Every finding on record at Oakview Hospice Care, Inc.

Observed in Record Review. In 1 of 3 applicable patient records reviewed, the plan of care did not include all goals based on the patient’s needs. While overall improvement was noted related to care planning, upon review of RR#1, it was noted the patient had a terminal diagnosis of hypertensive heart and chronic kidney disease and was on cardiac medications including amlodipine, aspirin, and hydrochlorothiazide; however, on review of the plan of care, there were no goals established related to cardiac management. This was reviewed and validated with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 1 of 3 applicable patient records reviewed, the plan of care did not include all interventions based on the patient’s needs. While overall improvement was noted related to care planning, upon review of RR#1, it was noted the patient had a terminal diagnosis of hypertensive heart and chronic kidney disease and was on cardiac medications including amlodipine, aspirin, and hydrochlorothiazide; however, on review of the plan of care, there were no interventions established related to cardiac management. This was reviewed and validated with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 2 of 3 applicable patient records reviewed, the certification of terminal illness (CTI) did not include all required elements. Upon review of RR#1, it was noted the certifying physician summary included the following statement, It is my clinical judgement that this patient has a life expectancy of 6 months or less, if the terminal illness runs it`s normal course and did not include information such as the primary terminal condition, related diagnoses, current subjective and objective medical findings, or current medication and treatment orders. Upon review of RR#2, it was noted the certifying physician summary included the following statement, The patient is actively dying, needs comfort measures and pain management and did not include information such as the primary terminal condition, related diagnoses, current subjective and objective medical findings, or current medication and treatment orders. However, on review of the CTIs, it was noted the RN clinical summary from their comprehensive assessment was located directly above the physician’s certifying summary and signature, which did provide a detailed summary of the patient’s condition including clinical information specific to the patient's appropriateness for hospice services. This was reviewed and validated with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 1 of 4 patient records reviewed, the hospice’s interdisciplinary group had not updated the comprehensive assessment in collaboration with the patient’s attending physician, at least every 15 days. In RR#4, the RN assessment was not completed every 15 days. For the past two months, the RN assessment visit was only completed/documented one time each month due to a visit scheduling error. This was reviewed and verified with the QAPI Coordinator.

Observed in Record Review. In 1 of 4 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including medications to meet the patient's needs. In RR#1, the patient was ordered Tylenol ES 500mg by mouth every 4-6 hours as needed for pain and Tramadol Hydrochloride 50mg by mouth every 12 hours prn for pain. There was no clear indications for use of these two prn pain medications (which medication to take when). This was reveiwed and verified with QAPI Coordinator.

Observed in Record Review. the organization had not provided the patient with care, treatment, or services according to the patient's individualized plan of care. In RR#4, it was noted the aide plan of care included providing a shower every visit, and applying deodorant and lotion every visit. In all but one hospice aide visit notes reveiwed, the aide did not provide/document these tasks outline on the aide plan of care. There was also no documentation by the aide as to why these tasks were not completed and/or who was contacted. This was reveiwed and verified with the Administrator/DPCS.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization had not respected the patient's right to elect and revoke hospice care, in accordance with Medicare hospice regulations. In the charts for RR#3 and RR#6, the patient's experienced falls with injury. The patients were informed that they must revoke the hospice benefit to seek treatment for their injuries, which they both did. This was discussed with the DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization had not assessed potential medication-related problems, including duplicate drug therapy. During HV#1, it was observed by the hospice surveyor that the medication list in the EMR included two prescriptions for Potassium Chloride 10mEq daily. One was written as K-Dur 10mEq Extended-Release tablet, 750mg, oral daily added at the admission. The second medication was added approximately 2 months later and entered as Potassium Chloride 10mEq Extended-Release Tablet 1 Tab ER oral daily. This was discussed with the DPCS.

Observed in Record Review. In 9 of 11 patient records reviewed, the hospice’s interdisciplinary group had not updated the comprehensive assessment in collaboration with the patient’s attending physician, if any, as frequently as the patient’s condition requires, but no less than every 15 days. In the chart for HV#1, the RN was making visits every two weeks, with the most recent visits 16 and 19 days between the most recent visits. However, the documentation in those visits included only supervisory notes, no assessment data regarding the patient. In the charts for HV#2, HV#3, RR#1, RR#2, RR#6, RR#7 and RR#8 the RN did not perform any assessment of the patients at least every 15 days. This was discussed with the DPCS who was unaware of the need for the RN to document an updated assessment of the patient every 15 days in order to update the POC. Additionally, in the chart for RR#1, the patient fell and sustained a laceration which the primary caregiver notified the after-hours nurse about. There was no further mention in the record about the laceration; the IDT meeting following the incident indicated that the patient had not had any falls since the previous IDT. In the chart for RR#5, the RN did not see the patient at all during the second benefit period. This was discussed with the DPCS.

Observed in Record Review. In 2 of 11 patient records reviewed, the patient record was not complete, promptly documented, readily accessible and systematically organized. In the chart for RR#1, there was conflicting information in the record. The comprehensive assessment indicated that the patient had oxygen at 2lpm and an oxygen safety risk assessment was completed, however the plan of care did not include any orders for oxygen nor any other indication that the patient had oxygen. In the chart for HV#3, there were seven SN visits in the current benefit period which had been started, but were incomplete, with varying amounts of documentation in them. This was discussed with the DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization had not established an interdisciplinary group as nursing had not participated in all team updates. In the chart for RR#1, there was no documentation to support that nursing participated in the final two IDG meetings; there was no SN input in to the update of the plan of care. This was discussed with the DPCS.

Observed in Record Review. In 3 of 11 patient records reviewed, the written plan of care (POC) was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for HV#1, the patient was at risk for pressure ulcer development and falls, however the plan of care included no goals related to those risks. In the chart for RR#3, there were no goals on the POC for the first benefit period. In the chart for RR#5, there were no goals of care on the POC for the final benefit period.

Observed in Record Review. In 5 of 11 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: A statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs. In the chart for HV#1, an order was written to decrease aide visits from 4 to 3 times per week. However, the POC was not updated to reflect this order and still read 4 times/week on the current POC. In the chart for HV#3, there were conflicting orders for the aide frequency. In one place on the POC, the aide frequency stated 3/week; another treatment order on the POC indicated 2/week. In the chart for RR#3, there were conflicting frequencies for nursing. RN visits were ordered weekly on the POC, yet there was also an order on the POC for RN every 2 weeks. The POC included an order for weekly LVN visits, however there was no frequency of LVN visits in the frequency of visits portion of the POC. In the chart for RR#5, there were no frequencies for any discipline on the POC for the final benefit period until the POC revision/IDT which occurred 3 days post discharge. In the chart for RR#8, the RN frequency was incomplete for the final benefit period and included a blank spot in the frequency with the duration of 2 weeks. This was discussed with the DPCS.

Observed in Record Review. In 5 of 11 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: Medications and treatment necessary to meet the patient’s needs. During HV#2, the patient confirmed that she takes Dexamethasone 1mg daily; this was not on the hospice POC; Levetiracetam 500mg - POC stated 1 BID, actual per patient is 2 tablets for the past 3-4 months at least. Super C - multivitamin was not on the POC; patient takes daily. In the chart for HV#1, the patient was assessed to be at high risk for pressure ulcer development and falls. There were no interventions on the current POC regarding these potential problems. In the chart for RR#1, the patient was at high risk for pressure ulcer development, and moderate fall risk at admission there were no interventions on the POC for these problems. There were no problems/interventions on the POC until the fourth update of the POC. In the chart for RR#3, there were orders for wound care, however the orders were missing the frequency of the care and who was to provide the care as the patient lived in an assisted living setting and nursing was only seeing the patient weekly. Additionally, the plan of care included an order for an oxygen concentrator, however no order for oxygen use. Additionally, there were no interventions on the POC for the entire first benefit period for the patient who was assessed to be at risk for falls and had pain management issues. The patient subsequently had a fall with injury while on service and revoked the hospice benefit to seek care. In the chart for RR#5, there were no interventions on the plan of care for the patient with pain issues, fall risk and shortness of breath on exertion and a history of non-compliance with medications. This was discussed with the DPCS.

Observed in Record Review. In 4 of 11 patient records reviewed, the organization had not provided the patient with care, treatment, or services according to the patient's individualized plan of care. During HV#1, the hospice aide performed a shower with the patient. The hospice plan of care indicated a bed bath was to be performed. In the chart for HV#2, the aide was ordered twice weekly. in week one - no visit was provided; in weeks two and week three - one visit each week was provided. In the chart for RR#2, RN visits were ordered weekly and no LVN visits were ordered. The LVN was seeing the patient weekly; the RN was seeing the patient every other week for supervisory visits only. In the chart for RR#4, the LVN was ordered to provide weekly visits. No LVN visits were provided. This was discussed with the DPCS.

Observed in Record Review. In 3 of 11 patient records reviewed, all disciplines that provide care, treatment or services to the patient had not collaborated in the care of the patient and had not coordinated their efforts to support the goals outlined in the plan of care. In the chart for RR#1, there was no documentation that any discharge planning occurred prior to the patient's discharge for extended prognosis. Additionally, the patient fell, lacerated her scalp and the primary caregiver contacted the hospice to inform the nurse of the situation as she wanted permission to transport the patient to the hospital for care. The nurse documented a discussion re: revocation if the caregiver sought ED care for the patient, however there was no documentation that the physician was made aware. There was no discussion in the following IDT regarding the change of condition. In the charts for RR#2 and RR#3, the patients both revoked the hospice benefit to pursue treatment post-fall. There was no indication in the record to indicate the physician was made aware of the falls nor the revocations. This was discussed with the DPCS.

Observed in Data Session. The organization had not maintained documentation of the quality assessment and performance improvement program and was not able to demonstrate its operation. The organization does collect data, however was not able to demonstrate effective use of that information. The organization had not documented improvement for the performance improvement projects which were identified in the past. The most recent PIP undertaken did not impact any improved palliative outcomes but was a conversion of referrals to admissions as identified in the second half of the past year. There was no documentation of the actual status of the project. This was discussed with the DPCS.

Observed in Data Session. The hospice had not selected performance improvement activities that are based on the prevalence and severity of problems in its high-volume, high-risk, and problem-prone areas. The hospice did not have any active performance improvement projects for the current year as confirmed with the DPCS.

Observed in Data Session. The hospice had not selected performance improvement activities that considered incidence, prevalence and severity of problems. The hospice did not have any active performance improvement projects for the current year as confirmed with the DPCS.

Observed in Data Session. The hospice had not selected performance improvement activities that affect palliative outcomes, patient safety and quality of care. The hospice did not have any active performance improvement projects for the current year as confirmed with the DPCS.

Observed in Record Review. In 5 of 11 patient records reviewed, the registered nurse had not supervised the hospice aide during an on-site visit to the patient’s home no less frequently than every 14 days. In the chart for HV#1, the RN was ordered every two weeks, however, between the most recent aide supervisory visits it had been 16 and at least 19 days between supervisory visits. In the chart for RR#4, more than 35 days passed before the first supervisory visit of the aide was documented. In the charts for RR#5 and RR#7, there were no documented aide supervisory visits in the final benefit periods. In the chart for RR#8, the supervisory visits were completed monthly for the last 4 months of the patient's service with the hospice. This was discussed with the DPCS.

Observed in Tracer Activities. 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, §418.114, §418.116, §418.52, §418.54, §418.56 and §418.58. This was discussed with the DPCS.

Observed in Tracer Activities. The organization does not provide short-term inpatient care for symptom management and respite. Upon discussion with the DPCS, the organization does not have a current contract to provide inpatient or respite services.

Observed in HR File Review. In 2 of 6 HR files reviewed, staff competence was not assessed and documented annually as required by organization policy. In the file for the DPCS, who does make patient visits, there were no clinical competencies documented since 2017. In the file for the MSW, there were competencies for 2019 only. This was discussed with the DPCS.

Observed in Record Review. In 1 of 8 patient records reviewed, in which a discharge alive occurred, the hospice discharge summary did not include the following: Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving physician. In the chart for RR#1, there was no discharge summary. This was discussed with the DPCS.

Observed in HR File Review. In 4 of 6 HR files reviewed, the organization had not verified and documented credentials of care providers using the primary source when licensure, certification, or registration is required by law and regulation to practice their profession. This was not done at the time credentials were renewed. In the files for the Medical Director, DPCS and Nurse, the verification of renewals were not completed and documented prior to expiration. In the file for the aide, there was no date on the renewal document to verify if the verification had been completed prior to the expiration date. This was discussed with the DPCS ad Office Manager.

Observed in HR File Review. In 3 of 6 HR files reviewed, the organization had not obtained a criminal background check on the applicant as required by law and regulation or organization policy. In the files for the MSW, Aide and Nurse, there was no criminal background check documented as verified with the DPCS and Office Manager.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization had not provided care, treatment, or services in accordance with licensure requirements, laws, and rules and regulations. In the charts for RR#1 and RR#5, the patient's were discharged from hospice, however no NOMNC's were presented to the patients. It was confirmed with the Office Manager, that the organization does have a process for advance notice of discharge.