Every finding on record at Pike County Health Department, Home Health and Hospice

Based on policy review, agency and facility record review, home visit observation, and interview, the agency failed to maintain an accurate/updated medication profile/plan of care (POC) in, but not limited to, one (Record/Patient #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: RECORD/PATIENT #3: Observation and interview on 01/17/2023 at 12:35 PM, during the patient's home visit at the long term care facility (LTCF) where he/she resided, showed multiple discrepancies: - Amlodipine (high blood pressure) 0.5 milligrams (mg), patient takes one daily. The agency's medication list showed amlodipine 5 mg take 0.5 tab daily; - Famotidine (gastric acid secretion inhibitor) 20 mg, patient takes one daily on the agencys medication profile. The LTCF medication administration record (MAR) did not include famotidine, it showed it was discontinued 01/11/2023; - Lasix (water pill) 40 mg BID (twice a day) for 90 days. The agencys medication list showed Lasix 40 mg BID; - Levalbuterol (Xopenex – bronchodilator) 1.25 mg/3 ml (millileter) one vial TID (three times a day) inhalation. LTCF MAR showed albuterol (bronchodilators) 2.5 mg nebulizer every 4 hours as needed; - Metoprolol (chest pain and high blood pressure) 50 mg BID, hold if heart rate (HR) is less than 60 or systolic blood pressure less than 110. LTCF MAR showed metoprolol 50 mg BID; and - Florastor (probiotic) 250 mg one capsule BID times 14 days. LTCF MAR showed Florastor 200 mg one capsule BID times 14 days. The evidence showed that the agency failed to accurately reconcile the patient's medications. The information was reviewed with the administrator and clinical manager on 01/19/2023 at 12:36 PM and they stated that staff should check the medications, and what the patient is taking should match the agency's medication profile. Its hard to do in the facilities because they dont always tell the agency what has been added or deleted. Findings included: Review of the agency's policy titled, "Nurse Case Manager Skilled Nursing Facility (SNF)/Nursing Facility (NF) or Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) visits, Review of Hospice- Med Profile, Plan of Care (POC) and Facility- Medication Administration Record (MAR), Treatment Administration Record (TAR), Physician Order Sheet (POC) Plan," dated 03/28/2020, showed in part: - The hospice will maintain an accurate medication profile and plan of care that matches the SNF/NF MAR and POS that include the patients prescription and over the counter drugs, herbal remedies and other alternative treatments that could affect drug therapy including treatments necessary to meet the needs of the patient; - At each visit to the SNF/NF, the registered nurse (RN) will perform medication reconciliation, which will include side-by-side review of the patients current medications on the hospice medication profile and hospice POC with the facilities MAR and POS to ensure they match; - The hospice nurse will notify the SNF/NF appropriate clinician regarding any discrepancies found and if changes are needed in their MAR and/or TAR and/or POS to reflect patients current hospice medications and plan of care; - The hospice nurse will notify the Medical Director and/or the attending physician of discrepancies and follow orders received; - The hospice nurse will correct the discrepancy/discrepancies before leaving the facility; and - The hospice nurse will document in the patients medical record: * The discrepancy/discrepancies found * The physician notified * The corrective action taken on part of the hospice * Who is the RN informed at the SNF/NF of what corrective actions are needed.

Based on policy review, record review, and interview the agency failed to develop an individualized plan of care (POC) in three (Records/Patients #1, #4, and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's policy titled, "Initial Plan of Care, Comprehensive Plan of Care," dated 03/26/2020, showed in part: - All hospice care and services furnished to patients and their families will follow an individualized written plan of care established by the hospice interdisciplinary group (IDG) in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patients needs if any of them so desire; - The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: * Interventions to manage pain and symptoms * Interventions to treat the patients symptoms such as nausea, vomiting, dehydration, constipation, dyspnea, emotional distress, insomnia, neuropsychiatric symptoms, and spiritual needs using accepted professional standards of practice * Any alternative therapy * Drugs and treatment necessary to meet the needs of the patient * Medical supplies and appliances necessary to meet the needs of the appliances necessary to meet the needs of the patient - The hospice IDG (in collaboration with the individuals attending physician (if any) will review, revise and document the individualized plan as frequently as the patients condition requires, but no less frequently than every 15 calendar days; and - A revised plan of care will include information from the patients updated comprehensive assessment and will note the patients progress toward outcome and goals specified in the plan of care. RECORD/PATIENT #1: Review of the comprehensive assessment completed 10/26/2022 showed: - Admitted to hospice on 10/26/2022; - Reason for admission malignant neoplasm of endocrine pancreas (type of cancer that starts in the pancreas); - Oxygen saturation 91% (the amount of oxygen in your blood, normal is 95% to 100%), shortness of breath (SOB), treatment of SOB initiated was ";opioids (a substance used to treat pain or cause sleep), non-medical" and patient refused oxygen; - Roxanol (used to treat the symptoms of moderate-to-severe acute and chronic pain) as needed was ordered and can be used for the shortness of breath, rest and controlled breathing improves SOB; and - Respiratory education included the use of opiates for SOB, SOB management, and signs and symptoms to notify registered nurse (RN). The plan of care failed to show individualized problems, goals, and interventions for respiratory problems. RECORD/PATIENT #5: Review of the clinical record showed the following: - The patient was admitted to hospice on 12/30/2022; - The primary diagnosis was Alzheimers (symptoms of dementia that gradually get worse over time. Alzheimer's disease first affects the part of the brain associated with learning); - Admitting diagnosis changed to encephalopathy (any disease of the brain that alters brain function or structure) on 01/03/2023 per a skilled nurse (SN) note; - There was no comprehensive assessment completed; and - The patient resided at a long term care facility. Review of the plan of care dated 12/30/2022 through 03/29/2023, showed the following: - No diagnosis listed; - Medications: * Morphine concentrate (treat pain or shortness of breath); * Lorazepam (treat anxiety or agitation); * Bisacodyl suppository (treat constipation); * Senna with docusate sodium (treat constipation); * Haloperidol (treat agitation/hallucinations); - No durable medical equipment listed, diet, functional ability, mental status, advance directive, allergies, prognosis, pain level or response; - No goal or interventions on bowel elimination incontinence; - No goal or interventions on neurological/memory/confusion; - No goal or interventions on pain; and - No interventions on bowel elimination: constipation/impaction, impaired communication, dysphagia, fall prevention, fall risk, Foley catheter care, anxiety/agitation, impaired aphasia, dysphagia – risk or aspiration. The plan of care failed to show individualized goals, and interventions for the patients health history and current problems.

Based on policy review, clinical record review, and interview, the agency failed to ensure that the licensed professional services, delivered by their healthcare professionals, were practiced under the hospice's policies and procedures in one (Record/Patient #5) of five full records reviewed. This deficient practice had the potential to adversely affect the quality of care provided to all the agency's patients. --- Findings included: Review of agency's policy, ";Change In Condition On Call Guidelines," dated March 24, 2020, showed in part: - It is the policy of this agency to have a nurse on call 24 hours a day, 7 days a week to ensure hospice patients and their caregivers receive the appropriate and necessary hospice care; - When appropriate a nurse will make a visit; - The following is a list of reasons for which the nurse may need to make a visit after hours: and *Any symptom of new onset that is unusual/uncomfortable for the patient. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice on 12/30/2022, with a primary diagnosis was Alzheimers (symptoms of dementia that gradually get worse over time) and the admitting diagnosis changed to encephalopathy (any disease of the brain that alters brain function or structure) on 01/03/2023 per a skilled nurse (SN) note. The patient resided at a long term care facility. Review of the referral packet received from the hospital showed the patient had a history of hydrocephalus (excess fluid in the brain). Review of the telephone note dated 01/15/2023 at 8:55 AM, showed in part the following: - Change in condition; - Spoke with a nurse at the long term care facility (LTCF); - On-call nurse received call from LTCF nurse stating that patient had experienced seizure-like activity, describing change of mentation and foaming at mouth after being transferred up to a wheelchair earlier this morning. The physician was contacted first for renewal of Ativan [medication to help reduce anxiety] order and that was administered. Patient was without further episode so far this morning. Agency registered nurse (RN) encouraged LTCF staff to notify the on call hospice RN of any changes or needs. She verbalized understanding. The hospice agency failed to make a visit and assess the patient with a new change in condition, and failed to offer a visit to assess the patient with a change in condition as the agency policy is written. Review of the hospice licensed practical nurse (LPN) routine visit dated 01/17/2023, showed patient appeared stable and no further seizure activity noted since the weekend when the physician was called to renew the lorazepam (generic brand for Ativan) order. The patient was not seen for two days by the hospice agency after a new change in condition. During an interview on 01/19/2023 at 1:50 PM, the administrator stated that a visit should have been offered.

Based on policy review, record review, and interviews, the hospice failed to ensure the bereavement counseling program and bereavement plan of care reflected the individualized needs and a support group of the bereaved as identified in bereavement risk assessments in two (Records/Patients #7 and #9) of two sampled records reviewed for bereavement. The deficient practice has the potential to affect all the bereaved families/caregivers of hospice patients. --- Findings included; Review of the agency's policy titled ";Bereavement Services", last revised November 2019 showed in part the following: - After a death has occurred, the bereavement assessment will be updated and the family/caregiver needs will be discussed at the next interdisciplinary team meeting; - Families/caregivers who choose to participate in the bereavement will be accorded the same confidentiality and privacy rights as a hospice patient; - Within three to five weeks after the patients death, a bereavement assessment will be completed by the bereavement counselor following the family/caregiver. This assessment will note and observe the bereaved for symptoms related to grief. The bereavement counselor will render a professional judgment as to whether the bereaved is experiencing normal grief, moderate grief, or severe grief reaction; and - The bereavement counselor will make information available to the bereaved person regarding bereavement support groups, other support groups available in the community, and the availability of individual counseling by the hospice personnel. Review of the agency's policy titled ";Bereavement Assessment", last revised November 2019 showed in part the following: - On admission, the Social Worker/Bereavement Counselor will complete a bereavement risk assessment that is discussed at the next interdisciplinary meeting. At a minimum, it will include services to be provided including individual counseling, and support groups; and - After the death occurs, the Social Worker/Bereavement Counselor will complete the bereavement follow-up assessment. Findings included: RECORD/PATIENT #7: Review of the patients hospice initial assessment showed the following: - The patient was admitted to hospice service on 05/27/2022; - Bereavement level high for the patient's niece; and - Skilled nurse expects patient to pass within a few days. Review of the hospice/nursing home death/discharge showed the patient passed away on 05/29/2022 with family at bedside. Review of the post death bereavement form showed the following: - The patients date of death was 05/29/2022; - A list of interventions to be completed with date completed and initials of staff completing the interventions; and - The intervention to offer support group invitation was blank. RECORD/PATIENT #9: Review of the patient summary showed the patient was admitted to hospice service on 03/11/2021. Review of the bereavement initial assessment showed the caregiver low risk for complicated bereavement. Review of the post death bereavement form showed the following: - The patients date of death was 01/29/2022; - A list of interventions to be completed with date completed and initials of staff completing the interventions; and - The intervention to offer support group invitation was blank. During an interview on 01/18/2023 3:15 PM, the Masters of Social Work/Bereavement Coordinator stated that the agency had no support group. During an interview on 01/19/2023 at 3:40 PM, the administrator stated that the agency had a support group prior to COVID, but nobody attended.

Based on policy review, clinical record review, and interview, the hospice provider failed to ensure all entries were appropriately authenticated and dated in accordance with the hospice policy and currently accepted standards of practice for one (Record/Patient #5) of five cases sampled for comprehensive assessment. The deficient practice has the potential to affect all patients on service. --- Findings included: Review of the agency's policy titled, "Initial and Comprehensive Assessment Including Time Frame, Content, Update and Patient Outcome Measures," dated March 26, 2020, showed in part: -The hospice will conduct and document in writing a patient-specific comprehensive assessment that identifies the patient need for hospice care and services, and the patient's need for physical, psychosocial, emotional, and spiritual care; - The comprehensive patient assessment will accurately reflect the patients current health status and include information to establish and monitor a plan of care; - The purpose of the initial assessment will be to gather the critical information necessary to treat the patient/familys immediate care needs; - The initial assessment is necessary to gather the essential information necessary to begin the plan of care and provide the immediate necessary care and services; and - The hospice interdisciplinary group, in consultation with the individuals attending physician will complete the comprehensive assessment no later than five calendar days after election of hospice care in accordance with § 418.24. Review of the agency's policy titled, "Clinical Records," dated March 26, 2020, showed in part: -The record will be complete, legible, readily accessible and systematically organized to facilitate retrieval with all initial and comprehensive assessments to be completed in the EMR [electronic medical record] within seven days from date of patient visit. Hospice will conduct and document in writing a patient-specific comprehensive assessment that identifies the patient need for hospice care and services, and the patient's need for physical, psychosocial, emotional, and spiritual care; - The comprehensive patient assessment will accurately reflect the patients current health status and include information to establish and monitor a plan of care; - The purpose of the initial assessment will be to gather the critical information necessary to treat the patient/familys immediate care needs; - The initial assessment is necessary to gather the essential information necessary to begin the plan of care and provide the immediate necessary care and services; and - The hospice interdisciplinary group, in consultation with the individuals attending physician will complete the comprehensive assessment no later than five calendar days after election of hospice care in accordance with § 418.24. RECORD/PATIENT #5: Review of the clinical record showed the following: - The patient was admitted to hospice on 12/30/2022; - The primary diagnosis was Alzheimers (symptoms of dementia that gradually get worse over time. Alzheimer's disease first affects the part of the brain associated with learning); - Admitting diagnosis changed to encephalopathy (any disease of the brain that alters brain function or structure) on 01/03/2023 per a skilled nurse (SN) note; - The comprehensive assessment was incomplete; and - The patient resided at a long term care facility. During an interview on 1/19/2023 at 1:44 PM, the clinical manager stated that the patients HIS (health information system - refers to a system designed to manage healthcare data. This includes systems that collect, store, manage and transmit a patient's electronic medical record) assessment was not completed, it was started on 12/30/2022 and had not been completed and signed. She would expect the comprehensive assessment to be completed within five days of admission and sent to the coding department.

Based on policy review, record review and interview, the agency failed to document a discharge summary that included a summary of the patient's stay including treatments, symptoms and pain management in, but not limited to, one (Record/Patient #8) of two discharge record reviewed. This deficient practice has the potential to affect the discharge needs of all patients served by the agency. --- Findings included: Review of the agency's policy titled, "Initial Plan of Care, Comprehensive Plan of Care," dated 03/26/2020, showed in part: - All patients discharged from a service and from hospice will have a discharge summary completed and filed in the clinical record; - Hospice personnel who provide care will complete a discharge summary at the time the discipline is discontinued, which may include, as appropriate: * The date of discharge, the date the physician and patient informed of discharge * The reason for discharge * The status of problems identified at admission and during the provision of care * The resolution of identified problems * Continuing symptom management needs * The overall status of the patient * A summary of the care or services provided - The discharge summary will be completed and within 72 hours of discharge from service; and - The administrative assistant will print the discharge summary from the patients electronic medical record and fax it to the patients attending physician. RECORD/PATIENT #8: Record review showed the patient was discharged from hospice on 01/03/2023, due to no longer being terminally ill. The record failed to include a discharge summary. During an interview on 01/18/2023 at 3:00 PM, the nursing coordinator stated that no discharge summary had been sent to the physician.

Based on contract review and interview, the agency's general inpatient (GIP) and respite contract with the hospital, failed to include the requirement that specifies the hospice retains responsibility for ensuring training of personnel who will be providing the patient's care in the facility, as well as description of the training, and the names of those giving the training, in one of one contracts reviewed. This deficient practice has the potential to affect respite services for all patients served by the agency. --- Findings included: Review of the agency's respite and GIP collaborative care agreement contract dated 01/21/2023, with a hospital, showed the hospice failed to include the requirement that the hospice retains responsibility for ensuring that the training of personnel who will be providing the patients care in the inpatient facility has been provided and that a description of the training and the names of those giving the training are documented. During an interview on 01/19/2023 at 11:00 AM, the nursing coordinator stated that there was no training provided to the inpatient personnel at the hospital.

Based on policy review, clinical record review, and interview, the agency failed to assume responsibility for professional management of the patient's hospice services in one (Record/Patient #5) of five applicable records reviewed, when the agency failed to ensure the patient was assessed after a new onset of symptoms related to the patients terminal diagnosis developed. This deficient practice has the potential to affect the care of all hospice patients who reside in a facility. --- Findings included: Review of agency's policy, Provision of Care to Residents of SNF/NF (skilled nursing facility/nursing facility) or ICF/MR (intermediate care facility/mental retardation)", dated March 26, 2020, showed in part: - Core services including nursing will be directly provided by hospice; - Hospice will assume responsibility for the professional management of the SNF/NF or ICF/MR residents hospice services provided, in accordance with the hospice plan of care and the hospice CoPs (condition of participation), and make any arrangements for hospice-related inpatient care in a participating Medicare/Medicaid facility; and - The hospice SNF/NF or ICF/MR will have a written agreement that specifies the provision of hospice services in the facility; - A provision that the hospice is notified if a significant change in a patients physical, mental, social or emotional status occurs; - A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care; and - An agreement that it is hospices responsibility to provide services at the same extent as those services would be provided if the resident were in his or her own home. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice on 12/30/2022, with a primary diagnosis was Alzheimers (symptoms of dementia that gradually get worse over time) and the admitting diagnosis changed to encephalopathy (any disease of the brain that alters brain function or structure) on 01/03/2023 per a skilled nurse (SN) note. The patient resided at a long term care facility. Review of the referral packet received from the hospital showed the patient had a history of hydrocephalus (excess fluid in the brain). Review of the initial comprehensive assessment dated 12/30/2022 showed no history of the patient having seizures. The patient resided in a LTCF (long term care facility) and required help with all of his/her ADLs (activities of daily living). Review of the telephone note dated 01/15/2023 at 8:55 AM, showed in part the following: - Change in condition; - Spoke with a nurse at the LTCF; - On-call nurse received a call from LTCF nurse stating that the patient had experienced seizure-like activity, describing change of mentation and foaming at mouth after being transferred up to a wheelchair earlier this morning. The physician was contacted first for renewal of Ativan [medication to help reduce anxiety] order and that was administered. Patient was without further episode so far this morning. Agency registered nurse (RN) encouraged LTCF staff to notify the on call hospice RN of any changes or needs. She verbalized understanding. The hospice agency failed to make a visit and assess the patient with a new change in condition and failed to offer a visit to assess the patient with a change in condition. Review of the hospice licensed practical nurse (LPN) routine visit dated 01/17/2023, showed patient appeared stable and no further seizure activity noted since the weekend when the physician was called to renew the lorazepam (generic name for Ativan) order. The patient was not seen for two days by the hospice agency after a new change in condition. During an interview on 01/19/2023 at 1:50 PM, the administrator stated that a visit should have been offered.

Based on policy review, record review, and interview, the hospice failed to ensure coordination of responsibility for bathing the patient and any treatments between the hospice agency and the LTCF (long term care facility), in one (Record/Patient #2) of two records reviewed of patients that resided in a LTCF. This deficient practice has the potential to adversely affect all hospice patients residing in a LTCF. --- Findings included: Review of the agency's policy titled, "Provision of Care to Residents of SNF/NF (skilled nursing facility/nursing facility) or ICF/MR (intermediate care facility/mental retardation)", dated March 26, 2020 showed in part: - The hospice and SNF/NF or ICF/MR will have a written agreement that specifies the provision of hospice services in the facility; - A written plan of care (POC) must be established and maintained in consultation with SNF/NF or ICF/MR representatives; and - The POC must identify the care and services that are needed and specifically identify which provider is responsible for performing the perspective function. RECORD/PATIENT #2: Review of the undated hospice coordinated task plan of care failed to show what days of the week the hospice skilled nurse and the hospice aide was responsible (the hospice agency or the facility) for the baths or treatments, ordered for the patient. Review of the POC, dated 01/09/2023 to 04/08/2023, failed to show who was responsible (the hospice agency or the facility) for baths or any orders for treatments on the days the hospice staff was visiting the patient. During an interview on 01/18/2023, beginning at 11:39 AM, the facility staff charge nurse stated that the hospice agency provides aide services and that there is nothing posted so the facility knows what days the hospice aide will provide services, he/she thinks that its more verbal. During an interview on 01/19/2023 at 1:25 PM, the administrator stated that the coordinated task plan should be completed.