Every finding on record at Rosales, Inc.

Observed in Record Review. In 6 of 6 patient records reviewed, the organization failed to ensure the plan of care reflect goals based on problems identified in the comprehensive assessment and that the goals are specific, measurable, achievable, realistic, and time-bound. In review of the goals, most lacked specific time frames to accomplish the goals. Many long term goals were to be accomplished in 2 weeks, and some short term goals had a time frame to the end of the benefit period. For example: in review of RRHV#1 an example of a goal was In 1-2 weeks patient will have a regular bowel movement at least 3-4 times a week. In RRNHV#2 an example was patient will have comfortable bowel elimination throughout the certification period, and in 1-2 weeks patient will not have any aspiration episode until the end of the benefit period. In RRNHV#3 an example was patient will demonstrate tolerance for activity and will have adequate strength/energy to function well while in hospice care within the next two weeks of hospice care. Further examples on goals that were not measurable and/or time-bound could be seen in all records reviewed. These observations were reviewed with the DPCS and Alt Administrator.

Observed in Record Review. In 3 of 6 patient records reviewed, the organization failed to ensure the medical director before the certification period review the patient's clinical information and provide written certification that the patient's life expectancy is six months or less if the illness runs its normal course. For example: on review of RRNHV#3, RRNHV#4, and RRNHV#5 the physician written certification narrative as part of the CTI failed to consider all the required elements and they lacked current subjective and objective findings. It was noted that in the 3 CTI's where the narratives lacked the required elements, there was a different attending physician. The medical directors narrative for RRNHV#4 stated Based on medical documentation, and assessment by interdisciplinary group, I certify patient is hospice eligible for 90 days benefit period. The narratives for RRNHV#3 and RRNHV#5 were similar. This observation was reviewed with the DPCS and Alt Administrator.

Observed in Record Review. In 1 of 1 patient records reviewed with wound not receiving services from wound physician, During RR# 10's patient record review it was noted the organization had not ensured staff followed the organization policy Wound Assessment which included measuring wound weekly. For example: review of RR# 10's patient record revealed a fall with skin tear to right leg that was measured the length at 3.5 cm. Further review of the record revealed the next wound measurement was 18 days later and dated 17 days prior to the surveyor review of the record. This was reviewed, discussed, and validated with the Director of Patient Care Services.

Observed in Record Review. In 1 of 2 bereavement records reviewed, During BR# 2'a bereavement record review it was noted the organization had not ensured an assessment at death was done to assess the bereavement risk in order to inform the decisions made by the IDG. For example: review of BR# 2's bereavement record revealed no post death bereavement risk assessment. This was reviewed, discussed, and validated with the Bereavement Coordinator and alternat Administrator.

Observed in Record Review. In 1 of 10 active patient record reviewed, During RR# 8's patient record review it was noted the organization had not ensured the interdisciplinary group updated the comprehensive assessment no less than every 15 days. For example: review of RR# 8' patient record revealed an IDG/Plan of Care update dated approximately 30 days prior to the surveyor review of the record and the next subsequent IDG/Plan of Care update dated 28 days later. This was reviewed, discussed, and validated with the alternate Administrator and alternate Director of Patient Care Services.

Observed in Patient Home. In 6 of 10 active patient records reviewed, During HV# 1, HV# 2, HV# 3, RR# 4, RR# 5, RR# 6's home observations and patient records review it was noted the organization had not ensured the patient's plan of care was based on goals and time frames, and services required to meet those goals. For example: during the home observation the registered nurse was observed performing wound care to HV# 2's pressure ulcers located on the bilateral heels. Review of HV# 2's plan of care revealed no goal for the pressure ulcers. During HV# 1's home observation the caregiver was observed applying calmoseptine and A&D ointment on HV# 1's coccyx and the registered nurse was observed applying a foam dressing to the coccyx. During HV# 1's home observation HV# 1's spouse shared HV# 1 had a history of a pressure ulcer to the coccyx and was at risk for another one because HV# 1 was in bed all the time, incontinent of bowel and bladder, and had lost a lot of weight. Review of the plan of care revealed no goal for risk of pressure ulcers. This was observed, reviewed, discussed, and validated with the alternate Director of Patient Care Services. Review of HV# 3's plan of care revealed the goal for Gastrointestinal Patient will maintain passage of soft formed stool at a frequency perceived as normal. However, there was no documentation of what was normal for HV# 3. Review of RR# 4 and RR# 5's plan of care revealed the goal for Neuro/Mental that patient will have appropriate mental and psychosocial function without an indication of what appropriate was for RR# 4 or RR# 5. Review of RR# 6's plan of care revealed a Pain goal Pain will be relieved within 2 hours of medication. However, there was no indication on what level was acceptable or what relieved was for RR# 6. This was reviewed, discussed, and validated with the alternat Director of Patient Care Services.

Observed in Patient Home. In 2 of 2 patient records reviewed with wound care, During HV# 1's home observation and RR# 10's patient record review it was noted the organization had not ensured the plan of care included all services needed for the palliation and management of the terminal illness and related conditions to include medications and treatments necessary to meet the patient's needs. For example: during HV# 1's home observation the caregiver was observed applying calmoseptine and A&D ointment on HV# 1’s coccyx and the registered nurse was observed applying a foam dressing to the coccyx. During HV# 1’s home observation HV# 1’s spouse shared HV# 1 had a history of a pressure ulcer to the coccyx and was at risk for another one because HV# 1 was in bed all the time, incontinent of bowel and bladder, and had lost a lot of weight. Review of HV# 1’s plan of care revealed no documentation of calmoseptine, A&D ointment, or foam dressing interventions or risk of pressure ulcers. This was observed, discussed, reviewed, and validated with the alternate Director of Patient Care Services. Review of RR# 10's patient record revealed a SN visit note dated approximately 34 days prior to the surveyor review of the record with documentation of a fall with a skin tear to the right leg. Review of the subsequent SN visits notes after the fall revealed wound care was provided on each visit that included cleaning with normal saline and applying Xero foam and wrapping in Kerlix. However, review of the IDG/Plan of Care updates dated after the fall revealed no documentation of the fall or the wound care dressing. Review of the IDG/Plan of Care updates revealed the wound care for a wound from approximately four months prior to the surveyor review of the record that had resolved prior to the fall. This was reviewed, discussed, and validated with the alternate Administrator and alternate Director of Patient Care Services. Observed in Record Review. In 2 of 10 active patient records reviewed, During HV# 3 and RR# 4's patient records review it was noted the organization had not ensured it assessed potential medication problems to include duplicate therapy. For example: review of HV# 3 and RR# 4's medication profiles revealed HV# 3 and RR# 4 were ordered more than one medication for pain control without direction on when to take the different pain medications. HV# 3 and RR# 4 were ordered morphine sulfate 20mg/mL take 0.5mL every 2 hours as needed for breakthrough pain/SOB and Acetaminophen 650mg rectal suppository every 4 hours as needed for pain/fever. This was reviewed, discussed, and validated with the alternate Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits conducted, During HV# 2's home observation it was noted the organization had not ensured care was provided according to the hospice plan of care. For example: during HV# 2's home observation the registered nurse (RN) was observed performing wound care to the bilateral heels stage 3 pressure ulcers. The RN cleaned the wounds with wound cleanser and Iodine swabs, applied a non-adherent pad to the pressure ulcers, and wrapped with kerlix. Review of the plan of care wound care revealed the bilateral wounds were to be cleaned with normal saline, apply Medihoney, cover with gauze, and wrap in kerlix. This was observed, reviewed, discussed, and validated with the alternate Director of Patient Care Services.

Observed in Data Session. During Leadership and Data Management session it was noted the organization had not ensured it analyzed and compared internal data over time to identify levels of performance patterns, trends, and variations. For example: review of the QAPI program, meeting minutes, and data review it was noted the organization was collecting data and reported the quarterly results with no documentation of analyzing the data over time to identify patterns, trends, or variations. This was reviewed, discussed, and validated with the alternate Administrator and alternate Director of Patient Care Services.

Observed in Patient Home. In 3 of 3 home visits conducted, During HV# 1, HV# 2, and HV# 3's home observations it was noted the organization had not ensured it reduced the risk of infections associated with medical equipment. For example: during the home visits the registered nurse was observed cleaning the stethoscope, B/P cuff, thermometer, and pulse oximetry with Oxivir TB wipes and immediately placed each piece of the equipment into the bag without allowing the manufacturer's IFU that included a contact time/kill time ranging from 1 to 5 minutes. This was observed, discussed, and validated with the alternate Director of Patient Care Services. Observed in Patient Home. In 3 of 3 home visits conducted, -During HV# 1, HV# 2, and HV# 3's home observations it was noted the organization had not ensured staff followed organization policy hand Hygiene that included using alcohol for hand sanitizing by rubbing the hands together until the alcohol was dry on the hands. For example: during the home visits the registered nurse (RN) was observed applying alcohol to the hands and then shaking the hands in the air to dry. This was observed, discussed, and validated with the alternate Director of Patient Care Services.

Observed in Record Review. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by Condition of Participation deficiencies 418.56; 418.100; 418.102; 418.104; and 418.116.

Observed in Record Review. In 2 of 5 patient records reviewed with recertification, During HV# 6 and HV# 7's patient record review it was noted the organization had not ensured the Medical Director reviewed the patient's clinical information at the time of recertification. For example: review of HV# 6's patient record revealed a recertification Certificate of Terminal Illness (CTI) signed one day after the certification period ended with no documentation under Physician Narrative and RN Assessment. Review of HV# 7's patient record revealed a recertification CTI signed by the physician one day after the certification period ended with no documentation under RN assessment and documentation under Physician Narrative, Patient is being seen by [a different physician] and patient continues to qualify for hospice. This was reviewed, discussed, and validated with the alternate Administrator and alternate Director of Patient Care Services.

Observed in Record Review. In 2 of 10 active patient record review, During RR# 4 and RR# 7's patient records review it was noted the organization had not ensured it maintained complete and accurate patient records. For example: Review of RR# 7's recertification Certificate of Terminal Illness (CTI) signed by the Medical Director revealed under RN assessment no documentation. Review of RR# 7's recertification RN comprehensive assessment revealed documentation that RR# 7 was non-ambulatory and documentation RR# 7 was able to walk 20 feet. Review of RR# 4's patient record revealed a start of care RN comprehensive assessment with documentation RR# 4 did not have oxygen. Further review of the start of are RN comprehensive assessment revealed an Oxygen Safety Risk Assessment with documentation that including documentation of an oxygen concentrator and safe storage of portable oxygen tank. This was reviewed, discussed, and validated with the alternate Administrator and alternate Director of Patient Care Services.

Observed in Record Review. In 7 of 10 active patient records reviewed, During HV#1, HV# 2, RR# 5, RR# 7, RR# 8, RR# 9, and RR# 10's patient records review it was noted the organization had not ensured entries into the patient records were complete, clear, and authenticated. For example: review of RR# 7's patient record revealed a recertification Certificate of Terminal Illness (CTI) signed by the Medical Director with no documentation under RN Assessment that was reviewed and validated with the alternate Administrator. Upon reviewing the recertification CTI with the alternate Director of Patient Care Services approximately five minutes later the recertification CTI had documentation under RN Assessment. An audit trail requested revealed the RN case manager had unlocked the recertification CTI and added the documentation under RN assessment. This was discussed and validated with the alternate Administrator and alternate Director of Patient Care Service. Further review of RR# 7's patient record revealed a recertification RN comprehensive assessment dated approximately 19 days prior to the surveyor review of the record with no signature. Review of HV# 1's patient record revealed the Initial Psychosocial Assessment dated approximately 60 days prior to the surveyor review of the record with no signature. Review of HV# 2's start of care RN comprehensive assessment revealed bilateral blisters to the heels. Review of HV# 2's start of care physician orders revealed wound care orders for Stage 3 pressure ulcers to bilateral heels. Review of HV# 2's Skilled Nurse (SN) visits notes revealed documentation wound care done in six of seven SN visit notes with no documentation on how the wound was cleaned or dressed. Review of HV# 2's patient record revealed an Initial Spiritual Assessment with no signature dated approximately 35 days prior to the surveyor review of the record. Review of RR#5's plan of care revealed HHA two visits a week. Review of RR#5's patient record revealed the last HHA visit note 13 days prior to the surveyor review of the record. Review of RR# 8's plan of care revealed HHA two visits a week and SN two visits a week. Review of RR# 8's patient record revealed the last HHA visit note dated approximately 13 days prior to the surveyor review of the record. Further review of RR# 8's patient record revealed the last SN dated approximately 24 days prior to the surveyor review of the record. Review of RR3 9's plan of care revealed HHA two visits a week and SN two visits a week. Review of RR# 9's patient record revealed the last HHA visit note was dated approximately 28 days prior to the surveyor review of the record and the last SN visit note was dated approximately 21 day prior to the surveyor review of the record. Review of RR# 10's patient record revealed multiple SN visit notes dating back approximately 70 days prior to the surveyor review of the record to and including the SN visit completed two days prior to the survey review of the record. This was reviewed, discussed, and validated with the alternate Administrator and alternate Director of Patient Care Services.

Observed in Record Review. During patient records review it was noted the organization had not ensured it maintained the security and integrity of health information. For example: review of RR# 7's patient record revealed a recertification Certificate of Terminal Illness (CTI) signed by the Medical Director with documentation Patient is seen by [another physician] and patient continues to qualify for hospice, with no other documentation. This was observed and validated with the alternate Administrator. Upon reviewing the recertification CTI with the alternate Director of Patient Care Services approximately five minutes later, the recertification CTI now had documentation under RN assessment. An audit trail was requested, and the audit trail revealed the RN case manager had unlocked the recertification CTI and added the RN assessment. This was reviewed, discussed, and validated with the alternate Administrator and alternate Director of Patient Care Services.

Observed in Record Review. In 1 of 1 patient records reviewed with discharge for extended prognosis, During DC# 2's patient record review it was noted the organization had not ensured it complied with law and regulation that included having a process for ensuring the Notice of Medicare Non-Coverage (NOMNC) was signed within 2 days of discharge. For example: review of DC# 2's patient record revealed a discharge summary with documentation that the Medical Director had determine DC# 2 had an extended prognosis and patient was discharged with a referral to a community physician and medication profile. Further review of DC# 2's patient record revealed a Revocation form signed by the family dated the day of discharge and there was no documentation of a NOMNC. This was reviewed, discussed, and validated by the alternate Administrator and alternate Director of Patient Care Services.

Observed in Record Review. In 8 of 8 patient records reviewed, The Hospice Nurse Surveyor reviewed 8 patient records, including 4 death records. Reviewed all of the IDG meetings for the patient records. All IDG meetings are present within the required time frame; however, all of the IDG meetings had been signed by the MD, DOPCS, LCSW and the SC. There had been no method of validating the clinicians providing direct care to the patients had been present or contributed to the meeting. Many times, the DOPCS had not seen the patient, but she was the only RN signature present. The HCO policy states that the DOPCS will appoint an RN Case Manager, and the RN Case manager will be responsible for coordination of services with the interdisciplinary group from referral to discharge. This had not been evident in the patient record. This was validated with the Administrator and the DOPCS. This was discussed and reviewed with the DPCS designee.

Observed in Record Review. In 1 of 1 patient records reviewed, the organization failed to respect the patient's right to participate in decisions about their care, treatment, or services. During RR#2, the hospice nurse surveyor observed the patent was discharged on 9/26/22 for extended prognosis but no ABN was provided to the family. Instead documentation was on the revocation form but clearly stated the patient was being discharged for extended prognosis. This was discussed and reviewed with the DPCS designee.

Observed in Record Review. In 3 of 3 patient records reviewed, the organization failed to assess and reassess per organizational policy and regulation. During record review for HV#1, RR#1 and RR#2, the hospice nurse surveyor observed no bereavement assessments completed at all. There was also no documentation of conversation with the family regarding bereavement services. Family was involved and signed consents but there was no attempt at a bereavement assessment. This was discussed and reviewed with the DPCS designee.

Observed in Record Review. In 3 of 3 patient records reviewed, the organization failed to assess and reassess its patients. During record review for HV#1, RR#1 and RR#2, the hospice nurse surveyor observed missing documentation of an interdisciplinary group taking place with collaboration from all disciplines at least every 15 days. For example: in HV#1 there was no documentation that the MD, SC or SW were involved in IDG. In RR#1, there was no documentation of the RN or Chaplain being involved in the 2 IDGs that were held. And for RR#2, SOC was 5/25/22. There was only documentation of IDG on 5/25/22 and 5/31/22. Patient was discharged on 9/26/22 with no further IDG documentation until mentioned by the surveyor. This was discussed and reviewed with the DPCS designee.

Observed in Record Review. In 1 of 3 patient records reviewed, the organization failed to maintain a complete and accurate patient record. During record review for HV#1, the hospice nurse surveyor observed no documentation of vital signs at admission. During survey the Administrator ( from home) added vitals but was not the person who did the original assessment. This was discussed with the DPCS designee.

Observed in Patient Home. In 1 of 1 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned. In HV#1, the hospice nurse surveyor observed the RN complete hand hygiene at the beginning of the visit but did not perform hand hygiene each time he reentered his nursing bag for supplies. Organizational policy and standard practice was to perform hand hygiene each time the bag is entered. This was discussed and reviewed with the DPCS designee.

Observed in Record Review. In 1 of 1 patient records reviewed, the organization failed to plan the patient's care. During record review for RR#1, the hospice nurse surveyor observed the patient passed away on 10/25/22 and there was no documentation of a bereavement care plan or outreach to develop one. This was discussed and reviewed with the DPCS designee.

Observed in Leadership Session. The governing body/ leadership team did not ensure that the following Conditions of Participation were met as determined through observation, documentation and staff interview: 418.54This was discussed and reviewed with the Admin designee.

Observed in Record Review. In 1 of 1 patient records reviewed, the organization failed to provide a written discharge summary to the patients physician in accordance with law and regulation. During record review for RR#2, the hospice nurse surveyor observed no documentation of a discharge summary, the template the organization used via HospiceMD was blank. And there was no documentation of a discharge summary being sent to the provider taking over the care. This was discussed and reviewed with the DPCS designee.