Every finding on record at Radiance Hospice, Inc.

Observed in Record Review. Upon review of the organizations admission packet and processes, it was noted that the organization failed to provide the patient and/or patient representative of an approximate dollar amount they will be responsible for in writing, even if that amount is zero. Further, on review of RR#8 there were multiple blanks on the patient's admission documents to include the benefit election, patient notification of non-covered items, and the photo consent. These observations were reviewed with the Administrator, and the DPCS Designee.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to ensure that a patient specific comprehensive assessment that identified the patient need for hospice care and services and related to bereavement was completed. For example: on review of HV#1, and RR#10, there was no documentation of an initial bereavement risk assessment completed. This observation was reviewed with the DPCS Designee.

Observed in Record Review. In 6 of 11 patient records reviewed, The organization failed to ensure that the plan of care include all services needed for the palliation and management of the terminal and related conditions to include a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. For example: On review of HV#3 there was an order for spiritual counselor and medical social worker to provide an initial comprehensive assessment within 5 days of admission and then to determine the visit frequency. A frequency order was not noted to be established in the plan of care, even though spiritual and social worker services were being provided and documented in the record. Similar lack of establishing frequency orders in the plan of care for MSW and/or Spiritual Care can be seen in RR#7, RR#5, HV#1, RR#4, and HV#2. These observations were reviewed with the DPCS Designee.

Observed in Record Review. In 8 of 11 patient records reviewed, The organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of HV#1, RR#4, RR#5 and RR#7 the patient was receiving spiritual care services however there were no measurable outcomes anticipated from implementing and coordinating the plan of care as spiritual care was not reflected in the care plans. In HV#3 the patient had a wound, oxygen, issues with pain, a foley, and colostomy, yet there were no open care plans to address these issues, as the only active care plan was for spiritual. In RR#7 the only active care plan noted on the plan of care was related to oxygen as all other care plans had been resolved. The patient had wound with wound care treatment that was not reflected in the plan of care. In RR#5 there were multiple issues being worked on by the social worker yet these issues were not reflected in the care plans. In RR#9 the patient had issues with a G-tube, agitation, and wound care not reflected in the care plans. In RR#8 the patient had ongoing issues with pain control yet the care plan was closed months prior and not reopened with ongoing issues. These observations were reviewed with the DPCS Designee.

Observed in Record Review. In 4 of 11 patient records reviewed, the organization's plan of care failed to include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of HV#1 the documentation noted the patient had a skin tear that was being treated with dressing changes, yet there were no physicians orders noted in the record for the dressing changes. On review of RR#4 the documentation noted a stage 1 to the patient coccyx yet there were no orders for the treatment specified in the plan of care. In HV#3 the patient was in a SNF and had wound to her sacrum, yet there were no treatment orders for the wound care reflected in the hospice plan of care. In RR#7 the patient was being seen by a consulting wound care professional for a shoulder wound, however there was documentation in the record for wounds to the shin and rt. elbow but no wound care orders on the plan of care for the wounds. These observations were reviewed with the DPCS Designee.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to ensure the plan of care include information from the patient's updated comprehensive assessment and include the patient's progress toward outcomes and goals. For example: on review of RR#6 there were multiple goals with specified time frames such as Patient will remain free of injury within 30 days and will have minimal episodes of confusion and forgetfulness within 30 days. For Pain the goals were Patient will have increased comfort/satisfaction from pain/discomfort as exhibited by verbal and non-verbal communication within 48 hours and Patient/PCG will verbalize/express understanding of medication/treatment orders and side effects with 30 days. The goals were established on admission in November and remained unchanged IDG to IDG to time of survey. Similar lack of progress toward goals can be seen in HV#2. These observations were reviewed with the DPCS Designee.

Observed in Record Review. In 3 of 11 patient records reviewed, the organization failed to ensure that the care and services were provided in accordance with the established plan of care. For example: on review of HV#1 the Hospice Aide was scheduled 2 times a week yet in week 3 no visits were documented, and in week 7 only one visit was documented. In RR#4 the aide was scheduled a frequency of 3 times a week yet at time of survey, over 3 weeks after admission, no visits for the aide had been documented in the clinical record. In RR#5 the hospice aide was ordered 3 times a week yet 5 times a week services were being provided. These observations were reviewed with the DPCS Designee.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to ensure the ongoing sharing of information between all disciplines providing care and services. For example: on review of RR#6 the documentation in the record noted that skilled nursing, scheduled weekly, were regularly declined and visits were only taking place every other week, yet there was no documentation that the physician and other members of the IDG were informed on the refused visits. In review of RR#10 the patient refused all personal care on each hospice aide visit, yet there was no documentation that this information was reported to the RN case manager or the IDG team. These observations was reviewed with the DPCS Designee.

Observed in Leadership Session. The surveyor noted the HCO did not have an effective, ongoing, organization wide, data-driven QAPI program as evidenced by the HCO was not able to produce this documentation at the time of survey. Observed in Leadership Session. The 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. Observed in Leadership Session. The surveyor noted the QAPI program did not involve all services provided as evidenced by the HCO was not able to produce this documentation at the time of survey. This observation was reviewed with the Administrator and DPCS Designee

Observed in Leadership Session. The 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 at the time of survey.

Observed in Record Review. The surveyor noted the organization failed to document what performance improvement projects were being conducted, the reasons for conducting and the measurable progress achieved as evidenced by the HCO was not able to produce this documentation at the time of survey.

Observed in Data Session. The surveyor noted the quality assessment and performance improvement was not organization wide as evidenced by there was no documentation of any QAPI activities prior to survey. Discussion with the Administrator, DPCS, and DPCS Designee noted that all staff is new and there was no evidence that prior staff had completed any QAPI activities.

Observed in Leadership Session. The 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.

Observed in Infection Control System Tracer. The 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 at the time of survey. The organization was able to produce current infection data from Hospice MD but no surveillance prior to this year. This was confirmed with DPCS Designee.

Observed in Data Session. The 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 at the time of survey. This was confirmed with the DPCS Designee. Observed in Data Session. The 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 at the time of survey. This was confirmed with the DPCS Designee. Observed in Data Session. The 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 at the time of survey. This was confirmed with the DPCS Designee. Observed in Infection Control System Tracer. The 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 at the time of survey. This was confirmed with the DPCS Designee. Observed in Data Session. The 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 at the time of survey. This was confirmed with the Administrator and DPCS Designee.

Observed in Leadership Session. The surveyor noted licensed professionals did not participate in the QAPI program as evidenced by there was no documentation of clinician involvement with the QAPI program.

Observed in HR File Review. In 1 of 1 HR files reviewed, for the Hospice Aide, the organization failed to ensure the aide's competence was initially assessed and documented as part of orientation. Upon review of the HR file for hospice aide the aide specific competency that included all required elements was noted in the HR file with the employee self assessment completed, yet there was no competency validation indicated by preceptors nor evaluation method, as these sections were left blank. These observations were reviewed with the Administrator and DPCS Designee. Observed in HR File Review. In 1 of 1 HR files reviewed, In the HR file reviewed for the CHHA (HR#6) the organization failed to assess that the Hospice Aide competency of required tasks was evaluated by observing the aide's performance of the tasks with a patient or pseudo-patient, as the competency in the HR file was blank and did not note the evaluation method. This observation was reviewed with the Administrator and DPCS Designee.

Observed in Record Review. In 9 of 11 patient records reviewed, the organization failed to ensure the registered nurse, who is responsible for the supervision of the hospice aide, provide the aide with complete written patient care instructions. For example: upon revies of HV#1, RR#4, and HV#2 the aide assignment noted the was to perform vital signs each visit yet there were no parameters set to inform the aide of when to report results to the RN. Similar lack of vital sign parameters can be seen throughout all hospice aide assignments. This observation was reviewed with the DPCS Designee.

Observed in Leadership Session. Upon review of all tracer activities, it was noted that there was a pattern of staff failing to follow established organization policy and the governing body/leadership did not ensure that the Conditions of Participation for 418.100, 418.58, and 418.56, were met per policy as determined through observations, documentation, and staff interviews.

Observed in HR File Review. In 7 of 7 HR files reviewed, the organization failed to ensure that staff competence was initially assessed and documented as part of orientation. Upon review of all HR files for clinicians the staff job specific competency was in the HR file with the employee self assessment completed yet there was no competency validation indicated by preceptors nor evaluation as these sections were left blank. These observations were reviewed with the Administrator and DPCS Designee.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to ensure the patient record contain all information that reflects the patient's care, treatment, and services. For example: upon review of HV#2 the RN comprehensive recert that was conducted in December, the documentation contained a date, time in and time out, and a narrative yet all other aspects of the note were noted to be blank. On the comprehensive assessment that was conducted by the RN on February 13th there was a time in and time out yet all other aspects of the clinical note were incomplete. In RR#5 the RN Recert comprehensive assessment visit made on 12/30/22 was incomplete. The MSW note for visit on 1/19/23 was noted to be incomplete. Per discussion the Administrator noted that the organizations policy is to submit documentation within 72 hrs of the visit. These observations were reviewed with the DPCS Designee and Administrator.

Observed in Record Review. In the record that included a live patient discharge the discharge summary failed to include all required elements. In RR#10 the patient was transferred to another hospice, however the discharge summary only noted the reason for patient transfer based on insurance reasons but failed to include a summary of the care, treatment, and services provided while the patient was on services, nor progress toward goals. This observation was reviewed with the DPCS Designee.

Observed in Record Review. In 1 of 11 patient records reviewed, The organization failed to ensure that the hospice plan of care identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. For example: on review of HV#3 the patient resided at a skilled nursing facility and was ordered blood glucose monitoring and wound care, yet the plan of care did not specify who was responsible to perform the tasks. This observation was reviewed with the DPCS Designee.