Every finding on record at Nurses Touch Home Health Provider, Inc.

Observed in HR File Review. In 3 of 9 Hospice HR files reviewed, there was no documentation to validate staff were provided emergency management training at least every 2 years. On HSPHR #4, #7 and #9, the employee has not received emergency management training. This was reviewed and confirmed with the Hospice leadership team.

Observed in Record Review. In 1 of 4 patient records reviewed that were live discharges, the organization did not respect the patient rights to revoke hospice. On review of HSPRRDC #3, the organization did not obtain a revocation for a discharge due to hospitalization. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. On 1 of 14 patient records reviewed the organization failed to complete initial assessment. On HSPRRHV #1, the chaplain and social worker failed to complete an initial assessment within five days after the election of hospice and there was no documentation that refusal of the service took place. This finding was reviewed with the DON.

Observed in Record Review. In 3 out of 7 active patient records reviewed, the organization failed to complete a comprehensive spiritual assessment on admission. Hospice Bereavement assessment policy (2-037.1) states that on admission the MSW or RN will complete a bereavement risk assessment to include survivor needs, services to be provided and grief risk factors. On HSPRRHV #1, it was noted that a bereavement risk assessment was not completed on admission. On HSPRRHV #2, it was noted that the MSW made a visit and identified the bereaved but did not assess survivor needs or grief risk factors. On HSPRRNHV #1, it was noted that the initial bereavement assessment has not been completed and the patient was admitted 1 month ago. This finding was reviewed with hospice leadership.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to ensure the plan of care was updated based on the patient’s reassessment and progress toward goals. In HSPRRNHV #3, the plans of care had not been updated to reflect the current assessment, for example the patient had a healed sacral wound, but the POC goals still reflected a sacral wound. This finding was reviewed with hospice leadership.

Observed in Record Review. In 5 of 7 active patient records reviewed, the organization failed to plan the patient's care with goals that were measurable and time specific. On HSPRRHV #1, goals were not measurable and specific with examples of “Hydration status will be maintained or optimized for comfort”, “Patient will maintain adequate urinary output appropriate to condition”, “Patient will maintain a comfortable and restful sleep pattern appropriate to condition”. On HSPRRHV #2, patient has orders for multiple pain medications but the goals is not measurable and specific to the patient with the goal as “Pain will remain in comfortable level during care.”. On HSPRRHV #3, the goals are not measurable and specific with examples of “verbalize having urinary elimination needs met at an acceptable level” and “Blood sugar management for pt. comfort”. In addition, goals were not measurable or specific on records HSPRRNHV #2 and HSPRRNHV #3 with examples of: “AchievIn 6 of 7 active patient records reviewed, the organization failed to plan the patient's care with goals that were measurable and time specific. On HSPRRHV #1, goals were not measurable and specific with examples of “Hydration status will be maintained or optimized for comfort”, “Patient will maintain adequate urinary output appropriate to condition”, “Patient will maintain a comfortable and restful sleep pattern appropriate to condition”. On HSPRRHV #2, patient has orders for multiple pain medications but the goals is not measurable and specific to the patient with the goal as “Pain will remain in comfortable level during care.”. On HSPRRHV #3, the goals are not measurable and specific with examples of “verbalize having urinary elimination needs met at an acceptable level” and “Blood sugar management for pt. comfort”. In addition, goals were not measurable or specific on records HSPRRNHV #2, HSPRRNHV #3 and HSPRRNHV #4 with examples of: “Achieve and maintain peripheral circulation for Pt comfort”, “promote regular bowel movement”, “Patient will maintain adequate nutritional intake” “Patient will maintain adequate circulation, and “Blood pressure will remain patient-specific acceptable range” This finding was discussed and reviewed with the Hospice leadership team.e and maintain peripheral circulation for Pt comfort”, “promote regular bowel movement”, “Patient will maintain adequate nutritional intake” “Patient will maintain adequate circulation, and “Blood pressure will remain patient-specific acceptable range”. This finding was discussed and reviewed with the Hospice leadership team.

Observed in Record Review. In 3 of 7 active patient records reviewed, the hospice nurse surveyor noted medication orders were not clear and accurate. On HSPRRHV # 1, the physician's orders in the plan of care documented Tylenol extra strength oral tablets” and “acetaminophen suppository both to be used PRN for pain with no indication how to handle the duplicate therapy. On HSPRRHV #3 and HSPRRNHV #2, the physician's orders in the plan of care documented Tylenol oral tablets” and “acetaminophen suppository both to be used PRN for pain with no indication how to handle the duplicate therapy or max dosing per day for acetaminophen use. This was discussed with the hospice team.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization did not provide care and treatment according to the patient's plan of care. On HSPRRDC #3, it was noted that the patient was to have weekly nursing visits and there was no documentation that nursing visits were made the two weeks prior to discharge from service. This finding was reviewed with Hospice Leadership.

Observed in Record Review. On 2 of 4 live discharged records reviewed, the organization did not coordinate care and services with the interdisciplinary team. On HSPRRDC #2 and HSPRRDC #4, discharge planning due to extended prognosis was not prior to discharging patients from service. This finding was reviewed with the Hospice Leadership team.

Observed in HR File Review. In 3 of Hospice HR files reviewed, the surveyor noted the organization failed to provide Blood Borne Pathogen training annually as required by the organization's policy. On review of HSPHR #4, HSPHR#7, HSPHR #9, employees have not received infection control and annual blood borne pathogen training for 2025. This was reviewed and confirmed with the Hospice leadership team.

Observed in Record Review. In 1 out of 1 patient records reviewed with aide services, the organization failed to plan the patient's care. During record review for HSPRRHV#3, the Hospice Nurse Surveyor observed the aide care plan had not been updated to reflect the care needs of the patient who is a full assist transfer from a wheelchair to the bed. The care plan did not delegate or provide instructions on the use of the wheelchair or the transfer from wheelchair to bed for the bath. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Tracer Activities. The organization failed to implement policies and procedures to ensure care and treatment of Hospice services. During tracer activities, the Hospice Nurse Surveyor observed the organizational leaders did not implement policies and procedures related to documentation which results in care planning findings in §418.56, and §418.54. This was discussed and reviewed with the Hospice Leadership Team.

Observed in HR File Review. In 1 of 9 Hospice HR files reviewed, the organization had not ensured competency was assessed at least every three years. On HSPHR #9, the Hospice Medial Director Designee had not had any competency reviewed in the last year years. This was reviewed and confirmed with the Hospice leadership team.

Observed in Record Review. In 2 of 3 bereaved records reviewed, the organization failed to ensure the medical record contained information that reflected the patient's care, treatment or services. Agency death policy (2-065.1) states that the nurse will notify the attending physician of death and document in the medical record all interventions and any significant information in the medical record. In HSPRRBR #1 and HSPRRBR #2, the patient passed away while on service but there is no documentation regarding the passing of the patient or that the physician was notified. This finding was reviewed with Hospice Leadership. Observed in Record Review. In 5 out of 7 active patient records reviewed, the organization failed to ensure the medical record contained information to accurately reflect the patient's care, treatment, and services. On HSPRRHV #1, the plan of care had not been updated for the last 21 days as evidenced by blank and unsigned IDG forms. On home observation for HSPRRHV #2 the registered nurse noted that the patient's medication profile listed at the assisted living facility contained Senna that has been signed by the assisted living facility staff as giving one time per day over the last month, but the Hospice medication list did not reflect orders for the Senna. In addition the documentation for IDG lacked showing the attendance of the social worker and chaplain attending the IDG meetings over the last month and lack of IDG documentation for the last 21 days.. On HSPRRHV #3, it was noted that all members of the IDG group had not been documenting their attendance and participation in IDG meetings. On HSPRRNHV #1 and HSPRRNHV #2, it was noted that the chaplain had not been documenting attendance to the IDG meeting. This finding was reviewed with Hospice leadership.On 2 of 14 patient records reviewed, the organization did not review the plan of care at least every 15 days. On HSPRRHV #2, the plan of care had not been updated for the last 35 days as evidenced by blank and unsigned IDG forms. This finding was reviewed with Hospice leadership.

Observed in Record Review. In 2 of 4 patient records reviewed that were live discharges, the organization did not provide a discharge summary the informed the receiving provider with a summary of the patient's care and progress towards goas while they were on hospice services. On HSPRRDC #2, it was noted that the discharge summary was completed but it only stated patient was discharged due to prolonged prognosis with no detail of the patient's care received or progress toward goals. On HSPRRDC #3, the discharge summary was created but only stated patient discharged to the hospital with no detail on the care received by the hospice. This finding was reviewed with Hospice Leadership.

Observed in Individual Tracer. In 1 of 2 patient records reviewed, it was found that the hospice plan of care, for nursing, had not contained measurable time frame goals. For example, for RRNHV # 1, the POC developed in late July 2023 had all the goals with a time frame of 90 days. Also, there were no goals identified for social worker and Chaplain services, who were visiting the patient monthly. This was validated by leadership and the staff reviewing the record with the surveyor.

Observed in Record Review. In 3 of 3 patient records reviewed, the Hospice Surveyor noted patients with documented pain that had been above their stated comfort level without documented intervention. HOS RR #1 the patient had complained of abdominal pain at a 7/10. Intervention addressed joint pain and not abdominal pain. There had been no documentation of what was done for the pain, nor any communication with the physician. HOS RR #2 the patient had been assessed with a pain level of 5/10, but the narrative note reported the patient had no pain. The following visit, the patient’s pain had been documented at 8/10 and no interventions had been documented. HOS RR #3 there had been two clinical notes where pain had not been assessed and then another note where pain had been documented at 6/10 and no interventions documented. These findings were validated with the Hospice DOPCS.

Observed in Tracer Activities. During review of data and discussion with leadership it was noted that they have created some basic performance improvement projects, but they are not documenting what data is to be collected and how it is to be utilized for improvement. For example: they have been monitoring hospitalizations, but they have just complied a list of patients hospitalized. Nothing has been done to document what their goal is for monitoring this data nor potential interventions to improve. Another item they are looking at is, timeliness of documentation, but again there is no goal and the documentation is a printed patient list with a 'check mark' by the patient name. Nothing specifically identifies the list as monitoring for documentation timeliness. This was validated with the QAPI Coordinator

Observed in Record Review. In 2 of 2 patient records reviewed, During HOSRR# 1 and HOSRR# 2's patient records review it was noted the organization had not ensured the plan of care was based on the patient's goals and time frames, settings, and services required to meet those goals. For example review of HOSRR# 2's plan of care revealed the diagnosis of DM type 2 and the medication profile revealed Metformin daily. However, review of the plan of care revealed no goal or interventions for DM type 2. Review of HOSRR# 1's plan of care revealed a visit frequency of one time a month for the MSW. However, review of the plan of care and subsequent IDT Plan of Care Updates revealed no goals for MSW. This was reviewed, discussed, and validated with the Director of Nursing designee.

Observed in Leadership Session. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.100 and §418.104

Observed in Record Review. In 1 of 2 patient records reviewed, During HOSRR# 2's patient record review it was noted the organization had not ensured it maintained complete and accurate patient records. For example: review of HOSRR# 2's patient record revealed a physician order dated five days prior to the surveyor review of the record and signed by the Administrator/Director of Nursing five days after the surveyor review of the record. Review of the audit trail provided by the Administrator designee revealed the physician order was created one day prior to the surveyor review of the record and signed same day as the surveyor review of the record. This was reviewed and discussed with the Administrator/Director of Nursing and the Administrator designee that validated the finding and shared it was an error and they were not aware the electronic medical record signature date could be manipulated to indicate a date that was not the date of the actual signature.

Observed in Record Review. In 1 of 2 patient records reviewed, During HOSRR# 2's patient record it was noted the organization had not ensured it maintained the security and integrity of the patient clinical record. For example: review of HOSRR# 2's patient record revealed the electronic medical record (EMR) electronic signature date could be manipulated. Review of a physician order revealed it was dated and signed five days after the surveyor review of the record. Review of the audit trail revealed the physician order was created one day prior to the surveyor review of the record and signed the same day as the surveyor review of the record. This was reviewed, discussed, and validated with the Administrator/Director of Nursing and the Administrator designee.

Observed in Patient Home. In 3 of 3 home visits conducted, the organization failed to provide information tailored to the patient's language, and ability to understand. For HOS 1 and HOS 2 the primary caregiver's preferred language was Spanish and for HOS 3 who lived independently and preferred language was Spanish, all the materials in the home folder including the Hospice Election of Benefits and Consents, Patient Rights and educational materials were all in English.

Observed in Patient Home. In 1 of 3 home visits conducted, the hospice nurse conducted a medication assessment but failed to identify all medications, regime changes, and/or errors. For example, for HOS 2 the medication list included Tylenol 325 mg 2 tabs orally every 6 hours as needed for elevated temperature and mild pain however failed to include parameters for temperature and pain levels and the patient was receiving Tylenol 500 mg tablets which the nurse failed to identify at the time of the medication assessment. Additionally, the nurse failed to identify the Vitamin B Complex and Melatonin which the patient was also receiving but were not included on the medication list.

Observed in Leadership Session. During review of data and discussion with leadership it was noted that the hospice did not have an effective, ongoing and organization wide QAPI program documented for 2020, 2021 and 2022. For example, there was no evidence that the Home Health QAPI program included the indicators of hospital admissions, hospital re-admissions, and the use of emergency care for 2020 and 2021. Also, there was no evidence that the Hospice QAPI program included improvement in the indicators related to improved palliative outcomes and hospice services. Finally, there was no evidence that Infection Control was an integral part of the QAPI program. This was validated with the Chief Operating Officer.

Observed in Leadership Session. During review of data and discussion with leadership it was noted that although raw data had been collected there was no evidence that data had been aggregated or analyzed to identify levels of performance, patterns and trends for the hospice programs. This was validated with the Chief Operating Officer. Observed in Leadership Session. During review of data and discussion with leadership it was noted that since the organization had not aggregated and analyzed their data they were unable to identify improvement opportunities for the hospice program. This was validated with the Chief Operating Officer.

Observed in Leadership Session. During review of data and discussion with leadership it was noted that there was no evidence of improvement projects being conducted for hospice, the reasons for conducting these projects, and the measurable progress achieved on them. This was validated with the Chief Operating Officer.

Observed in Patient Home. In 1 of 3 home visits conducted, staff failed to use standard precautions. For HOS 3 there were three instances during the wound care procedure to the patient's left lower extremity that the RN removed her gloves and then donned new gloves without performing hand hygiene in accordance with the organization's policies 9-009.1 Hand Hygiene and 9007.1 Standard Precautions. The RN used a bandage scissors to remove the kerlix wrap and ABD then changed gloves without using hand sanitizer before donning the new gloves, she then removed the telfa dressing exposing the open wound and changed gloves without using hand sanitizer and finally, after apply Desitin cream the RN changed gloves without using hand sanitizer. This was validated with the DPCS/Admin designee.

Observed in Document Review. Although the Volunteer Coordinator discussed recruitment activities, the hospice had not documented its efforts to recruit and retain volunteers for 2020, 2021 or year to date 2022. This was validated with the Volunteer Coordinator.

Observed in Document Review. Although the hospice had volunteers assisting with office and bereavement services the organization had not documented the cost savings achieved through the use of volunteers for 2020 or 2021. This was validated with the Volunteer Coordinator.

Observed in Leadership Session. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation and staff interviews: 418.78, 418.58, 418.60 and 418.100. This was discussed with the Chief Operating Officer.