Every finding on record at Mount Evans Hospice, Inc

Based on interview and record review, the hospice failed to ensure a registered nurse (RN) made an on-site visit to the patient's home at least every 14 days to assess the quality of care and services by the hospice home health aide (HHA) and ensure services met the needs of the patient in 10 of 12 patient records reviewed who received HHA services (Patients #1, #2, #3, #5, #7, #9, #10, #12, #13 and #15). --- Findings include: 1. The clinical record for Patient #5 was reviewed on 8/9/23. The patient was admitted for hospice care and services on 5/17/23 with a terminal diagnosis of heart failure. The plan of care (POC) for the certification period dated 5/17/23 to 7/15/23 included orders for skilled nursing (SN) services three times a week for three weeks the weeks, one time a week for one week, two times a week for four weeks and ten visits as needed (PRN) for end of life (EOL), falls and symptom management; HHA services one time a week for nine weeks; Chaplain to evaluate and treat PRN; and Medical Social Worker (MSW) to evaluate and treat PRN. The patient resided at home. Subsequent POC for the certification period dated 7/16/23 to 9/13/23 included orders for SN services two times a week for eight weeks and ten visits PRN; HHA services one time a week for 10 weeks; MSW services one time a month for two months and two visits PRN; and Chaplain services PRN. a) Clinical record review revealed the hospice failed to ensure HHA supervisory visits were completed, at a minimum, every 14 days. Review of the clinical record from 5/17/23 to 8/9/23 revealed Patient #5 received SN and HHA visits in accordance with the POC. However, the record failed to reveal documentation of four required supervisory visits during the certification period dated 5/17/23 to 7/15/23 and documentation of two required supervisory visits during the certification period dated 7/16/23 to 9/13/23. The was a total of six supervisory visits without documentation of completion to ensure Patient #5 received appropriate HHA services in accordance with the POC. During an interview on 8/9/23 at 3:59 p.m., RN #6 stated she was the RN for Patient #5, had completed a separate visit note for each required HHA supervisory visit and they should all be found in the record under the visit management section. She further stated the supervisory visit notes were in the record however, when she reviewed the record on 8/9/23, the HHA supervisory visits notes were no longer there and she was not sure what happened to them. She stated there had been an update to the electronic medical record (EMR) system last night and now the notes were gone. She stated she completed the most recent supervisory visit on 8/4/23 and added the note to the record at that time but confirmed it was no longer in the record as of 8/9/23. During an interview on 8/9/23 at 4:10 p.m., the alternate administrator (Employee #7) confirmed the supervisory visit notes for Patient #5 were not in the EMR. She stated there may have been a glitch with the EMR and would contact the EMR company to find out why the notes were no longer available. During interview on 8/10/23 at approximately 12:31 p.m., Employee #7 stated on 7/14/23 there was a co-visit between RN #6 and HHA #5 and RN #6's documentation showed there was some teaching that was done. However, further review of the note did not indicate it had been a supervisory visit, nor did it contain any information regarding a supervisory visit. An interview with HHA #5 was not able to be completed during the survey. 2. The clinical record for Patient #3 was reviewed on 8/7/23. The patient was admitted for hospice care and services on 11/11/22 with a terminal diagnosis of acute respiratory failure with hypoxia. The POC for the certification period dated 5/10/23 to 7/8/23 included orders for SN one time a week for eight weeks and six visits PRN for change in condition requiring SN assessment, symptom management, EOL care and assessment of death and post mortem care; HHA services one time a day for one day and then two times a week for eight weeks; and MSW services two times a month for two months and two visits PRN for change in condition, long range planning, emotional support/counseling and resource coordination. The patient resided in a skilled nursing facility (SNF). Subsequent POC for the certification period dated 7/9/23 to 9/6/23 included orders for SN services one time a week for nine weeks and six visits PRN for change in condition requiring SN assessment, symptom management, EOL care, assessment of death and post mortem care; HHA services two times a week for eight weeks then one visit on 9/4/23; MSW services two times a month for two months and two visits PRN for change in condition, long range planning, emotional support/counseling and resource coordination; and Chaplain services every two weeks for nine weeks and four visits PRN for decline in condition. a) Clinical record review revealed the hospice failed to ensure HHA supervisory visits were completed, at a minimum, every 14 days. Review of the clinical record 5/17/23 to 8/9/23 revealed Patient #3 received SN and HHA visits in accordance with the POC. However, the record failed to reveal documentation of four required supervisory visits during the certification period dated 5/10/23 to 7/8/23 and documentation of two required supervisory visits during the certification period dated 7/9/23 to 9/6/23. The was a total of six supervisory visits without documentation of completion to ensure Patient #3 received appropriate HHA services in accordance with the POC. During interview on 8/9/23 at 1:28 p.m., RN #4 stated supervisory visits should be completed every fourteen days and the EMR sent alerts to remind her when the supervisory visit was due. She stated she knew she needed to make sure her supervisory visits were well documented and often documented on both a mobile iPad and a mounted iPad in her home. RN #4 confirmed there were no supervisory visits documented in the EMR between 5/17/23 and 8/9/23 for Patient #3 and further stated she would ensure both her iPads were synced this evening so the visits would show in the record. Additional review of the record for Patient #3 on 8/10/23 failed to show any documentation of supervisory visits completed. 3. The clinical record for Patient #7 was reviewed on 8/10/23. The patient was admitted for hospice care and services on 2/18/21, with a terminal diagnosis of cerebrovascular disease. The POC for the certification period dated 4/9/23 to 6/7/23 included orders for SN visits one time a week for nine weeks and 12 visits PRN to provide nursing assessment, symptom management, EOL care and assessment of death and post mortem care; MSW visits twice weekly for two months and two visits PRN for change of condition, long range planning, emotional support and counseling and resource coordination; and HHA services once daily for one day and then twice weekly for eight weeks for assistance with hygiene, support and post mortem care. The patient resided in a SNF. Subsequent POC for the certification period dated 6/8/23 to 8/6/23 included orders for SN visits once weekly for eight weeks and six visits PRN for symptom management, wound care, decline in condition and post mortem care; and HHA services once weekly for one week and then twice weekly for eight weeks. a) Clinical record review revealed the hospice failed to ensure HHA supervisory visits were completed, at a minimum, every 14 days. Review of the clinical record from 5/1/23 to 8/6/23 revealed Patient #7 received SN and HHA visits in accordance with the POC. Further review revealed HHA supervisory visits were conducted on 5/24/23 and 7/24/23 during the recertification visits. However, the record failed to show documentation of two required supervisory visits during the certification period dated 4/9/23 to 6/7/23 and documentation of three required supervisory visits during the certification period dated 6/8/23 to 8/6/23. This was a total of five supervisory visits without documentation of completion to ensure Patient #7 received appropriate HHA services in accordance with the POC. 4. Similar findings of the hospice failing to complete HHA supervisory visits every 14 days was found with Patients #1, #2, #9, #10, #12, #13 and #15. 5. Review of a document titled "Hospice Education for RN Monthly Meeting," dated 1/19/23 showed the hospice RN staff was educated specifically on the nature and frequency of HHA supervisory visits to include completion every 14 days on-site and at least once annually with direct observation of the HHA. Further review showed the training was attended by seven agency RNs including RNs #4, #6 and #8. 6. During an interview on 8/10/23 at 12:44 p.m., Employee #9 stated the Quality Assurance (QA) RN (Employee #10) stated she checked for completed supervisory visits every time a patient was recertified. QA RN #10 confirmed the EMR had not been sending the notifications to hospice RNs to complete the necessary supervisory visits, nor was she receiving the notifications the supervisory visits had not been completed. During a further interview at 1:26 p.m., Employee #9 stated the completion of the supervisory visits "fell under the radar" and were not completed. She stated no one received the alerts to complete them and no one received the alerts they weren't completed. She stated this was likely due to a "glitch" with the EMR and hospice staff had been working with the EMR company since yesterday, when the state agency (SA) surveyors notified the hospice of the issue, to immediately rectify the situation.