Every finding on record at Northwest Healthcare Alliance, Inc

Based on record review and interview, the agency failed to uphold the patient's right to exercise their rights as a hospice patient and to voice grievances regarding treatment or care that is, or fails to be, furnished by the hospice agency, by failing to comply with federal regulations and internal processes in their response to the patients appeal of their discharge for 2 of 2 live discharge patients. Failure to follow federal regulations and internal processes for patients appealing the agencys determination of their ineligibility to receive hospice services puts patients at risk of physical and emotional harm from denial of palliative and end-of-life care. --- Findings included: 1. Record review of the agency's Patient Rights and Responsibilities document showed that the patient has the right to exercise his or her rights as a patient of the hospice, and voice grievances regarding treatment or care that is (or fails to be) furnished and must not be subjected to discrimination or reprisal for doing so. 2. Record review of the agency's policy titled, "Live Discharge/Transfer of the Hospice Patient." The policy showed that patients who are no longer eligible for the Medicare hospice benefit due to no longer meeting the eligibility requirements will be provided with a Notice of Medicare Non-Coverage (NOMNC) to inform the patient/representative of their right to appeal the decision. The NOMNC will be provided to the patient at least 2 calendar days before Medicare hospice services end, even if the patient agrees with the hospice's decision to discharge. The Detailed Explanation of Non-Coverage (DENC) must only be provided if the patient/representative chooses to appeal the hospice's decision to discharge. 3. Record review for 2 of 2 live-discharged hospice patients showed the following: a. Patient #301 was admitted to hospice care on 03/22/23 with a primary diagnosis of severe calorie protein malnutrition. Patient #301 was discharged on 03/15/24 due to no longer meeting eligibility requirements. The record showed a Medicare Election Form signed by the patient's Power of Attorney (POA) on 03/22/23. The form showed that the patient received a copy of the Patient Rights and Responsibilities document. The record showed that the patient representative signed the Notice of Medicare Non-Coverage (NOMNC) on 03/07/24. The NOMNC allows the beneficiary to appeal the hospice agency's decision to discharge the patient. The patient representative appealed the discharge with the Quality Improvement Organization (QIO) Kepro through the hospice expedited determination process on 03/07/24. The agency received the appeal notice on 03/08/24 according to the timestamp on the fax. The record showed no evidence that the agency responded to the appeal notification by sending the requested medical records for review. The record showed no evidence that the IDG team discussed the patient's appeal prior to discharge. The record also showed no evidence that the agency provided the Detailed Explanation of Non-Coverage (DENC) as required when a patient requests an expedited determination or an additional NOMNC which allows the patient to appeal the agency's decision to proceed with discharging the patient. Record review of documents submitted by Patient #301's POA showed an email from Patient #301's POA to the agency's Patient Care Manager (Staff #303) sent on 03/15/24. The email stated that the POA still had serious concerns regarding the agency's decision to discharge Patient #301. The email stated that they had not received the requested agency policies and procedures used to determine Patient #301's discharge from the agency. The documents showed an email response from the Patient Care Manger (Staff #303) to Patient #301's POA on 03/15/24 that stated that Patient #301 would be discharged effective today, 03/15/24. Discharge paperwork would be mailed to the POA's home. The documents showed no evidence that Staff #303's response addressed the POA's ongoing concerns documented in the emails or provided the POA with the requested documents prior to Patient #301 being discharged from hospice services. On 05/15/24 at 1:00 PM, the Investigator interviewed the Patient Care Manager (Staff #303) about the agencys response to the appeal notification. Staff #303 stated that the agency submitted the requested documents; however, they were unable to provide evidence of what was submitted due to the Care Coordinator responsible for submitting the documents no longer being employed at the agency. Staff #303 also stated that they were aware that the patient ";won" the appeal prior to discharge. Staff #303 stated that it was their understanding that the patient ";won" the appeal because the agency did not submit the documentation in time and not because they determined the patient to be eligible for services. b. Patient #302 was admitted to hospice services on 07/19/22 with a primary diagnosis of malignant neoplasm of upper-inner quadrant of right female breast. Patient #302 was discharged from hospice services on 03/08/24 due to no longer meeting eligibility requirements. The record showed a Medicare Election Form signed by the patient on 07/19/22. The form showed that the patient received a copy of the Patient Rights and Responsibilities document. The record showed that the patient signed the Notice of Medicare Non-Coverage (NOMNC) on 03/06/24. The NOMNC allows the beneficiary to appeal the hospice agency's decision to discharge the patient. The patient representative appealed the discharge with the Quality Improvement Organization (QIO) Kepro through the hospice expedited determination process on 03/06/24. The agency received the appeal notice on 03/07/24 according to the timestamp on the fax. The record showed a "Checklist of Requested Disclosure of Protected Health Information" completed on 03/08/24 to release patient records to Kepro. The record showed no evidence that the agency provided the Detailed Explanation of Non-Coverage (DENC) as required when a patient requests an expedited determination or an additional NOMNC which allows the patient to appeal the agency's decision to proceed with discharging the patient. 4. On 05/15/24 at 9:00 AM and 1:00 PM, the Investigator interviewed the Registered Nurse Case Manager (Staff #302) and Patient Care Manager (Staff #303) about the DENC. The Patient Care Manager and Registered Nurse Case Manager stated that they were unaware of the requirement to issue a DENC to the patient as part of the appeal process. They both also stated that they were unfamiliar with the live-discharge process and expedited determination process.

Based on record review and interview, the agency failed to ensure that the clinical record included all required documentation for a patient who is discharged from hospice services in accordance with §418.26, including the physician's order for discharge. Failure to obtain the physician's order for discharge places the patient at risk of unmet care needs. --- Findings included: 1. Record review of the agencys policy titled, ";Live Discharge/Transfer of the Hospice Patient." The policy showed that a patient must be discharged from hospice services if the patients condition changes such that the patient cannot continue to be certified as terminally ill by the hospice Medical Director or hospice physician. Prior to discharging a patient for any reason other than a patient revocation, transfer, or death, the hospice agency must obtain a written physicians discharge order from the hospice Medical Director. If a patient has an attending physician involved in their care, this physician should be consulted before discharge and their review included in the discharge documentation. When a patient is discharged, relevant information for discharge is documented in the medical record. Documentation is sent to the patients physician and may include the reason for discharge, etc. 2. Record review and interview for 5 of 11 live-discharged patients showed the following: a. Patient #301 was admitted to hospice services on 03/22/23 with a primary diagnosis of unspecified severe protein calorie malnutrition. Patient #301 was discharged from hospice services on 03/15/24 due to the agency determining that they no longer met hospice eligibility requirements. The record showed a Face-to-Face encounter by the hospice Medical Director (Staff #301) dated 02/19/24. The Face-to-Face encounter showed that Staff #301 determined that Patient #301 no longer met the criteria for hospice services and recommended discharge. The record showed no evidence of a written physician's order to discharge Patient #301 from hospice services on 03/15/24. The record showed no evidence that the agency consulted with Patient #301's attending physician prior to discharge or evidence of their review of the discharge plan. The record also showed that the discharge summary was sent to the incorrect attending physician. The records showed that on 09/08/23 during a re-certification visit, the agency was notified that the patient had changed primary care providers. Record review of the agency's "Fax Status Report" showed that on 03/20/24 the "Discharge-Transfer Summary Report" was sent to a Medical Assistant in the original attending physician's office. The record showed that on 03/29/24 the "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" was sent to the original attending physician. The record showed no evidence that Patient #301's new primary care provider received the discharge summary. On 05/15/24 at 9:00 AM, the Investigator interviewed the agency's Registered Nurse Case Manager (Staff #302) about the discharge process for Patient #301. Staff #302 stated that the agency's discharge process is for the nurse to write the discharge order and either the Medical Director or the attending physician would sign the order. Staff #302 stated that they would call and notify the attending physician of the discharge and send the verbal order for signature. Staff #302 stated that they were unaware that the clinical record did not show evidence of a discharge order being written for Patient #301. b. Patient #302 was admitted to hospice services on 07/19/22 with a primary diagnosis of malignant neoplasm of upper-inner quadrant of right female breast. Patient #302 was discharged from hospice services on 03/08/24 due to no longer meeting eligibility requirements. The record showed an order written on 03/15/24 that stated, "Correct Calendar to put RN18 H the week of March 3rd." The record showed no evidence of a written physician's order to discharge prior to Patient #302's discharge on 03/08/24. On 05/15/24 at 9:00 AM, the Investigator interviewed the agency's Registered Nurse Case Manager (Staff #302) about the physician's discharge order. Staff #302 stated that the agency's medical record system uses the visit code RN18 H for a hospice discharge visit. Staff #302 stated that as the Registered Nurse Case Manager they write the discharge order for either the hospice Medical Director or patient's attending physician to sign. Staff #302 also stated that if an order was not located in the chart, then it was not written. c. Patient #303 was admitted to hospice services on 06/01/23 with a primary diagnosis of hemiplegia following CVA. Patient #303 was discharged from hospice services on 03/18/24 due to no longer meeting eligibility requirements. The record showed no evidence of a written physician's order to discharge. d. Patient #304 was admitted to hospice services on 06/28/23 with a primary diagnosis of neurocognitive disorder with lewy bodies. Patient #304 was discharged from hospice services on 12/22/23 due to no longer meeting eligibility requirements. The record showed no evidence of a written physician's order to discharge. e. Patient #305 was admitted to hospice services on 06/12/23 with a primary diagnosis of chronic ischemic heart disease. Patient #305 was discharged from hospice services on 02/02/24 due to no longer meeting eligibility requirements. The record showed no evidence of a written physician's order to discharge. 3. On 05/15/24 at 1:00 PM, the Investigator interviewed the agency's Patient Care Manager (Staff #303) about the agency's live-discharge process. Staff #303 stated that prior to the current Medical Director the agency did not do live-discharges therefore this was a relatively new process for staff. Staff #303 stated that a physician's discharge order is required for live-discharges. Staff #303 acknowledged that the agency failed to obtain a written physician's order for discharge for both Patient #301 and #302.

Based on record review and interview, the agency failed to implement their live-discharge policy which included ensuring that the patient record contained documentation that will assist in the post-discharge continuity of care for the patient. Failure to follow its own discharge policy and ensure that the patient receives continuity of care post-discharge from hospices services may result in unmet care needs for the patient. --- Findings included: 1. Record review of the agency's policy titled, "Live Discharge/Transfer of the Hospice Patient" showed that a patient must be discharged from hospice services if the patient's condition changes such that the patient cannot continue to be certified as terminally ill by the hospice Medical Director or hospice physician. The discharge planning process must be initiated by the Interdisciplinary Group (IDG) team before the date of discharge when a patient's condition stabilizes, if the disease progression has halted, or if there are indications of improvement in the individual's condition such that hospice may soon no longer be appropriate. The patient/representative should be informed of the possibility of discharge should the plateau continue. The discharge planning process must include planning for necessary family counseling, patient education, or other services before the patient is discharged because they are no longer terminally ill. When a patient is discharged, relevant information for discharge is documented in the medical record. 2. Record review for Patient #301 showed they were admitted to hospice care on 03/22/23 with a primary diagnosis of severe calorie protein malnutrition. Patient #301 was discharged on 03/15/24 due to no longer meeting eligibility requirements. The record showed a Medicare Election Form signed by the patient's Power of Attorney (POA) on 03/22/23. The record showed a Face-to-Face visit by the hospice Medical Director on 02/19/24. The note showed that although the patient's weight is very low and they have significant cognitive deficits, their condition and weight have been stable for months. At this time, they no longer meet criteria for hospice services. The hospice Medical Director recommended discharge. The record showed no evidence that the patient or patient representative was informed of the possible discharge when the Medical Director (Staff #301) determined that the patient's condition had stabilized on 02/19/24. The record showed a "Hospice IDG Comprehensive Assessment and Plan of Care Update Report," dated 02/29/24. The document showed no evidence of discharge planning despite being conducted after Staff #301's Face-to-Face encounter that showed that Staff #301 determined that Patient #301 no longer met eligibility requirements. The record showed a hospice re-certification visit on 03/01/24 for the episode 03/16/24 to 05/14/24 completed by a Registered Nurse Case Manager (Staff #302). The re-certification visit showed that Patient #301 continued to meet eligibility requirements because the patient's condition was life limiting. It also showed that "using measurable, objective data, the current clinical status of the patient is different from the clinical status at previous re-certification periods as evidenced by frail, cachectic, 69 lbs, 3 lb total weight loss since admission, stage 2 pressure ulcer to right hip requiring monitoring, wound care, frequent repositioning." "The acuity of the patient or the trajectory of the illness continue to support the terminal prognosis and need for Hospice services related to pain management, skin integrity, safety, emotional support socialization, confused, agitated at times, mostly non-verbal, high risk for falls, infection skin breakdown. Three falls this period, previously rare falls." The record showed a skilled nursing visit on 03/07/24. The record showed that the Registered Nurse Case Manager (Staff #302) met with Patient #301's son/Power of Attorney (POA) and provided the notification of discharge. The note showed that Staff #302 discussed eligibility, durable medical equipment, protocols and the date of discharge. The record showed that Patient #301's POA signed the Notice of Medicare Non-Coverage (NOMNC) on 03/07/24. The NOMNC allows the beneficiary to appeal the hospice agency's decision to discharge the patient. Patient #301's POA appealed the discharge with the Quality Improvement Organization (QIO) Kepro through the hospice expedited determination process on 03/07/24. The record showed a "Hospice IDG Comprehensive Assessment and Plan of Care Update Report," dated 03/18/24. The document showed the same narrative documented on Staff #301's re-certification visit dated 03/01/24 and Staff #301's Face-to-Face encounter dated 02/19/24. This IDG meeting is dated after Patient #301 was discharged on 03/15/24. Agency staff reported that this IDG meeting occurred on 03/14/24, however the record is dated 03/18/24. The IDG note showed no evidence that the IDG team discussed the patient's appeal or the agency's decision to proceed with discharge. The record showed a "Hospice IDG Comprehensive Assessment and Plan of Care Update Report," dated 03/28/24. Staff #301 documented that based on clinical stability, Patient #301 will be discharged from Hospice services. Staff #302 completed the discharge summary and documented the reason for discharge as Patient #301 "no longer meets Medicare criteria for Hospice eligibility. The status of the patient and reason for the discharge was reviewed with the Medical Director and an order for discharge was received. The patient's attending physician was consulted with on 03/01/24 and was in agreement with the plan." This IDG meeting occurred after Patient #301 was discharged on 03/15/24 and showed no evidence of post-discharge continuity of care planning occurred prior to discharge. The record showed no evidence that the agency's IDG team initiated discharge planning when Patient #301's condition stabilized or there were indications of their condition improving. The record showed no evidence that the agency informed the patient or patient representatives of the possibility of discharge from hospice services when Patient #301's condition was determined to have stabilized or there were indications of their condition improving as indicated on the Face-to-Face encounter documented by Staff #301 on 02/19/24. The record showed no evidence that the agency included planning for any necessary family counseling, patient education or other services before Patient #301 was discharged from hospice services. The record showed no evidence that the agency coordinated and consulted with Patient #301's primary care provider prior to their discharge from hospice services to ensure post-discharge continuity of care. 3. On 05/15/24 at 1:00 PM, the Investigator interviewed the agency's Registered Nurse Case Manager (Staff #302) about the discharge process for Patient #301. Staff #302 stated that in hindsight they do believe that Patient #301 no longer met the eligibility requirements for hospice services but that during the re-certification visit on 03/01/24 they did not document this because they were unsure of Patient #301's eligibility until the Medical Director (Staff #301) decided they were ineligible. Staff #302 stated that they discussed the possibility of Patient #301 being discharged with their POA in February 2024 but acknowledged that there is no documentation in the record. Staff #302 also stated that during IDG, the team discussed Patient #301's eligibility status and that they remember discussing more details with Staff #301 but acknowledged that there is no documentation in the record. 4. On 05/15/24 at 1:00 PM, the Investigator interviewed the agency's Patient Care Manager (Staff #303) about the discharge process for Patient #301. Staff #303 stated that they are responsible for adding narrative notes in the IDG document based upon conversations that occur during the IDG meetings. They stated that they had not been adding any narrative notes to the IDG documents, therefore the record does not show the communication between the IDG team regarding the patient's discharge. Staff #303 also acknowledged that the IDG notes do not document communication with the patient or patient representative regarding discharge planning or the agency's actions in response to the appeal. The Investigator also interviewed Staff #303 about the agency's overall discharge process. Staff #303 stated that the agency's discharge process includes watching and monitoring for changes until the re-certification visit. At the re-certification visit staff make their final decision. If discharge is anticipated, then the agency notifies the patient that the IDG team will be discussing possible discharge at the re-certification IDG meeting. The agency would notify the patient typically 2 weeks prior to discharge. If it is determined that the agency will discharge the patient, then staff contact the primary care provider and arrange for medications and equipment. The NMNOC is issued at 48 hours prior to discharge to allow the agency to make a smooth discharge transition.

Based on record review and interview, agency failed to follow the plan of care as ordered by the physician for 1 of 22 patients (Patient #322).Failure to follow the plan of care, as ordered by the physician, could place the patient at risk of worsening symptoms of existing diagnoses. --- Findings included: 1. Surveyor #3 reviewed the record for Patient #322, admitted on 03/20/23 with a primary diagnosis of Alzheimer's Dementia. The review showed: The plan of care dated 03/20/23 showed that the physician ordered Skilled Nursing (SN) services 2 times per week for 13 weeks. For the weeks of 04/16/23, 4/23/23, 04/30/23, 05/21/23 and 06/04/23, Patient #322 only received 1 of 2 SN visits each week. A total of 5 SN visits were missed during the episode from 03/30/23 to 06/17/23. There was no documentation in the record to explain the missed SN visits, nor was there documentation that the physician had been notified of the missed SN visits. The recertification plan of care for the episode from 06/18/23 through 09/15/23 showed that the physician ordered home health aide (HHA) services 1 time per week for 13 weeks. On 07/06/23, the physician ordered HHA visits to increase to 2 times per week. On 07/14/23, the physician ordered the HHA visits to decrease to 1 time per week. Patient #322 only received 1 HHA visit on 07/11/23 for the episode. A total of 8 HHA visits were missed from 06/18/23 to date of survey. There was no documentation in the record to explain the missed HHA visits, nor was there documentation that the physician had been notified of the missed HHA visits. 2. On 07/25/23 at 2:50 PM, Surveyor #3 interviewed the agency's Executive Director (Staff #301) about the lack of documentation and notification to the physician of the missed visits. Staff #301 stated that their electronic medical records, Home Care Home Base, system does not allow the agency to not document missed visits. Staff #301 stated that they were unsure how the agency's system deleted those visits from the patient's calendar without documentation.

Based on record review and interview, the agency failed to implement policies and procedures defining the process for blood borne pathogen exposure, risk assessment and access to vaccinations (Hep B) in compliance with the Washington Administrative Code (WAC). Failure to implement required policies and procedures on the process for blood borne pathogen exposure, risk assessment and access to vaccination may place the clients and staff at risk of exposure to infectious diseases. Reference: WAC 246-335-525 Personnel, contractor and volunteer policies. The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (e) Exposure to bloodborne pathogens such as Hepatitis B and HIV, and other potentially infectious materials in compliance with the department of labor and industries chapter 296-823 WAC. Key elements include, but are not limited to: (i) Conducting an initial risk assessment of the environment in which personnel, volunteers, and contractors perform their assigned duties to determine occupational exposure. The results of the risk assessment will inform policy and procedure development and level of employee training and education. Annually, agencies must determine if significant changes have occurred that would require a new risk assessment to be performed; (ii) If the risk assessment concludes that workers have a reasonably anticipated risk of occupational exposure to blood and other potentially infectious materials, agencies must offer workers the Hepatitis B vaccine series at the agency's expense. Workers have the right to decline the Hepatitis B vaccine series. --- Findings included: 1. Record review for 2 of 6 direct care personnel showed the following: a. A Home Health Aide (Staff #303) was hired on 12/05/22. The record showed that Staff #303 signed the agency's Hepatitis B vaccination acceptance form on 12/05/22. The record showed no documentation that the agency provided Staff #303 the Hepatitis B vaccine series upon hire. b. A Chaplain (Staff #305) was hired on 10/23/17. The record showed that Staff #305 signed the agency's Hepatitis B vaccination acceptance form on 10/24/17. Staff #305 added documentation on the form that they had started the vaccination series in 2012 but did not complete it. The record showed no documentation that the agency provided Staff #305 the Hepatitis B vaccine series upon hire. 2. On 07/26/23 at 9:30 AM, Surveyor #3 interviewed the agency's Business Manager (Staff #302) about the agency's procedure for providing the Hepatitis B vaccination to staff if accepted upon hire. Staff #302 stated that the agency waits until they have 2 staff accept the vaccine series before initiating the series. 3. On 07/26/23 at 11:00 AM, Surveyor #3 interviewed the agency's Executive Director (Staff #301) about the agency's procedure for providing the Hepatitis B vaccination to staff if accepted upon hire. Staff #301 stated that the agency orders the vaccine and provides the vaccine series at the agency. Staff #301 provided no explanation for the agency not providing the vaccine to Staff #303 and #305.

Based on record review and interview, the agency failed to document Home Health Aide (HHA) supervision visits by an RN every 2 weeks for 2 of 22 patients. (Patient #312 and #316) whose records were reviewed and were receiving HHA services for longer than 14 days. Failure to supervise Home Health Aides every 2 weeks places the patients at risk of receiving services that are not reflective of the patient's changing needs. --- Findings included: 1. Record review for 2 of 22 patients showed the following: a. Patient #312 was admitted on 06/02/23 with a primary diagnosis of chronic pancreatitis. The care plan showed that the physician ordered HHA services 2 times per week for 11 weeks. The record showed no documentation that the agency conducted any HHA supervisory visits during the current episode. b. Patient #316 was admitted on 05/08/23 with a primary diagnosis of diffuse large B cell lymphoma. The care plan showed that the physician ordered HHA services 1 time per week for 13 weeks. The record showed no documentation that the agency conducted any HHA supervisory visits during the current episode. 2. On 07/25/23 at 2:30 PM, Surveyor #3 interviewed the agency's Executive Director (Staff #301) about the missing HHA supervisory visits. Staff #301 stated that the RN's assigned to both Patient #312 and Patient #316 were new to the agency and needed education regarding documentation of HHA supervisory visits. Staff #301 also stated that the agency created a performance improvement project for HHA supervisory visits prior to the RN's being hired to improve compliance with HHA supervisory visits.