Every finding on record at Loyalty Hospice Care,Inc.

Observed in Tracer Activities. CLD Not Cleared. No Survey Occurred. the organization failed to complete all needed assessments. During record review for HOSRRHV#2 and HOSRRNHV#3, and HOSRRNHV#8, initial bereavement assessments were not completed according to regulation. For example in HOSRRHV#2, the initial bereavement assessment was not completed until day 20. In HOSRRNHV#3, the bereavement assessment was not documented. Also in HOSRRNHV#3, the patient had no documentation of the initial spiritual assessment. In HOSRRNHV#8, the initial bereavement assessment was not completed. This was discussed and reviewed with the Hospice DPCS Designee.

Observed in Tracer Activities. CLD Not Cleared. No Survey Occurred. the organization failed to assess and reassess its patient's. During record review for HOSRRHV#1, HOSRRHV#2, HOSRRNHV#1, HOSRRNHV#2, HOSRRNHV#3, HOSRRNHV#5, HOSRRNHV#6, HOSRRNHV#8, HOSRRNHV#9, HOSRRNHV#10, HOSRRBR#1, HOSRRBR#2, the Hospice Nurse Surveyor observed the patients RN comprehensive assessments were not completed at least every 15 days. In HOSRRHV#1, the RN visit was 24 days apart. In HOSRRHV#2, the RN visit was 28 days apart. In HOSRRNHV#1, the visits were performed by an LVN and no visits were made by an RN between certifications. There was one time period of 3 months and one time period of 6 weeks. In HOSRRNHV#2, the visits were performed by an LVN and no RN visits were made between certifications. There were two periods of time with almost 3 months between RN visits. In HOSRRNHV#3, the RN visits were not completed at least every 15 days. For example there was a time period of 89 days and 48 days. In HOSRRNHV#5, the RN visits were only completed at recertification. The LPN did all other visits. The visits were 84 days and 63 days respectfully. In HOSRRNHV#6, the RN visits were only completed at recertification, with no RN's visiting in between. In HOSRRNHV#8, the RN did not perform comprehensive assessments every 15 days. In HOSRRNHV#9, the comprehensive assessment was only completed at recertification for the first two periods. In HOSRRNHV#10, the RN only visited for recertification for all 7 benefit periods. . In HOSRRBR#1, the patient was on service for 21 days. The only RN visit was at start of care. In HOSRRBR#2, the patient had no RN visits between certification periods for the first two certifications. This was discussed and reviewed with the Hospice DPCS Designee.

Observed in Tracer Activities. with ordered oxygen, the organization failed to maintain a complete and accurate record. During record review for HOSRRHV#1, the Hospice Nurse Surveyor observed the Plan of Care contained oxygen orders for 2-4 Liters oxygen PRN per NC. And the treatment area of the plan of care stated 1-5 liters of oxygen PRN per NC. This was discussed and reviewed with the Office Intake Coordinator.

Observed in Tracer Activities. CLD Not Cleared. No Survey Occurred.

Observed in Tracer Activities. CLD Not Cleared. No Survey Occurred. Observed in Tracer Activities. CLD Not Cleared. No Survey Occurred. Observed in Tracer Activities. CLD Not Cleared. No Survey Occurred.

Observed in Tracer Activities. with ordered oxygen, the organization failed to maintain a complete and accurate record. During record review for HOSRRHV#1, the Hospice Nurse Surveyor observed the Plan of Care contained oxygen orders for 2-4 Liters oxygen PRN per NC. And the treatment area of the plan of care stated 1-5 liters of oxygen PRN per NC. This was discussed and reviewed with the Office Intake Coordinator.

Observed in Tracer Activities. CLD Not Cleared. No reSurvey Occurred. the organization failed to maintain a complete and accurate record. In HOSRRHV#1, the patient EMR medication and the medication list in the home did not match the medications the patient was actually taking. The patient had Zofran for nausea but Reglan was in the home. The patient was also taking Terbinafine HCL and it was not on the medication list. This was discussed and reviewed with the Office Intake Coordinator.

Observed in Tracer Activities. CLD Not Cleared. No Survey Occurred. the organization failed to document that the discharge summary was sent to the provider taking over care upon discharge. During record review for HOSRRNHV#5, HOSRRDC#1, HOSRRNHV#6, the Hospice Nurse Surveyor observed a discharge summary but no documentation it was sent. For example in HOSRRNHV#5, the patient was discharged due to symptoms managed but there was no documentation that the discharge summary was sent to the provider. In HOSRRDC#1, the patient was discharged for extended prognosis but there was no documentation that the discharge summary was sent. In HOSRRNHV#6, the patient had a planned discharge for Port replacement for daily meds but there was no documentation that the discharge summary was sent to the provider taking over care. This was discussed and reviewed with the Office Intake Coordinator.

Observed in Record Review. In 3 of 17 patient records reviewed, the organization failed to complete all needed assessments. During record review for HOSRRHV#2 and HOSRRNHV#3, and HOSRRNHV#8, initial bereavement assessments were not completed according to regulation. For example in HOSRRHV#2, the initial bereavement assessment was not completed until day 20. In HOSRRNHV#3, the bereavement assessment was not documented. Also in HOSRRNHV#3, the patient had no documentation of the initial spiritual assessment. In HOSRRNHV#8, the initial bereavement assessment was not completed. This was discussed and reviewed with the Hospice DPCS Designee.

Observed in Record Review. In 12 of 17 patient records reviewed, the organization failed to assess and reassess its patient's. During record review for HOSRRHV#1, HOSRRHV#2, HOSRRNHV#1, HOSRRNHV#2, HOSRRNHV#3, HOSRRNHV#5, HOSRRNHV#6, HOSRRNHV#8, HOSRRNHV#9, HOSRRNHV#10, HOSRRBR#1, HOSRRBR#2, the Hospice Nurse Surveyor observed the patients RN comprehensive assessments were not completed at least every 15 days. In HOSRRHV#1, the RN visit was 24 days apart. In HOSRRHV#2, the RN visit was 28 days apart. In HOSRRNHV#1, the visits were performed by an LVN and no visits were made by an RN between certifications. There was one time period of 3 months and one time period of 6 weeks. In HOSRRNHV#2, the visits were performed by an LVN and no RN visits were made between certifications. There were two periods of time with almost 3 months between RN visits. In HOSRRNHV#3, the RN visits were not completed at least every 15 days. For example there was a time period of 89 days and 48 days. In HOSRRNHV#5, the RN visits were only completed at recertification. The LPN did all other visits. The visits were 84 days and 63 days respectfully. In HOSRRNHV#6, the RN visits were only completed at recertification, with no RN's visiting in between. In HOSRRNHV#8, the RN did not perform comprehensive assessments every 15 days. In HOSRRNHV#9, the comprehensive assessment was only completed at recertification for the first two periods. In HOSRRNHV#10, the RN only visited for recertification for all 7 benefit periods. . In HOSRRBR#1, the patient was on service for 21 days. The only RN visit was at start of care. In HOSRRBR#2, the patient had no RN visits between certification periods for the first two certifications. This was discussed and reviewed with the Hospice DPCS Designee.

Observed in Record Review. In 1 of 1 patient records reviewed, with ordered oxygen, the organization failed to maintain a complete and accurate record. During record review for HOSRRHV#1, the Hospice Nurse Surveyor observed the Plan of Care contained oxygen orders for 2-4 Liters oxygen PRN per NC. And the treatment area of the plan of care stated 1-5 liters of oxygen PRN per NC. This was discussed and reviewed with the Office Intake Coordinator.

Observed in Record Review. In 5 of 17 patient records reviewed, the organization failed to plan the patient's care. During record review for HOSRRHV#1, HOSRRHV#3, HOSRRNHV#1, HOSRRNHV#3, HOSRRNHV#6, .... the Hospice Nurse Surveyor observed the plan of care did not reflect the patient's current status. For example in HOSRRHV#1, the patient had goals for nausea and vomiting but had no documentation of issues with nausea and vomiting. In HOSRRHV#3, the patient had a respiratory goal to use Oxygen for SOB but when the symptoms worsened and Duo-nebs were orders the POC was not updated.In HOSRRNHV#1, the patient had a goal of spiritual counselor to establish trusting relationship with pt/ cg by end of the first certification. The goal was not updated and the patient had been on service for 10 months. The patient also had a goal of Pt will verbalize and / or express decreased episodes of SOB within 24-48 hours and the goal was placed 5 months prior to survey. In HOSRRNHV#3, the patient had a goal of SW will help to complete final arrangements. The SW was going out regularly but the goal was not updated and had been in place for one year. In HOSRRNHV#6, the patient had a goal at SOC for Patient`s family will verbalize understanding of terminal illness with coping skills needed for uncomplicated grief before patient`s death Family will have normal grieving as related to terminal disease to be resolved by the end of the first certification. This goal was not updated or resolved upon discharge 7 months later. This was discussed and reviewed with the DPCS Designee.

Observed in Record Review. In 2 of 17 patient records reviewed, the organization failed to plan the patient's care. During record review for HOSRRHV#2, HOSRRNHV#5, the Hospice Nurse Surveyor observed the plan of care did not contain all needed elements. For example in HOSRRHV#2, the patient received orders 15 days prior to survey for daily blood sugar checks but this was not addressed on the plan of care. In HOSRRNHV#5, the patient went to the hospital 5 days after admission and was sent home with antibiotics for a URI but this was not addressed on the POC. This was discussed and reviewed with the Hospice DPCS Designee.

Observed in Record Review. In 1 of 17 patient records reviewed, the organization failed to provide care, treatment, or services. During record review and a home visit, the Hospice Nurse Surveyor observed the patient had orders entered 14 days prior to survey for daily blood sugar checks. There were no blood sugar checks documented and when the daughter in law was asked from surveyor she stated we only check it once a week or so and have had no issues. It runs around 90. This was discussed and reviewed with the Hospice Intake Coordinator.

Observed in Record Review. In 1 of 17 patient records reviewed, the organization failed to provide interdisciplinary, collaborative care, treatment or services. During record review for HOSRRHV#3, the Hospice Nurse Surveyor observed a missed visit occurred with the patient but there was no documentation of notification to the IDG per policy. This was discussed and reviewed with the Hospice DPCS Designee.

Observed in Record Review. In 5 of 5 patient records reviewed, where aide services were ordered, the organization failed to supervise effectively. During record review for HOSRRHV#1, HOSRRHV#2, HOSRRNHV#1, and HOSRRNHV#2, and HOSRRNHV#8, the Hospice Nurse Surveyor observed the HHA supervision was not being documented at least every 14 days. For example in HOSRRHV#1, the visit was completed on the telephone. In HOSRRHV#2 and HOSRRNHV#1, the aide supervision was being completed approximately once a month. In HOSRRNHV#2, the aide supervision was only completed at recertification so was not completed in the two months between those visits. In HOSRRNHV#8, the aide was not supervised for 5 weeks then 90 days. This was discussed and reviewed with the Hospice DPCS Designee.

Observed in Tracer Activities. The organization failed to provide services that meet the patient needs. During the attempted review of the volunteer program, the surveyor requested documentation of recruitment and retention efforts. No documentation was provided. This was discussed and reviewed with the Office Coordinator.

Observed in Tracer Activities. The organization failed to provide services to meet the patient's needs. During conversation about QAPI with the DPCS Designee, documentation stated that the current percentage for volunteer use related to patient care hours was 0%. It was also 0% for 2024. This was discussed and reviewed with the DPCS Designee.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by not implementing policies and procedures, findings at HHA and LVN supervision, missed comprehensive assessments, not following orders and medication issues. CLS at 418.54, 418.76, 418.100 and 418.104. This was discussed and reviewed with the Office Intake Coordinator. Observed in Tracer Activities. There was no evidence that the governing body and leadership had established processes to support patient care treatment and services through sustained compliance as evidenced by repeat findings in the LD, PC, RC and RI chapters. This was discussed and reviewed with the Office Intake Coordinator. Observed in Tracer Activities. Organization's leadership had not designated a person to assume full responsibility for the managements of the day to day operations of the Hospice. During survey activities the Hospice Nurse Surveyor observed the Owners, the Administrator and the DPCS were all absent from survey process. This was also the case in the previous survey. The surveyor was advised that the owners and DPCS went on vacation. The Administrator was sick. There were survey findings in Supervision of HHA and LVN, comprehensive assessment, volunteer services, following orders and medication management. This was discussed and reviewed with the Intake Coordinator.

Observed in Record Review. In 2 of 2 patient records reviewed, the organization failed to maintain a complete and accurate record. During record review for HOSRRBR#1 and HOSRRBR#2, the Hospice Nurse Surveyor observed the death notification occurred to the physician however, the documentation that the physician pronounced death was not completed. This was discussed with the Office Coordinator.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to maintain a complete and accurate record. In HOSRRHV#1, the patient EMR medication and the medication list in the home did not match the medications the patient was actually taking. The patient had Zofran for nausea but Reglan was in the home. The patient was also taking Terbinafine HCL and it was not on the medication list. This was discussed and reviewed with the Office Intake Coordinator.

Observed in Record Review. In 3 of 3 patient records reviewed, the organization failed to document that the discharge summary was sent to the provider taking over care upon discharge. During record review for HOSRRNHV#5, HOSRRDC#1, HOSRRNHV#6, the Hospice Nurse Surveyor observed a discharge summary but no documentation it was sent. For example in HOSRRNHV#5, the patient was discharged due to symptoms managed but there was no documentation that the discharge summary was sent to the provider. In HOSRRDC#1, the patient was discharged for extended prognosis but there was no documentation that the discharge summary was sent. In HOSRRNHV#6, the patient had a planned discharge for Port replacement for daily meds but there was no documentation that the discharge summary was sent to the provider taking over care. This was discussed and reviewed with the Office Intake Coordinator.

Observed in Individual Tracer. On observation at HV # 1 it was found that the RN had not followed hand hygiene practices. The nurse was observed wearing gloves while performing a vital sign assessment . They removed their gloves ,but did not cleanse their hands, and then entered their nurse bag to get their stethoscope. They then cleaned the equipment used, and placed them in their bag without again cleansing their hands. The nurse left the patient's home without cleansing their hands

Observed in Record Review. In 1 of 11 patient records reviewed, the organization had not involved the patient in making decisions about their care, treatment, or services. In the chart for RR#3, the patient was discharged due to extended prognosis, however there was no documentation that a NOMNC was provided to the patient as required by regulation. This was discussed with the RN present for survey activities.

Observed in Tracer Activities. The organization had not followed a written policy addressing the privacy of health information. During survey activities, at least one individual not employed by the organization was present in the office while patient specific information was being discussed including patient names and visit types while planning survey activities. This was confirmed with the owner and RN present during survey activities.

Observed in Record Review. In 5 of 11 patient records reviewed, the update of the comprehensive assessment was not based on changes that had taken place since the initial assessment and did not include information about the patient’s progress toward desired outcomes and a reassessment of the patient’s response to care. In the charts for HV#2, HV#3, RR#2, RR#3 and RR#8 the MSW and Chaplain IDT notes did not address progress toward goals, rather restated what they planned to provide to the patient and/or caregivers. This was discussed with the owner.

Observed in Record Review. In 1 of 11 patient records reviewed, the patient record was not complete, promptly and accurately documented, readily accessible, and systematically organized to facilitate retrieval. In the chart for HV#2, the most recent SN note was contradictory. The note stated wound on left leg has been resolved yet further in the note it stated patient remains with an open wound to front/back of lower left leg.. This was discussed with the owner.

Observed in Record Review. In 1 of 11 patient records reviewed, the 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: A statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs. In the chart for RR#7, there were no frequencies of visits for any discipline for the final benefit period. This was discussed with the owner and RN present for survey activities.

Observed in Record Review. In 1 of 11 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including medications and treatment necessary to meet the patient’s needs. In the chart for RR#1, the LVN instructed to administer hot/cold packs prn pain. This treatment was not on POC; there were no orders. This was discussed with the owner and RN present at the survey.

Observed in Record Review. In 2 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 patient's progress toward goals. In the chart for RR#8, the MSW and Chaplain frequencies on the POC were not updated and continued to read initial evaluation... through the second benefit period. In the chart for RR#2, the MSW assessment indicated a plan to follow up monthly, yet the POC only indicated an initial evaluation visit. This was discussed with the owner and RN present for survey activities.

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. In the chart for RR#4, the plan of care (POC) included a SN visit frequency of weekly. The first week of care, 3 SN visits were provided. Additionally, the POC included an order for oxygen from 2-3 lpm. During the initial SN assessment, the oxygen was documented as being at 5lpm. This was discussed with the RN present during survey activities.

Observed in Data Session. The organization had not maintained documentation of the quality assessment and performance improvement program and was not able to demonstrate its operation. The organization collected, aggregated and analyzed data routinely, however, the organization was not able to demonstrate what projects had produced any measurable improvement over the past eighteen months; the past year and current year to date (the data available to review during survey). This was discussed with the owner and RN present for survey activities. Observed in Data Session. the organization's QAPI program had not focused in indicators to were related to improved palliative outcomes. The organization collected, aggregated and analyzed data, however, was not able to demonstrate any effective improvement. The most recently documented performance improvement project for the organization was number of live discharges vs deaths in Q1 and Q3 of 2021 and increase rate of volunteer recruitments and patient care is the PIP for Q1 2022. This was discussed with the owner and RN present for survey activities.

Observed in Data Session. The organization had not documented what performance improvement projects are being conducted, the reasons for conducting these performance improvement projects, nor the measurable progress achieved on them. While the QAPI plan included items labeled PIP in Q1 and Q3 2021, Q1 2022, (no active PIP's in Q2 & Q4 2021), there was no documentation to support why the projects were chosen nor any progress toward goals. This was discussed with the owner and RN present for survey activities.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization had not used standard precautions, including the use of personal protective equipment, to reduce the risk of infection. During HV#2 and HV#3, the LVN washed her hands at the sink, however turned the faucet off with bare hands and returned to her clinical bag to get paper towels to dry her hands inconsistent with Hand Hygiene policy which required use of the paper towel to turn off the faucet. Additionally, the organization required a barrier underneath the clinical bag unless the bag was placed on a clean, dry surface which could be easily disinfected. During both visits, the LVN picked up the bag from the barrier at the end of the visit, removed the barrier and immediately replaced the bag directly onto the upholstered surface of the furniture while she placed the used barrier in the trash. This was discussed with the nurse after the visits.

Observed in Data Session. The organization had not improved hand hygiene compliance. There was no hand hygiene data available to review during the survey as discussed with the RN present for survey activities.

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:  - §418.100, §418.58, §418.60 and §418.116. This was discussed with the owner and RN present for survey activities.

Observed in Record Review. In 1 of 11 patient records reviewed, the patient record did not contain the following clinical information: specific notes on care, treatment, or services. In the chart for HV#2, the most recent SN note stated dressing done per MD order. This was discussed with the owner.

Observed in Document Review. In 2 of 3 contracts reviewed, the written agreement with an outside agency providing contracted services for the hospice did not include the following: a stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This requirement was missing in the contracts for DME and pharmacy services as discussed with the owner and Intake Coordinator.

Observed in Data Session. It was determined that the organization was not in compliance with the CMS COVID-19 staff vaccination requirements as evidenced by fully vaccinated rates reported as 68% at the time of survey. CMS requires 100 % compliance. This was discussed with the owner and RN present for survey activities.