Every finding on record at One Health Hospice Inc.

Observed in Record Review. In 2 of 10 patient records reviewed, it was noted by the nurse surveyor that the comprehensive assessment was not completed within five calendar days of the election of the hospice benefit. For RRHV#2 and RRHV#3, the social worker completed his initial assessment and the bereavement risk assessment two days late. There was no documentation in the electronic medical record to indicate why the visits were not completed timely. Findings were discussed and verified with the Director of Patient Care Services (DPCS) and the RN Case Manager.

Observed in Record Review. In 1 of 10 patient records reviewed, t was noted by the nurse surveyor that for RRNHV#2 the RN did not visit the hospice patient no less than 15 days to conduct an assessment. The patient did not have a documented RN for a 3 week period. Finding was verified with the Director of Patient Care Services (DPCS) and the RN Case Manager.

Observed in Record Review. In 10 of 10 patient records reviewed, the nurse surveyor noted that the goals were not measurable or individualized. For example, RRHV#2, “Patient pain will be managed at acceptable level of pain for patient” and RRHV#3, “Patient will maintain the best possible nutritional status and comfort through symptom management and appropriate interventions.” There were no short-term goals at start of care to address issues of immediate needs such as understanding medication management, symptom management, pain management, or safety. Most dates for achieving goals were at the time of death/discharge end Findings were discussed and verified with the Director of Patient Care Services (DPCS) and the RN Case Manager.

Observed in Record Review. In 2 of 10 patient records reviewed, it was noted by the nurse surveyor that the spiritual assessment was not completed as part of the comprehensive assessment. For RRHV#1, and RRHV#3 the spiritual counselor did not complete his initial spiritual assessment, nor was it clearly documented that the patient had refused the visit. Findings were discussed and verified with the Director of Patient Care Services (DPCS) and the RN Case Manager.

Observed in Record Review. In 2 of 2 patient records reviewed, reviewed who had the hospice aide, it was noted by the nurse surveyor that the hospice aide care plan did not contain all the necessary or current information. For RRHV#1, the patient had continuous oxygen however the hospice aide care plan did not include any mention of the oxygen or what the aide should do with it during the patient’s bed bath. Additionally, the patient had several wounds that the care plan did not address. Both for RRHV#1 and RRDC#1, there were no instructions as to when the hospice aide should notify the nurse. Findings were discussed and verified with the Director of Patient Care Services (DPCS) and the RN Case Manager.

Observed in Record Review. In 1 of 2 patient records reviewed, that had a hospice aide, it was noted by the nurse surveyor that hospice aide supervisory visits were not documented no less frequently than every fourteen days. For RRNHV#1, the hospice aide supervisory visit was documented three days late for the last required hospice aide supervisory visit. Finding was verified with the Director of Patient Care Services (DPCS) and the RN Case Manager.

Observed in Patient Home. In 2 of 2 home visits conducted, it was noted by the nurse surveyor that the medication profile was inaccurate. During RRHV#2, it was noted during the medication reconciliation by the skilled nurse, that the patient had been taking Eliquis, Tamsulosin (Generic for Flomax), Calcium, Advil (prn for pain), and Vitamin D since admission, however, they had never been added to the patient’s medication profile. Additionally, the patient’s daughter in law was applying Absorbine liquid topically to the patient’s painful shoulder which had not been added to the medication profile. For RRHV#3, it was noted during the medication reconciliation by the skilled nurse, that the patient had been taking Pepcid, Vitamin E, Iron, B-Complex and MiraLAX since admission, however, they had never been added to the patient’s medication profile. The patient had been on service for a little over two months. Findings were verified by the RN Case Manager who was conducting the visits. Findings were then later discussed further with the Director of Patient Care Services (DPCS) and the RN Case Manager.

Observed in Emergency Management Session. During the Emergency Management session with the Nursing Supervisor, the surveyor noted the organization failed to show evidence it had documented the evaluation of all emergency response exercises and all responses to actual emergencies includes the identification of deficiencies and opportunities for improvement. For example, two table top exercises were conducted in 2022 (Active Shooter and Excessive Heat), however there was no documented After Action Report or evaluation / modifications implemented. This was not compliant and validated by the Nursing Supervisor.

Observed in Individual Tracer. In 6 of 6 patient records reviewed, HV/RR1, HV/RR2, HV/RR3, RR4, RR5, RR6 during the record review, the surveyor noted the organization failed to demonstrate it respected the patient's right to elect hospice care, in accordance with Medicare hospice regulations. For example, RR1, RR2, RR3, RR4, RR5, RR6 the Medicare Election of Hospice Benefit form in the consent section of the patient records designated the name of a different hospice agency than the organization. This was validated by the Nursing Supervisor.

Observed in Individual Tracer. In 3 of 6 home visits conducted, HV/RR1, HV/RR2, RR3 during the home visit and subsequent record review, the surveyor noted the hospice failed to demonstrate the patient record was accurately documented. For example, RR1 there was evidence the initial FAST score's were documented as 7A and 6E in two different sections of the record; in all records, the physician ordered Oxygen at 3L/NC as needed, while the patient's individualized emergency plan documented 2L/NC; the DME section of the comprehensive assessment did not include the oxygen concentrator. This was not compliant with policy and validated by the Nursing Supervisor.

Observed in Individual Tracer. In 3 of 3 patient records reviewed, HV/R1, HV/ RR2, HV/RR3 during the home visit and subsequent record review, the surveyor noted the written plan of care failed to show evidence it was based on the patient’s goals and the time frames, settings, and services required to meet those goals. The goals were not measurable. For example all records included an End of Life goal : What are the goals of hospice care? Caring for the whole person, not just the disease. Addressing your physical, emotional, social, and spiritual needs. Focusing on you and your family. Providing the best possible quality of life for whatever time remains. These were not specific, individualized or measurable. RR2 the goal related to skin integument stated: Pressure ulcers are an injury that breaks down the skin and underlying tissue. They are caused when an area of skin is placed under pressure. They are sometimes known as bedsores or pressure sores This is not a measurable, individualized goal. This is not compliant with the organization's policy and validated by the nursing supervisor who indicated the current software did not allow for development of individualized, measurable goals.

Observed in Individual Tracer. In 3 of 3 home visits conducted, HV/RR1,HV/RR 2 , HV/RR3 during the home visit and subsequent record review the surveyor noted the interdisciplinary group, failed to show evidence it documented that it reviewed, revised /updated the plan of care every 15 days. For example RR1, RR 2, RR3 there was only one interdisciplinary group meeting documented during the month prior to the survey. There was no documentation that the plan was reviewed/revised for 28 days in any of the three active records. This was not compliant with the organization's policy and validated by the Nursing Supervisor.

Observed in Individual Tracer. In 6 of 6 patient records reviewed, RR1, RR2, RR3,RR4, RR5, RR6 during the record review, the surveyor noted the organization did not show evidence the plan of care goals addressed the patient's progress towards goals and outcomes. The software reflected a % progress toward goal, however there was no narrative or summary in the plan of care or clinical notes that supported the progress. The language in the plan of care regarding the ongoing goals and interventions did not change. For example, RR5 the patient expired at home however there was clinical documentation in the notes or IDG that indicated the imminence of death which occurred within days of the IDG. This was validated by the Nursing Supervisor who indicated the software was a challenge to use and the only way progress could be documented was with selecting the % option in the template.

Observed in Individual Tracer. In 1 of 3 home visits conducted, HV3, during the home visit and subsequent record review the surveyor noted the organization failed to show evidence it had followed physician orders. For example, HV3, the surveyor was informed the patient's oxygen concentrator was stored at the daughter's home a few blocks away from the patient's residence, the oxygen was not available to the patient as ordered. The family were required to call the daughter in the event the oxygen was needed by the patient. This was not documented in the patient record. This was validated by the nursing supervisor.

Observed in Individual Tracer. In 1 of 3 home visits conducted, HV/RR1 during the home visit the surveyor noted the organization failed to demonstrate it implemented infection prevention and control activities when cleaning and performing disinfection of medical supplies and devices. For example the nurse bag equipment was cleaned with over the counter disinfectant wipes that contained 0.26% Alky-Dimethylbenzene ammonium chloride and 99% other disinfectants. This was not compliant with the organization's Nurse Bag Technique Policy or according to manufacturer's guidelines that indicated equipment should be cleaned with alcohol. Observed in Individual Tracer. In 1 of 3 home visits conducted, HV 3, the aide failed to conduct hand hygiene with glove changes. For example, the aide donned gloves and changed gloves, but failed to conduct hand hygiene between glove changes. This was not compliant with the organization's hand hygiene policy and validated by the Nursing Supervisor.

Observed in Infection Control System Tracer. During the Infection Control Session with the Nursing Supervisor, the surveyor noted the organization had not identified infection risks based on the following: geographic location, community, and population served and the care, treatment, or services it provides. For example, the Supervisor was able to report there were no infections reported within the past year, including the intended tracking process, however, the only identified community risk factor was the current COVID pandemic. No other risks had been identified or analyzed. In addition, the QAPI priorities for 2022 presented to the surveyor were included infection control language, they broad and were for home health as they referenced OASIS Error Reports , OBQM/OBQI reports. This was not compliant with the Infection Control Policies.

Observed in Record Review. In 1 of 1 bereavement records reviewed, RR5 and during bereavement session the surveyor noted the organization had not developed a bereavement plan of care that specified the type of bereavement services to be offered and the frequency of service delivery. For example, the initial bereavement risk assessment conducted did not generate a plan of care and there was no evidence of a post death risk assessment or subsequent bereavement plan was developed. This was not compliant with the organization's Bereavement Risk Assessment policy 2-037.1 # 4 which states after death, the hospice social worker or bereavement coordinator will complete the bereavement follow up assessment. The survivor received a condolence card and declined further services, however there was no documentation that any bereavement risk assessment or plan developed post death. In addition, the program indicated mailings were to be sent at time of death (condolence card), and at 3 and 9 months. However there was no evidence of the sample letters or cards in the program binder presented to the surveyor during the survey process.

Observed in HR File Review. In 1 of 1 eligible hospice aide files, HR8 during the personnel file review and discussion with the HR Director, the surveyor noted the organization failed to show evidence the hospice aide successfully completed a competency evaluation before providing patient care. For example, HR8, the orientation documentation in the record included a written exam and a competency skill checklist marked V/W was marked on selected competency skills related to direct care, however these were all conducted on the same day (date of hire) and there was no indication the supervisor evaluated the aide's skills or observed the performance of the task/skills on a patient or pseudo patient prior to providing patient care.

Observed in HR File Review. In 1 of 1 hospice aide personnel files, HR8, during the personnel file review and discussion with the HR Director, the surveyor noted the organization failed to show evidence the hospice aide participated in at least 12 hours of in-service training during each 12-month period. HR 8, the aide was hired one year prior to the survey date (February), however, there was only 7 hours of in-service/education reported within the past 12 months. This was validated by the HR Director.

Observed in Individual Tracer. In 4 of 6 patient records reviewed, HV1, HV2, HV3 , RR5 during the home visit and subsequent record review the surveyor noted organization failed to show evidence the hospice aide provided services ordered by the physician or allowed practitioner in the plan of care. For example, HV1 the aide obtained vital signs during one visit, that were not directed on the plan of care; HV/RR 2 the aide documented vital signs at each visit from 10/22/22 through 12/21/22. RR 5 the aide obtained vital signs at each visit which was not included on the assignment sheet. HV3, the aide documented vital signs 10/20-12/17. HV3 the aide failed to complete all tasks identified on the assignment sheet, including oral hygiene, combing hair and nail care. This was not compliant with organization policy and validated by the Nursing Supervisor.

Observed in Tracer Activities. During the volunteer session and discussion with the Volunteer Coordinator, the surveyor noted the organization failed to show evidence that volunteers provided day-to-day administrative or direct patient care in an amount that equals 5% of the total patient care hours of all paid hospice employees and contract staff. For example, the total hours recorded that related to the volunteer program, met the 5% criteria, the volunteer hours were not provided by a volunteer as the organization did not have a volunteer. The volunteer hours recorded were provided by the Volunteer Coordinator, a paid employee. This was not compliant and validated by the Volunteer Coordinator and the Nursing Supervisor.

Observed in Leadership Session. The Governing Body failed to ensure the following Conditions of Participation had been met as determined through observation, documentation and staff interviews: 418.60, 418.100, 418.52 and 418.56.

Observed in Document Review. In 2 of 3 contracts reviewed, During contract review and discussion with the HR Director, the surveyor noted the organization failed to show evidence the designated leaders approved contractual agreements. For example, neither the Pharmacy or DME contracts were signed by the vendor; the DME contract was signed by the hospice organization's prior owner who was not the designated leader. This was validated by the Director.

Observed in HR File Review. HR9 there was no evidence that an initial peer clinical competency had been conducted for the Medical Director. Observed in HR File Review. In 6 of 9 HR files reviewed, HR 4, HR5, HR6, HR 7 HR 8 during personnel file review and discussion with the HR Director, the surveyor noted the organization had documented during orientation that all staff had been evaluated for Nursing Core Clinical skills competencies, including aseptic technique (e.g. wound care, sterile dressing) and blood glucose monitor skills testing. This included non nursing personnel including HR$, (Volunteer Coordinator/Volunteer); HR5 (MSW), HR6 (Chaplain), HR7( Bereavement Coordinator) and HR8 (Hospice Aide). This was validated by the HR Director. Observed in HR File Review. In 1 of 9 HR files reviewed, the organization had not defined the competencies it required of its staff who provide patient care, treatment, or services. For example, HR 2 the Volunteer did not have evidence of hospice volunteer training conducted upon hire. . The HR Director/Volunteer Coordinator presented a signed and dated Volunteer Training form to the surveyor during the onsite clarification process, stating he had read the manual upon hire.

Observed in Individual Tracer. In 3 of 6 home visits conducted, HV/RR1, HV/RR2, RR3 during the home visit and subsequent record review, the initial CTI did not include documentation supporting the hospice eligibility on the CTI form as the section was left blank; another record had CTI language appeared to be a cut and paste with pre-loaded questions related to eligibility criteria rather than a summary

Observed in Individual Tracer. In 1 of 3 home visits conducted, HV/RR1 during the home visit and subsequent record review, the surveyor noted the patient record failed to demonstrate it contained the following clinical information: A list of medications, including dose, strength, frequency, route, date and time of administration for prescription and nonprescription medications, herbal products, and home remedies that relate to the patient's care, treatment, or services. For example, HV1, the following discrepancies were noted during the medication reconciliation process: Acetaminophen suppositories not on medication list; Docusate 100 mg 1-2 tablets at HS PRN constipation on label, medication list states frequency is 2 tablets daily for constipation; Lorazepam 0.5 mg sublingual or PO was noted on the label, however the medication list indicated: Lorazepam 0.5 mg with dose noted as 5 mg. May administer 5 mg (1 tablet) every 4 hours as needed; Medication bottle did not have time for administration noted however medication list: Atorvastin Calcium 10 mg 1 tablet po daily at night; Vitamin D3 dosage on bottle was 50 mcg 1 tablet po daily, compared to medication list: Vitamin D3 25 mcg 1 capsule po in the morning. This was not compliant with the organization's medication profile policy and validated by the Nursing Supervisor.

Observed in Individual Tracer. In 1 of 3 home visits conducted, in HV/RR1 patient had 02 PRN ordered, equipment provided but reportedly seldom used. The filter on the oxygen concentrator in the patient's room was dirty and the nurse indicated he had not monitored or instructed the facility on care or cleaning of the concentrator, including the filter, nor could the nurse confirmed the DME provided the education. This was not compliant with the organization's oxygen risk policy pertaining to cleaning equipment and validated by the Nursing Supervisor.

Observed in Document Review. In 2 of 3 contracts reviewed, During contract review, and discussion with the HR Director, the surveyor noted the organization failed to show evidence the written agreement with an outside agency included the following: the manner in which contracted services will be evaluated by the hospice and a stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. For example, neither Pharmacy or DME agreements contained language regarding evaluation process /requirements by the hospice or the criminal background requirements. This was validated by the Director.