Every finding on record at Passion and Love Hospice Inc

Observed in Record Review. In 1 of 2 patient records reviewed, that were admissions it was noted in record RRNHV#2 that there was no initial bereavement assessment documented. This was confirmed with the RN QAPI Coordinator present

Observed in Record Review. In 1 of 1 patient records reviewed, for bereavement serivces. During BRRR#1 it was noted the organization did not follow their policy, Bereavement Services # 2-010 that after a death occurs the bereavement assessment will be updated and the family/caregiver needs will be discussed at the next IDG meeting. There was lack of documentation that the post death bereavement assessment and proposed bereavement POC was discussed at an IDG after the patient expired. This was discussed with the RN/QAPI Coordinator present.

Observed in Record Review. In 2 of 4 patient records reviewed, During RRNHV#1 record review it was noted a frequency for the nursing visits once a week and aide visits twice a week, there was lack of documentation of a SN visit in December 2024 and 2 HHA visits in December 2024 without documentation of the reason the visit was missed. During RRNHV#3 record review it was noted that the frequency for SN of once a week, there was no documentation of 2 visits in December 2024. This was confirmed with the RN QAPI Coordinator present.

Observed in Record Review. In 6 of 10 patient records reviewed, During HV#1, HV#3, RR#1, #2, and #3 it was noted the choice of physician on the consent was blank. During RR#6 it was noted the notification of non covered serivces was signed however the form was blank. This was discussed with the DPCS.

Observed in Record Review. In 1 of 10 patient records reviewed, During RR#1 it was noted the goals were not individualized as follows: Patient will manifest blood pressure and pulses within acceptable limits throughout the episode of care. Patient will achieve and maintain blood glucose levels within acceptable range throughout the episode of care. Pain will remain in comfortable level during care with current intervention throughout the episode of care. This was discussed with the organization leadership.

Observed in Record Review. In 6 of 10 patient records reviewed, During RR#1 it was noted on the RN initial assessment the patient has lost more than 10% of his body weight in the last 6 months with a poor appetite and documented as a concern of the patient. The POC lacked interventions related to the nutritional deficit identified by the RN. The patient was assessed with a high risk for skin breakdown on the Braden skin assessment. The POC lacked interventions related to prevention of skin breakdown. During HV#1 and RR#2 it was noted patient had difficultly swallowing as documented on the RN initial assessment. Aspiriation precautions instruction was not added to the POC under the nutrition deficit. During RR#1, RR#2 , RR#3, RR#4, RR#5 and HV#1 it was noted an order for 2L of oxygen PRN SOB. The POCs lacked interventions on oxygen safety and use. During RR#4 and RR#5 it was noted during an IDG meeting documentation of the possible need for a conservatorship process to be explored by the MSW. Interventions were not added to the POC by the MSW to assist with conservatorship needs. During RR#5 it was noted a picture of the patients lower left extremity that was labeled Dry Scaly Skin on Both LE. The POC was note updated to include integument interventions. During RR#6 it was noted on the initial RN assessment a pain rating of 5/10 on the lower back area. Interventions related to pain assessment and relief were not added to the POC. This was discussed with the organization leadership.

Observed in Record Review. In 2 of 10 patient records reviewed, During HV#1 record review it was noted the patients was prescribed Plavix 75 mg every Monday, Wednesday and Friday. During RR#5 it was noted the patient was prescribed Plavix 75 mg daily. The POCs lacked instruction to the patient and PCG on s/s bleeding and bleeding precautions. This was discussed with the organization leadership.

Observed in Record Review. In 10 of 10 patient records reviewed, During RR#1-7 and HV#1-3, it was noted the same order was not individualized for the use of oxygen therapy as needed. The order for oxygen 2-4L/min, titrate to comfort lacked the clinical parameters for liter flow choice. This was discussed with the organization leadership.

Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement serivces. During BRRR#1 and #2 it was noted the organization did not follow their policy, Bereavement Services # 2-010 that after a death occurs the bereavement assessment will be updated and the family/caregiver needs will be discussed at the next IDG meeting. There was lack of documentation that the post death bereavement assessment and proposed bereavement POC was discussed at an IDG after the patient expired. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 10 patient records reviewed, During HV#3 record review it was noted a frequency for the spiritual counselor for visits once a month. There was lack of documentation of a visit in October 2024 without documentation of the reason the visit was missed. This was reviewed with the organization leadership.

Observed in Record Review. In 1 of 10 patient records reviewed, During RR#1 it was noted an order for the aide to take vital signs every visit without parameters of when to notify the RN. This was discussed with the organization leadership.

Observed in Document Review. During reivew of the volunteer program it was noted the volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff for Quarter 1-3, 2024. this was discussed with the organization leadership.

Observed in Document Review. In 2 of 4 contracts reviewed, During review of the therapy contract and pharmacy contract it was noted the contract did not include how the organization would coordinate, supervise and evaluate their contracted services. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 2 patient records reviewed, who were discharged alive. During reivew of Live D/CRR#2, there was lack of documentation that the organization provided the hospital where the patient was admitted with a copy of the hospice discharge summary and, if requested, a copy of the patient’s clinical record. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 2 patient records reviewed, who were discharge alive. During Live D/C RR#1, there was lack of documentation that the organization provided the patient’s attending physician with a copy of the hospice discharge summary and, if requested, a copy of the patient’s clinical record. This was discussed with the organization leadership.

Observed in Record Review. In 2 of 10 patient records reviewed, During RR#1 it was noted the RN initial assessment was completed toward the end of October 2024 with a frequency of 1x/week for the SN. There was lack of documentation of SN notes in the MR after the initial visit 15 days ago. The aide frequency was 2x/week after the first week. Per the organization policy on clinical note submission of two times per week, the record lacked aide visits after the first visit the beginning of November 2024, nine days ago. During HV#3 record reivew it was noted last aide note in the record was the end of October, 12 days ago. This was discussed with the organization leadership.

Observed in Document Review. During review of the admission information packet in the office and in the homes during HVs, it was noted information was not found in admission packets, patient handbooks or documents provided to patient and family with a copy of the organization policy on the disposal of controlled medications. This was discussed with the organization leadership.

Observed in Document Review. During review of the SNF contract is was noted lack of a provision stating that the hospice will report all mistreatment, neglect, or verbal, mental, sexual, and physical abuse to the SNF, NF, or ICF/IID administrator within 24 hours of the hospice becoming aware of the alleged violation, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice. This was discussed with the organization leadership.

Observed in Document Review. In 2 of 4 contracts reviewed, The therapy contract and the DME contract lacked the provision that the contracting agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This was discussed with the organization leadership.

Observed in Data Session. During the data session review with leadership, the surveyor noted the organization failed to show evidence it had aggregated or analyzed palliative outcome data using HIS or organization specific indicators. Administrator stated Casper reports were late in generating data to use for performance improvement measures in a meaningful manner.

Observed in Infection Control System Tracer. During the Infection Control session the surveyor noted that the organization infection control and prevention plan lacked a goal limiting spread of infections associated with procedures. Observed in Infection Control Tracer. During the infection control session, the surveyor noted the written infection prevention and control plan goals were not specific and were identified as limiting, minimizing and reducing infection. The plan lacked the prioritization of infection risks in the analysis presented to the surveyor completed in December 2021. Observed in Infection Control Tracer. During the Infection Control session the surveyor noted the written Infection Control Plan lacked a goal limiting the spread of infection with the use of medical equipment, devices and supplies. Observed in Infection Control Tracer. During review of the organization infection control plan it was noted lack of a goal established for limiting unprotected exposure to pathogens.

Observed in Emergency Management Session. During the Emergency Management session, the surveyor noted that there was no documented succession plan that listed who replaces the key leader(s) during an emergency if the leader is not available to carry out his or her duties. There was no evidence of a delegation of authority plan that described the decisions and policies that can be implemented by authorized successors during an emergency and criteria or triggers that initiate this delegation. This was validated by the Administrator.

Observed in Individual Tracer. In 2 of 2 Bereavement records reviewed, BR12, BR13, the surveyor noted the hospice failed to conduct and document a patient-specific bereavement reassessment that identified the survivor's need for continued hospice care and services. For example, BR12, BR13, there was no evidence that a post death bereavement risk assessment had been conducted or care plan developed for the survivors. There was no documentation in the electronic record or paper binder. This was not compliant with the Bereavement Services policy and validated by the Administrator.

Observed in Individual Tracer. In 1 of 3 home visits conducted, HV1, the surveyor noted the organization failed to develop a plan of care that would meet the patient's needs based on alleged staffing shortages in regard to aide services. For example, during the visit and record review, the surveyor noted that a hospice aide care plan had been created one month prior to the survey. During the discussion with the daughter and nurse, it was reported that aide services had been requested by the daughter due to her own change in health related to fatigue and illness. However, aide services had not yet been implemented. Subsequent review of the record did not include documentation of daughter's change in condition, her request or the service status. The IDG note indicated CHHA services were declined rather than delayed. The DPCS stated they were unable to provide an aide due to lack of available staff. Aide services must then either be rendered by LPNs and RNs when such staffing situations occur or the patient should be referred to an agency that can meet the patient's needs. This was validated by the DPCS.

Observed in Individual Tracer. In 2 of 2 bereavement records reviewed, BR12, BR 13, the surveyor noted the hospice failed to develop and maintain a system of communication and integration in the provision of care. For example, BR12, BR13, the there was no evidence the post death bereavement services, including the survivor risk level and the plan of care were discussed at the first IDG meeting post death. This was not compliant with the Bereavement Services Policy (#4) and validated by the Administrator.

Observed in Data Session. During the Data Session with the Owner(s)/ Administrator and DPCS, the surveyor observed the organization failed to demonstrate it had a written quality improvement program/performance improvement (QAPI) plan. The organization was unable to show evidence it maintained documentation of an operational, functional program. There was no overarching plan that established improvement opportunities based upon data, priorities and goals for improvement.

Observed in Data Session. During the data session with leadership, the surveyor noted the organization failed to show evidence it had developed performance improvement indicators related to palliative outcomes and hospice services. For example, since there was no written QAPI plan, there was no documentation of measurable improvement indicators related to palliative care outcomes. This was validated by the DPCS.

Observed in Data Session. During the data session with leadership, the surveyor noted the organization failed to document what performance improvement projects were being conducted, the reasons for conducting these projects, and the measurable progress achieved on them. For example, there was no written Performance Improvement Plan that summarized and evaluated the QAPI program and projects. Although the organization had some data collection, analysis was inconsistent, and there was no evidence a process existed to evaluate results of data and actions taken to improve results.

Observed in Individual Tracer. In 2 of 3 home visits conducted, HV1, HV2, during the home visit, the surveyor observed the organization failed to demonstrate it reduced the risk of infections associated with medical supplies and equipment. For example, the nurse was observed to place the blood pressure cuff, stethoscope and thermometer into a large sealable plastic bag after direct patient care, without cleaning the equipment. Upon arrival at the second home visit, the nurse removed the sealed plastic bag containing the soiled equipment from her clinical bag, removed the equipment and placed it on a barrier next to the second patient. The nurse proceeded to clean the equipment. This was not compliant with the organization's nurse bag technique policy which requires equipment to be cleaned immediately after patient use and prior to returning it to the clinical bag.

Observed in Infection Control System Tracer. During the Infection Control Session the surveyor noted that since there was no written Infection Control Plan, the organization was unable to show evidence it had established goals to include limiting use of medical equipment, devices and supplies. Observed in Infection Control System Tracer. During the Infection Control Session the surveyor noted that since there was no written Infection Control Plan, the organization was unable to show evidence it had established goals to include limiting unprotected exposure to pathogens. Observed in Infection Control System Tracer. During the Infection Control Session the surveyor noted that since there was no written Infection Control Plan, the organization was unable to show evidence it had established goals to include limiting spread of infections associated with procedures. Observed in Infection Control System Tracer. During the infection control session, the surveyor noted that since there was no written infection prevention and control plan or goals, there was no documentation addressing its prioritized risks.

Observed in Document Review. During discussions with the Volunteer Coordinator, the surveyor noted the organization had not accurately calculated that volunteer staff 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 2021 data calculated did not include total paid staff hours. The data provided to the surveyor did not reflect accurate information and the there were no logs provided for prior years 2019 or 2020 to determine previous history. This was validated by the Volunteer Coordinator.

Observed in Leadership Session. The Governing Body failed to ensure the organization met compliance with the following Conditions of Participation were met as determined through observation, documentation and staff interviews: 418.60 ((418.60 (a); 418.60 (b)) ; 418.58 ((418.58 (a), 418.58 (d)), and 418.100 ((418.100 (b), 418.100 (c) (1) (v)).

Observed in Individual Tracer. In 1 of 3 home visits conducted, HV1, during the home visit and subsequent record review, the surveyor noted the organization failed to provide hospice aide services. For example, HV1, the caregiver requested aide services and an aide assignment sheet/ plan of care was developed one month prior to the survey date. However, no aide services were provided. The DPCS stated there were three aides on staff but there were no aides available to provide the services. HV1, the surveyor noted the organization failed to develop a plan of care that would meet the patient's needs based on alleged staffing shortages in regard to aide services. For example, during the visit and record review, the surveyor noted that a hospice aide care plan had been created one month prior to the survey. During the discussion with the daughter and nurse, it was reported that aide services had been requested by the daughter due to her own change in health related to fatigue and illness. However, aide services had not yet been implemented. Subsequent review of the record did not include documentation of daughter's change in condition, her request or the service status. The IDG note indicated CHHA services were declined rather than delayed. The DPCS stated they were unable to provide an aide due to lack of available staff. Aide services must then either be rendered by LPNs and RNs when such staffing situations occur or the patient should be referred to an agency that can meet the patient's needs. This was validated by the DPCS.

Observed in Document Review. In 1 of 1 DME Contract reviewed, During contract review, the surveyor noted the contract for Durable Medical Equipment (DME) services included an expired DMEPOS accreditation certificate. This was validated by the Administrator.

Observed in Individual Tracer. In 2 of 3 home visits conducted, HV1, HV2, the surveyor noted the organization had not implemented its infection prevention and control activities to minimize, reduce, or eliminate the risk of infection. For example, in HV1 and HV2, the nurse placed the baggie of dirty equipment on the floor, prior to returning it to the nursing bag. She failed to consistently conduct hand hygiene when accessing the nursing bag. This was not compliant with the organization's bag technique policy and validated by the DPCS.

Observed in Document Review. In 1 of 3 contracts reviewed, During contract review, the surveyor noted the hospice failed to include language in the DME agreements that required criminal background checks on contracted employees who provide direct patient care or have access to patient records. This was validated by the Administrator.