Every finding on record at Mega Hospice Care, Inc.

Observed in Competency Session. In 7 of 7 HR files reviewed, the organization did not provide annual training relevant to their emergency response roles to staff and individuals providing on-site services under arrangement at least every two years. During the Emergency Management system tracer, it was learned that emergency training was not done as part of employee orientation and every two years. This observation was reviewed with the Administrator and acting Director of Nursing.

Observed in Patient Home. In 3 of 3 home visits conducted, the hospice did not provide written information to patients and families on their advance directive policy, nor was education about it documented in the patient records. This observation was reviewed with the Administrator and acting Director of Nursing.

Observed in Proficiency Testing. In 10 of 11 patient records reviewed, revisions to interdisciplinary meeting notes did not include comprehensive assessments that documented decline, changes to plans of care, and goals. Nursing documentation did not reflect changes that had occurred since the previous meeting. For example, in the record of HV#2 the patient had a new skin tear to the right posterior ear. No problem, interventions or goals were created. In the record of HV#3 the patient had redness around a G-tube insertion site. Orders were obtained to clean and dress the area for 30 days but the plan of care was not revised. Spiritual care and psychosocial notes had no changes noted, and documented only to continue the plan of care, despite there being no problems, interventions, or goals created by those disciplines. This was found in records where services were provided as well as records where services were declined. This observation was reviewed with the Administrator and acting Director of Nursing. Observed in Record Review. In 1 of 11 patient records reviewed, the hospice did not document that an update of the comprehensive assessment was accomplished no less frequently than every 15 days. In the record of HV#3 it was noted that two interdisciplinary meetings were not documented over a period of four weeks. This observation was reviewed with the Administrator and acting Director of Nursing.

Observed in Record Review. In 10 of 11 patient records reviewed, the organization did not develop plans of care that were based on the patient’s goals and the time frames, settings, and services required to meet them. Most goals were generic and very few were specific, measurable, attainable, relevant, and/or timed. For example: “Patient will maintain optimum peripheral circulation; will minimize complications due to impaired mobility; will verbalize having urinary elimination needs met on a daily basis; will have adequate food and fluid intake every meal.” The surveyor also found that goals were not individualized. For example, there was a goal for blood pressure to be within normal range within a week, but there were no elevated readings documented. Another goal was to have minimized episodes of shortness of breath, but no shortness of breath was documented. All target resolution dates were either the last day of the benefit period or the next interdisciplinary meeting date. This observation was reviewed with the Administrator and acting Director of Nursing.

Observed in Record Review. In 8 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. For example, the spiritual counselor and social worker did not define when patients would be seen, did not regularly visit patients, and did not contribute to or participate in patient’s plans of care by identifying problems, and creating interventions and goals to address those problems. This observation was reviewed with the Administrator and acting Director of Nursing.

Observed in Patient Home. In 1 of 3 home visits conducted, services were not provided according to the plan of care. For example, in the record of HV#1 it was observed that although there was an order for oxygen at 2 lpm per minute via nasal cannula prn for SOB, there was no concentrator or back up tank in the home. This observation was reviewed with the Administrator and acting Director of Nursing.

Observed in Record Review. the hospice did not provide current subjective and objective medical findings to support terminal diagnoses. The surveyor found no objective data such as diagnostic findings, or a history and physical to support terminal diagnoses. Rather, patients were admitted based solely on personal history and their desire to stop curative treatment. As well, some primary diagnoses did not support a life expectancy of six months or less if the diseases followed their normal trajectories. This observation was reviewed with the Administrator and acting Director of Nursing.

Observed in Record Review. In 2 of 2 patient records reviewed, where the patient was discharged for extended prognosis or died, the surveyor found that the primary care provider was not notified in the records of RR#6 and RR#7 This was confirmed by the Administrator and Director of Patient Care Services. Observed in Record Review. In 1 of 1 patient records reviewed, where the patient was transferred to another organization, the surveyor noted in the record of RR#5 that the hospice did not document that information was shared with other service providers who would be providing care, treatment, or services. This was confirmed by the Administrator and Director of Patient Care Services.

Observed in Patient Home. In 3 of 3 home visits conducted, the hospice did not ensure that the patient, patient’s representative, and family were educated on policies and procedures for managing the safe use and disposal of controlled medications when they were ordered. For example, there was a comfort kit in every home, but patient handbooks did not include a copy of the narcotic use and disposal policy, nor was there documentation of education on the policy having been provided and explained. This observation was reviewed with the Administrator and acting Director of Nursing.

Observed in Patient Home. In 3 of 3 home visits conducted, the hospice did not provide the patient and caregiver with an explanation of the plan for care, treatment, or services, or instructions on the safe and effective use of medications. For example, patients’ handbooks did not include current copies of the plans of care or medication lists, nor was there documentation in the records of education having been provided on these topics. This was validated by the Administrator and acting Director of Nursing. Observed in Patient Home. In 3 of 3 home visits conducted, Education was not provided to the patient based on the their conditions and assessed needs. For example, patients’ handbooks contained a generic template to support the development of an individualized plan in the event of a natural disaster or emergency, but these had not been completed. The patient at HV#1 lived alone and had full time caregivers but had wandered away from home on one occasion. The patients at HV#2 and HV#3 were both bedbound and used oxygen intermittently which might hinder a safe and rapid response and evacuation when necessary. This was validated by the Administrator and acting Director of Nursing.

Observed in Record Review. In the record of RR #6 the surveyor found that the patient was discharged for extended prognosis. The Medicare Notice of Non-Coverage document was signed on the day of discharge. This does not comply with the minimum Medicare requirement of two days notification prior to discharge. This observation was reviewed with the Administrator and acting Director of Nursing.