Every finding on record at Promise Hospice, Inc.

Observed in Record Review. In 1 of 14 patient records reviewed, it was noted by the nurse surveyor that the initial bereavement risk assessment was not completed as part of the comprehensive assessment. For RRNHV#1, the initial bereavement risk assessment was completed by the Medical Social Worker three months after the patient’s admission. Finding was verified by the CEO/Administrator and the Office Manager.

Observed in Record Review. In 10 of 10 patient records reviewed, for all active records, the nurse surveyor noted that the goals were not measurable or individualized. For example, RRHV#1, “Pt will verbalize and/or express decreased episodes of SOB at rest,” and RRHV#3, “Comfort will be promoted as skin integrity changes throughout disease and dying process” 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. Dates for achieving goals were al at the end of the certification period. Finding was verified with CEO/Administrator and the Director of Patient Clinical Services (DPCS).

Observed in Record Review. In 1 of 10 patient records reviewed, for active patients, it was noted by the nurse surveyor that PRN frequencies for the skilled nurse, medical social worker, and spiritual counselor did not have a reason for when to make the as needed PRN visits (they were not qualified). For RRNHV#6, all PRN visit frequencies were quantified for a number of how many could be made, but not for the reason in which they would be made. Finding was verified by the CEO/Administrator and the DPCS.

Observed in Record Review. In 1 of 10 patient records reviewed, for active patients it was noted by the nurse surveyor that for RRNHV#5, the patient had a foley catheter, however, there was no doctor order for when the foley should be changed or maintained. Finding was verified by the DPCS.

Observed in Patient Home. In 2 of 3 home visits conducted, it was noted by the nurse surveyor that for RRHV#1, the patient had and oxygen concentrator and had PRN oxygen ordered, however the oxygen concentrator in the room did not have tubing attached or anywhere in the room. RRHV#2, the patient had a backup oxygen cylinder in her room at the foot of the bed, it was in a stand, but did not have a regulator or tubing. Additionally, she did not have a concentrator in her room as noted on the plan of care. Findings were verified by the Administrator/CEO and the DPCS Services who were present on the home visit.

Observed in Record Review. In 8 of 10 patient records reviewed, for active patients it was noted by the surveyor that the interdisciplinary meeting notes reflecting updates to the comprehensive plan of care were not completed by the Registered Nurse for the last IDG for RRHV#1, RRHV#2, RRHV#3, RRNHV#1, RRNHV#4, RRNHV#5, RRNHV#6, or RRNHV#7. Finding was verified by the Office Manager, the DPCS, and the CEO/Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the nurse surveyor observed that the medication profile was inaccurate. During RRHV#2 it was noted that the medication profile did not accurately reflect the medications that the patient was taking. The patient had an Albuterol Sulfate Inhaler in her medication box that she was taking PRN for SOB or wheezing; however this was not noted on the medication profile in her EMR. Additionally, she also had Diphenpoxylate-Atrop 2.5, 1 tab every six hours as needed for diarrhea which was also not reflected in the EMR. Finding was verified by the Administrator/CEO and the DPCS Services who were present on the home visit.

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted by the nurse surveyor that for RRHV#1 two back up small oxygen tanks were stored standing up on a shelf in a closed, locked, unventilated closet in the hallway outside the patient room. Finding was verified by the Administrator/CEO and the DPCS Services who were present on the home visit. This was corrected on site and cylinders were laid on the floor in the patient room.

Observed in Emergency Management Session. The organization did not conduct an exercise to test its emergency operation plan in 2021.

Observed in Record Review. In 1 of 11 patient records reviewed, During RR#7 it was noted the financial information on co-pays or deductibles was blank.

Observed in Record Review. In 11 of 11 patient records reviewed, During HV#1-3 and RR#1-8 it was noted during the IDG meetings there was lack of updated documentation from the RN, LCSW and Chaplain on a consistent basis during each IDG meetings. The chaplain did not documents any summaries of spiritual issues or care during IDGs, the LCSW documented summaries sporadically and the RN documentation during IDG meetings did not summarize the clinical findings every 15 days. The IDG updates did not include progress toward outcomes or the patient's response to care.

Observed in Record Review. In 3 of 11 patient records reviewed, During RR#10 assessment of bereavement services provided it was noted although the patient expired the beginning of August 2021, there was documentation of IDG meetings without mention of the patient's death. The last IDG meeting one month after the death documented the IDG agrees that current Plan of Care is effective in managing symptoms and progress towards pt/family/cg centered goals. During RR#4 it was noted the POLST form was signed by the patient but the direction on choices for life sustaining orders was blank. In addition the hospice election date was blank and the physician choice was blank. During HV#1 record review it was noted the POC contained multiple problems, interventions and goals identified in previous hospice admissions with dates prior to the current EOB date.

Observed in Record Review. In 11 of 11 patient records reviewed, During HV#1-3 and RR#1-#8 it was noted all the goals were to be accomplished either by death or discharge or within the certification period except pain which was to be controlled with a target date within 2 weeks for each patient when pain was identified as a problem/deficit.

Observed in Record Review. In 1 of 11 patient records reviewed, During RR#7 it was noted hospice aide services were identified on the POC with interventions and goals in July 2022. There were no visits documented to date in August 2022. The frequency of visits on the POC is blank. The hospice aide assignment form frequency was twice a week.

Observed in Record Review. In 8 of 11 patient records reviewed, During RR#1 it was noted the POC included interventions related to schizophrenia but the diagnosis was not on the POC as a related condition or history of mental illness. During RR#4 it was noted on the POC a problem identified as 'high risk meds with interventions and goals. There were no high risk medications on the med profile per the organization policy. During RR#5 it was noted the patient refused the MSW and Chaplain during first certification and throughout the subsequent certifications but there are interventions and goals on the POC for the MSW and Chaplain. During RR#1 it was noted an order on the POC for oxygen 2L. The order lacked the if the oxygen was continuous or if PRN with the PRN indicator. During RR#4 it was noted documentation by the RN that the patient's oxygen flow was 2L. There was lack of documentation of the complete order for oxygen therapy within the POC or on the medication profile. During RR#7, it was noted during the initial RN assessment the documentation that the patient was receiving oxygen therapy at 2L. The complete oxygen order was not on the medication profile or the POC. During HV#1-3 and RR#2,3,5,6, it was noted each patient was recertified multiple times since their initial certification period. The IDG/POC were not updated. The problems identified, interventions and goal dates remained the same from the initial certifications.

Observed in Record Review. In 2 of 11 patient records reviewed, During RR#2 it was noted the first IDG meeting was 16 days after the SOC date. During HV#1 it was noted the first IDG meeting was documented on day 23 after the SOC.

Observed in Record Review. In 4 of 11 patient records reviewed, During RR#4 it was noted volunteer services on the POC with the frequency of 1x/week. Eleven days after the SOC, there is lack of documentation of volunteer visits or communication notes indicating the reason why visits were not provided. During HV#3 it was noted the Chaplain frequency on the POC for the first 2 certification periods was 2 PRN. The Chaplain visited the patient once a week. There were no notifications to the IDG of the change in frequency. In addition MSW services were declined by the patient with a frequency documented of 2 PRN visits were on the POC. During RR#6 it was noted the frequency of Chaplain visits on the POC were 2 PRN. The Chaplain visited the patient every week during the certification. During RR#9, assessment of the survivor bereavement plan of care and services, it was noted the organization Bereavement Services policy # 2-010 was not followed. The policy stated the bereaved will be contacted at 3, 6, 9 months post death and anniversary of death. The record did not include documentation of contact at 3 months initiated by the organization as part of the plan. The patient was deceased the middle of February 2022. In addition the bereavement POC was not discussed at the IDG meeting after the death.

Observed in Patient Home. In 2 of 3 home visits conducted, During HV#1 and #2 it was noted the SN after disinfecting the equipment used to assess vital signs, placed the clean equipment on the same barrier the equipment was placed after use.

Observed in Infection Control System Tracer. During review of the organization infection control plan it was noted the organization's written infection prevention and control goals did not include limiting the spread of infections associated with the use of medical equipment, devices, and supplies. Observed in Infection Control System Tracer. During review of the organization infection control plan it was noted the organization's written infection prevention and control goals did not include limiting the spread of infections associated with procedures. Observed in Infection Control System Tracer. During review of the organization infection control plan it was noted the organization's written infection prevention and control goals did not include limiting unprotected exposure to pathogens.

Observed in Record Review. Leadership and the governing body should have reasonably known about documentation issues identified during the findings in the following CoPs 418.56 and 418.60.

Observed in Record Review. During RR#1 it was noted the medication profile did not include 2 medications (Wellbutrin and Seroquel) that were identified on the POC related to schizophrenia by the RN and also in the social work assessment.

Observed in Document Review. During review of the Skilled Nursing Facility contract it was noted it lacked a provision that stated 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. The contract provision of hospice responsibility included report suspected or witnessed abuse and/or neglect