Every finding on record at Memorial Medical Center

Observed in Record Review. In 1 of 21 patient records reviewed, the organization failed to document reassessment. During record review for HOS RRNHV#3, the Hospice Nurse Surveyor observed the patient had two wounds to the left shin. One wound was a stage 3 and the other was a stage 4. The wounds were not being assessed as part of the comprehensive assessment. Upon conversation with the Hospice Director, it was noted that the facility manages the wound so they would not be there necessarily to assess. The wound was not assessed for 2 months. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 1 of 21 patient records reviewed, the organization failed to maintain complete and accurate patient records. During record review for HOS RRHV#5, the Hospice Nurse Surveyor observed the signed care plan stated Oxygen at 2-4 liters PRN but the medication list stated Oxygen 2-4 liters continuous. During home visit with the surveyor, the patient was on 2-4 liters PRN. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 6 of 21 patient records reviewed, the organization failed to plan the patient's care. During record review for HOS RRHV#3, HOS RRHV#4, HOS RRHV#5, HOS RRNHV#1, HOS RRNHV#2, and HOS RRMHV#4, the care plan did not reflect patient and family goals with measurable outcomes. For example in HOS RRHV#3, the patient had a goal of patient desired nutrition needs will be met which did not have detail of what the patient specific goal was and was to be met throughout cert. In HOS RRHV#4, the patient had a goal of pain will not interfere with sleep, activities time with family and friends throughout cert. The goal did not contain details of measurable outcomes and the timeframe was not individualized. In HOS RRHV#5, the patient had a goal of will verbalize acceptable level of anxiety throughout cert without detail of what level was acceptable. In HOS RRNHV#1, the patient had a recent wound to the axilla and a goal of comfort, manage drainage, control odor, maintain integument which was not complete or measurable. In HOS RRNHV#2, the patient had a SW goal of SW will make biweekly visits for emotional support but SW visits had been discontinued and the goal was not completed. In HOS RRNHV#4, the patient had a goal of chaplain visits every two weeks which was not individualized or patient centered. This was discussed and reviewed with the Hospice Team. Observed in Record Review. In 2 of 21 patient records reviewed, the organization failed to plan the patient's care. During record review for HOS RRNHV#8 and HOS RRNHV#10, the care plan did not reflect patient and family goals with measurable outcomes. In HOS RRNHV#8, the patient had a goal of desired nutrition hydration needs will be met through cert which was not measurable. In HOS RRNHV#10, the patient had lung cancer and a respiratory goal of changes to respiratory system will continue to be identified which was not patient centered or measurable. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 3 of 21 patient records reviewed, the organization failed to plan the patient's care. During record review for HOS RRHV#4, HOS RRNHV#3, and HOS RRNHV#7, the Hospice Nurse Surveyor observed not all elements of the plan of care were documented. For example in HOS RRHV#4, the patient had been struggling with anxiety that was also affecting her sleep but it was not addressed on her POC. In HOS RRNHV#3, the patient had increased dyspnea but the goals were closed out previously and there were no interventions on the POC. In HOS RRNHV#7, the patient had goals and interventions for wound but the wound was healed. The goals were not closed out. This was discussed with the Hospice Team.

Observed in Record Review. In 1 of 3 bereavement records reviewed, the hospice pharmacist surveyor noted that the bereavement care plan indicated that the organization would call the bereaved at 1,3,and 5 months post death, but there was no documentation to indicate that the 3-month call had occurred or for what reason it was not completed as planned. This omission was validated with the hospice administrator and the bereavement cordinator at the time of the survey.

Observed in Record Review. In 1 of 2 resident records reviewed, the organization failed to supervise effectively. During record review for HOS RRHV#6, the Hospice Nurse Surveyor observed the patient aide services were being supervised once a month, not every 14 days as required. This was discussed and reviewed with the Hospice Team. Observed in Record Review. In 1 of 2 patient records reviewed, the organization failed to supervise effectively. During record review for HOS RRNHV#12, the Hospice Nurse Surveyor observed the patient aide services were not being supervised at least every 14 days. In HOS RRNHV#12, the aide had been making visits for approximately a month and no supervision had taken place. This was discussed and reviewed with the Hospice Team.

Observed in Tracer Activities. During a review of the organization's retention and recruitment activities for volunteers, the hospice pharmacist noted that while the organization stated that they had tried to recruit additional volunteers, there was no documentation to support this activity. This omission was validated with the Hospice administrator and the Volunteer cordinator at the time of the survey.

Observed in Record Review. In 3 of 21 patient records reviewed, the organization failed to document clinical review for the initial certification of terminal illness. During record review for HOS RRHV#5, HOS RRHV#6 and HOS RRNHV#1, the Hospice Nurse Surveyor observed the CTI did not consider all required elements. For example in HOS RRHV#5, the documentation from the provider did not contain documentation that a review had taken place of the current subjective and objective data, current medical findings and the current medications and treatments. In HOS RRHV#6, the documentation did not contain documentation that a review had taken place of related diagnosis, current medical findings and current medications and treatments. HOS RRNHV#1, the patient was admitted 6 weeks prior to survey but the CTI was blank and not signed. This was discussed and reviewed with the Hospice Team. Observed in Record Review. In 3 of 21 patient records reviewed, the organization failed to document review of the initial clinical information related to the certification of terminal illness, During record review for HOS RRNHV#8, HOS RRNHV#9, and HOS RRNHV#10, the Hospice Nurse Surveyor observed the all required documentation was not included in the review of certification of terminal illness. For example in HOS RRNHV#8, the physician failed to document review of the medical record. The only documentation on the CTI stated diagnosis and comfort measures. In HOS RRNHV#9, the documentation review did not include all required elements, such as comorbidities, current treatments and medications. In HOS RRNHV#10, the documentation failed to include information that comorbidities, current treatment and medications were reviewed. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 2 of 21 patient records reviewed, the organization failed to document review of the patient clinical information. During record review for HOS RRHV#2, and HOS RRHV#6, there was lack of documentation for the CTI for recertification. For example in HOS RRHV#2, the Hospice Nurse Surveyor observed the recertification narrative was blank. In HOS RRHV#6, the documentation for recertification did not include subjective/ objective data, medical findings and current medication and treatment. This was discussed and reviewed with the Hospice Team. Observed in Record Review. In 3 of 21 patient records reviewed, the organization failed to document clinical review before the recertification process. During record review for HOS RRHV#8, HOS RRNHV#9, and HOS RRNHV#10, the documentation was not completed. For example HOS RRHV#8, the medical director failed to document review of patient comorbidities, current treatment and medications. In HOS RRNHV#9, the documentation failed to include patient comorbidities treatment and medications. In RRNHV#10, the documentation only included the diagnosis, it did not contain information that comorbidities, treatment and medications were reviewed. This was discussed and reviewed with the Hospice Team.

Observed in Document Review. In review of admission documents provided to the patient at the start of care it was noted that the organization's policy about advance directives had not been provided to the patient. This was discussed with the hospice director and ambulatory president.

Observed in Record Review. In 3 of 13 patient records reviewed, The organization failed to effectively screen and assess patient's pain. For example: in HOS RR#4 there was no comprehensive pain assessment completed during the admission assessment. In the pain section of the assessment it was documented that pain was not an active problem and the comprehensive pain assessment was not completed, yet in the pain comments it was documented that the patient has occasional arthritic pain controlled with Tylenol, and had a twinge of pain under left arm, but resolved, MD ordered hydrocodone. The first and only comprehensive pain assessment was completed in week 3. Example #2: in HOS RR#5 there was no comprehensive pain assessment completed during the admission assessment even through the documentation stated the patient has a history of lower back pain. No comprehensive pain assessment was recorded to date. Similar finding was noted in the admission assessment for HOS RR#3, where no comprehensive pain assessment was recorded even though the documentation shows a history of pain. Example #3, upon review of HOS RR#4 it was noted the aide notified the SN of an episode of severe pain experienced by the patient. The SN then reached out to the patient/caregiver and encouraged to take Norco as prescribed, but documented the patient was scared to death to take Norco and further instructed them to call hospice if needed. There was no follow-up until a routine nursing visit 3 days later, where there was no mention of the pain episode nor a comprehensive pain assessment conducted. This observation was reviewed with the Hospice Systems Director and the Quality Coordinator.

Observed in Record Review. In 1 of 13 patient records reviewed, The organization failed to document a comprehensive assessment as related to wound care. For example: in HOS HV#1, documentation in the clinical record noted a small stage 2 wound on the patient's coccyx in week 1. No comprehensive wound assessment to include description of the wound bed, surrounding skin, presence of drainage, and treatment provided was noted in the record as required by organization policy. This observation was reviewed with the Hospice Systems Director and the Quality Coordinator.

Observed in Record Review. In 2 of 2 patient records reviewed, For bereavement services surveyor noted lack of initial bereavement assessments. Both records also lacked bereavement risk assessments after death. This was verified by System director. Observed in Record Review. In 1 of 13 patient records reviewed, Surveyor noted on RR7 no initial bereavement risk assessment was completed as part of the patient-specific comprehensive initial assessment. This was validated with Hospice system director.

Observed in Record Review. In 5 of 13 patient records reviewed, In RR10, RR 7 , RR 6, HOSHVRR 2, HOSHV3 Surveyor noted goal timelines not appropriate based on reassessment of the patient. Examples in HOSHVRR 2 include goal pain will not interfere with sleep and activities and Pt/Cg will verbalize pain relief measures both initiated on 9/17/21 but documented to be achieved by 12/15/21. Also in HOSHVRR 2 surveyor noted other goals Pt/Cg will verbalize understanding of aspiration precautions written on 9/17/21 with goal to be achieved by 12/15/21. Pt has recent history of aspiration precautions and he is having issues with aspiration and pocketing food per the initial assessment. Surveyor noted in RR7 care plan established on 11/3/21 with goal pain goal 2/10 will be maintained and will not interfere with sleep goal to be achieved by 1/21/22. In record HOSHV3 POC established 10/13/21 with goal to maintain current integumentary status goal by 1/9/22. Patient had wound. These timeframes represent the end of the benefit period but should be shorter term goals based on urgency of the problem.

Observed in Record Review. In 1 of 13 patient records reviewed, the organization failed to provide indications on medications necessary to meet the patients needs. For example: upon review of the medication profile for HOS RR#1, the patient was noted to be prescribed multiple PRN pain medication to include morphine concentrate, morphine IR, hydrocodone, and naproxen. There is no indication beyond PRN for pain to guide the patient to know which pain medication to take related to the type or severity of the pain experienced. This observation was reviewed with the Hospice Systems Director and the Quality Coordinator.

Observed in Record Review. In 1 of 13 patient records reviewed, Surveyor noted In HOSHV 3 Ondansetron and Prochlorperazine both missing indications for use. Finding Verified with Quality nurse. Survey also noted on HOSHV3 nurse documented applying zinc on wound without order. . Observed in Record Review. In 2 of 13 patient records reviewed, The organization failed to ensure the care and services needed to meet the patient's needs were planned. For example: in HOS HV#1, documentation in the clinical record notes a small stage 2 wound on the patient's coccyx in week 1. No orders for wound care were noted in the record, nor was the wound included in the plan of care. Example 2: in review of the record for RR#4, nursing documentation in week 2 states nystatin to be requested there is no indication in the record that the request was made as there is no follow-up documentation nor an order obtained. These observations were reviewed with the Hospice Systems Director and the Quality Coordinator. Observed in Record Review. In 6 of 13 patient records reviewed, it was noted that there were range orders without parameters for dosing. For example, in hospice record review #7 there were order for oxygen 2-4 liters titrate as needed. In another example, in record review for hospice home visit #3 the order for morphine stated, 5-10 mg every four hours for mild pain and in another example, in record review for hospice home visit #2 the order for morphine stated, 5-10 mg every fours as needed. This same finding was noted in hospice record review #6 and #1.

Observed in Record Review. In 5 of 13 patient records reviewed, the organization failed to ensure the revised plan of care included information from the patient's updated comprehensive assessment and the patient's progress toward outcomes and goals. For example: in the record review for HOS HV#1, the current plan of care includes a pain goal pain rating of a 2/10 will be maintained by: achieve-by date. The achieve-by date was 2 weeks prior to the IDG meeting with no indication of updates to the plan of care. Similar findings with past achieve-by dates with no noted updates to goals was noted throughout the plan of care, and also noted in HOS RR#1, and HOS RR#4. Example 2: Upon review of HOS RR#2 the care plans including respiratory, cardiovascular, GI/GU, musculoskeletal, and integumentary, the goals were established at the start of care and the achieve by date was the end of the certification period. There was no indication of updates to the plan of care from the patient's updated comprehensive assessment with progress toward outcomes and goals noted in the record. This observation was reviewed with the Hospice Systems Director and the Quality Coordinator.

Observed in Record Review. In HOSHVRR 3 surveyor noted the HHA providing care to the patient did not collaborate in the care of the patient and coordinate their efforts to support the goals outlined in the plan of care. HHA visit date 9/18/21 refused multiple tasks and gave bed bath instead of ordered shower without documentation to support communication with RN. Observed in Record Review. In 3 of 13 patient records reviewed, The organization failed to ensure the sharing of information between disciplines providing care for the patient. For example: in HOS HV#1, the aide, on multiple occasions, documented that vital signs, and oral care were refused, yet there is no indication that the refusals were reported to the RN. Also multiple visits the aide documented sore on butt and on one occasion BM unknown. There was no indication this information was reported to the RN. Example 2: in HOS RR#1, skilled nursing documentation in week 1 states Discussed stopping glipizide as he is not eating much and it was just started 2 weeks ago and he was agreeable. There was no indication in the record that the change in patient status was reported to the physician or the IDG. These observations were reviewed with the Hospice Systems Director.

Observed in Record Review. In 2 of 2 patient records reviewed, For bereavement services surveyor noted the hospice did not develop a bereavement plan of care that specifies the type of bereavement services to be offered and the frequency of service delivery. This was confirmed by system administrator

Observed in Record Review. In 1 of 13 patient records reviewed, It was noted that the organization failed to ensure the patient record contained specific notes on care, treatment, or services. For example: in HOS HV#1 the hospice aide assignment specified to record patient BM and report if no BM X 3 days. In week 3 the Aide did not document a BM and in the next visit recorded BM unknown. This observation was reviewed with the Hospice Systems Director and the Quality Coordinator.

Observed in Record Review. In 1 of 13 patient records reviewed, the organization failed to ensure the medical director reviewed the clinical information for the patient and provide written certification. For example: in HOS RR#3, the initial certificate of terminal illness noted in the record lacked a physician narrative and physician signature. The recertification for benefit period 2 also lacked the physician narrative and signature. This observation was reviewed with the Hospice Systems Director and the Quality Coordinator.

Observed in Record Review. In 1 of 13 patient records reviewed, The patient record did not contain documentation to reflect the care and services provided. For example: upon review of HOS RR#5 it was noted that the skilled nursing visit completed in week 5 had no documentation beyond the first page of a three page visit note. A narrative of the visit was noted in the inter-office communication. This observation was reviewed with the Hospice Systems Director.

Observed in Patient Home. In 2 of 2 home visits conducted, Surveyor noted the agency medication list did not match medications patient was taking. In HOSHV2 surveyor noted agency medication list did not include ibuprofen taken three times daily and noted acetaminophen two times daily when the patient is taking 3 times daily. In HOSHV3 surveyor noted agency medication list included Hydrocodone ordered daily and patient only taking prn. Observed in Record Review. In 1 of 13 patient records reviewed, The organization failed to ensure the patient record contained pertinent information related to care and treatment. For example: In HOS RR#1 the nursing documentation notes that the patient may try some mag citrate today, yet mag citrate is not on the patient's medication profile. These observations was reviewed with the Hospice System Director and the Quality Coordinator.

Observed in Record Review. In 2 of 13 patient records reviewed, In HOSHVRR 2, CTI dated 9/17/21 not signed by medical doctor as of 11/17/21. Agency policy for Physician orders requires signature of orders within 60 days. In HOSHVRR 3 surveyor noted the HHA providing care to the patient, visit date 9/18/21 gave bed bath instead of ordered shower without documentation to support communication with RN for new order.

Observed in Record Review. In 1 of 13 patient records reviewed, In RR8 surveyor noted the agency does not have documentation to support discharge summary sent to the attending physician. Verified with System director.

Observed in Record Review. In 1 of 13 patient records reviewed, the organization failed to identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. For example: upon review of the record for HOS RR#2 there is no evidence noted in the clinical record of collaboration and/or coordination with the skilled nursing facility through the clinical documentation nor reflected in the plan of care. This observation was reviewed with the Hospice Systems Director and the Quality Coordinator.

Observed in Document Review. In review of contract with Optum pharmacy and Heritage Skilled Nursing Facility it was noted that the contracts did not contain a stipulation that all contracted entities obtain criminal background checks on contracted employees who have direct patient contact or access to patient records. This was discussed with the hospice director.

Observed in HR File Review. In 1 of 9 HR files reviewed, HR1 missing documentation to support documentation of background check. Verified with System administrator.