Every finding on record at Melrose Healthcare Group

Observed in Record Review. In 1 of 3 patient records reviewed, where the patient had revoked the hospice benefit, there had been no signed revocation document. RRDC #2, there had been no documented revocation form found. This was validated with the office manager. Observed in Record Review. In RRHV #2, During an interview with the patient’s son who signs all documents for the patients care reported that “he didn't know how he go on with this agency. He was just told this is the agency that will be providing care and they started showing up” Of note, the signatures on the patient physician orders for Life Sustaining Treatment (POLST) and the Consent for Surveyor to observe the patient visit had not matched the Election of Hospice Benefit Consent Forms.

Observed in Record Review. In 1 of 10 patient records reviewed, the Surveyor noted the initial bereavement assessment had not been documented. RRDC #1, there had been no bereavement assessment present in the Electronic Medical Record. This was validated with the Office Director.

Observed in Record Review. In 4 of 5 patient records reviewed, where the patients were currently on service, the Surveyor noted the Plan of Care (POC) had not been followed. For example, RRHV #1, Spiritual Care (SC) and had made 1 visit without an order as had the Medical Social Worker (MSW). The MSW had visits conducted all visits telephonically without and orders indicating this was allowable. In RRHV #2, the SC made 2 visit without any orders present. In RRHV #3, both the SC and MSW made 2 home visits without orders. RRNHV #4, the patient had all MSW visits completed telephonically; however, there had not been any orders in the EMR to conduct the visits in the manner. This was validated with the Director of Patient Care Services.

Observed in Patient Home. In 2 of 3 home visits conducted, the Surveyor noted the HCO had not implemented their infection prevention policy related to cleaning and disinfection of equipment utilized during patient visits. For example, RRHV #1 and RRHV #2, the clinician had disinfected the equipment and placed on a dirty barrier rather than on the clean barrier. The equipment had then been replaced into the clinical bag wearing dirty gloves. The clinician had also utilized a phone during the visit with dirty hands and then replaced it into his pocket without disinfection. This was validated with the Office Manager. Observed in Patient Home. In 2 of 3 home visits conducted, the Surveyor noted the clinician had not consistently followed the HCO Hand Hygiene policy No. 9-009. For example, RRHV #1 and RRHV #2, the clinician had been observed using an alcohol-based hand rub; however, he had rubbed his hands together for less than 10 seconds and not until dry according to policy. The clinician had also changed gloves 2 times without disinfecting his hands in between and entered his clinical bag 3 times without hand disinfection. This was validated with the Office Manager.

Observed in HR File Review. In 1 of 1 HR files reviewed, of the Hospice Aide the Surveyor noted the HA had not had an initial field evaluation documented to validate skills in providing care to hospice patients. This was validated with the HR staff member.

Observed in Tracer Activities. The Surveyor noted the organization had not documented any volunteer recruitment activities. During discussion, the Volunteer coordinator vocalized that she had been trying to recruit, but had not realized documentation of activity had been required. Validated with Leadership team present.

Observed in Tracer Activities. The Surveyor noted there had been no recruitment activities and no volunteer hours to support the organization with cost savings. This was validated with the Leadership team present.

Observed in Tracer Activities. The Surveyor noted that the HCO had no volunteers, so had not met the 5% total required. This was validated with the Leadership team present during the review of the volunteer program.

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 Condition Level findings at §418.100, .§418.104, §418.116, §418.78

Observed in HR File Review. In 6 of 6 HR files reviewed, the Surveyor had been unable to validate initial competencies of staff. In all HR files reviewed, the initial orientation competency had initials of person completing the competency at the top of the page and then a line to the bottom. The column that was for how the competency was validated (whether verbal, demonstrated or observed) had been blank. This was validated with the HR person present during the review.

Observed in Record Review. In 4 of 10 patient records reviewed, where the patient had been recertified for Hospice services, the Surveyor noted the recertification Certificate of Terminal Illness (CTI) had not been signed prior to the recertification date. For example, the Surveyor noted the Hospice Medical Director had not reviewed the clinical information and signed the Certificate of Terminal Illness (CTI) prior to recertification. For example, RRHV #2, and RRHV #3, the CTI had been signed 6 days post recertification. RRNHV #4, the CTI’s had been signed 2 days, 6 days and 11 days post recertification. RRNHV #5 the recertification CTI had been signed 7 days post recert. This was validated with the Office Manager.

Observed in Record Review. In 2 of 5 patient records reviewed, where the patients have been currently on service with the HCO, the Surveyor noted the patient clinical documentation in the Electronic Medical Record (EMR) had been inaccurate and conflicted with direct observation of the patient (by the Surveyor) and other clinician documentation. For example, RRHV #3, the most recent documentation of the patient had been documented by the Registered Nurse (RN) performing the comprehensive assessment as: bedbound and immobile, incontinent of bowel and bladder, disoriented, unable to make his needs known, speaking less than 6 words, and requiring assistance in 6/6 ADL's. The Surveyor observed the patient as alert and oriented x 4, conversant with clinician and answering all questions appropriately, ambulating with the assistance of a cane only (back and forth to the bathroom), and managing all his own medications. Per the daughter, the patient had never been bedbound, and requires minimal to stand by assistance at most for his ADL's. He has very mild cognitive impairment at this time. The Surveyor also noted the RN clinical documentation had consistently presented the patient inaccurately with documentation being duplicated over the course of 3 months. When clarification sought related to the documentation, the DPCS reported that the EMR pre-populates inaccurate information. She did verbalize cutting and pasting the narrative “because the patient does not change very much.” RRNHV #4 the patient had been on service for 13 months. The RN clinical documentation had been consistently duplicated every 2 weeks on the comprehensive visits for the past 11 months. The RN documented a comprehensive nursing visit every other Saturday. A telephone call was placed to the patient to validate patient condition and care received. The patient reported that “he receives care every week on Fridays from the LVN and 2 times per week by the Hospice Aide (Thursdays and Sundays)”; however, he reported that he had never met the RN who documented the visits and never has nursing visits on Saturdays. He also reported that he had never heard the name of the registered nurse and could not recall a description of her. Discussion with the DPCS and she reports that the patient is confused and just doesn’t remember; however, there is no documentation in the patient record to indicate confusion.

Observed in Patient Home. In 2 of 3 home visits conducted, the Surveyor noted the medication profile in the electronic medical record (EMR) had not been updated to reflect the medications the patient was currently being administered. For example, in RRHV #1 The patient chronic medications that had not been included on the EMR included: Baclofen 10 mg qd, Gabapentin 100 mg tid, Alandronate q month, Primidone 50 mg, Olmesartan 40mg, Potassium 8mEq, Acetaminophen 500mg bid, Centrum Silver, and had injectable insulin Lantus solostar 30units bid. In RRHV #3, the patient had: Advil, Allergosan 1% ointment (chlorphenamine hydrochloride), Meloxicam 50 mg (since 2022), Meclizine 25 mg (2022), Clindamycin 4 times per day prior to dental work, and Lanaprost 0.005% daily. This was validated with the clinician present for the visit.

Observed in Patient Home. In 8 of 10 patient records reviewed, the Surveyor noted the Physician Orders for Life Sustaining Treatment (POLST) had been incomplete. For example, in RRHV #1, RRHV #2, RRHV #3, RRNHV #4, RRNHV #5, RRDC #1, RRDC #2, and RRDC #3, the POLST had been missing the physician date of signature and the NPI number. This was validated with the Office Manager.

Observed in Tracer Activities. The surveyor observed in RRHV #3 that the Medical Director certified the patient as meeting Medicare Hospice Criteria based on highly inaccurate documentation provided by the DPCS. The DPCS, who was the RN who admitted the patient onto service, indicated in her assessment documentation that the patient was bedbound, dependent in 6 of 6 ADLs, spoke less than 6 words, disoriented and incontinent of bowel and bladder. However, the patient’s daughter reported the patient had never been bedbound, required minimal standby assistance with ADLs and had mild cognitive impairment. In addition, the LVN visit documentation for the same period supported the daughter’s statements. When the DPCS was confronted with these disparities, she confirmed that her documentation did not accurately reflect the patient’s condition and thus his eligibility to participate in the Medicare Hospice Program. When the Medical Director was questioned about the erroneous documentation on the Certificate of Terminal Illness that he signed, he stated that he received the information from the assessment done by the DPCS. In fact, following being confronted with these inaccuracies the organization moved to discharge the patient as not meeting hospice criteria—even though his condition had not changed since admission. Thus, the DPCS knowingly provided inaccurate documentation to the Medical Director to certify the patient as terminally ill for a patient who was not eligible for reimbursement under the Medicare Hospice benefit which occurred over a four-month period. In addition, the surveyor noted in RRHV #2, the patient’s son who was the power of attorney, reported that he didn’t know how the patient “got on with this agency. He was just told this is the hospice that will be providing care and they started showing up”. The son reported he did not remember signing consent forms. Of note, the son’s signature on the Hospice Surveyor Home Visit Consent Form and the Election of Benefit form were clearly and radically different.