Every finding on record at Sacred Journey Hospice LLC

It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code fire drills at varied times on all shifts. This standard was not met as evidenced by document review and interview. Agency policy #10-017.1 stated in part, "The IPU will conduct a fire drill at least quarterly. Each shift will have their quarterly fire drill at varied times. The drill (time, date, and participants), results, and evaluation will be documented in written reports." During an observation tour of the in-patient unit (IPU) on 8/29/2023, it was revealed the hospice did not ensure fire drills were completed and documented per requirements. A review of the IPU written reports of fire drills revealed the last documented fire drills were conducted during the morning shift on 12/2/2022 and the evening shift on 12/10/2022. During an interview on 8/29/2023, the Director of Operations and Administrator reported that the IPU manager was on leave, and they could not locate additional documented fire drills for the first and second quarters of 2023.

It is required that each patient’s individualized written plan of care 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 and observation. In 3 of 26 (12%) clinical records reviewed, the agency did not ensure the patient's plan of care was individualized and included interventions specific to problems identified in the comprehensive assessment. Clinical Record 3: The recertification comprehensive assessment completed on 6/27/23 documented, "dysphagia currently: yes, specifically with proteins and medication...having more choking episodes with foods." The physician narrative dated 7/2/23 documented, "requires a soft pureed diet with smaller portions over the past two weeks due to worsening dysphagia." The POC, effective 5/13/23 to current, did not include problems, goals, or interventions related to dysphagia, aspiration precautions, or dietary modifications identified in the comprehensive assessment. Clinical Record 13: The initial comprehensive assessment completed on 5/3/23 documented that the patient was NPO (nothing by mouth) and had a PEG (percutaneous endoscopic gastrostomy) tube. The plan of care, effective 5/3/23 to current, documented the following nutrition-related nursing diagnosis problems: "altered Nutrition/hydration...need for 0/A (observation/assessment) of nutrition/hydration." The goals documented included: "patient/caregiver verbalizes understanding of anorexia and cachexia in the dying process...patient/family verbalizes understanding of issues related to decreased appetite." The interventions documented included: "assess nutritional status and determine factors that may contribute to inadequate nutrition...explore with family concerns of decreased appetite and nurturing aspects of food." The plan of care did not document problems, goals, or interventions regarding the NPO status and PEG tube identified in the comprehensive assessment. Clinical Record 16: The initial comprehensive assessment completed on 4/13/23 documented that the patient was NPO and had a PEG tube. The plan of care (POC), effective 4/13/23 to current, documented the following nutrition-related nursing diagnosis problems: "altered Nutrition/hydration...need for 0/A (observation/assessment) of nutrition/hydration." The goals documented included: "patient/caregiver verbalizes understanding of anorexia and cachexia in the dying process...patient/family verbalizes understanding of issues related to decreased appetite." The interventions documented included: "assess nutritional status and determine factors that may contribute to inadequate nutrition...explore with family concerns of decreased appetite and nurturing aspects of food." The plan of care did not document problems, goals, or interventions regarding the NPO status and PEG tube identified in the comprehensive assessment. During an interview and a joint review of the records on 8/30/23, the Administrator confirmed the plans of care did not include the interventions to meet the needs of the above patients.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview, and observation. Agency policy #7-009.1 stated in part, "Hand decontamination using an alcohol-based hand rub should be performed.... A. Before having direct contact with patients. C. After contact with a patient's intact skin...F. After contact with inanimate object in the immediate vicinity of the patient." In 4 of 9 (44%) home visit observations, the agency did not ensure the clinical staff followed the agency's hand hygiene policy. Home Visit 1: During the visit on 8/28/2023, the Social Worker (SW) [Personnel Record 11] did not perform hand sanitization before and after having contact with the patient's skin. Additionally, the SW provided the caregiver with a stylus to sign their tablet to confirm the visit. After completion, the SW immediately returned the stylus to their case without sanitizing the stylus or their hands. Home Visit 2: During the visit on 8/28/2023, the SW [Personnel Record 11] did not perform hand sanitization before and after having contact with the patient's skin and personal items. Home Visit 3: During the visit on 8/29/2023, the Chaplain [Personnel Record 9] did not perform hand sanitization before and after having contact with the patient's skin and personal items at the patient's bedside. Home Visit 4: During the visit on 8/29/2023, the Chaplain [Personnel Record 9] did not perform hand sanitization before and after having contact with the patient's skin and personal items at the patient's bedside. During an interview and a review of the observations on 8/28/23 and 8/29/23, the Administrator confirmed that the clinicians did not follow the agency's policy.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, interview, and observation. In 3 of 20 (15%) records reviewed, in which hospice aide services were accepted, the agency did not ensure the Registered Nurse (RN) provided specific instructions for the hospice aide, leaving the hospice aide (HA) to make decisions which were outside the scope of practice. Clinical Record 2: The initial comprehensive assessment completed on 7/14/2023 documented the patient had a PICC (peripherally inserted central catheter) line in the upper right arm. The RN documented in the interdisciplinary team meeting notes dated 8/18/2023, "Nurse visited twice a week to monitor and manage symptoms and PICC line in right upper extremity." The Aide Care Plan, effective 7/14/2023 to current, assigned the HA the following task: bathing (chair/bath). The care plan did not provide guidance to the aide that the patient had a PICC line or specifics as to whether the dressing could or could not get wet with bathing. Clinical Record 5: During the home visit on 8/29/2023, the HA was observed applying barrier cream to the patient's buttocks. The Aide Care Plan included "skin care" as an assigned task but did not provide specifics regarding applying creams or lotions. During an interview, the Administrator stated that when the care plan says "skin care," the aides know they may apply lotion or barrier cream. The Administrator agreed that it should identify the type of lotion/cream and where to apply it. Clinical Record 16: The initial comprehensive assessment completed on 4/13/2023 documented the patient had a PEG (percutaneous endoscopic gastrostomy) tube in place. The Hospice Aide Care Plan, effective 4/13/2023 to current, assigned the HA the following task: bathing (bath/bed) every visit. The Aide Care Plan did not inform the aide that the patient had a PEG tube in place or what, if any, care the HA was to provide to the PEG tube site. During an interview and a joint review of the records on 8/29/2023, the Administrator and Director of Operations confirmed the aides should have been informed of any tubes/lines the patients had in place. Furthermore, they reported that "skin care" must be further defined.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record review of a patient discharged to a hospital, the agency did not ensure that the discharge summary was forwarded to the receiving facility. Clinical Record 19: The patient elected hospice care on 6/6/22 and was discharged to the hospital on 7/7/23. The Skilled Nursing (SN) visit note dated 6/24/23 documented the family called 911 because the patient was having trouble breathing. The SN documented a call was placed to the hospital's emergency room (ER) and the SN was informed the patient was critical and was being admitted for septic shock. A review of the clinical record revealed no evidence that a discharge summary was provided to the receiving facility, the hospital. During an interview on 8/30/23, the Administrator and Director of Operations confirmed that they could not find any documented proof that the discharge summary had been provided to the hospital. It was reported that they identified they had "some breakdown" in this process when they switched to the new electronic medical records system (a year ago) and are working on it.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record review of a patient discharged for no longer being terminally ill, the agency did not ensure the attending physician was provided a copy of the discharge summary. Clinical Record 20: A review of the discharge visit note dated 7/27/23 revealed the patient selected an attending physician to follow them post-hospice discharge. The record did not contain documentation that the discharge summary was forwarded to the patient's attending physician. During an interview on 8/30/23, the Administrator and Director of Operations confirmed they could not find any documented proof that the discharge summary was provided to the attending physician. It was reported that they identified they had "some breakdown" in this process when they switched to the new electronic medical records system (a year ago) and are working on it.