Every finding on record at Navigate Ahm LLC

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene, use of gloves, mask, eye protection, or face shield depending on anticipated exposure, safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids, safe handling of soiled items in the patient’s care environment, other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, interview, and observation. In 2 of 3 (67%) home visit observations it was revealed that the organization did not ensure the staff followed the agency’s hand hygiene policy. Agency policy, “Hand Hygiene IC.15,” stated in part, “Hand hygiene with soap and water. Staff will apply the amount of product recommended by the manufacture to hands and rub hands together vigorously for at least 15 seconds. Staff will dry their hands and wrists thoroughly with a clean paper towel. They will use a paper towel to turn off the faucet. Hand hygiene with an alcohol-based hand rub. Alcohol-Based Hand Rub – An alcohol-containing preparation designed for application to the hands for reducing the number of viable microorganisms on the hands. In the United States, such as preparations usually contain 60%-95% ethanol or isopropanol. Staff will rub hands together covering all surfaces of hands and fingers, until hands are dry. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations. Staff may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situations described below, prior to entry into the supply bag, immediately before touching a patient, after touching a patient or the patient’s immediate environment.” Home Visit 2: During the home visit (Clinical Record 2) on 11/1/2023 with the Hospice Aide (HA) (Staff 8), the HA was observed to go to the sink and wash her hands with water. There was an empty bottle of soap in the sink. The aide turned off the water with her clean hand. The aide looked for a towel by opening cabinets with her clean wet hands. The family stated that there were no towels in the house. The aide then used hand sanitizer to wash her hands before entering the bag. The HA did not wait for the hands to dry before entering the bag to retrieve vital sign equipment. The HA took the patient’s vitals then led the patient to the kitchen sink to wash hands. The HA washed the patient’s hands and her hands with water only. The HA then dried off her hands and the patient’s hand with the same clean chux and did not use a clean paper towel to dry her hands as described in agency policy. Home Visit 3: During the home visit (Clinical Record 4) on 11/1/2023 with the Registered Nurse (RN) (Staff 2), the RN was not observed sanitizing her hands per agency policy prior to reaching into her bag to remove equipment to be used in patient care. The RN was observed reaching into the nursing bag to remove a Lysol wipe and used it to wipe her hands. The agency’s hand hygiene policy did not include Lysol wipes as an acceptable form of hand hygiene. As the RN removed equipment from the bag, she used the same Lysol wipe to clean the thermometer, blood pressure cuff, stethoscope, measuring tape and pulse oximeter prior to taking vital signs. She was also observed using the same Lysol wipe to clean the equipment prior to returning equipment to her bag and after use on the patient. During an interview on 11/2/2023, the Administrator agreed the staff did not follow the agency’s hand hygiene policy.

It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of the four (4) training and competency evaluations programs described below. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personnel records of hospice aides reviewed revealed the organization did not ensure that hospice aide services were provided by an individual who has successfully completed one of the four training programs. Personnel Record 8: (Hospice Aide); hire date 9/26/2023. The Hospice Aide job description signed by the employee listed qualifications: minimum of one year of CNA/HHA/HA experience. License Certification: Registered with the State CNA registry, HHA certification preferred. There was no documented evidence that the hospice aide completed one of the four training programs. There was no documented evidence that the hospice aide had completed one of the four training programs, had a minimum of one year of CNA/HHA/HA experience or that the hospice aide was registered with the State CNA registry or certified as an HHA. During a joint record review and an interview with the Administrator on 11/2/2023, the Administrator agreed, there was no documented evidence that the hospice aide completed a training program or met the minimum qualifications listed on the hospice aide job description. Additionally, the Administrator stated, “we aren’t having the aide do any more visits, we discussed with the nurses and the nurses will provide the care until a new hospice aide is hired, we have one we are arranging an interview with.”

It is required that the individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program. The hospice maintains documentation that each hospice aide has met the requirements. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 1 (100%) personnel records of hospice aides reviewed revealed the organization did not ensure that a competency evaluation was completed prior to the aide performing care independently. Agency policy, “Hospice Aide/Homemaker Competency Evaluation, HR.45,” stated in part, “The Hospice will ensure that each Hospice Aide successfully completes a hospice aide skills and competency evaluation in accordance with federal and state laws and regulations prior to the aide performing care independently. The Registered Nurse will document observation of skills as required and will sign and date the completed checklist.” Personnel Record 8: (Hospice Aide); hire date 9/26/2023. There was no evidence that a Registered Nurse (RN) documented that a skills competency evaluation was completed at the time of hire and prior to the aide providing patient care according to the agency’s policy. During a joint record review and an interview with the Administrator on 11/2/2023, the Administrator agreed, there was no documented evidence a hospice aide skills competency was completed.

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. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review and interview. In 5 of 8 (62%) clinical records reviewed, the agency did not ensure that the medication profile included all the patient's current medications. Agency policy Medication List and Monitoring PC.85, stated in part, the Hospice will maintain a current, accurate list of all prescription and over the counter medications taken by the patient. The medication will be documented on the medication profile. The medication profile will also include, dosage, frequency, route. Clinical Record 1: The patient elected the hospice benefit on 04/28/2023, with a terminal diagnosis of Alzheimer’s disease. The current medication profile in the medical record included an order that stated Senna Plus 50-8.6mg 1 capsule orally as needed for constipation, effective date 04/28/2023. The medication order on the plan of care did not include a frequency of administration for this “as needed” medication. During interdisciplinary team (IDT) meetings dated 05/15/2023, 05/30/2023, 06/13/2023, 06/27/2023, 07/11/2023, 07/25/2023, and 08/08/2023, the IDT documented the medication profile had been reviewed at each meeting. Clinical Record 2: The patient elected the hospice benefit on 08/09/2023, with a terminal diagnosis of cerebral vascular accident. The hospice plan of care dated 08/09/2023 included an order for oxygen at 2 liters per minute via nasal cannula. The Registered Nurse documented in the comprehensive assessment dated 08/09/2023 that the patient had oxygen at 2 liters per minute via nasal cannula as needed for dyspnea. Oxygen was not included on the patient's medication profile. Clinical Record 3: The patient elected the hospice benefit on 08/05/2023, with a terminal diagnosis of lung cancer. The hospice plan of care dated 08/05/2023 included an order for oxygen at 2 liters per minute via nasal cannula. The Registered Nurse documented in the comprehensive assessment dated 08/09/2023 that the patient had oxygen at 2 liters per minute via nasal cannula as needed for dyspnea. Oxygen was not included on the patient’s medication profile. A physician’s order dated 08/05/2023 ordered, Haloperidol 2mg/ml .5-1ml orally every six hours as needed for agitation and Zofran 4 mg 1 orally every four hours as needed for nausea. Review of the patient’s medication profile revealed Haloperidol 2mg/ml .5-1ml orally as needed for agitation and Zofran 4mg orally as needed for nausea. The medication profile did not include the frequency of administration for Haloperidol and Zofran as ordered by the physician. Clinical Record 4: The patient elected the hospice benefit on 06/14/2023, with a terminal diagnosis of breast cancer. The hospice plan of care dated 06/14/2023 included an order for oxygen at 3-4 liters per minute via nasal cannula as needed for dyspnea. The Registered Nurse documented in the comprehensive assessment dated 06/14/2023 that the patient had oxygen at 3-4 liters per minute via nasal cannula as needed for dyspnea. Oxygen was not included on the patient’s medication profile. A physician’s order dated 06/14/2023 ordered, Acetaminophen 500mg 1-2 tablets by mouth every six hours as needed for pain. Review of the patient’s medication profile revealed Acetaminophen 500mg 1-2 tablets by mouth every six hours as needed but did not include an indication or reason for administration of the medication. The medication profile was documented as reviewed at the interdisciplinary team (IDT) meeting dated 06/27/2023. Clinical Record 8: The patient elected the hospice benefit on 06/14/2023, with a terminal diagnosis of chronic obstructive pulmonary disease. The hospice plan of care dated 06/14/2023 included an order for oxygen at 4 liters per minute via nasal cannula as needed for dyspnea. The Registered Nurse documented in the comprehensive assessment dated 06/14/2023 that the patient had oxygen at 4 liters per minute via nasal cannula as needed for dyspnea. Oxygen was not included on the patient’s medication profile. The medication profile was documented as reviewed at the interdisciplinary team (IDT) meeting dated 06/27/2023. During an interview dated 08/24/2023, the Director of Patient Care Services reviewed the records and stated that the drug profiles had since been corrected.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. This standard was not met as evidenced by clinical record review and interview. In 2 of 8 (25%) clinical records reviewed, the agency did not ensure the initial bereavement assessment was completed as part of the initial comprehensive assessment. Clinical Record 1: The patient elected the hospice benefit on 04/28/2023, with a terminal diagnosis of Alzheimer’s disease. The initial bereavement assessment was dated 07/06/2023, 69 days after the start of care, and was not included in the initial comprehensive assessment. Clinical Record 3: The patient elected the hospice benefit on 08/05/2023, with a terminal diagnosis of lung cancer. The initial bereavement assessment was dated 08/18/2023, 13 days after the start of care, and was not included in the initial comprehensive assessment. During an interview dated 08/24/2023, the Director of Patient Care Services reviewed the records and stated the assessments had been completed late and now understood that the initial bereavement assessment needed to be completed as part of the initial comprehensive assessment.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by review of clinical records and interview with the Director of Patient Care Services which revealed the following issues with the development and implementation of patients’ interdisciplinary care plans: failure to ensure the individualized written plan of care was established in collaboration with the patient or the patient representative [HCPC.19.I/L543]; failure to ensure that each patient’s individualized written plan of care included a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs [HCPC.21.I/L547]; and failure to ensure that care and services were provided in accordance with the plan of care [PCPC.23.D/L555]. The cumulative effect of this deficiency has resulted in the hospice agency's inability to ensure the provision of quality care for the Condition of Participation CFR 418.56, Interdisciplinary group, care planning, and coordination of services. This deficient practice illustrated a systemic process failure that had the potential to affect all patients receiving hospice care services from the agency.

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG [interdisciplinary group] in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 2 of 8 (25%) clinical records reviewed, the agency did not ensure that the individualized written plan of care was established in collaboration with the patient or the patient representative. Clinical Record 1: The patient elected the hospice benefit on 04/28/2023, with a terminal diagnosis of Alzheimer’s disease. The hospice IDG documented review and updates to the patient’s plan of care at IDG meetings dated 05/15/2023, 05/30/2023, 06/13/2023, 06/27/2023, 07/11/2023, 07/25/2023 and 08/08/2023. There was no documented evidence of patient/caregiver involvement in the updates to the patient’s plan of care. Clinical Record 3: The patient elected the hospice benefit on 08/05/2023, with a terminal diagnosis of lung cancer. The IDG documented review and updates to the patient plan of care at the IDG meeting dated 08/08/2023. There was no documented evidence of patient/caregiver involvement in the updates to the patient’s plan of care. During an interview dated 08/24/2023, the Director of Patient Care Services reviewed the IDG notes and updated care plans and stated the box they normally check to indicate patient /caregiver involvement and agreement with care planning had inadvertently been left blank.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including 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 1 of 8 (12%) clinical records reviewed, the agency did not ensure that each patient’s individualized written plan of care included a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. Clinical Record 1: The patient elected the hospice benefit on 04/28/2023, with a terminal diagnosis of Alzheimer’s disease. Hospice aide services were initiated per physician's order dated 06/27/2023. The hospice plan of care was reviewed and updated at IDT [interdisciplinary team] meetings dated 06/27/2023, 07/11/2023, 07/25/2023 and 08/08/2023. These updated plans of care did not include a visit frequency for the hospice aide. During an interview dated 08/24/2023, the Director of Patient Care Services reviewed the record and agreed the aide frequency had been inadvertently omitted from the plans of care.

It is required that the hospice’s policies and procedures define a system of communication and integration that sustains coordination of services and provides documentation of exchange of information. The policies and procedures ensure that care and services provided are in accordance with the plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 8 (50%) clinical records reviewed the agency did not ensure that care and services were provided in accordance with the plan of care. Clinical Record 1: The patient elected the hospice benefit on 04/28/2023, with a terminal diagnosis of Alzheimer’s disease. The hospice plan of care dated 04/28/2023 ordered the Skilled Nurse (SN) frequency two times a week, the Medical Social Worker (MSW) once a month and the Chaplain once a month. The SN provided a visit at the start of care dated 04/28/2023. The was no documented evidence in the clinical record that the nurse provided a second visit the week of 04/28/2023. The clinical record contained no evidence of MSW visits for the months of May and July 2023 and no evidence of Chaplain visits for the months of April and June 2023. The clinical record contained no documentation to explain the reasons for these missed visits. Clinical Record 5: The patient elected the hospice benefit on 06/08/2023, with a terminal diagnosis of chronic obstructive pulmonary disease. The hospice plan of care dated 06/08/2023 ordered the SN frequency two times a week and the Medical Social Worker (MSW) one time each month. The SN provided a visit at the start of care dated 06/08/2023. There was no documented evidence in the clinical record that the nurse provided a second visit the week of 06/08/2023. The clinical record contained no evidence of a MSW visit for the month of June 2023. The clinical record contained no documentation to explain the reasons for these missed visits. Clinical Record 7: The patient elected the hospice benefit on 07/21/2023, with a terminal diagnosis of end stage renal disease. The hospice plan of care dated 07/21/2023 ordered the SN frequency two times a week. Review of the start of care comprehensive assessment dated 07/21/2023 revealed the SN documented the planned frequency of visits was three times per week. Clinical record review revealed two SN visits had been completed the week of 07/21/2023 and three SN visits had been completed for the weeks of 07/24/2023 and 07/31/2023. Clinical Record 8: The patient elected the hospice benefit on 06/14/2023, with a terminal diagnosis of chronic obstructive pulmonary disease. The hospice plan of care dated 06/14/2023 ordered the Chaplain to visit once each month. The clinical record contained no evidence of a Chaplain visit for the month of June 2023. The clinical record contained no documentation to explain the reasons for these missed visits. During an interview dated 08/24/2023, the Director of Patient Care Services reviewed the associated records and identified the missing visits and stated that the charts had since been corrected with missed visit entries and documented physician communication.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 4 (25%) clinical records reviewed that included bereavement services, the agency did not ensure that a post death bereavement assessment was completed as per agency policy. Agency policy Bereavement PC. 130, stated in part, after the death of a patient the Bereavement Coordinator will complete a follow -up assessment and develop a POC [plan of care] for bereavement services based on the re-assessment and the family and/or caregiver's willingness to receive services Clinical Record 4: The patient elected the hospice benefit on 06/14/2023, with a terminal diagnosis of breast cancer. The patient’s death was dated 06/20/2023. The Bereavement plan of care was initiated on 06/20/2023 however there was no evidence of a post death follow-up bereavement assessment as stated in agency policy. During an interview dated 08/24/2023, the Director of Patient Care Services reviewed the record and stated that the assessment could not be located and had inadvertently been missed.

It is required that a hospice aide provides services, ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by clinical record review and interview with the Director of Patient Care Services, which revealed the following issues regarding Hospice Aide services: failure to ensure written patient care instructions for a hospice aide were prepared by a Registered Nurse who is responsible for the supervision of the hospice aide [HCDT.15.I/L625]; failure to ensure the hospice aide provided services as ordered on the aide plan of care aide assignment [HCDT.16.I/L626]; and failure to ensure hospice aides are supervised by a Registered Nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days [HSRM.25.I/L629]. The cumulative effect of this deficiency has resulted in the hospice agency's inability to ensure the provision of quality care for the Condition of Participation CFR 418.76, Hospice Aide and Homemaker Services. This deficient practice illustrated a systemic process failure that had the potential to affect all patients receiving hospice care services from the agency.

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 1 of 2 (50%) clinical records reviewed that included hospice aide services, the agency did not ensure written patient care instructions for the hospice aide were prepared by a RN who is responsible for the supervision of the hospice aide. Clinical Record 1: The patient elected the hospice benefit on 04/28/2023, with a terminal diagnosis of Alzheimer’s disease. Aide services were initiated on 06/27/2023 per physician's order. The hospice aide care plan assignment was created and signed by the Administrator on 08/16/2023, 50 days after the physician ordered aide services for the patient. The Administrator that signed the aide care plan assignment is not an RN. The aide plan of care assignment included the following tasks but did not include a frequency for each task, TPR [temperature, pulse, respirations], encourage fluids, clothing assist, foot care, nail care, skin care, bed bath, oral care, peri care and shower. During an interview dated 08/24/2023, the Director of Patient Care Services (DPCS) stated the Administrator had originally created the hospice aide care plan while on the phone with the software vendor. The DPCS confirmed the aide care plan had since been reviewed, corrected and signed.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed that included hospice aide services, the agency did not ensure that hospice aide services were provided as ordered on the plan of care. Clinical Record 1: The patient elected the hospice benefit on 04/28/2023, with a terminal diagnosis of Alzheimer’s disease. Hospice aide services were initiated per physician's order dated 06/27/2023. There was no documented evidence of aide tasks completed for the aide visit dated 07/05/2023 and no documented explanation as to why care was not provided at the visit. Clinical Record 7: The patient elected the hospice benefit on 07/21/2023, with a terminal diagnosis of end stage renal disease. The hospice aide plan of care assignment dated 07/21/2023 ordered the aide frequency of visits once a week. The clinical record contained no documented evidence of an aide visit the week of 07/21/2023. During an interview dated 08/24/2023, the Director of Patient Care Services reviewed the associated records and agreed with the findings that no care had been documented and a visit was missed for the hospice aide.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed, that included hospice aide services, the agency did not ensure the completion of aide supervisory visits every 14 days. Clinical Record 1: The patient elected the hospice benefit on 04/28/2023, with a terminal diagnosis of Alzheimer's disease. Hospice aide services were initiated per physician's order dated 06/27/2023. The clinical record contained no documented evidence of aide supervisory visits by the Registered Nurse from 06/27/2023 through 07/20/2023. During an interview dated 08/24/2023, the Director of Patient Care Services reviewed the record and was unable to locate an aide supervisory visit prior to 07/20/2023 and stated the supervisory visits were inadvertently missed.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. This standard was not met as evidenced by clinical record review and interview. In 2 of 8 (25%) clinical records reviewed, the agency did not ensure that the hospice medical director or physician designee reviewed the clinical information for each patient being evaluated for admission and provided written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. Clinical Record 2: The patient elected the hospice benefit on 08/09/2023, with a terminal diagnosis of cerebral vascular accident. At the time of record review on 08/24/2023, there was no documented evidence in the clinical record that the physician completed the certification of terminal illness (CTI). Clinical Record 4: The patient elected the hospice benefit on 06/14/2023, with a terminal diagnosis of breast cancer. At the time of record review on 08/24/2023, there was no documented evidence in the clinical record that the physician completed the certification of terminal illness (CTI). During an interview dated 08/24/2023, the Director of Patient Care Services (DPCS) reviewed the records and was unable to locate the CTI for each record. The DPCS stated CTIs have been placed on the agenda for IDT meeting and stated CTI forms had since been created and were pending physician review and completion.