Every finding on record at Mennonite General Hospital, Inc.

Observed in Record Review. In 1 of 2 patient records reviewed, where the patient had a high risk medication prescribed, the plan of care had not addressed any teaching, interventions or goals nor any safety precautions related to bleeding precautions. This was evident in RRNHV#3 where the patient had Eliquis prescribed. There is documentation that the education had been completed. This was validated with the DOPCS.

Observed in Emergency Management Session. During review of Emergency Plan and Policies as well as review of documentation of drills and real events, it was noted that there had been no evaluation of the incidents. This was confirmed by the hospice director.

Observed in Document Review. During review of patient information packet both in office and in patient homes it was noted that there was no documentation of charges or any patient responsibility for charges in the hospice program. This was discussed with the administrator and hospice director.

Observed in Record Review. In 12 of 12 patient records reviewed, it was noted that the form allowing the patient to elect an attending physician or the hospice medical director to manage their hospice care was not completed and placed in the record. This was noted in all records reviewed and was confirmed by the hospice director.

Observed in Record Review. In 1 of 13 patient records reviewed, it was noted that in record review for home visit #1 the initial bereavement risk assessment was not done until one month after the start of care. This was reviewed with the hospice director.

Observed in Record Review. In 3 of 3 patient records reviewed, of patient's receiving Warfarin and Eliquis it was noted that the plan of care did not address any teaching, interventions, or goals nor any safety precautions related to bleeding precautions. This was noted in record review #2 and record review #1 and #5 and was confirmed by the hospice director.

Observed in Record Review. In 12 of 12 patient records reviewed, it was noted that the goals stated on the plan of care were not measurable or timed. For example, pt will report that pain is at or below tolerance level, Pt,/CG will be knowledgeable of pain management throughout the course of care, Pt./Cg will receive support with grieving process, symptoms problematic to pt will be addressed to meet the goal of dying with dignity. These were noted on every record reviewed. This was discussed with administrator and hospice director.

Observed in Record Review. In 2 of 2 patient records reviewed, for live discharge it was noted in DCRR#1 that there was no order in the record for discharge from this hospice and to transfer to another hospice per patient request. In review of DCRR#2 there was no discharge order for the patient who elected to revoke hospice care. This was discussed with the hospice director.

Observed in Record Review. In 2 of 12 patient records reviewed, it was noted that in review of record for home visit #3 the plan of care was not reviewed or discussed every 15 days. In one instance there were 21 days between IDT meetings in which this patient was discussed. In record review #6 there were 23 days between IDT meetings for this patient. This was confirmed by the hospice director. Observed in Record Review. In 7 of 12 patient records reviewed, it was noted that for an IDT meeting held two months ago the MSW and the Chaplain were not in attendance as evidenced by the sign in sheet as the lack of documentation from these disciplines. Additionally the hospice director confirmed that these disciplines did not provide a verbal report to another team member for discussion at the team meeting. Lastly there were multiple IDT meeting notes reviewed where there was no indication that the physician had attended either remotely or by phone. This was noted in record reviews for home visits #1 and #3 and in record reviews #1, #2 and #3. In record review #5 and #6 there was no documentation of attendance by the MSW or Medical Director in an IDT for this month. Additionally in record review #6 there was no documentation of attendance by the Chaplain at an IDT 3 months ago. Observed in Record Review. In 4 of 12 patient records reviewed, it was noted that the plan of care was not updated when there were changes in patient condition. For example, in record review for home visit #2 the patient developed a UTI and was treated with Rocephin however the plan of care was not updated. In record review for home visit #1 the pt had UTI in and was treated with Cipro and then in the following month had another infection and was treated with Rocephin however the plan of care was never updated to reflect either of these changes. In DCRR#2 the patient developed an infection at the site of the PEG tube and was treated with Doxycycline however the plan of care was not updated. In record review #6 the patient developed a UTI and was treated with antibiotics but the plan of care was not updated. This was confirmed by the hospice director assisting with record review.

Observed in Record Review. In 1 of 2 patient records reviewed, for bereavement services, it was noted that the plan of care was not followed. For example, the plan of care stated that the following the initial bereavement call the survivor would receive monthly mailings, a three month follow up evaluation and a 6 month call. The record reviewed that following the initial bereavement call the only other intervention was a three month mailing. There was no documentation of any other planned intervention or refusal of care. This was reviewed with the hospice director assisting with record review. Observed in Record Review. In 1 of 12 patient records reviewed, it was noted that care was not provided at the ordered frequency on the plan of care. For example, in record review for home visit #2, bath visits were to be done 3 wk 1, however only two visits were made that week. This was discussed with the hospice director and medical director.

Observed in Document Review. During document review, data review and discussion with quality nurse and hospice director it was determined that the hospice quality program was not organization wide and did not include any indicators from bereavement, volunteer or contracted services. Additionally there were no palliative outcomes being assessed other than pain however that indicator was a review of documentation in the record and did not demonstrate outcomes.

Observed in Data Session. During discussion with hospice leadership during the data session it was noted that there had been no Performance Improvement Projects in the past two years and therefore did not reflect the scope, complexity, and past performance of the hospice's services and operations. The only initiative described was one related to supervisory visits being done every 14 days.

Observed in Data Session. During discussion with hospice leadership during the data session it was noted that there had been no Performance Improvement Projects in the past two years and therefore did not reflect the scope, complexity, and past performance of the hospice's services and operations. There was no documentation of any projects.

Observed in Record Review. In 5 of 8 patient records reviewed, where bath services were ordered, it was noted in review of record for home visit #1 it was noted that supervisory visits were not done every 14 days. In one instance there was a 19 day interval and in another instance a 21 day interval between supervisory visits. In review of record for home visit #2 there was 16 days between supervisory visits. In review of record for home visit #3 there was 21 days between supervisory visits. In record review #2 there was a 28 day interval and another interval of 64 days between supervisory visits. In record review #5 there was no supervisory visit since the start of care 22 days ago. This was confirmed by the hospice director.

Observed in Data Session. During discussion with hospice director during the data session it was noted that there has been no active volunteers for the past two years since the pandemic.

Observed in Data Session. During discussion with hospice director during the data session it was noted that there has been no active volunteers for the past two years since the pandemic.

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: 418.58, 418.102, 418.52, 418.56 and 418.100,

Observed in Record Review. In 5 of 12 patient records reviewed, it was noted that the initial Certification of Terminal Illness did not include a narrative statement. In record review for home visit #1 the only statement on the certification was that the patient had a terminal diagnosis and less than 6 month life expectancy. This was also observed in record review for home visit #3 and record review #1 and #2 and #6. This was discussed with the hospice medical director and the hospice director.

Observed in Record Review. In 1 of 13 patient records reviewed, it was noted that the recertification Certificate of Terminal Illness was not documented in a narrative format by the physician. This was confirmed by the hospice director. This was noted in record review #2.

Observed in Tracer Visit. In 2 of 3 home visits conducted, it was noted that the medication sheet did not reflect the medications in the home. For example, the following discrepancies were noted: Tramadol/Acetominophen was listed as every 4 hours PRN, however the prescription bottle stated every 4-6 hours PRN, the morning dose of Humulog was listed as 45 units however the caregiver is giving 30 units and the bedtime dose was listed as 35 but the caregiver is giving 20 units. Levothyroxine was listed as 75 mcg before meals, however the order is for only one dose daily, Fluoxetine was stated on the medication sheet as 40 mg caps but give 20 mg daily, however in the home the only medication was 20 mg cap. Lastly, there were Tessalon Pearls in the home but this medication was not on the list. This was reviewed with the nurse and supervisor present on the visit. During home visit #3 it was noted that the Lispro Insulin was on the hospice medication sheet for both am and pm PRN. Upon discussion with caregiver it was stated that this medication had been discontinued due to low blood sugars and poor appetite. This was discussed with the administrator and hospice director.

Observed in Record Review. In 2 of 2 patient records reviewed, who were discharged it was noted that there was no documentation of a discharge summary. This was confirmed by the hospice director for DCRR#1 and #2.

Observed in Record Review. In 2 of 2 patient records reviewed, who were discharged it was noted that there was no documentation of a discharge summary. This was confirmed by the hospice director for DCRR#1 and #2.

Observed in Document Review. During review of hospice admission packet both in office and in patient homes it was noted that the agency policy on the management and disposal of controlled drugs was not provided to the patient or patient family/representative. Specifically, in home visit #1 the patient was on controlled substances. This was discussed with the hospice director and medical director.

Observed in Emergency Management Session. In review of the Emergency Management Plan and documents and conversation with agency leaders, the surveyor determined that the hospice does not analyze the response to drills, exercises and actual emergencies for opportunities for improvement. In 2020 there was a drill documented for an earthquake but the evaluation listed all the things that went well. There was no documentation of areas of concern that could be improved. In 2021 the agency utilized it's plan for COVID but there was no documented evaluation of the plan.

Observed in Record Review. In 1 of 11 patient records reviewed, the agency failed to perform patient assessments according to policy. Per the Director of Patient Care Services, the agency policy requires a wound assessment to include the location and size of the wound, the location, the appearance of the wound bed, the presence and measurement of any tunneling, the presence or absence and amount of drainage. In HO RR#4 the patient had a large foot wound at the site of toe amputations. The medical record included a picture of the wound but no further assessment that would include the appearance of the wound bed, the presence and measurement of any tunneling, the presence or absence and amount of drainage. This was validated with the Director of Patient Care Services.

Observed in Record Review. In 1 of 11 patient records reviewed, the agency failed to resolve duplicate medications. In HO RR#4 the patient had duplicate orders for Neurontin 300mg daily and 600 mg at hs without any further direction as to when to take the daily dose. This was validated with the Director of Patient Care Services.

Observed in Record Review. In 10 of 11 patient records reviewed, the agency failed to address all identified needs in the plan of care (See PC.01.03.01 EP18). Because needs identified in the initial assessment were not addressed in the plan of care there were no goals established to meet these needs.

Observed in Record Review. In 10 of 11 patient records reviewed, the agency failed to address all the needs identified in the patient's comprehensive assessment on the plan of care. In HV#2 nutrition, swallowing difficulties, skin risk, and fall risk were identified in the initial nursing comprehensive assessment but there were no corresponding interventions or measurable outcomes in the plan of care to manage those identified needs. Other needs identified with no corresponding interventions and goals on the plan of care include: HV#3- swallowing difficulty, skin risk, fall risk; HO RR#1-difficulty swallowing, skin integrity, skin risk, fall risk; HO RR#2 patient agitation and fall risk, HO RR#3- skin risk, fall risk; HO RR#4- the patient had a large foot wound from toe amputations and a sacral wound; HO RR#5 difficulty swallowing, fall risk; HO RR#6 difficulty swallowing liquids and meds, bedbound, abdominal distention, fall risk; and RR#8 fall risk. Nurses were performing wound care but there were no specific orders for wound care on the plan of care.

Observed in Record Review. In 3 of 11 patient records reviewed, the hospice agency failed to provide care in accordance with the plan of care. In HO RR#2 G-tube feeds were documented at 45ml per hour but they were ordered at 67 ml per hour. In HO RR#4 the physician order read wound care per ESC. There is no agency policy or protocol that would define what that order means. The nurses were providing wound care as follows: to the foot wound; cleanse with wound cleanser, apply Aquacel, cover with border gauze, change every 2 days; to the sacral wound - cleanse with Dermawound, apply Solcite gel, cover with xeroform, and border gauze, change daily. There were no orders in the medical record for the wound care that was being provided by the nursing staff. In HO RR#6 oxygen was documented at 3.5L/min but the physician order was at 2l/min.

Observed in Patient Home. In 1 of 3 home visits conducted, the clinician failed to perform hand hygiene in accordance with agency policy and CDC guidelines. In HV#1 the aide put on multiple layers of gloves and during care peeled off a level and replaced it without doing hand hygiene in violation of CDC guidelines. This was validated with the quality nurse who accompanied the surveyor.

Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement family members, the agency failed to document a bereavement plan of care. In BV#1 and BV#2 the family received regular mailings but there was no plan of care established to document the kinds of services to be offered or the frequency with which they would be offered. This was validated with the nurse assisting the surveyor in navigation of the EMR.

Observed in Tracer Activities. In review of the volunteer program the volunteer coordinator reported that she currently has no volunteers and has not had any since 2017. Since there have been no volunteers available since 2017 the agency was not able to demonstrate that volunteers provide at least 5% of the total patient care hours provided by the hospice.

Observed in HR File Review. In 1 of 6 HR files reviewed, the agency failed to document competency evaluation every 3 years. In HR#1 for the Quality Nurse who is almost exclusively office based, the agency has sent her out to do home visits due to staffing shortages. There was no competency documented since 2017 for her clinical skills. Per the Director of Patient Care Services, she was not part of the annual competency program because she is office based.

Observed in Record Review. In 1 of 11 patient records reviewed, the hospice agency failed to maintain an accurate medical record. In HO RR#1 the initial nursing assessment documented the presence of two wounds. There was no detailed assessment of the wounds but there was considerable documentation of education done about wound care. There was never any further mention of any wounds anywhere else in the medical record over the next 40 days of care until survey. The Director of Patient Care Services indicated that the presence of wounds would have been documented in IDG notes and therefore this was most likely an error in charting.