety, and Lorazepam 2 mg every 6 hours as needed for anxiety and restlessness. The patient also had both Bisacodyl and Senna ordered as needed for constipation. RRNHV #2 the patient had both Polyethylene Glycol and Senna ordered as needed for constipation. The patient also had Home Oxygen 2-5 lpm as needed with no clear indication of what would trigger a flow rate change. RRNHV #4 the patient had Sennosides and Polyethylene Glycol both ordered as needed for constipation. The patient also had Lorazepam every 4 hours as needed for agitation and Olanzapine every 6 hours as needed for agitation/anxiety. RRNHV #5 patient had Lorazepam every 4 hours as needed for anxiety/agitation as well as haloperidol every 4 hours as needed agitation. In RRNHV #8, the patient had the medication Santyl ordered without specific indication of where it was to be applied. RRNHV #7 the patient had Diastat Acudial rectal kit 1 time per day as needed for seizures and diazepam every 12 hours as needed for seizures, RRNHV # 11- the order for Silver Sulfadiziazine Apply to affected skin for skin irritation/wound care had been missing the area of application. The patient also had MiraLAX, Senna and Bisacodyl ordered as needed for constipation and Tramadol and Acetaminophen ordered as needed for pain. RRNHV #12 incomplete wound care order as it had not contained who was to complete the care nor the frequency. RRNHV #13 Orders for Dulcolax and Senna as needed for constipation. This was validated with the compliance team present during the record review. Observed in Record Review. In 11 of 14 patient records reviewed, of active patient records, the Surveyor noted the Plan of Care missing patient specific identified problems. For example, In RRNHV #1 the patient had issues with constipation; however, this had not been included on the POC. RRNHV #2 the patient had constipation and a new pressure injury on the buttocks, but this had not been included on the poc. The patient in RRNHV #3 had liver cirrhosis with significant ascites that was being drained 3 times per week; however, there had been nothing on the POC to even indicate that this had been a problem for the patient. In RRNHV #4 the patient had edema, insomnia, nausea and shortness of breath, but these had not been addressed on the POC and in RRNHV #6 the patient was a diabetic on 2 doses of insulin; however, diabetes had not been included on the POC. The same patient also had a primary diagnosis of CHF that had not been addressed, as well as COPD, edema and urinary tract infections. RRNHV #7 POC had not contained pneumonia and pulmonary symptoms, as well as g-tube and feedings. In RRNHV #8 the POC had not contained nutrition, fall, and the recent GI bleed. RRNHV #9 the POC had not addressed: pain, dysphagia, dysarthria, dyspnea, falls and nutrition. RRNHV #10 the POC had not included nutrition, cirrhosis complications, and diabetes. RRNHV #11 the POC had not included: Peg-Tube, Tube Feeds, nausea, skin redness and CHF and in RRNHV #14 the POC had been missing falls, constipation, and CHF. This was validated with the Compliance team present during the record review.

Observed in Record Review. In 3 of 14 patient records reviewed, of active patients, the Surveyor noted orders for the use of Durable Medical Equipment requiring interventions had been missing from the Plan of Care. For example, in RRNHV #3 the patient had liver failure with significant abdominal ascites. The RN and the PCG had been draining off 1,000- 2,000 ml of fluid 3 times per week using an Aspira Drainage Kit. There had been no orders for this procedure in the patient record. RRNHV #7, the patient had a G-Tube and a continuous feeding pump system. The patient medical record had no orders related to the care of the G-tube, nor the safe care and management of the feeding pump. In RRNHV #8 the patient had an open wound receiving care by the RN and the care home; however, there had been no orders to provide the care. This was validated with the Compliance Team present during the record review.

Observed in Record Review. In 1 of 14 patient records reviewed, of active patients, the Surveyor noted orders for specific patient education noted on the IDG, but could not validate that the education occurred. IDG RRNHV #10 had orders for diabetic education, including monitoring of blood sugars; however, there had been no documentation that the education had been provided nor that blood sugars had been monitored. This was validated with the Compliance Team present during the record reviews.

Observed in Patient Home. In 1 of 9 home visits conducted, the hospice did not use standard precautions to reduce the risk of infection. For example, at RRHV#3 an RN performed hand hygiene but only covered her palms and the anterior surfaces of her fingers with the gel multiple times. These actions did not comply with the Hand Hygiene policy or CDC guidelines. This RFI was reviewed with hospice leaders at the Vice President, Director and Manager level.

Observed in Record Review. In 2 of 2 patient records reviewed, where a Hospice Aide (HA) was ordered, the HA Plan of Care (POC) created by the RN has assigned tasks to the HA that had not applied to the patient they were providing care to. In RRNHV #3 and RRNHV #4, the HA POC had 'Empty Ostomy' listed as care to be provided; however the patient had not had an ostomy. This was validated with the Compliance team present during record review.

Observed in Record Review. In 3 of 5 patient records reviewed, where the patient had Hospice Aide (HA) Services ordered, care was not documented as being provided according to the ordered plan of care. For example, in RRHV #2 and RRHV #3, the HA had orders to record the last bowel movement (BM); however, this had not been documented as completed. In RRNHV #12, the HA had orders to record the BM and the Mid Arm Circumference; however this had not been documented as completed. This was validated with the Compliance team present during the record review.

Observed in Record Review. In 1 of 9 home visits conducted, and records reviewed the hospice did not ensure that a registered nurse supervised the hospice aide during an on-site visit to the patient’s home. In the record RRIPU#1 supervisory visits were not documented every 14 days as required.

Observed in Tracer Activities. Volunteer competence was not assessed and documented as part of orientation. This was learned during the volunteer program tracer and confirmed during the HR competency session. This RFI was reviewed with hospice leaders at the Vice President, Director and Manager level.

Observed in Record Review. In 2 of 14 patient records reviewed, of active patients, the Surveyor noted education on the proper use of equipment had not been documented as provided to the caregiver providing the care. For example, in RRNHV #3, the patient care giver had been using an Aspira System to drain 1000-2000 ml of fluid from the patients abdomen 3 times per week. The patient record had no documentation to support that the pcg had received education on providing this care nor that the PCG had demonstrated safe use of the system including observation of infection control. RRNHV #7, the patient had a G-Tube feeding system with continuous feeds. There had been no documentation available to validate education had been provided to the parent providing the care. This was validated with the Compliance team present during the record reviews.

Observed in Patient Home. In 1 of 9 home visits conducted, the hospice did not coordinate the patient's care, treatment or services. For example, during visit RRHV#6 no current plan of care, hospice election form, advance directives, and certificates of terminal illness were found in the skilled nursing facility where the patient resided. This RFI was confirmed by the Compliance Manager who was at the visit.

Observed in Patient Home. In 1 of 9 home visits conducted, the organization did not identify potential safety risks. At RRHV#2 one of two M-24 tanks and 2 M-4 tanks were standing unsecured in the patient’s home. The HHA did not identify the problem or act to correct it. This RFI was confirmed by the Compliance Manager who was at the visit.