Every finding on record at Loyal Hospice Care, Inc.

Upon patient record review, 2 of 14 (Patient 3,8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 3 medication profile includes "Calmoseptine Ointment topically daily as needed to affected areas" with no specific location identified. Patient 8 medication profile includes "Amlodipine Besylate 10 mg tab 1 tab po daily as needed for HTN. Hold for SBP <110 or HR <60." There are no parameters to identify when to take the medication for HTN.

Upon patient record review, 2 of 14 (Patient 3, 8) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 3 plan of care includes "Calmoseptine Ointment topically daily as needed to affected areas" with no specific location identified. Patient 8 plan of care includes "Amlodipine Besylate 10 mg tab 1 tab po daily as needed for HTN. Hold for SBP <110 or HR <60." There are no parameters to identify when to take the medication for HTN.

Upon patient record review 1 of 14 (Patient 12) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 12 has no evidence of hospice aide services ordered by the IDG. The Hospice aide services is not included in the patient plan of care. There is a hospice aide visit once weekly throughout benefit period.

Observed in Record Review. In 1 of 11 patient records reviewed, the initial comprehensive assessment did not include the patient’s need for physical, psychosocial, emotional, and spiritual care, including bereavement needs. In the chart for RR#1, the RN assessed a need for a bereavement assessment in her screen, however no bereavement assessment had been documented as part of the initial comprehensive assessment. This was discussed with the DPCS.

Observed in Record Review. In 1 of 2 patient records reviewed, in which the patient had or developed a wound, the hospice had not provided education and training to the primary caregiver as appropriate to the responsibilities assigned to the caregiver in the plan of care. In the chart for RR#4, the patient developed a pressure wound with orders for daily treatment. The hospice nurse was not seeing the patient daily. There was no documentation in the patient record to indicate the primary caregiver was instructed on providing the patient's wound care as confirmed with the Alternate DPCS.

Observed in Record Review. In 6 of 11 patient records reviewed, the written plan of care (POC) was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. Examples included: In the chart for HV#1, the MSW identified that there were issues with self-esteem and depression. She provided education and counseling, yet the POC was not updated with a goal related to this issue. In the chart for HV#2, the MSW had been working this benefit period on the goal of increased IHSS time for the PCG. This goal was not on the hospice POC. In the chart for HV#3, the patient was at high risk for pressure ulcer development. There was no goal related to this problem on the POC. Additionally, there were no goals for MSW or Spiritual Care on the current or previous POC. In the chart for RR#7, there were no updated goals on the POC for MSW and Spiritual Care. RR#8 did not include any goals related to the social work problems/interventions. RR#5 had no goal for the interventions documented by the Chaplain in the visit notes. This was discussed with the Alternate DPCS.

Observed in Record Review. In 6 of 11 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, and did not include treatments necessary to meet the patient's needs. In the chart for HV#1, the MSW identified the patient's anxiety and self-esteem issues for which she provided education and counseling to the primary caregivers, yet did not update the POC to add this identified issue, and the interventions to address the issue. In the chart for HV#2, the MSW had been making contact with the patients case worker in an effort to increase the patient's approved IHSS hours through multiple phone calls with the case worker and the patients PCG. These interventions had not been added to the hospice POC. In the chart for HV#3, the patient had been assessed to be at high risk for pressure ulcer development. There were no interventions on the POC for this problem. Additionally, the MSW is seeing the patient every recert period. Per assessment, she provided supportive counseling and emotional support to the PCG. These interventions were not on the POC. The Chaplain is seeing the patient every certification period. Per the assessment the PCG wanted spiritual support for her mother; the Chaplain saw the patient for spiritual care and pastoral support. The notation indicated the PCG and patient wished to continue spiritual care services, yet there were no interventions on the POC. In the chart for RR#7, the interventions planned by the MSW and Chaplain were not included on the POC. RR#8 did not include the interventions documented by the MSW during those visits. In RR#5, the Spiritual Care interventions documented in the note were not added to the POC. This was discussed with the Alternate DPCS.

Observed in Record Review. In 3 of 11 patient records reviewed, the plan of care (POC) revisions were not based on information from updates to the patient’s comprehensive assessment and did not address the patient’s progress toward goals and outcomes. In the chart for HV#1, there was no documented progress toward Social Work or Spiritual Care goals in the chart. The Social Work goal, identified upon admission was the patient would sign the 5 Wishes document. This document was signed, however the goal remains active on the POC, with the status of pending. In the chart for HV#2, there was no progress toward goals for Spiritual Care and Social Work. For example, there was a goal identified at admission, more than seven months prior to the date of this survey of Pt will have mortuary plan in place Rather than any determination/documentation as to whether the goal had been met, the target date keeps being advanced to the next IDT with the status of pending. The chart for RR#3, there is no progress toward goals documented for psychosocial problems identified at the admission of patient's daughter has no coping skills and patient had no funeral or burial plans. This was discussed with the Alternate DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization had not provided the patient with care, treatment, or services according to the patient's individualized plan of care (POC). In the chart for RR#1, the POC indicated aide visits were to be weekly. The aide is seeing the patient twice weekly. This was discussed with the Alternate DPCS.

Observed in Record Review. In 1 of 2 patient records reviewed, in which the patient had or developed a wound, all disciplines that provide care, treatment or services to the patient had not collaborated in the care of the patient and had not coordinated their efforts to support the goals outlined in the plan of care. In the chart for RR#4, the patient developed a pressure wound. The wound pictures in the chart, dated 8 days apart, showed a marked increase in wound size and erythema as well as change in wound bed color. There was no indication the physician was made aware of the worsening status of the patient's wound as confirmed with the DPCS.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization had not followed accepted standards of practice. During HV#2, the clinician washed her hands in the patient's bathroom, using the patient's bar soap and wiped with a fabric hand towel that was hanging on a bar in the bathroom. She turned off the faucet with bare hands prior to using the towel. Upon discussion with the Alternate DPCS, the organization follows CDC guidelines for hand hygiene, which the practice observed was not compliant.

Observed in Data Session. The organization had not identified infection risks based on the analysis of its surveillance activities and available infection control data. During the Data Session and review of the infection control risk assessment, the organization's own surveillance data had not been included in the risk assessment. The risk assessment consisted of the geographic location and public health data as discussed with the Alternate DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, the registered nurse had not supervised the hospice aide during an on-site visit to the patient’s home no less frequently than every 14 days. While the RN made a visit every 14 days, there was no documentation that the aide was supervised during those visits as confirmed with the Alternate DPCS.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.56. This was discussed with the Alternate DPCS and owner.

Observed in Record Review. In 2 of 2 patient records reviewed, In the chart for RR#6, the patient had a wound upon admission. No wound measurements were included with the initial comprehensive Nursing assessment. No measurements were ever documented for this patient on service for 2 months. In the chart for RR#4, the patient developed a pressure ulcer during the benefit period. Wound measurements were initially obtained, however never again documented. In numerous routine SN notes, the SN did not document any wound assessment at all.

Observed in Record Review. In 2 of 11 patient records reviewed, the patient record did not contain information that reflected the patient's care, treatment or services. During HV#2, during discussion with the MSW, patient and PCG, it was apparent that the MSW had been in contact with the PCG numerous times during the benefit period, working with her and the patient's case worker in an effort to increase the number of paid caregiver hours, yet there was no documentation in the patient record to capture any of these contacts. In the chart for RR#4, the care provided was not completely documented and read SN provided wound care to pressure sore in coccyx area This was confirmed with the MSW and discussed with the Alternate DPCS.

Observed in Record Review. In 1 of 3 patient records reviewed, in which a patient was discharged alive, the hospice discharge summary did not include a summary of the patient’s stay, including treatments, symptoms, and pain management. In the chart for RR#8, there was no summary of the stay, treatments, symptoms and pain management included in the discharge summary. This was discussed with the Alternate DPCS.