Every finding on record at Ojax Hospice, Inc.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization failed to ensure the patient record was complete, promptly, and accurately documented. For example: on review of RRNHV#5 the MSW was requested to visit the patient related to a family issue/problem and 9 days later there is not documentation in the record of the visit. This was discussed with the DPCS present.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization failed to ensure the plan of care revisions are based on information from updates to the patient's comprehensive assessment. For example: throughout 2 active records reviewed there was a noted lack of updates to the goals and interventions as the care plans remained the same with little to no change IDG to IDG throughout the past months care. In RRNHV#1 an example was In 1-2 weeks, family/PCG will verbalize comfort in taking care of their loved ones needs. yet the goal was set greater than 2 weeks ago and remained unchanged IDG to IDG. In RRNHV#5 an example was In 4-5 weeks, patient/family will verbalize understanding re: natural course of disease process. This goal had been in place for over 7 months without update. These were reviewed and discussed with the DPCS present.

Observed in Record Review. In 1 of 1 patient records reviewed, the organization failed to involve the patient in making decisions about their care, treatment, or services. For example: on review of RRNHV#1 the Notice of Non-Covered Items, Supplies and Drugs for was signed on admission yet was incomplete and only included the patient's diagnoses but did not include any non-covered items. This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization failed to conduct and document a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. For example: on review of RRNHV#2 there was no documentation of an initial bereavement risk assessment . This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 2 of 5 patient records reviewed, The organization failed to ensure the update of the comprehensive assessment was accomplished by the hospice interdisciplinary group considering any changes that took place since the initial assessment no less frequently than every 15 days. For example: In review of RRNHV#3 there was noted a 28 day gap in the RN comprehensive assessment as there were no documented RN visit in a 28 day period in May. In RRNHV#4 there were no documented IDG meeting for a 42 day period from mid April to late May. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization failed to ensure the patient record was complete, promptly, and accurately documented. For example: on review of RRNHV#4 the most recent RN comprehensive assessment in the RN's narrative the upper portion noted the previous pain level was 7 and current level was 7, yet in the assessment portion of the visit note and in the following paragraph of the narrative the documentation noted the current pain level was 2. In RRNHV#5 there was an order to change the patient pain medication from 20 mg to 30 mg of oxycodone yet the RN's documentation continued to show 20mg in the nursing documentation. In the most recent RN visit note the assessment portion of the note specified 20mg yet the narrative noted the correct 30mg dosage. Further, the MSW documented that visit frequency was 1 time per cert period yet the last order noted the frequency for 1 time a month. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 1 of 5 patient records reviewed, The organization failed to ensure the patient and/or primary caregiver receive education and training based on the patient's assessed needs. For example: on review of RRNHV#5 there was an order to increase the pain medication Oxycodone from 20mg to 30 mg every 8 hours PRN pain yet no documentation of education to the patient/caregiver regarding the new medication. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 4 of 5 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRNHV#2 the patient was being seen by the Chaplain yet there was no spiritual care plan to guide the care. In RRNHV#3 there was documentation of medication changes for cough yet the patient's issue with cough was not reflected in the care plan. Further the patient was being seen by the Chaplain yet there was no spiritual care to guide care. In RRNHV#4 the patient was being seen by the social worker and chaplain yet there were no psychosocial or spiritual care plans established. In RRNHV#5 there was documentation of increase in the pain medication to address increased pain yet there was no reflection of the change in patient pain noted in the care plan. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 4 of 5 patient records reviewed, the organization failed to ensure the plan of care revisions are based on information from updates to the patient's comprehensive assessment. For example: Throughout all active records reviewed there was a noted lack of updates to the goals and interventions as the care plans remained the same with little to no change IDG to IDG throughout care. In RRNHV#2 an example was 'In 4-5 weeks, Pt/Family/PCG will verbalize satisfaction re: adequate GU care AEB no incidence of GU-related infection and other complications yet the goals was set in March and remained with update to time of survey well beyond 4-5 weeks. In RRNHV#3 an example was In 2-5 days, Patient will receive incontinence supplies to keep him/her dry and facilitate maintenance of personal care/hygiene. and Urinary incontinence: In 4-5 weeks, Pt/Family/PCG will verbalize satisfaction re: adequate GU care AEB no incidence of GU-related infection and other complications. These goals had been in place since admission in March without update except to change the target date. In RRNHV#4 there multiple goals that were noted to be well beyond the target dates set for March. Similar issues with care plans that continued without update from IDG to IDG could also be noted in RRNHV#5. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 4 of 5 patient records reviewed, the organization failed to ensure the care and services were provided in accordance with the plan of care. For example: In review of RRNHV#2 the MSW and Chaplain were ordered per the plan of care a frequency of monthly yet there were no visits in April and May documented for the MSW, and no visit in May for the Chaplain. In RRNHV#3 the Skilled Nurse was ordered weekly yet there was no documentation of a SN assessment the 3rd week of May. The MSW and Chaplain were ordered monthly yet there were no visits documented in April and May for the social worker, and no visit in May for the Chaplain. In RRNHV#4 the MSW was ordered a frequency of monthly yet the documentation noted only visiting one time per certification period. The Nurse was ordered 2 times a month, but documentation showed visiting weekly. In RRNHV#5 the was no documentation of MSW visits over the last certification period yet documentation noted visits one time per certification period. These observations were reviewed with the Administrator/DPCS

Observed in Tracer Activities. Upon review of all tracer activities, it was noted that there was a pattern of staff failing to follow established organization policy and the governing body/leadership did not ensure that the Conditions of Participation for 418.100, 418.54, and 418.56, were met and sustained as recommended from external authorized agencies, such as accreditation, certification, or regulatory bodies as determined through observations, documentation, and staff interviews.

Observed in Record Review. In 4 of 7 patient records reviewed, the organization failed to involve the patient in making decisions about their care, treatment, or services. For example: on review of RRHV#1, RRHV#2, RRHV#3, and RRNHV#5 the Notice of Non-Covered Items, Supplies and Drugs for was signed on admission yet was incomplete and only included the patient's diagnoses but did not include any non-covered items. This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 4 of 7 patient records reviewed, the organization failed to ensure the patient chooses their own attending physician. For example: In RRHV#1 the section in the hospice election for choosing attending physician was left blank. In RRHV#2, RRHV#3, and RRNHV#7 the hospice election form used did not address the patient choosing an attending physician. In both records reviewed there was a form named Patient Consent for Primary Care Physician that included the patient name, physician name and the ability to check I wish to continue my primary care physician, I would like prefer ****Hospice medical director to attend to my primary care needs, or I would prefer ****Hospice Medical Director to intercede for only my terminal illness treatment needs and pain management. The form further states I was presented with a list of current physicians that ****Hospice works with and I was given the right to choose my physician yet the form was not signed by the patient or patient representative. This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 1 of 7 patient records reviewed, the organization failed to ensure the comprehensive assessment was completed no later that 5 calendar days after the election of hospice care. For example: on review of RRNHV#7 the spiritual counselor did not document a spiritual assessment until nearly a month post start of care. This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 2 of 7 patient records reviewed, the organization failed to conduct and document a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. For example: on review of RRHV#2 the patient was documented to be diabetic taking insulin and oral hypoglycemics with blood glucose monitoring ordered yet the RN visits for comprehensive reassessment there was no documentation that the endocrine system was assessed. In RRHV#3 the patient was also diabetic and the medication profile noted blood glucose monitor and testing strips yet there was no documentation of assessment of the patient's endocrine system in the nursing notes. This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 4 of 7 patient records reviewed, The organization failed to ensure the update of the comprehensive assessment was accomplished by the hospice interdisciplinary group considering any changes that took place since the initial assessment no less frequently than every 15 days. For example: on review of RRHV#2 there was an 18 day gap in February in the RN visits to conduct the comprehensive reassessment. In RRNHV#4 there were greater than 15 day gaps in RN comprehensive assessments of an 18 day gap from February to March and a 20 day gap December to January. In RRNHV#6 there was a 22 day gap in December, a 17 day gap from December to January, and a 27 day gap from March to April. In RRNHV#5 there was a 17 day gap in RN assessment since the patient was admitted in March. Further in RRNHV#5 there were new medications added to the patient's medication profile, yet there no mention in the IDG of the changes in the comprehensive assessment as the RN noted in the IDG summary no significant change noted at this time. In RRNHV#4 the last documented IDG meeting was early April leaving greater than 15 since the last documented IDG meeting to date of survey. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 3 of 7 patient records reviewed, the organization failed to ensure the patient record was complete, promptly, and accurately documented. For example: on review of RRHV#1 the most recent documented nursing note stated in the narrative that the pain level was at 8 and they further down in the narrative it stated the pain level was 7. In the Initial comprehensive assessment also for RRHV#1 the Hospice Item Set (HIS) section noted no to the question opioid started or continued but the patient medication profile stated the patient was on Percocet. Similar documentation of answering no to the HIS question of opioid initiated or continued on admission yet the patient was on an opioid was noted in RRHV#3 and RRNHV#7. In RRHV#3 there was documentation on a nursing note in April that the patient was non-diabetic yet the patient was on oral hypoglycemics for diabetes. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 4 of 7 patient records reviewed, The organization failed to ensure the patient and/or primary caregiver receive education and training based on the patient's assessed needs. For example: on review of RRHV#2 the patient was diabetic prescribed insulin, oral hypoglycemics, and blood glucose monitoring 2-3 times a day yet there was no documentation of diabetes education provided such as signs and symptom of hypo and hyperglycemia. There was no education of administering glycemic agents and blood glucose monitoring nor the patient and/or caregiver's proficiency in providing the medications and glucose monitoring. Similar lack of diabetes education documentation was noted on RRHV#3. In RRNHV#5 there was documentation of new medication orders for Diclofenac, Xanax, and Robitussin yet there was no documentation noted in the record for informing the patient/caregiver of the new medications, indications, dosage, frequency, and potential side effects. In RRNHV#6 there was a new order for diclofenac and there was also no documentation of education to the patient/caregiver regarding the new medication. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 7 of 7 patient records reviewed, the organization failed to ensure the plan of care includes all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#1 the patient was being seen by the Spiritual Counselor yet there was no spiritual care plan to guide the care. In RRHV#2 the patient was being seen by the Spiritual Counselor and the Social Worker yet there was no spiritual, or psychosocial care plans open. Further, throughout all active records review there were no psychosocial or spiritual care plans established in the Plan of Care. In RRHV#2 the patient was diabetic on insulin, oral hypoglycemics, and ordered blood glucose monitoring yet no endocrine care plan to guide the care. Documentation in the CTI noted numbness and tingling in the extremities yet the issues were not reflected in the plan of care. In RRHV#3 there was a blood glucose monitor and test strips noted on the medication profile, but no orders for blood glucose monitoring such as who was to perform, frequency, and parameters for reporting. In RRNHV#5 there were new orders for diclofenac, Xanax and Robitussin yet the changes were not reflected in the plan of care. In RRNHV#6 there was a new order for Diclofenac but the change in patient status and medication addition was not reflected in the plan of care. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 7 of 7 patient records reviewed, the organization failed to ensure the plan of care revisions are based on information from updates to the patient's comprehensive assessment. For example: on review of RRHV#1 the care plan goal for pain stated In 2-3 weeks, prompt/adequate pain relief will be achieved & maintained w/in 0-2 (0-10 scale) through pharmacologic or nonpharmacologic measures however the documentation each nursing visit, since admission week 4 of March, the nurse consistently documented the patient pain at the start of visit was in the range of 7 to 8, yet the plan of care was not revised or updated to reflect the continued issues with pain. In RRHV#2 there was a similar failure to update the plan of care as the patient also had the same goal as RRHV#1 with consistent documentation of high pain scores on nursing visit yet no updates or revisions to the plan of care when the patient failed to meet the goal. Further in RRRHV#2 there was consistent documentation of poor appetite consuming only 3-6 spoonful's each meal yet the goal established on the plan of care noted In 1-2 weeks and onwards, Pt will have adequate food and fluids as tolerated or desired AEB 90- 100% consumption of food/ water rations every meal had been in place without update/revision since admission nearly a year ago. Throughout all active records reviewed there was a noted lack of updates to the goals and interventions as the care plans remained the same with little to no change IDG to IDG throughout care. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 5 of 7 patient records reviewed, the organization failed to ensure the care and services were provided in accordance with the plan of care. For example: In review of RRHV#1, RRHV#2, RRNHV#4, and RRNHV#6 the plan of care noted a frequency for the skilled nurse of 2 times a month, yet the RN was visiting the patient 2 times a month and the LVN was visiting weekly. In RRHV#1 the MSW per the plan of care was scheduled 1 time a month yet there were no visit by the MSW and documentation in communication note stated that social worker was declined. In RRHV#2 the MSW was also ordered 1 time a month but there were only three visits documented since the initial assessment in May of 2023. In RRHV#3, RRNHV#4, and RRNHV#6 there were also examples of the MSW ordered 1 time a month per the Plan of Care yet not documenting monthly visits. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 2 of 7 patient records reviewed, The organization failed to ensure ongoing sharing of information between all disciplines providing care and services in all settings. For example: on review of RRHV#1 the patient's pain level on each nursing visit was consistently documented at 7 or 8, greater that the tolerable level of less that 3 per the plan of care yet there was no documentation that the physician was contacted to report the finding. Also in RRHV#2 the patient pain level was consistently documented in the nursing notes at levels of 7 and 8 with a documented goal of less than 3 and stating patient suffering severe discomfort yet again there was no documentation that the physician was contacted to report the patient's severe pain. These observations were reviewed with the Administrator/DPCS.

Observed in Data Session. On review of the organizations QAPI program they were unable to demonstrate operation for 2021, 2022 and the first three quarters of 2023 and evidenced by the Leadership was unable to produce QAPI meeting and analysis of data prior to quarter 4 2023. This observation was reviewed with the Administrator/DPCS and Designee.

Observed in Data Session. On review of the QAPI program the organization Leadership was unable to produce documentation of analysis and comparing internal data over time to identify levels of performance, patterns, trends and variations for 2021, 2022 and the first 3 quarters of 2023. This observation was reviewed with the Administrator/DPCS and Designee.

Observed in HR File Review. In 1 of 1 HR files reviewed, for the hospice aide, the organization failed to ensure the required elements of the initial competency evaluation were evaluated by observing the aides performance of the tasks with a patient or pseudo-patient. On review of the HR#7 the aide's initial competency was documented as evaluated verbally and not by direct observation for the required elements of: Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other staff - Reading and recording temperature, pulse, and respirations - Appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination - Safe transfer techniques and ambulation - Normal range of motion and positioning. This observation was reviewed with the DPCS/Administrator.

Observed in Record Review. In 1 of 7 patient records reviewed, the organization failed to ensure the RN supervise the hospice aide during an on-site visit no less frequently than every 14 days. On review of RRHV#1 there were no documented aide supervisory visits to assess the quality of care and services noted on the clinical record from start of aides services in March to date of survey spanning 29 days. This observation was reviewed with the DPCS/Administrator.

Observed in Record Review. Upon review of all tracer activities, it was noted that there was a pattern of staff failing to follow established organization policy and the governing body/leadership did not ensure that the Conditions of Participation for 418.100, 418.104, 418.116, 418.54, 418.56, 418.58 and 418.52 were met per policy as determined through observations, documentation, and staff interviews.

Observed in Record Review. In 4 of 4 patient records reviewed, the organization failed to ensure the record contain information to reflect the patient's care treatment and services. For example: in RRDC#2, RRDC#3, RRDC#6, and RRDC#7 discharged for extended prognosis, there was no documentation noted in the record of what led the IDG team to make the decision to discharge as no longer terminally ill. In RRDC#3 there was documentation in the IDG meeting leading up to discharge noting pain at 9/10 moaning, restless, and short of breath. There was also documentation of a respiratory infection in the month the patient was discharged. In RRDC#2, RRDC#3, and RRDC#7 there was no documentation of discharge planning or discharge instructions. In RRDC#7 there were discharge planning forms in the record but the form was signed on admission. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 2 of 7 patient records reviewed, the organization failed to ensure all entries in the record were legible, clear, complete, and appropriately authenticated and dated in accordance with policy and accepted standards of practice. For example: in RRDC#7 and RRDC#1 the Notice of Medicare Non-Coverage was noted to be signed but not dated. This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 3 of 7 patient records reviewed, The organization failed to ensure maintenance of complete and accurate records. For example: In RRDC#4 and RRDC#5 the patient discharge summary noted the patient revoked seeking aggressive treatment but the discharge order on the record noted discharged for extended prognosis. In RRDC#1 the record was noted to be a discharge for extended prognosis yet the discharge summary noted the discharge to be revoke seeking aggressive treatment. These observations were reviewed with the Administrator/DPCS.

Observed in Patient Home. The organization failed to operate and furnish services in compliance with all applicable Federal, State, and local laws and regulations related to the health and safety of patients. On home observation for RRHV#3 the LVN was observed to perform blood glucose monitoring in the home, however the Hospice did not have a CLIA Certificate as required by law and the organization policy that stated the hospice will perform permitted laboratory tests in the home and will apply for and maintain a CLIA waiver on file. This observation was reviewed with the DPCS/Administrator and the Designee. Observed in Record Review. In 6 of 7 patient records reviewed, for live discharge the organization failed to follow discharge process that complied with law and regulation. For example: on review of 4 discharge records for extended prognosis there was no clear discharge process that was followed in all 4 records reviewed. In RRDC#2 and RRDC#6 there was no Notice of Medicare Non-Coverage (NOMNC) noted on the record. In RRDC#3 the NOMNC was signed on the day of discharge and not presented the required 2 days prior, and in RRDC#7 the NOMNC was signed but not dated. In 2 of 3 patients that revoked the process for discharge was also unclear. In RRDC#1 was discharged as seeking aggressive treatment but there was no revocation form, but there was also a NOMNC signed and not dated on the record. RRDC#5 was documented as revocation, but there was a NOMNC that was signed on the day of discharge along with the revocation. These observations were reviewed with the Administrator/DPCS.