Every finding on record at Methodist Fremont Health

Observed in Record Review. In 1 of 10 patient records reviewed, the hospice’s interdisciplinary group did not comply with their policy Assessment and Reassessment which states that the comprehensive assessment will be completed no later than five calendar days after the election of hospice care. In review of the medical record for RRHV #1 the psychosocial assessment had not been completed until 11 days following the election of the hospice benefit. This was validated by the Hospice Director.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not follow their policy Medication Management which states the patient's medication list is reconciled on each visit . A licensed professional will update the medication list whenever changes occur (omissions, duplications, adjustments, deletions, additions). For HOS RRHV #3 the RN did not perform a complete medication reconciliation of the patient's medications. The RN was observed to set up a weekly medication planner for the patient and reconciled the scheduled medications. At the surveyor request the RN completed the reconciliation of the prn and comfort kit medications noting several issues including MiraLAX which was on the medication list as daily but was being used prn, Acetaminophen which the patient did not have and needed to be ordered and Glycopyrrolate (Robinul) with only 2 tablets left and needed to be refilled. This was validated by the Hospice Manager.

Observed in Record Review. In 3 of 10 patient records reviewed, the plan of care did not include goals that were specific, measurable, achievable with time frames to meet those goals. For example for HOS RRHV #3 and RRNHV #1 for the pain problem the goal was; patient will have satisfactory pain control as evidence by caregiver report of perceived satisfaction however the goal did not identify a pain rating that would be satisfactory for the patient or a time frame to meet the goal. Also for HOS RRNHV #3 the pain goal was patient's pain will be within a comfortable level within 2 days however failed to identify a pain rating. This was validated by the Hospice Manager.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization did not provide the patient with care, treatment, or services according to the hospice plan of care. In review of the medical record for HOS RRHV #1 the plan of care included for the social worker to visit the patient 1 time per month however there was no evidence of a visit by the social worker in the third month of hospice care. This was validated by the Hospice Director.

Observed in Patient Home. In 1 of 3 home visits conducted, Device or disinfectant manufacturer instructions for use (IFU) were not followed but patient was not likely placed at risk for BBP transmission as evidenced by: staff did not follow contact time (wet time) when cleaning equipment used in patient care as specified by the disinfectant manufacturer’s IFUs for Oxiver. This was validated by the Hospice Director.

Observed in Record Review. In 1 of 3 patient records reviewed, the surveyor observed that the individualized plan of care goals were not all individualized and measurable , For example RR#2, the goals stated patient/caregiver will have pain controlled to acceptable level, however, the acceptable level was not included in the care plan. Additional goals were broad and not measurables such as :patient/caregiver will utilize pharmacologic and non pharmacologic strategies to promote ease of breathing; caregiver comprehends nutritional intake decreased as patient declines; and patient and caregiver will verbalize pharmacologic and nonpharmacologic measure to control pain. There were no as evidenced by statements with these goals. All of the goals had a time frame of by the end of the certification period. There were no designated short term or long term goals. These observation were discussed with the Clinical Manager and QAPI Manager.

Observed in Record Review. In 1 of 13 patient records reviewed, the organization failed to conduct and document a patient-specific comprehensive assessment that identified that the patient's need for care and services. For example: upon review of HOS HV#1, whose pain was noted as an issue, the initial comprehensive and subsequent pain assessments documented the patient's current pain level but failed to assess the patient pain goal and tolerable levels per organization policy. This observation was reviewed with the Hospice Clinical Leader.

Observed in Record Review. In 3 of 4 patient records reviewed, who had wounds, the organization failed to ensure that a comprehensive assessment and reassessment was conducted to identify the patient's needs as related to wound care and detailed in the organization policy. For example: Upon review of HOS HV#2 it was noted in the record that the patient had a wound to the right shoulder. There was no documentation of a comprehensive wound assessment to include description, size, and type of wound, surrounding skin, presence of odor or drainage, and treatment provided as required by organization policy. In HOS RR#8 it was noted in the documentation the presence of 2 wounds to the right leg. There was no documentation of any comprehensive wound assessment or reassessment noted in the record. There is a similar finding in HOS RR#12 where there is documentation that the hospice aide reported open areas to the patient's buttocks, however there is no documentation of any wound assessment or reassessment of the wound beyond the aide's documentation that stated the wounds were healing. This observation was reviewed with the Hospice Clinical Leader and the Hospice QAPI Nurse.

Observed in Record Review. In 13 of 13 patient records reviewed, the organization did not ensure that the individualized plan of care reflected goals based on the patient's needs, nor that the plan of care goals were individualized, specific, and measurable. For example: throughout all clinical records reviewed by the hospice surveyor, the established goals were found to not be individualized, specific, or measurable. In HOS HV#1 the goal for pain was patient will be comfortable throughout illness to death. In HOS HV#3 non-specific goals such as patient will remain free of injury and nutrition intake will be consistent with terminal phase of illness. A spiritual goal was patient will be spiritually prepared for death. In HOS RR#4 a goal was noted of patient will die free of distressing symptoms. The non-specific goals are not individualized as the same goals can be seen throughout all clinical records reviewed. Further, the goals were not noted to based on the patient's needs. In HOS HV#2 the patient was ordered antibiotics for an infection, yet this was not reflected on the care plan. In HOS HV#3 that patient was on multiple laxatives yet constipation was not reflected on the care plan. In HOS RR#4 the patient was diagnosed with a UTI that was not reflected on the care plan. In HOS RR#5 and HOS RR#6 the patient had a foley catheter and there was an interventions for foley catheter, but there was no goal established for the urinary issues. Similar issues with goals were noted throughout all hospice records reviewed. Further, throughout all records there was a noted disconnect from the interventions to the goals. These observations were reviewed with the Hospice Clinical Leader, and the Hospice QAPI Nurse.

Observed in Record Review. In 2 of 13 patient records reviewed, The organization failed to comply with the statement of the scope and frequency for services necessary to meet the specific and family needs. For example: upon review of HOS RR#10 the MSW was scheduled to visit the patient 1 time a month, yet no visit was documented for the month of March 2022. In HOS RR#13 the MSW was also scheduled for 1 time a month, but no visit for November 2022 was noted in the patient record. These observations were reviewed with the Hospice QAPI Nurse.

Observed in Record Review. In 1 of 13 patient records reviewed, the organization failed to ensure that the patient had the drugs and treatment necessary to meet the needs of the patient. For example: upon review of HOS RR#9 the patient was diabetic and on insulin. There was an intervention noting that the facility was responsible for blood glucose monitoring, however there no frequency for the monitoring, nor were there parameters for reporting high or low blood glucose levels. This observation was reviewed with the Hospice Clinical Leader and the Hospice QAPI Nurse.

Observed in Record Review. In 1 of 2 patient records reviewed, bereavement records reviewed. The organization failed to ensure the care and services are provided in accordance with the plan of care. For example: upon review of bereavement policy, there was a protocol for initial bereavement call/visit for 14 days post death for a low bereavement risk score. During interview with the bereavement coordinator it was stated that calls were made within 30 days. In Bereavement record #1 the initial call was made 44 day post patient death. This observation was reviewed with the Bereavement Coordinator and the Hospice Clinical Leader Observed in Record Review. In 2 of 3 patient records reviewed, that had indwelling urinary catheters, the organization failed to ensure that the care and services were provided in accordance with the plan of care. For example: when reviewing HOS RR#5 the patient was admitted with a foley catheter. The intervention noted the catheter was to be changed monthly. In the initial assessment it was noted that the catheter was due to be changed in week 4. According to documentation the catheter was not changed until week 9. In HOS RR#13 the patient had a suprapubic catheter. The intervention ordered the catheter was the hospice responsibility and to be changed monthly. Upon review of all skilled nursing visits for the month prior and to the patient's day of discharge for extended prognosis there was no documentation in the record that the catheter was changed per orders. These observations was reviewed with the Hospice Clinical Leader and the Hospice QAPI Nurse.

Observed in Leadership Session. Based on a review of the Hospice QAPI data, there was no aggregation, reporting or analysis of all services provided under contract on a program level. Except for one complaint retrieved from the hospital data base, there was no other data available on contract evaluation for 2020, or 2021. The Hospice had contracts for durable medical equipment, pharmacy, and nursing home care. These observations were discussed with the manager.

Observed in Tracer Activities. the organization failed to develop a bereavement plan of care that noted the kind of bereavement services to be offered and the frequency of the service delivery. For example: During the bereavement program review with the bereavement coordinator the bereavement care plans did not include specific, individualized interventions, as the timing and frequency for calls and/or visits, and services were not specified. Upon discussion the bereavement coordinator the organization had updated the bereavement plan of care form and the form now in use for all bereavement plans lacked the timing and frequency for the calls and/or visits. This observation was reviewed with the Bereavement Coordinator and the Hospice Clinical Leader.

Observed in Record Review. In 1 of 12 patient records reviewed, who were receiving hospice aide services, the registered nurse did not provide written patient care instructions for the hospice aide as related to reporting patient weights. For example: During the home observation with the hospice aide for HOS HV#1, the patient was weighed and had gained weight. Upon interview with the aide it was stated that she did not report when the patient gained weight but would report to the nurse if the patient lost weight. The Hospice Aide plan of care included the task of weekly weights yet no parameters for reporting changes in weight were included in the written instructions. This observation was reviewed with the Hospice Clinical Leader.

Observed in Leadership Session. “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, 418.100, and 418.56.

Observed in Record Review. In 2 of 13 patient records reviewed, the organization failed to ensure that the clinical record contained information to reflect the patient's care, treatment, and services. For example: On review of HOS HV#2 nursing notes and the facility orders it was noted that the patient had a wound that was being treated with Mepilex dressings, however there were no dressing orders noted in the Hospice record for wound care. Example 2: during HOS HV#2 home observation during medication reconciliation, the medication profile included lorazepam yet the lorazepam had been discontinued in the facility orders approximately a month earlier. Example 3: In review of the record for HOS HV#2 the medication profile noted orders for antibiotics for left arm cellulitis, however there was no documentation in the record of the circumstances leading up to the order, education to the family, nor follow up until the next scheduled SN visit. Example 4: In HOS RR#9, the patient medication profile included sliding scale insulin, yet there was no frequency for administering the insulin as required by policy. These observations were reviewed with the Hospice Clinical Leader.

Observed in Record Review. In 2 of 2 patient records reviewed, that were discharged live, the organization failed to complete a discharge summary that included all of the required elements. For example the discharge summary for HOS RR#12, and HOS RR#13 lacked summary of care, treatment, or services it provided to the patient, nor did it contain the patient’s progress toward goals, or a list of community resources or referrals made or provided to the patient. This observation was reviewed with the Hospice Clinical Leader and the Hospice QAPI Nurse.

Observed in Record Review. In 1 of 6 patient records reviewed, that were in a skilled nursing facility, the organization failed to specifically 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 HOS RR#5 the patient had a foley catheter with an intervention for monthly catheter changes. There was no indication in the record who was responsible, the hospice or the facility staff for the foley changes. This observation was reviewed with the Hospice Clinical Leader and the Hospice QAPI Nurse.