Every finding on record at Multicare Health System

is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. This standard was not met as evidenced by clinical record review and interview. In 2 of 27 (7%) clinical records reviewed revealed that the agency did not ensure that a comprehensive assessment was completed within 5 days. Clinical Record 15: The hospice benefit election was dated 04/18/2024. The RN performed the initial assessment on 04/18/2024. The chaplain called the patient on 04/19/2024 to inquire about their willingness for chaplain support. The patient's caregiver stated that they would really like to have a chaplain. There was no further contact noted by the chaplain until the chaplain performed an assessment on 04/30/2024 (12 days after the election of hospice care). Clinical Record 20: The RN performed an initial assessment on 07/25/2024 and identified the patient's request for chaplain visits. The chaplain note dated 07/26/2024 indicated that chaplain called and left a message requesting a call back on 07/26/2024. The clinical record contains no follow-up from the chaplain until 08/01/2024. The Chaplain assessment was completed on 08/01/2024 (7 days after the election of hospice care). During a joint record review with the clinical reviewer on 08/08/2024, the finding was confirmed and reported she was unaware there was such a discrepancy with the chaplains getting assessments completed within 5 days.

It is required that the comprehensive assessment includes consideration of the following factors: The nature and condition causing admission, including the presence, or lack of, objective data and subjective complaints symptoms and symptom severity, including dyspnea, nausea, vomiting, constipation, and skin integrity. This standard was not met as evidenced by clinical record review and interview. In 1 of 27 (4%) clinical records reviewed revealed the agency did not ensure the comprehensive assessment included physical assessments that would promote the patient's comfort. Clinical Record 13: The RN recertification assessment was completed on 07/31/2024. The clinical assessment did not contain wound, genitourinary, cardiac, or respiratory assessments. There were no additional notes or documentation to demonstrate that all areas were assessed. During a joint review on 08/07/2024, the clinical reviewer stated in part, "This assessment is not complete. It is missing several elements and should include more detail about the decubitus wound and include GU, Cardiac, and Respiratory assessment. I am not sure how they skipped the elements but we need to lock the software so they can’t skip things."

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review and interview. In 1 of 27 (4%) clinical records reviewed revealed the agency did not ensure that all medications were listed on the drug profile. Clinical Record 13: The medication profile included a new order for a Lidocaine 4% patch to be placed onto the skin once daily. The medication profile and the physician's order did not indicate the location on the body where the lidocaine patch should be placed. The RN visit note on 07/10/2024 read in part, "superficial open area reported to be improving - zinc paste. The zinc paste was not included in the medication profile." On 08/07/2024, the clinical reviewer confirmed finding during joint record review.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments and includes all services necessary for the palliation and management of the terminal illness. This standard was not met as evidenced by clinical record review and interview. In 1 of 27 = 4% clinical records reviewed revealed that the plan of care did not clearly address the interventions for the individualized patient needs. Clinical Record 1: The RN recertification assessment dated 06/17/2024 revealed that the patient had a foley catheter and a skin tear to the right knee. The plan of care for the certification period 07/03/2024 - 09/30/2024 did not give specific instructions related to the foley catheter. There was no description of the size of the foley catheter or balloon. There were no orders regarding when to change or replace the foley catheter. The plan of care also did not address the skin tear to the knee with any orders to clean or dress the area. The plan of care contained an order that stated, special skin care as specified: starting 04/04/2024 clean the wound with wound wash or normal saline, pat dry, apply barrier cream, and cover with foam dressing. Replace foam dressing as needed for soiling or saturation. The plan of care did not describe where the wound to be dressed was located. The clinical record review was completed with the clinical reviewer on 08/06/2024. She confirmed the findings and stated, "Oh yes, this care plan should have specifics."

It is required that each patient’s individualized written plan of care a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 2 of 27 (7%) clinical records reviewed revealed the agency did not ensure that all orders for disciplines included a frequency and duration. Clinical Record 1: The plan of care for the benefit period 07/03/2024 -09/30/2024 contained an order for the chaplain to identify and assist the patient with issues of angst or spiritual distress, and to explore the patient's concept of afterlife. The plan of care did not contain orders for frequency and duration orders. Clinical Record 21: Massage therapy was ordered on 07/01/2024. The order stated, "Massage therapy as a form of non-pharmacological care and support." The order did not contain frequency or duration orders. The clinical reviewer confirmed findings during joint record review on 08/08/2024 and stated, "I don't know how that was missed."

It is required that the hospice maintains a coordinated, agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. This standard was not met as evidenced by personnel record review, document review and interview. In 2 of 12 (17%) personnel records reviewed revealed the agency did not ensure the hospice maintained a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. Document 2: Organization Policy # 14617216 "Blood Borne Pathogens Exposure Control" plan last revised 11/2023 stated in part, "vii. Hepatitis B Vaccination Program: A. All employees, regardless of job risk are strongly encouraged to get the Hepatitis B Vaccine series within (10) days of employment or assignment. B. All employees with potential exposure are required to participate in the program by either taking the vaccine or signing a waiver declining the vaccine." Personnel Record 10: A review of the Volunteer Coordinator's personnel record (DOH 05/13/2019) revealed no documented evidence of receipt of Hepatitis B vaccination status or declination of the vaccination series Personnel Record 12: A review of the Volunteer's personnel record (DOH 09/21/2023) revealed no documented evidence of receipt of Hepatitis B vaccination status or declination of the vaccination series During interview on 08/07/2024, clinical manager reported that the corporate HR did not consider Volunteers and the Volunteer Coordinator at risk, so they did not track Hep B acceptance or declination.

It is required that hospice aides are assigned to a specific patient by a registered nurse (RN) who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 4 of 21 (19%) clinical records with an aide revealed that the agency did not ensure that aide care plans provided enough information to provide appropriate care within the scope of practice. Clinical Record 1: The start of care was 04/04/2024 and revealed that the patient had a colostomy. The RN recertification assessment on 06/17/2024 confirmed that colostomy was still in place. The aide plan of care created by the RN on 04/04/2024 did not include information to address the patient’s colostomy. Clinical Record 13: The start of care was 04/08/2024. The RN visit assessment on 06/11/2024 described a stage 3 pressure ulcer on the coccyx. Wound care orders were obtained on 06/11/2024 and required a dressing to be changed weekly. The aide plan of care dated 06/11/2024 did not provide any instruction to the aide related to the wound care area or dressing on the coccyx. Clinical Record 16: The start of care was 01/04/2024. The RN recertification assessment on 06/28/2024 revealed that the patient had a stage 4 sacral ulcer, a Foley catheter, and a peg tube that was clamped. The aide plan of care developed on 06/28/2024 did not include notification to the aide that the patient had a peg tube or that the patient had a pressure ulcer with a dressing. There were no directions to the aide related to the dressing and what to do with the affected areas during bathing process. Clinical Record 15: The RN start of care assessment on 04/18/2024 revealed that the patient had a seizure disorder. The plan of care dated 04/19/2024 and continuing through the recertification period 07/17/2024-10/14/2024 did not include seizure precautions or notification to the aide that the patient had a seizure disorder. During the clinical record review with the Clinical reviewer on 08/07/2024 and 08/08/2024, the findings were confirmed by the clinical reviewer.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 21 (5%) clinical records reviewed with aide services revealed the agency did not ensure the aide reported and documented the report to the registered nurse (RN) related to changes in patient condition. Clinical Record 26: On 07/02/2024, the aide documented that the patient had a new red rash under the right breast and left side of the groin area. There was no documentation in the clinical record to indicate that the aide notified the RN. The RN visit on the same date of 07/02/2024 did not mention any notifications from the aide and noted that the patient's skin was warm and dry but did not note any rash under the breasts and left side of the groin area. During the record review on 08/08/2024, the clinical reviewer confirmed the clinical record did not contain a notification to the RN related to changes in patient condition.