Every finding on record at Midland Care Connection, Inc.

Based on document review, policy review and interviews, the hospice failed to ensure the plan of care reflected family goals identified in initial and updated assessments, for one of three patients receiving hospice inpatient services (Patient 2). The hospice failed to ensure symptom management goals of the family at end of life were assessed and included in the plan of care. This deficient practice has the potential to place patients' families at risk for unmet expectations for end of life care. Findings Include: Review of a Hospice policy titled, "Care Plan Development and Update," Revised and Approved 4/22, showed, all care provided to patients will be in accordance with the written Plan of Care (POC) based on individual needs. Patient goals within the POC will be discussed and mutually agreed upon by the care team, attending physician and the patient/caregiver. Each member will review and provide their input to the POC and the plan will specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions. The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: interventions to manage pain and symptoms, detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs, measurable outcomes anticipated from implementing and coordinating the plan of care, drugs and treatment necessary to meet the needs of the patient, medical supplies and appliances necessary to meet the needs of the patient, interdisciplinary team documentation of the patient or caregivers level of understanding, involvement, and agreement with the plan of care. Review of a Hospice policy titled, "Interdisciplinary Team (IDT) Meeting and Documentation, Revised and Approved 11/19," showed, the Hospice Interdisciplinary Team (IDT) is made up of a Medical Director, Registered RN Case Managers, Social Workers, and Chaplains. Additional members may include: Physical Therapists, Occupational Therapists, Speech Language Pathologists, Dieticians, Pharmacists, Home Health Aides/Homemakers, Volunteers and/or Manager of Volunteer Services, and Bereavement staff. The IDT is responsible for procedures regarding day-to-day patient care and is a forum to review and update hospice patients ' plans of care. Ensures that the IDT maintains responsibility for directing, coordinating, and supervising the care and services provided. Ensures that the care and services are provided in accordance with the plan of care. Ensures that care and services provided are based on all assessments of the patient and family needs. Provides for and ensures the ongoing sharing of information between all disciplines providing care and services in all setting, whether the care and services are provided directly or under arrangement. Patient 2 Review of Patient 2's medical record showed he was admitted on 06/23/22 with a diagnosis of Acute and Chronic Respiratory Failure. The patient was admitted to the hospice inpatient unit for symptom management of pain and dyspnea at end of life; the wife and family were present throughout stay. Patient previously lived at home wife and 2 minor children (9 children total). He was alert and oriented to person, place and situation; decisional. Review of Patient 2's Plan of Care, dated 06/23/22 showed the nursing plan did not include interventions and goals necessary to meet family-specific needs based on problems, needs or expectations assessed at the end of life. Review of the Hospice Inpatient Initial Assessment, completed by Staff D, RN on 06/23/22 showed the reason for Inpatient Care: Pain control and symptom management. The assessment included pain and shortness of breath screening, medications review, and instructions related to the plan of management for pain and shortness of breath, with the patient. There was no documented review and instruction, related to management of pain and symptoms, with the patient's wife (primary caregiver) and family. Review of Patient 2's Nurse Practitioner (NP) Visit Note, completed by Staff E, NP on 06/23/22 showed "Plan" GIP (General Inpatient) level of care for symptom management. A rapid Methadone (drug used to treat chronic pain) titration is to be initiated today, which will require a GIP level of care for safety due to the long and variable half-life of the drug. Methadone 10 mg PO (by mouth) every 3 hours PRN (as needed) ordered for rapid titration. The assessment noted the patient's wife and three children were involved with the patients care; three children present at the house (inpatient unit). The assessment showed "decisional capacity", with a notation that the patient is currently decisional. Review of Patient 2's NP Visit Note, completed by Staff E, on 06/24/22 showed "Plan" GIP (General Inpatient) level of care for symptom management; to continue the rapid titration every 3 hours; dosing may be scheduled after 5-7 days and breakthrough pain medication may be added at that time. The note showed Patient 2 reported he was in pain and was having difficulty with the Methadone titration, as his breakthrough pain medication was being held for titration purposes; discussed treatment options with him and he was agreeable to continue with the rapid methadone titration at this time (same plan). There was no documented review or instruction, related to the initiation and continuation of the current (same) plan to manage pain and symptoms, with the patient's wife or family present at the hospice inpatient unit. There was no documentation of the caregiver(s) level of understanding, involvement, and agreement with the plan of care. Review of Patient 2's Palliative Care Consult Note, dated 06/22/22, from the patient's hospitalization, prior to admission at the hospice house inpatient unit, showed "Current Sx (symptom) Burden: Pt reports moderate pain, takes Methadone 10 mg PO, TID (three times a day) and has been started in the ICU (intensive care unit). Patient also has PRN Morphine as needed, but it's been limited due to his blood pressure. He states that once he goes on comfort cares (hospice inpatient unit), he would appreciate more aggressive pain management despite his BP, but he understands the current limitations in the ICU." During an interview on 08/17/22 at 12:13 PM, the patient's wife confirmed her expectation for her husband's care at the hospice house (IPU) was to have his pain managed. She stated she and the patient had discussed this with the hospital physician during the patient's hospitalization, who had assured her IV (intravenous access) would be left in place so that IV pain medication could be used as needed at the hospice house. She confirmed she had not participated in a discussion about this topic with the hospice's Nurse Practitioner nor Physician, since her husband's admission at the hospice house and that IV medications for pain were not given to her husband and she had unanswered questions. During an interview on 08/17/22 at 9:15 AM, Staff E, NP, confirmed she could not recall a discussion with the patient's wife concerning Methadone titration for pain nor the pain/symptom management plan for the patient.

Based on document review, policy review and interviews, the hospice failed to ensure communication needs identified in the bereavement assessment were completed by nursing staff with family and failed to ensure follow-up communication about bereavement counseling services offered for the patient's children was completed and included in the plan of care for one of three patients receiving hospice inpatient services (Patient 2). This deficient practice has the potential to place patients' families and bereaved at risk for unmet expectations and needs for bereavement care. Findings Include: Review of a Hospice policy titled, Bereavement Services 418.64 (d)(1)(ii), Approved 04/21, showed the program for the provision of bereavement (grief) services, after the client's death. The plan of care for these services should reflect assessed family needs, as well as a clear delineation of services to be provided and the frequency of service delivery. Patient 2 Review of Patient 2's Bereavement Visit-After Death Visit note completed by Staff B, Bereavement Counselor (BVC) on 07/11/22, showed the client (wife) had some questions about her husband's passing and why it wasn't as peaceful as others she had been present for several years ago. She stated "His pain seemed better controlled at the hospital than with hospice and his passing was very traumatic for my kids. It wasn't peaceful like I thought it would be, is that normal?" Staff B, BVC documented she offered to reach out to nursing and have someone contact her to answer her questions, which she expressed great appreciation for. There was no further bereavement documentation noted. Review of Patient 2's Counselor Care Plan (Bereavement POC), completed by Staff B, dated 07/11/22 showed the grief process and grieving bereavement plan was in process. The Bereavement plan did not include interventions/goals related to the outreach promised by bereavement services, regarding nursing staff and end of life questions by the bereaved. During an interview on 08/17/22 at 10:15 AM, Staff B, BVC confirmed she sent an email to the Inpatient Unit Director for follow-up contact with the family at the time of the contact. During an interview on 08/17/22 at 1:35 PM, Staff A, Administrator confirmed there was a transition happening with a new Inpatient Unit Director (nursing director) at the time of the bereavement email and that follow-up with the family, by the nursing staff had not been completed. During an interview on 08/17/22 at 2:05 PM, the patient's attending physician, Staff C, confirmed the hospice "dropped the ball" concerning follow up contact by nursing, confirming the hospice staff did not contact the wife regarding questions about the patient's passing. During an interview on 08/17/22 at 12:13 PM, the patient's wife confirmed the hospice had not contacted her about her questions. The hospice failed to ensure communication needs identified in the bereavement assessment were completed by nursing staff with the family and included in the plan of care. Review of Patient 2's the Bereavement Visit-After Death visit note completed by Staff B, Bereavement Counselor (BVC) on 07/11/22, showed the client (bereaved) felt her 13- year old would benefit from grief counseling. Client requested an email with further information about counseling and other activities which the BVC. Review of Patient 2's medical record showed there was no documentation to support follow up from the hospice bereavement services. Review of Patient 2's Counselor Care Plan (Bereavement POC), completed by Staff B, dated 07/11/22 showed the grief process and grieving bereavement plan was in process. The Bereavement plan did not include interventions/goals related to the outreach promised by bereavement services, for grief counseling services and activities for the client's children. During an interview on 08/17/22 at 10:15 AM, Staff B, BVC confirmed that she had discussed grief counseling for children in the home, with the patient's wife, during the assessment. She confirmed, upon review of her email history and documentation, that follow- up contact with the bereaved was not completed. During an interview on 08/17/22 at 12:13 PM, the patient's wife confirmed the hospice had not contacted her about her questions, nor the counseling services for her children.

Observed in HR File Review. In 1 of 8 HR files reviewed, the hospice surveyor noted that the organization had not provided emergency preparedness training to all staff at least every two years. For example, in review of HR1, there was no documentation that the volunteer had been trained in emergency preparedness at least every two years. This was validated onsite by the Volunteer Services Coordinator.

Observed in Record Review. In 14 of 16 patient records reviewed, the hospice surveyor noted that the organization had not identified specific and/or measurable outcomes that could reasonably be expected to be achieved. For example, in review of the medical record for HOSHV1, the following outcomes were identified but not measurable: Patient will demonstrate understanding of appropriate use of meds for pain management; Pt /CG will demonstrate understanding of available community resources; Patient will be free of preventable complications. In HOSRR1 and HOSHV2 the following outcome was identified but not measurable: Optimal activity level achieved and maintained within baseline respiratory and energy parameters. In review of the medical for HOSHV3, HOSHV4, and HOSRR3 the following outcome was identified but not measurable: Patient will maintain optimum bowel functioning consistent with food intake and stage of disease process. In review of the medical for HOSRR5, the following outcome was identified but not measurable: Maintenance of respiratory baselines as evidenced by breathing at optimal level within disease parameters. Similar goals that were not measurable were found for HOSRR7, HOSRR8, HOSRR9, HOSRR10, HOSRR11, and HOSRR12. In review of the medical record for HOSRR3 and HOSRR5, the patient's risk for falls was addressed with the following goal: Patient /caregiver will verbalize understanding of falls prevention, home safety measures. However, the only intervention for this goal was to: Assess patient's mobility impairment including gait, endurance, coordination and balance. In HOSRR4, the patient's anxiety was addressed with the following goal: Patient/caregiver will verbalize appropriate interventions for stress/anxiety management. However, the only intervention for the goal was to: Assess patient's coping mechanisms. In HOSRR7 the goal of Patient/caregiver verbalizes plan for evacuation in the event of an emergency did not have interventions to address the goal. In HOSRR8, the goal of Patient/caregiver will demonstrate measures to maintain skin integrity' only had the intervention Assess patient's risk for developing pressure ulcers. In HOSRR9, the goal of Patient /caregiver will verbalize understanding of falls/injury prevention and home safety measures' had only the intervention Assess patient's mobility impairment including gait, endurance, coordination and balance. In HOSRR11, the goals of Patient/caregiver verbalize understanding of disease process including prognosis, signs/symptoms, complications, effect of disease on body systems and what to report and Patient /caregiver will verbalize understanding of falls/injury prevention and home safety measures, did not have interventions to address these educational needs. Each intervention was to Assess. In HOSRR12, the goal of Patient will remain free of falls until 6/22/22 had only the intervention Ask patient about falls at every visit. These observations were discussed with the Director of Hospice.

Observed in Record Review. In 3 of 16 patient records reviewed, the hospice surveyor noted that the plan of care did not address all needs identified in the comprehensive assessment. For example, in review of the medical record for HOSHV1, HOSHV2, and HOSRR1, the patient was identified as being at risk for falls but this was not addressed in the plan of care. This observation was discussed with the Care Team Coordinator.

Observed in Record Review. In 8 of 16 patient records reviewed, the hospice surveyor noted that the organization had not specified the unique medications and treatments necessary to meet the patient's needs. For example, in review of the medical record for HOSHV1, the plan of care contained the following order: Insulin Aspart PenFill 100 units/mL injectable solution; Inject 15-25 units injectable 3 times a day (before meals). It was not specified under what circumstances each dosage should be administered. In review of the medical record for HOSHV2, the surveyor found that the plan of care had Norco and Tylenol ordered as needed for pain without further defining when each one should be taken. This patient also had an order for Lorazepam 0.5 mg oral tablet; Take 0.5-1 tab(s) oral Every 8 hours as needed; Sob/Anxiety. It was not specified under what circumstances each dosage should be administered. In review of the medical record for HOSHV3, the surveyor found that the plan of care had Promethazine HCl, Codeine Phosphate, Tessalon perles and Tussionex ordered as needed for cough without further defining when each one should be taken. In review of the medical record for HOSRR3, the plan of care had oxycodone and acetaminophen ordered as needed for pain without further defining when each one should be taken. In review of the medical record for HOSRR4, the plan of care had oxycodone, lidocaine and acetaminophen ordered as needed for pain without further defining when each one should be used. In addition, mometasone was ordered as needed but did not include an indication for use. In review of the medical record for HOSRR8, the plan of care had Norco, Morphine, and acetaminophen ordered as needed for pain without further defining when each one should be used. In review of the medical record for HOSRR9, the plan of care had morphine and acetaminophen ordered as needed for pain without further defining when each one should be used. In review of the medical record for HOSRR12, the plan of care had hydromorphone and acetaminophen ordered as needed for pain without further defining when each one should be used. This was discussed with the Care Team Coordinator and/or the Director of Hospice.

Observed in Record Review. In 1 of 11 patient records reviewed, where the patient had hospice aide services ordered, the hospice surveyor noted that the organization had not completed a supervisory visit at least every 14 days. For example, in review of the medical record for HOSHV2, supervisory visits were completed on 2/22, then on 3/11 and then on 3/29. This was discussed with the Care Team Coordinator

Observed in Record Review. In 2 of 10 patient records reviewed, where the patient had oxygen ordered, the hospice surveyor did not find where the organization had informed and educated the patient, family, and/or caregiver about the following: - The findings of the oxygen safety risk assessment - The causes of fire - Fire risks for neighboring residences and buildings - Precautions that can prevent fire-related injuries - Recommendations to address the specific identified risk(s). This education was not in evidence within the medical record for HOSRR5 and HOSRR10. This observation was discussed with the Director of Hospice.

Observed in Building Tour. During the tour of the hospice inpatient unit, the hospice surveyor observed sprinkler head filaments that were covered with dust or other foreign material. The sprinklers were observed in the following areas: Pantry- 1 sprinkler; Kitchen Office-2 sprinklers; Kitchen- 4 sprinklers; Hallway- 3 sprinklers. This was verified onsite by the Facility Manager. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. During the tour of the hospice inpatient unit, the hospice surveyor observed two penetrations above the ceiling, through the firewall at the stairwell that were not completely sealed. This was verified onsite by the Facility Manager. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.