Every finding on record at Reele Corporation

It is required that the hospice emergency preparedness (EP) training program includes EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 12 (8%) of personnel records reviewed for individuals providing services under arrangement revealed that the organization did not ensure that EP training was provided according to organizational policy. Organizational Policy titled Emergency Management Plan, Training, states in part, "The training includes initial training in emergency preparedness policies and procedures and their assigned emergency response roles to all new and existing staff, individuals providing service under arrangement, and volunteers if applicable. The training is provided at least every two (2) years unless more frequent training is necessary due to a significant update to the organization's policies and procedures." The therapy contract for services including Physical Therapy, Occupational Therapy, and Speech Therapy executed on 8/27/2020 stated in part, "Therapists shall be required to attend the orientation, monthly staff meetings, team conferences, Professional Advisory Group meetings, and in-service training." Personnel Record 12: Review of the personnel record for the physical therapist (PT) providing services under arrangement revealed no documented evidence of EP training for 2021, 2022, or 2023. Interview: During the wrap-up conference on 11/7/2023, the Administrator/DPCS stated that contract therapists, including Staff 12, were included in staff EP training that was provided annually to all agency staff and volunteers in 2021, 2022, or 2023.

It is required that the patient receive effective pain management and symptom control for conditions related to terminal illness. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 14 (7%) clinical records reviewed revealed that the organization did not ensure that the patient received effective pain management. Clinical Record 1: The patient was admitted to hospice services on 8/11/2023 with a primary terminal diagnosis of Hypertensive Heart Disease with Chronic Kidney Disease and cellulitis of bilateral lower extremities. The patient was admitted with a physician's order for Tylenol 500 mg every 6 hours as needed for pain. On the initial Plan of Care (POC) dated 08/11/2023 and on subsequent POC, there were no documented evidence for intervention or goals related to the patient’s pain. During Home Visit 1 on 11/6/2023 with Staff 4 LCSW/Bereavement Coordinator, the patient stated his pain level was 6 out of 10. He stated he took Tylenol with little relief prior to the home visit. He also discussed his previous issues with pain and how it had been so severe that he "wished God would just take him away." The LCSW visit note dated 10/6/2023 stated that the patient reported a pain level of 8 out of 10 and that the currently prescribed medication only helped to relieve the pain "a little". A Spiritual counselor visit note dated 10/9/2023 included a quote from the patient that due to the severity of the pain that he was experiencing was "so bad all over his body" and "he thought of giving up". "I asked God to take me up". There was no documented evidence that the RN case manager notified. During the interdisciplinary group meetings on 10/18/2023, there was no documented evidence of updates to the POC to include the problem of uncontrolled, severe pain with patient-specific interventions and goals. During the wrap-up conference on 11/7/2023, it was revealed to the Administrator/DPCS and members of the clinical leadership team that the Clinical Record 1 did not include any pain interventions or goals. The Administrator/DPCS expressed concern with the clinical notes written by the IDG members regarding the patient's reports of uncontrolled pain and indicated that she would follow up with the RN Case Manager.

It is required that the hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) and must consider changes that have taken place since the initial assessment. It must include information on the patient's progress toward desired outcomes, as well as a reassessment of the patient's response to care. The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 14(7%) of clinical records reviewed the organization did not ensure an individualized plan of care (POC) reflected patient pain goals and interventions based on problems identified during comprehensive assessments. Clinical Record 1: The patient elected the hospice benefit on 8/11/2023 with a primary diagnosis of Hypertensive Heart Disease with Chronic Kidney Disease and cellulitis of bilateral lower extremities. There was no intervention or goals for pain on the initial POC effective 8/11/2023 or any subsequent POC updates. The LCSW visit note documented on 10/6/2023 indicated that the patient reported a pain level of 8 out of 10 and that the currently prescribed medication only helped to relieve the pain "a little". A Spiritual counselor visit note dated 10/9/2023 included a quote from the patient that due to the severity of the pain that he was experiencing was "so bad all over his body" and "he thought of giving up". "I asked God to take me up". Review of the interdisciplinary group meeting 10/18/2023 revealed there were no updates to the POC to include the problem of uncontrolled, severe pain with patient-specific interventions and goals. During the wrap-up conference on 11/7/2023, it was revealed to the Administrator/DPCS and members of the clinical leadership team that the Clinical Record 1 did not include any pain interventions or goals. The Administrator/DPCS expressed concern with the clinical notes written by the IDG members regarding the patient's reports of uncontrolled pain and indicated that she would follow up with the IDG and physician. The Administrator/DPCS noted that patient care coordination happens on a HIPAA-compliant texting platform that doesn't get put into the medical record and "disappears after thirty days". "We need to get all of the discussions [documented] in the clinical record."

It is required that each patient’s individualized written plan of care, reflects patient goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 14 (7%) of clinical records reviewed the organization did not ensure an individualized plan of care reflected patient pain goals and interventions based on problems identified during comprehensive assessments. Clinical Record 1: The patient was admitted to hospice services on 8/11/2023 with a primary terminal diagnosis of Hypertensive Heart Disease with Chronic Kidney Disease and cellulitis of bilateral lower extremities. The patient was admitted with a physician's order for Tylenol 500 mg every 6 hours as needed for pain. There was no plan of care (POC) intervention or goals for pain on the initial POC effective 8/11/2023 or any subsequent POC updates. During Home Visit 1 on 11/6/2023 with Staff 4 LCSW/Bereavement Coordinator, the patient stated his pain level was 6 out of 10. He stated he took Tylenol with little relief prior to the home visit. He also discussed his previous issues with pain and how it had been so severe that he "wished God would just take him away." The LCSW visit note documented on 10/6/2023 indicated that the patient reported a pain level of 8 out of 10 and that the currently prescribed medication only helped to relieve the pain "a little". A Spiritual counselor visit note dated 10/9/2023 included a quote from the patient that due to the severity of the pain that he was experiencing was "so bad all over his body" and "he thought of giving up". "I asked God to take me up". Neither note includes documentation that an RN case manager was notified. During the interdisciplinary group meetings on 10/4/2023 and 10/18/2023, there were no updates to the POC to include the problem of uncontrolled, severe pain with patient-specific interventions and goals. During the wrap-up conference on 11/7/2023, it was revealed to the Administrator/DPCS and members of the clinical leadership team that the Clinical Record 1 did not include any pain interventions or goals. The Administrator/DPCS expressed concern with the clinical notes written by the IDG members regarding the patient's reports of uncontrolled pain and indicated that she would follow up with the RN Case Manager.

It is required that a revised plan of care includes information from the patient’s updated comprehensive assessment and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records, the organization did not ensure that a revised plan of care included all information from a patient's comprehensive assessment and patient-specified goals. Clinical Record 1: The patient was admitted to hospice services on 8/11/2023 with a primary terminal diagnosis of Hypertensive Heart Disease with Chronic Kidney Disease and cellulitis of bilateral lower extremities. The patient was admitted with a physician's order for Tylenol 500 mg every 6 hours as needed for pain. On the initial Plan of Care (POC) dated 08/11/2023 and on subsequent POC, there was no documented evidence for intervention or goals related to the patient’s pain. During Home Visit 1 on 11/6/2023 with Staff 4 LCSW/Bereavement Coordinator, the patient stated his pain level was 6 out of 10. He stated he took Tylenol with little relief prior to the home visit. He also discussed his previous issues with pain and how it had been so severe that he "wished God would just take him away." The LCSW visit note dated 10/6/2023 stated that the patient reported a pain level of 8 out of 10 and that the currently prescribed medication only helped to relieve the pain "a little". A Spiritual counselor visit note dated 10/9/2023 included a quote from the patient that due to the severity of the pain that he was experiencing was "so bad all over his body" and "he thought of giving up". "I asked God to take me up". There was no documented evidence that the RN case manager notified. During the interdisciplinary group meetings on 10/18/2023, there was no documented evidence of updates to the POC to include the problem of uncontrolled, severe pain with patient-specific interventions and goals. During the wrap-up conference on 11/7/2023, it was revealed to the Administrator/DPCS and members of the clinical leadership team that the Clinical Record 1 did not include any pain interventions or goals. The Administrator/DPCS expressed concern with the clinical notes written by the IDG members regarding the patient's reports of uncontrolled pain and indicated that she would follow up with the RN Case Manager.

It is required that the infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 12 (8%) of personnel records reviewed for contracted providers revealed that the organization did not ensure that contracted providers received infection control education in accordance with agency policy. Organizational Policy titled Training/Inservice Education states in part, "Mandatory in-services will be attended by all disciplines. The written plan for annual in-services will include but not be limited to infection control." Personnel Record 12: Review of the personnel record for the physical therapist (PT) revealed no documented evidence of infection control education for 2021, 2022, or 2023. Interview: During the wrap-up conference on 11/7/2023, the Administrator/DPCS stated that contract therapists have not been included in annual infection control training.

It is required that licensed professionals participate in hospice sponsored in-service training. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 12 (8%) of personnel records reviewed revealed that the organization did not ensure that all licensed professionals participated in hospice sponsored in-service training. Organizational Policy titled Training/Inservice Education states in part, "Mandatory in-services will be attended by all disciplines." The therapy contract for services including Physical Therapy, Occupational Therapy, and Speech Therapy executed on 8/27/2020 states in part, "Therapists shall be required to attend the orientation, monthly staff meetings, team conferences, Professional Advisory Group meetings, and in-service training." Personnel Record 12: Review of the personnel record for the contracted physical therapist (PT) revealed no documented evidence of in-service training for 2021, 2022, or 2023. Interview: During the wrap-up conference on 11/7/2023, the Administrator/DPCS stated that contract therapists have not been included in staff monthly in-services that are attended by all agency staff and volunteers.

It is required that the hospice must provide nursing care and services by or under the supervision of a registered nurse. Nursing services must ensure that the nursing needs of the patient are met as identified in the patient's initial assessment, comprehensive assessment, and updated assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 14 (14%) clinical record reviewed revealed that the agency did not ensure that the nursing needs of the patients were met. Clinical Record 1: The patient elected the hospice benefit on 8/11/2023 with a primary diagnosis of Hypertensive Heart Disease with Chronic Kidney Disease and cellulitis of bilateral lower extremities. There was no intervention or goals for pain on the initial POC effective 8/11/2023 or any subsequent POC updates. The LCSW visit note documented on 10/6/2023 indicated that the patient reported a pain level of 8 out of 10 and that the currently prescribed medication only helped to relieve the pain "a little". A Spiritual counselor visit note dated 10/9/2023 included a quote from the patient that due to the severity of the pain that he was experiencing was "so bad all over his body" and "he thought of giving up". "I asked God to take me up". Review of the interdisciplinary group meeting 10/18/2023 revealed there were no updates to the POC to include the problem of uncontrolled, severe pain with patient-specific interventions and goals. Clinical Record 14: The patient elected the hospice benefit on 3/15/2023 and died on GIP level of care in a skilled nursing facility on 4/13/2023 with a primary terminal diagnosis of Alzheimer’s Disease. Physician order documented on 4/13/2023 at 12:50 PM by an office based LVN stated "change routine level of care to general inpatient level of care for respiratory distress and pain management till further order. Received new orders from [visit LVN per MD]." Skilled nursing visit note documented on 4/13/2023 at 11:00 AM by a visit LVN stated "Received patient in bed. Patient is not arousable to stimuli. He is lethargic. Facility charge nurse states patient was having shortness of breath and elevated temperature this morning. Temperature was 103. Tylenol suppository and Roxanol was given. Patient is afebrile during visit. He is on O2 at 5L/min. O2 sat is 60% during visit. Noted lower extremities have bluish/purplish discoloration during visit. Wife is present during visit. Paramedics were called but declined to take patient to the hospital due to death being imminent and wife refusing to change DNR status. Spoke to patients’ family to discuss patients decline in condition. They understood and stated they wanted to continue with comfort measures. Dr made aware. New orders for Fentanyl patch and Roxanol carried out. Will place patient under general inpatient level of care. Facility charge nurse and daughter made aware. Roxanol 10 mg given during visit. Will continue to monitor. There was no documentation that the agency clinical manager admitted the patient to GIP according to agency policy and completed an updated assessment. Agency policy titled Inpatient Services states in part, "Admission and Discharge from inpatient services will be the responsibility of the hospice Case Manager. “This policy is dated December 2018. During a joint record review on 11/7/2023 with the Administrator/DPCS, it was confirmed that a registered nurse had not visited the patient to change the level of care to general inpatient. This patient died within a few hours of these interventions, midafternoon of 4/13/2023. In addition, The Administrator/DPCS expressed concern with the clinical notes written by the IDG members regarding the patient's reports of uncontrolled pain and indicated that she would follow up with the IDG and physician. The Administrator/DPCS noted that patient care coordination happens on a HIPAA-compliant texting platform that doesn't get put into the medical record and "disappears after thirty days". "We need to get all of the discussions [documented] in the clinical record."

It is required that written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (17%) of clinical records reviewed for patients receiving hospice aide services revealed that the organization did not ensure that hospice aide written instructions included patient specific safety precautions. Clinical Record 2: The patient elected the hospice benefit on 12/27/2022 with a primary terminal diagnosis of Hypertensive heart disease and seizure disorder. During the home visit observation in the skilled nursing facility conducted on 11/07/2023 with a hospice aide (Staff 6), the patient stated he had a history of seizures. He further stated that prior to hospice admission he had a seizure while taking a shower. A review of the aide care plans dated 12/27/22, 3/13/23, 6/19/23, 8/14/23 and 10/9/23 revealed that the agency did not ensure the written instructions for seizure precautions were included on the aide care plan. Interview: During the wrap up conference on 11/7/2023, the Administrator/DPCS and members of the organization leadership team were informed that the hospice aide’s written instructions did not include seizure precautions for a patient with known seizure activity. A joint clinical record review with the Administrator/DPCS confirmed seizure precautions had not been included in the hospice aide care plan.