Every finding on record at Pruitthealth Hospice, Inc.

Based on review of the policy titled, ";Hospice QAPI Policy", review of Monthly QAPI minutes, and staff interviews, it was determined the hospice failed to measure, analyze, and track quality indicators that enable the hospice to assess processes of care, hospice services and operations. --- Findings include: Review of the policy titled, ";Hospice QAPI Policy," revised 8/1/2017 reveals the following: Scope: PruittHealth Hospice QAPI Program is ongoing and comprehensive, including all facets of care and services offered by the organization at each level of the organization. Communication: The PruittHealth Hospice QAPI Committee is responsible for reviewing and analyzing data that may impact patient/family care, which may include but not be limited to: • Service Metrics- related to patient satisfaction and customer service. • Quality Metrics- related to improving clinical outcomes and reducing adverse outcomes. • People Metrics- related to improving partner satisfaction and reducing turnover. • Finance Metrics- related to increasing operating income and efficiency while reducing costs. • Growth Metrics- related to increase in volume and revenue. Review of documents titled ";Monthly QAPI Minutes" failed to reveal an ongoing systematic review of measurable quality indicators. On 5/29/2024 at 3:00 p.m., an interview with the Administrator and Director of Health Services (DHS) AA revealed that patient falls and complaints are discussed in ";morning meetings" but could not describe how that information is quantified, tracked, and communicated to the QAPI Committee for review. On 5/30/2024 at 9:30 a.m., an interview with the Administrator and DHS BB confirmed no other QAPI documents were available for review.

Based on review of the policy titled, ";Bereavement Care Planning for Hospice", staff interviews and clinical record reviews, it was determined the hospice failed to develop a bereavement plan of care with bereavement services to be offered and the frequency of services for three patients (P) (P#11, P#12 and P#13) of three sampled bereavement records. --- Findings include: Review of policy titled ";Bereavement Care Planning for Hospice," revised 11/29/2021 reveals the following: Procedure: 4. The bereavement plan of care reflects the assessed needs of the bereaved and notes the kind of bereavement services to be offered and the frequency of delivery. 1. P#11 was admitted to hospice on 11/22/2022 with a date of death of 12/22/2023. Review of Interdisciplinary Care Plan failed to reveal specific plans of care for the identified bereaved (a bereaved person is one who has a relative or close friend who has recently died) that included services to be offered and the frequency of delivery of those services. 2. P#12 was admitted to hospice on 12/11/2023 with a date of death of 1/29/2024. Review of Interdisciplinary Care Plan failed to reveal specific plans of care for the identified bereaved that included services to be offered and the frequency of delivery of those services. 3. P#13 was admitted to hospice on 3/1/2024 with a date of death of 3/6/2024. Review of Interdisciplinary Care Plan failed to reveal specific plans of care for the identified bereaved that included services to be offered and the frequency of delivery of those services. During an interview with the Administrator on 5/30/2024 at 9:00 a.m., the Administrator confirmed all bereavement care plan documents had been provided and acknowledged the lack of specific bereavement interventions with frequencies for P#11, P#12, and P#13. On 5/29/2024 at 2:00 p.m., an interview with Director of Health Services (DHS) AA revealed that bereavement care plans and documentation are in the electronic medical record.

Based on a review of the policy titled, ";Hospice QAPI Policy," record reviews, observation, and staff interviews, it was determined the hospice governing body failed to ensure the hospice measures, analyzes, and tracks quality indicators as part of the Quality Assurance Performance Improvement (QAPI) program, failed to ensure the development of bereavement plans of care for three patients (P) (P# 11, P#12 and P#13) of three sampled bereavement records and failed to ensure the hospice coordinated care with the Skilled Nursing Facility (SNF) and physician by ensuring the plan of care specifies which provider is responsible for performing care identified in the plan of care for one patient (P) (P#17) of 20 sampled patients. --- Findings include: 1. Review of the policy titled, ";Hospice QAPI Policy", revised 8/1/2027 reveals the following: Communication: The governing body will ensure there is an ongoing program for quality improvement and patient safety that is defined, implemented and maintained by PruittHealth Hospice. Review of documents titled ";Monthly QAPI Minutes" failed to reveal an ongoing systematic review of measurable quality indicators. On 5/29/2024 at 3:00 p.m., an interview with the Administrator and Director of Health Services (DHS) AA revealed that patient falls and complaints are discussed in ";morning meetings" but could not describe how that information is quantified, tracked, and communicated to the QAPI Committee for review. On 5/30/2024 at 9:30 a.m., an interview with the Administrator and DHS BB confirmed no other QAPI documents were available for review. 2. P#11 was admitted to hospice on 11/22/2022 with a date of death of 12/22/2023. Review of Interdisciplinary Care Plan failed to reveal specific plans of care for the identified bereaved (a bereaved person is one who has a relative or close friend who has recently died) that included services to be offered and the frequency of delivery of those services. P#12 was admitted to hospice on 12/11/2023 with a date of death of 1/29/2024. Review of Interdisciplinary Care Plan failed to reveal specific plans of care for the identified bereaved that included services to be offered and the frequency of delivery of those services. P#13 was admitted to hospice on 3/1/2024 with a date of death of 3/6/2024. Review of Interdisciplinary Care Plan failed to reveal specific plans of care for the identified bereaved that included services to be offered and the frequency of delivery of those services. On 5/29/2024 at 2:00 p.m., an interview with DHS AA revealed that bereavement care plans and documentation are maintained in the electronic medical record. On 5/30/2024 at 9:00 a.m., an interview with the Administrator confirmed all bereavement care plan documents had been provided and acknowledged the lack of specific bereavement interventions with frequencies for P#11, P#12, and P#13. 2. Observation of P#17 at the nursing home facility with Hospice Aide (HA) AA on 5/29/2024 at approximately 11:15 a.m. revealed patient lying in bed with eyes closed. HA AA proceeded to perform a bed bath. Patient noted to have a wound on sacral area with a soiled bandage hanging off sacral area. Review of the Interdisciplinary Team Care Plan with a start date of 1/17/24 failed to reveal documentation of sacral wound care assessment findings or updates. Additionally, the clinical record failed to reveal coordination with the physician of the need to evaluate patient for a wound protocol. The interdisciplinary team care plan failed to specifically identify the services that the nursing facility would be responsible for providing to the patient. The clinical record failed to reveal Registered Nurse (RN) coordinated care with the nursing home staff regarding the patients wound and need for wound care orders. During an office interview on 5/29/24 at approximately 3:00 p.m. with Director of Health Services (DHS) BB, it was confirmed that the clinical record lacked documentation of physician notification of coccyx wound care status and that the wound was being assessed and care was being performed by hospice staff. DHS BB confirmed the clinical record lacked coordination with the nursing home staff and physician regarding wound care orders and did acknowledge that hospice is responsible for the overall care of the patient.

Based on review of records, home visit observation, and staff interview, it was determined the hospice failed to effectively coordinate with the nursing home facility and physician to ensure the plan of care identified the care and services needed and specifically identified which provider would be responsible for performing the care identified in the plan of care for one patient (P) (P#17) of 20 sampled patients. --- Findings include: Review of facility policy titled; ";Coordination of Hospice Services" revision date 11/04/19 indicated: Procedure 1. The Director of Health Services assumes overall responsibility for assuring there are effective methods of communications that allow for the coordination of the care and services provided by the hospice. 2. An assigned hospice RN coordinates the patients plan of care and facilitates the ongoing sharing of information with the attending physician, contracted facilities, vendor, other member of the interdisciplinary Group (IDG) and non-hospice healthcare providers furnishing services unrelated to the terminal diagnosis Observation of P#17 at the Skilled Nursing Facility (SNF) with Hospice Aide (HA) AA on 5/29/24 at approximately 11:15 a.m. revealed patient lying in bed with eyes closed. HA AA proceeded to perform a bed bath. Patient noted to have a wound on sacral area with a soiled bandage hanging off sacral area. Review of the interdisciplinary Team Care Plan with a start date of 1/17/24 failed to reveal documentation of sacral wound care assessment findings or updates. Additionally, the clinical record failed to reveal coordination with the physician of the need to evaluate patient for a wound protocol. The interdisciplinary team care plan failed to specifically identify the services that the nursing facility would be responsible for providing to the patient. The clinical record failed to indicate the RN coordinated care with the nursing home staff regarding the patients wound and need for wound care orders. During an office interview on 5/29/24 at approximately 3:00 p.m. with the Director of Health Services (DHS), it was confirmed that the clinical record lacked documentation of physician notification of coccyx wound care status. It also lacked evidence that the wound was being assessed and care was being performed by hospice staff. The DHS did confirm the clinical record lacked coordination with the nursing home staff and physician regarding wound care orders and did acknowledge that hospice is responsible for the overall care of the patient.

Based on record reviews, staff interview, and review of agency policy, it was determined the hospice agency failed to ensure that all orders for services provided were documented, signed and dated on the day of delivery of service by the individual providing the care. The clinical notes failed to be included in the patient's medical record within seven days, whether furnished directly or under arrangements by the hospice agency for one Patient (P) (P#1) of four sampled patients. The findings include: --- Review of the clinical record for P#1 with an admission date of 1/10/2023 and a diagnosis of cerebral infraction (or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood) revealed a plan of care which required the skilled nurse (SN) to visit the patient one time weekly. At each visit, the SN is required to assess cognitive status for sensory limitations/impairments, coping behaviors, assess current pain management, gastrointestinal status, musculoskeletal status, need for and proper use of assistive devices, nutritional status, pain severity, patient safety, functional status, monitor mid-arm circumference, teach pain management and prevention of pressure ulcers and skin breakdowns. The SN visited the patient on 2/17/2023, 2/23/2023 and 3/22/2023 however, the SN visit notes only contained an aide supervisory note. The visit notes lacked documentation of any physical assessments performed by the SN during the visit. The SN failed to follow the plan of care for patient assessment. Additionally, the patient was admitted to respite care services on 2/17/2023 and discharged on 2/22/2023. The clinical record lacked documentation of the services provided while the patient was in respite care. An interview was conducted at the hospice agency office with the Administrator and Director of Health Services on 5/2/2023 at 11:00 a.m. The Director of Health Services confirmed the SN failed to document a full physical assessment during the SN visits on 2/17/2023, 2/23/2023, and 3/22/2023. The Director of Health Services confirmed the nurses are required to follow the ordered plan of care to include a physical assessment at each visit. It was also confirmed that the record lacked documentation of the services provided during the patient's respite stay. The Director of Health Services was able to provide some respite care documentation which included skilled nurse notes dated 2/17/2023, 2/18/2023, 2/21/2023 and 2/22/2023 and failed to provide notes presented for 2/19/2023 and 2/20/2023. The clinical record failed to include any aide visit notes from the respite care staff. The hospice agency failed to provide a policy related to elements that should be included in a skilled nurse visit note. The Director of Health Services revealed that while there is no policy the skilled nurses are required to follow the plan of care for each patient.