Every finding on record at Prime Care Hospice, Inc.

Observed in Record Review. In 1 of 4 patient records reviewed, During RR#1 it was noted the RN recertification clinical assessment summary in November 2023 was identical to the recertification assessment summary in February 2024. This was reviewed with the organization leadership.

Observed in Record Review. In 3 of 4 patient records reviewed, During RR#2 it was noted the spiritual counselor (SC) frequency on the POC was 1 visit/month. During October 2023-February 2024 it was noted the SC made phone call visits per the family request and documented the findings of the phone calls at the IDG meetings. During RR#1 it was noted the SC made phone call visits to the patient and family in December 2023-Feburary 2024. During RR#3 it was noted the SC made phone call visits to the patient and caregivers in October 2023-December 2023 and February 2024. The POCs were not updated by the IDG to include phone calls in addition to onsite visits for the SC. This was discussed with the organization leadership.

Observed in Individual Tracer. In 1 of 1 home visits conducted, During HV#1 it was noted the admission packet information patient/caregiver instruction section for disaster mitigation and preparedness included information in the case of an earthquake and COVID-19 care and isolation. The organization HVA listed areas of prioritized vulnerability were COVID-19 and fires. The admission packet did not contain information on wild fire safety and preparedness. This was discussed with the organization leadership.

Observed in Leadership Session. The Hospice Nurse Surveyor noted the hospice governing body did not designate one or more individuals to be responsible for the QAPI program as evidenced by the HCO was not able to produce this documentation at the time of survey. During discussion with the Leadership Team, the CEO and CFO noted the DON is in charge of the QAPI program however the Governing Body has not officially named the DON responsible for operating the QAPI program.

Observed in Infection Control Tracer. The organization failed to have documentation of educating staff about, at a minimum, the influenza vaccine; non-vaccine control and prevention measures; and the diagnosis, transmission, and impact of influenza. In discussion with Leadership, they noted they have plans per the IC plan to educate staff on Influenza but have not implemented the education for this year at time of survey. This observation was reviewed with the CEO and CFO.

Observed in Tracer Activities. The organization failed to evaluate its emergency management program, emergency operations plan, and continuity of operations plan. During tracer activities for Emergency Management, the Hospice Nurse Surveyor observed the organization had documentation of evaluation for the year 2019, but no documentation was provided to the surveyor of an emergency management program evaluation at least every two years. The leaders noted that there was a person in place for those years and that person is no longer with the organization. They could not locate the documentation from that time period. This was discussed and reviewed with the Hospice Team.

Observed in Tracer Activities. The organization failed to plan and conduct exercises to test its emergency operations plan and response procedures. During tracer activities for Emergency Management, the Hospice Nurse Surveyor observed the organization had documentation of drills, at least annually, for 2019 and 2023. But no documentation was provided to the surveyor for 2020, 2021 and 2022. The leaders noted that there was a person in place for those years and that person is no longer with the organization. They could not locate the documentation from that time period. For the current year, the Emergency Operations Plan and drills is in place. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 9 of 14 patient records reviewed, the organization failed to assess and reassess its patient's. During record review for RRHV#1, RRHV#2, RRHV#3, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#6, and BR#1, the Hospice Nurse Surveyor observed the Initial Bereavement Assessment was not completed in its entirety, according to organizational policy and process. For example all records listed did not contain the name, relationship or phone and contact information for the bereaved, In RRNHV#2, the narrative states contacted bereaved individual with no identifying information. In RRNHV#3, the narrative stated initiated contact with mourning individual. For RRHV#3, the Hospice Nurse Surveyor observed the RN did not document wound assessment according to the organizational policy. On 5/16, the patient had new orders for a Stage 2 pressure Ulcer on the buttocks but the RN assessment did not include location, size, length, width and depth as required by the organizational assessment policy. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to assess and reassess its patient's. During record review for all records, the Hospice Nurse Surveyor observed there was no documentation of progress towards desired outcomes. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 4 of 14 patient records reviewed, the organization failed to plan the patient's care. During record review for RRNHV#1, RRNHV#3, RRNHV#4, and BR#2, the Hospice Nurse Surveyor observed the POC did not include all services needed for palliation and management of the terminal illness and related conditions. For example in RRNHV#1, the patient had new onset weakness but it was not addressed on the POC. For RRNHV#3, the patient had new onset decrease of nutritional intake and insomnia but it was not addressed on the POC. For RRNHV#4, the patient was placed on Continuous Care but it was not addressed on the POC. For BR#2, the patient had no goals or interventions liste on the POC. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to provide interdisciplinary, collaborative care, treatment, or services. During record review for RRNHV#4, the Hospice Nurse Surveyor observed the patient was placed on continuous care with a contracted agency but their was no documentation of collaboration or coordination with the staff member taking over. The patient was seen by the Hospice Staff on 8/8 and was immediately transitioned to continuous care with a contracted LVN, but there was no documentation from the organization that a plan of care was provided or that a collaborative conversation took place. This was discussed with the Hospice Team.

Observed in Record Review. In 13 of 14 patient records reviewed, the organization failed to plan the patient's care. During record review for RRHV#1, RRHV#2, RRHV#3, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6, RRNHV#7, RRBR#1, RRBR#2, RRDC#1, and RRDC#2, the Hospice Nurse Surveyor observed the goal timeframes were not individualized and measurable. For example in RRHV#1 all target dates were for 5/18 and were not updated as of survey. For RRHV#2, all goal dates were for 4/20 and not updated. RRHV#3 all goal dates were listed as 8/28. For RRNHV#2, the target dates were all expired and not updated. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to provide care, treatment, or services for each patient. During record review for RRHV#3, the Hospice Nurse Surveyor observed wound care orders were not provided according to the hospice plan of care. Wound care orders were entered on 5/16 for 2x daily and there was no documentation in the electronic medical record of the nurses providing wound care or providing education to caregivers to provide the wound care. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 2 of 14 patient records reviewed, the organization failed to provide interdisciplinary, collaborative care, treatment, or services. During record review for RRHV#1 and RHV#3, the Hospice Nurse Surveyor observed not all disciplines were adding to the plan of care. For example in RRHV#1, both SW/ SC were seeing the patient but they were not documenting their efforts in the plan of care. And for RRHV#3, SC was seeing the patient but not documenting efforts in the plan of care. Upon conversation with the SW, she stated that she reports issues to the DON who then adds to the POC but there was no documentation to support those conversations. This was discussed and reviewed with the Hospice Team.

Observed in Tracer Activities. The Hospice Nurse Surveyor noted the HCO did not have an effective, ongoing, organizationwide, data-driven QAPI program as evidenced by the HCO was not able to produce this documentation for 2020, 2021 and 2022, at the time of survey. During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team. Observed in Tracer Activities. The Hospice Nurse Surveyor noted the HCO was not able to demonstrate the operation of its QAPI program as evidenced by the HCO was not able to produce the documentation of the program at the time of survey for 2020, 2021 and 2022. During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team. Observed in Tracer Activities. The Hospice Nurse Surveyor noted the QAPI program did not involve all services provided as evidenced by the HCO was not able to produce this documentation for 2020, 2021 and 2022, at the time of survey. During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team.

Observed in Tracer Activities. The Hospice Nurse Surveyor noted the QAPI program did not demonstrate improvement in its palliative outcomes and hospice services as evidenced by the HCO was not able to provide documentation for 2020, 2021 and 2022 at the time of survey.During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team.

Observed in Tracer Activities. The Hospice Nurse Surveyor noted the hospice did not use patient care indicator data in the design of its quality assessment and improvement program as evidenced by the HCO was not able to produce this documentation for 2020, 2021 and 2022 at the time of survey.During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team.

Observed in Tracer Activities. The Hospice Nurse Surveyor noted the HCO did not use the results of data analysis to identify improvement opportunities as evidenced by lack of documentation for 2020, 2021, and 2022. During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team. Observed in Tracer Activities. The Hospice Nurse Surveyor noted the HCO did not analyze and compare data over time to identify levels of performance, patterns, trends and variations as evidenced by lack of documentation for 2020, 2021, and 2022. During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team.

Observed in Tracer Activities. The Hospice Nurse Surveyor noted the governing body did not approve the frequency and detail of data collection as evidenced by the HCO was not able to produce this documentation for 2020, 2021 and 2022 at the time of survey. During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team.

Observed in Tracer Activities. The Hospice Nurse Surveyor noted the hospice did not select performance improvement activities that affect patient safety, palliative outcomes or that were high-volume, high-risk, problem-prone areas as evidenced by the HCO was not able to produce this documentation for 2020, 2021, and 2022 at the time of survey. During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team.

Observed in Tracer Activities. The Hospice Nurse Surveyor noted the hospice did not collect data on adverse patient events as evidenced by the HCO was not able to produce this documentation for 2020, 2021 and 2022 at the time of survey. During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team.

Observed in Tracer Activities. The Hospice Nurse Surveyor noted the HCO did not act when planned improvements were not achieved or sustained as evidenced by lack of documentation for 2020, 2021, and 2022. During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team. Observed in Tracer Activities. The surveyor noted the HCO did not act on improvement opportunities as evidenced by lack of documentation for 2020, 2021, and 2022. During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team.

Observed in Tracer Activities. The Hospice Nurse Surveyor noted the number and scope of performance improvement projects were not based on patients’ needs and internal organization needs as evidenced by lack of documentation for 2020, 2021, and 2022. During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team.

Observed in Tracer Activities. The Hospice Nurse 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 as evidenced by the HCO was not able to produce this documentation for 2020, 2021, and 2022 at the time of survey. During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team.

Observed in Tracer Activities. The Hospice Nurse Surveyor noted the HCO leadership did not establish priorities for data collection/PI activities as evidenced by no documentation of a Performance Improvement Plan or activities for 2020, 2021, and 2022. During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team. Observed in Tracer Activities. The Hospice Nurse Surveyor noted performance improvement was not organization wide as evidenced by no documentation of a QAPI plan or activities for 2020, 2021 and 2022. During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team. Observed in Tracer Activities. The Hospice Nurse Surveyor noted the HCO did not evaluate its improvement actions were effective as evidenced by the HCO was not able to produce this documentation for 2020, 2021, and 2022 at the time of survey. During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team.

Observed in Tracer Activities. The Hospice Nurse Surveyor noted the hospice governing body did not designate one or more individuals to be responsible for the QAPI program as evidenced by the HCO was not able to produce this documentation for 2020, 2021 and 2022 at the time of survey.During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team.

Observed in Tracer Activities. The Hospice Nurse Surveyor noted the HCO did not maintain an infection control program as evidenced by the HCO was not able to produce this documentation for 2020, 2021 and 2022 at the time of survey. During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team.

Observed in Patient Home. In 2 of 2 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned. During RRHV#1 and RRHV#2, the Hospice Nurse Surveyor observed the staff member did not follow the policy on bag technique. During both visits the RN did not close her nursing bag, in alignment with the organizational policy. And during RRHV#1, the RN filled her bag with paper towel from the patient residence. This was discussed and reviewed with the Administrator and Administrator Designee. Observed in Patient Home. In 2 of 2 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned. During RRHV#1 and RRHV#2, the Hospice Nurse Surveyor observed the RN, in both cases, went into her bag several times without completing hand hygiene between each entry.

Observed in Tracer Activities. The Hospice Nurse Surveyor noted the HCO did not use evidence-based national guidelines, expert consensus or review and evaluation of health care literature in the development of infection prevention and control activities. This was evidenced by the organization was not able to produce this documentation for 2020, 2021 and 2022 at the time of survey. During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team. Observed in Tracer Activities. The Hospice Nurse Surveyor noted the HCO did not include surveillance as part of their infection prevention and control activities as evidenced by the HCO was not able to produce this documentation for 2020, 2021 and 2022 at the time of survey. During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team.

Observed in Tracer Activities. The Hospice Nurse Surveyor noted the organization’s infection prevention and control goals did not address limiting the spread of infections associated with procedures as evidenced by the organization was not able to produce this documentation for 2020, 2021 and 2022 at the time of survey. During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team. Observed in Tracer Activities. The Hospice Nurse Surveyor noted the organization’s infection prevention and control goals did not address limiting the spread of infection associated with the use of medical equipment, devices and supplies as evidenced by the organization was not able to produce this documentation for 2020, 2021 and 2022 at the time of survey. During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team. Observed in Tracer Activities. The Hospice Nurse Surveyor noted the organization’s infection prevention and control goals did not address its prioritized risks as evidenced by the organization was not able to produce this documentation for 2020, 2021, and 2022 at the time of survey. During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team. Observed in Tracer Activities. The Hospice Nurse Surveyor noted the organization’s infection prevention and control goals did not include improving compliance with hand hygiene guidelines as evidenced by the organization was not able to produce this documentation for 2020, 2021 and 2022 at the time of survey. During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team. Observed in Tracer Activities. The Hospice Nurse Surveyor noted the organization’s infection prevention and control goals did not address limiting unprotected exposure to pathogens as evidenced by the organization was not able to produce this documentation for 2020, 2021 and 2022 at the time of survey. During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team.

Observed in Tracer Activities. The Hospice Nurse Surveyor noted the HCO did not educate licensed independent practitioner about the influenza vaccine; non-vaccine control measures; and the diagnosis, transmission and treatment of the flu as evidenced by the HCO was not able to produce this documentation for 2020, 2021 and 2022 at the time of survey. During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team.

Observed in Tracer Activities. The Hospice Nurse Surveyor noted licensed professionals did not participate in the QAPI program as evidenced by lack of documentation for a QAPI program for 2020, 2021, and 2022. During discussion with the Hospice Team, the surveyor noted they have just re-implemented their previous system and have a plan in place for the current year. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 7 of 14 patient records reviewed, the organization failed to provide for its planned scope and level of care, treatment, or services. During record review for RRHV#1, RRHV#2, RRHV#3, RRNHV#1, RRNHV#2, RRNHV#4, and BR#2, all core services were not documented as part of IDG. the Hospice Nurse Surveyor observed the organization failed to offer MSW services, as required. For example in RRHV#1, RRNHV#1, RRNHV#2, RRNHV#4, the SW documented SW proposed teleconference to pt/ caregiver. The DON stated that the SW was pregnant and on bed rest so unable to do visits. For RRHV#2 and RRHV#3, the SW did not have documentation of participation in IDG. For BR#2, the RN did not have documentation of participation in IDG for 7/6, 7/20 and 8/3. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 1 of 4 patient records reviewed, the organization failed to plan the patient's care. During record review for RRHV#2, the Hospice Nurse Surveyor observed the aide care plan failed to address bleeding precautions as the patient was on Eliquis ( an anti-coagulant). This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 1 of 1 patient records reviewed, The organization failed to provide a contractual agreement safely and effectively. During record review for RRHV#4, the Hospice Nurse Surveyor observed a contracted LVN took over continuous care. The contract did not state that services may be provided in accordance with the patient's plan of care. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 5 of 14 patient records reviewed, the organization failed to maintain a complete and accurate patient record. During record review for RRHV#2, RRHV#3, RRNHV#7, RRDC#1 and RRDC#2, the Hospice Nurse Surveyor observed the HHA visits were not completed. After discussion with the Hospice Team, it was noted that some of the staff members are behind on their documentation. The organizational policy stated the documentation would be turned in by day 7. For RRHV#2, no documentation had been completed for HHA visits ( ordered 2x week) for 2 weeks. For RRHV#3, the HHA visit had not been documented for the last 8 days. For RRDC#1, the patient had their last SN visit on 1/18/23 and was discharged on 2/25/23 with no documentation in between. And for RRDC#2, the patient had their last SN visit on 1/18/23 with discharge on 2/1/23 and no documentation of visits in between. For RRNHV#7, the last nursing visit was on 1/18/23 with discharge on 2/25/23 and no documentation in between. Nursing was ordered 1x weekly. This was discussed and reviewed with the Hospice Team.