Every finding on record at Lightbridge Hospice, LLC

Observed in Emergency Management Session. During review of the organization EOP it was noted the plan was not reviewed and/or updated at least every 2 years. The last review of the plan was dated 2022. This was discussed with the DPCS.

Observed in Record Review. In 1 of 3 patient records reviewed, for post death bereavement services. During BRRR#1 it was noted lack of an initial bereavement assessment completed during the initial comprehensive assessment. This was discussed with the Administrator.

Observed in Record Review. In 13 of 14 patient records reviewed, During HOSRR#2, HOSRR#1, HOSRR#3, HOSRR#4, HOSRR#5, HOSRR#6, HOSRR#7, HOSRR#8, HOSRR#9, HOSRR#10, HOSHV#1, HOCHV#3 and HOSHV#4 it was noted lack of documentation that the need for volunteer services to offer support or respite to the patient, family, or other caregivers was assessed. This was discussed with the DPCS.

Observed in Record Review. In 5 of 14 patient records reviewed, During patient medical record reviews it was noted goals were not individualized and lacked outcome time frames. For example in HOSRR#6: GI goals to be accomplished by the end of the certification date, Pt/PCG will verbalize/ demo understanding of instruction under neuro/mental goals however the goal lacked an outcome date, Pain: Pt/PCG will verbalize/demonstrate understanding of education as it relates to pain management by the end of the certification. During HOSHV#1 it was noted the following goals were not individualized without an outcome time frame: maximize quality of life and dignity as the dementia progresses, and maintain safety. During HOSRR#10 it was noted goals were not individualized and lacked outcome dates: nutrition: intake appropriate for disease process, neuro: symptoms not producing discomfort, coping: verbalizes fear and anxiety, utilizes available strength and support, safety: implement interventions to reduce falls based on pat's assessed risks, education:maximize pt/pcg understanding of anticipated changes and preparation for management of these needs.During HOSRR#9 it was noted goals that were not individualized and lacked outcome dates: safety: demonstrate use of 02, pt will sustain no falls, education: pt will verbalize understanding of teaching provided on med admin reason, purpose including expected outcome (no date to accomplish). During HOSRR#8 it was noted the following goals that were not individualized and lacked outcome dates: cardio/pulmonary: use 0xygen properly. pt/CG verbalizes understanding of instruction intervention, GI:, pt will not experience any distressing symptoms related to poor appetite, coping: verbalizes fear and anxiety, utilizes available strengths and support related to coping, safety: oxygen safety. This was discussed with the DPCS and leadership.

Observed in Record Review. In 2 of 14 patient records reviewed, During HOSHV#2 it was noted the patient complained of back pain with a physician order for Salon-pas transdermal patch that was not discussed at the IDG meeting 5 days later. During HOSHV#1 record review it was noted lack of an update to the POC during an IDG meeting 2 days after it was documented the patient sustained a skin tear to his right hand the end of January 2025. This was discussed with the DPCS. Observed in Record Review. In 10 of 14 patient records reviewed, During HOSRR#1 it was noted on the RN initial assessment, the patient was at a risk of aspiration and had a wet sounding cough and wheezing left upper lobe. The POC lacked interventions related to aspiration precautions and interventions related to the documented respiratory deficit. During HOSRR#2 it was noted the RN initial evaluation documented the pt.'s cardiac status was stable with normal heart sounds, no edema, peripheral pulse present 4 extremities and the respiratory assessment with breathing normal on room air, absence of dyspnea however there were interventions on the POC related to cardio pulmonary deficits and interventions documented on oxygen use and safety although there was lack of a documented order for oxygen therapy. In addition, the patient's terminal dx was Alzheimer's disease however the POC lacked neuro-mental interventions. During HOSHV#2 it was noted the patient had volunteer visits 2-4x/month since 2024 however there was lack of interventions for the volunteer on the POC. The patient was assessed to be at a moderate nutritional risk during the initial RN assessment however nutrition interventions were not added to the POC. There were interventions on the POC for oxygen safety, however there was lack of documentation for an order for oxygen therapy. During HOSRR#5 it was noted the POC lacked instruction on aspiration precautions and had assessment of pain status however there was lack of interventions to accomplish the pain goals. During HOSRR#6 it was noted the patient was assessed to have difficulty swallowing and dysphagia was listed as a diagnosis however the POC lacked instruction on aspiration precautions. The cardiac status on the comprehensive RN initial assessment was documented without any deficits identified and no cardiac medications listed on the medication profile however there were cardiac interventions added to the POC. During HOSRR#7 it was noted aspiration risk on an IDG note the middle of March 2025, the patient was losing weight with weights documented and had been prescribed antibiotics for a URI. There was lack of a documented update to the POC that included nutrition and respiratory interventions. During HOSRR#8 it was noted on the RN initial assessment breathing labored with dyspnea after 20 feet 02 2L continuous however the POC lacked respiratory interventions. During HOSHV#1 record review it was noted the patient had a skin tear to this right hand the end of January 2025 with dressing change orders from the physician. Skin/wound care interventions were not added to the POC. In addition there were oxygen interventions on the POC however there was no order for oxygen therapy. During HOSRR#9 it was noted lack of interventions on aspiration precautions. During HOSHV#3 it was noted documentation that the patient was at risk for aspiration in March 2025 and a new order for Keppra in May 2025 for seizure activity without interventions added to the POC to address aspiration risk and seizure activity. This was discussed with the DPCS.

Observed in Record Review. In 1 of 14 patient records reviewed, During HOSHV#2 it was noted lack of volunteer service frequency of visits on the recertification in March 2025 and May 2025. This was discussed with the DPCS.

Observed in Record Review. In 1 of 14 patient records reviewed, During HOSRR#1 it was noted a goal on the POC Facility staff will verbalize understanding of oxygen use as directed by MD each visit however there was lack of documentation of an order for oxygen therapy that included liter flow and frequency for use. This was discussed with the DPCS.

Observed in Data Session. During review of QAPI reporting data it was noted the organization has a process to identify patient complaints however there was lack of reporting and analysis documented at QAPI meetings. The organization collected data on their volunteer program that included use and cost savings of the program however the data was not presented at QAPI meetings. This was discussed with the leadership.

Observed in HR File Review. In 1 of 11 HR files reviewed, During HR#10 file review it was noted lack of an initial competency for the bereavement coordinator. This was discussed with the DPCS.

Observed in Record Review. In 1 of 14 patient records reviewed, During HOSHV#3 it was noted during the SN visits lack of documentation of the wound care procedure. The documentation stated wound care performed per order. This was discussed with the DPCS.

Observed in Document Review. Although there was general education on the disposal of medications, information was not found in admission packet, or patient handbook that education was provided to patient and family about the organization's written policies and procedures on the management and disposal of controlled medications. This was discussed with the administrator.

Observed in Record Review. In 1 of 13 patient records reviewed, the surveyor noted that the patient record was inaccurate or contains errors (i.e. conflicts with other documentation). For example, in the admission assessment HV#1 there was documentation that the patient's skin was intact. However there was also documentation that the patient had a new ostomy in place with sutures that would require removal, a G tube in place and a fungal infection on the buttocks requiring medication. Also, on the admission assessment and multiple other nursing notes the ostomy was described as a colostomy, however on several other nursing notes it is described as a ileostomy. This was confirmed with the DPCS.

Observed in Record Review. In 13 of 13 patient records reviewed, the surveyor noted that documented plan of care goals were not individualized and measureable. For example, record HV#1 included goals Use oxygen properly, Maximize coordination of care between providers, and Check blood glucose occasionally. HV#1 POC included 18 of 51 goals at recert and 16 of 51 goals with no time frames. HV#2 included goals Maintains safety and Maintain skin integrity. However, the patient's record indicated that the patient had 2 open wounds and a coccyx fungal infection all with wound care orders in place. HV#2 POC included 14 of 37 goals at recert and 21 of 37 goals with no time frames. The 13 records reviewed all included similar goals that were not individualized or measureable. This was confirmed with the DPCS present.

Observed in Record Review. In 1 of 3 patient records reviewed, that included Bereavement care the hospice POC did not include all services needed. For example, in record BR#1 Bereavement care was not included on the POC following the patient's death. Mailings to the family and 1 phone call were recorded, but no plan. This was confirmed with the DCPS present. Observed in Record Review. In 3 of 13 patient records reviewed, the surveyor noted that the hospice plan of care did not detail the frequency of all services. For example, in RR#1, RR#8 and RR#3 a volunteer music therapist had documented multiple visits with the patient for music therapy, however the plan of care did not include the music therapist, volunteer frequencies or goals for the music therapy. This was confirmed with the DPCS present.

Observed in Record Review. In 5 of 13 patient records reviewed, the surveyor noted that care was not provided according to hospice plan of care. For example, record HV#2 and HV#3 the hospice plan of care required MSW visits at least once a month and in both records no MSW visit was documented in April. Record RR#1 the hospice POC required Chaplain visits 1 to 3 times a month and no visit was documented in May. Record RR#2 the hospice POC required HHA visits 1 time per week and for 3 weeks during spring the HHA documented 2 visits per week. Also, RR#3 the POC required HHA visits 1 time per week however 1 week in March the HHA documented 3 visits in a week. This was confirmed with the DPCS present.

Observed in Patient Home. In 2 of 3 home visits conducted, that included the staff bringing equipment into the patient home, the surveyor noted that the organization did not follow infection prevention and control activities when performing disinfection of medical supplies and devices. For example, HV#2 the staff LVN and HV#3 the RN did not follow contact time (wet time) as specified by the disinfectant manufacturer’s IFUs and packaging. The nurses used purple Sani wipes that required a 2 minute contact time, this was not observed. This was confirmed with the nurse and DPCS present.

Observed in HR File Review. In 2 of 8 HR files reviewed, the surveyor noted that staff competency was not assessed as part of orientation. For example, the volunteer HR record did not include documentation of an initial competency. Also, the PC RN/Palliative Care nurse record included documentation of an initial competency, however it was incomplete. 14 items indicated as required were not addressed. This was confirmed with the HR representative present.

Observed in Patient Home. In 1 of 1 home visits conducted, that included oxygen in the home, the surveyor noted that the staff did not provide education on the safe storage of oxygen cylinders in the home. For example, visit HV#3 the patient had 3 E-tanks free standing between a chair and table with nothing to secure them. When questioned the patient was unaware of securing E-tanks and the patient record did not include documentation of education for properly securing oxygen tanks. This was confirmed with the DPCS present.