Every finding on record at Saint Laura Palliative and Hospice Care, Inc.

Upon patient record review 1 of 14 (Patient #5) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #5: There was not a spiritual care initial assessment completed on this patient, despite the RN noting in the initial assessment that spiritual care was needed.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #1: The patient has 2 wounds. A stage 3 on the coccyx as well as a DTI on right heel. The nurse is assessing the wounds, however the assessment is incomplete as there are no measurements of the wounds. The agency policy requires wound measurement at least once every two weeks.

Upon patient record review, 9 of 14 (Patient #1,2,3,4,5,6,7,9,10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: The patient has a nebulizer and a suction machine. There are no goals or interventions for the nebulizer or suction machine in the POC. There are no interventions or goals for spiritual care, despite SC seeing patient monthly. Patient #2: There are no interventions or goals for SC, despite SC seeing patient monthly. There are no interventions and goals for nutrition. The patient is receiving Ensure. Patient #3: The patient has a Hoyer lift. There are no interventions or goals related to the Hoyer lift on the Mobility POC. Patient #4: The IDG states that Spiritual care was declined, although the SC is seeing the patient monthly. There are no interventions or goals for SC, despite SC seeing patient monthly. The patient is admitted with a primary diagnosis of Prostate cancer. There are no interventions or goals related to cancer diagnosis on the POC. Patient #5: The patient is on anticoagulants, however, bleeding precautions as well as interventions for education to patient/caregiver regarding use of anticoagulants are included in the POC. Patient #6: The patient is on anticoagulants, however, bleeding precautions as well as interventions for education to patient/caregiver regarding use of anticoagulants are included in the POC. There are no interventions or goals for SC, despite SC seeing patient monthly. Patient #7: The patient is on anticoagulants, however, bleeding precautions as well as interventions for education to patient/caregiver regarding use of anticoagulants are included in the POC. There are no interventions or goals for SC, despite SC seeing patient monthly. The Endocrine POC states blood sugars will be in range. There is no range listed. Patient #9: The patient is on anticoagulants, however, bleeding precautions as well as interventions for education to patient/caregiver regarding use of anticoagulants are included in the POC. There are no interventions or goals for SC, despite SC seeing patient monthly. The patient has a nebulizer and a suction machine. There are no goals or interventions for the nebulizer or suction machine in the POC. Patient #10: The patient is on anticoagulants, however, bleeding precautions as well as interventions for education to patient/caregiver regarding use of anticoagulants are included in the POC. There are no interventions or goals for SC, despite SC seeing patient monthly. The patient has a nebulizer, and oxygen concentrator, and a suction machine. There are no goals or interventions for the nebulizer, oxygen concentrator, or suction machine in the POC.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #3: The MSW is seeing the patient monthly, however, the existing Frequency order in the IDG states "initial and prn". This order has not been updated since July of 23. PRN frequencies cannot stand alone as this is not a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.

Upon patient record review, 3 of 14 (Patient #1,3,5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: The wound order for this patient states, "Stage 3 to coccyx. Cleanse with wound wash, pat dry, apply Medi-honey, cover with Mepilex border daily for 21 days" A second location states, "DTI to R Heel, Cleanse with wound wash, pat dry, apply Medi-honey, cover with Mepilex border daily for 21 days" neither of these orders specify who will do the dressing. Patient #3: The wound order for this patient states, "Right Heel DTI. Cleanse with NS, pat dry, apply Medi-honey then cover with Mepilex border dressing dressing daily x 21 days then reassess". The order does not specify who will change the dressing. Patient #5: The wound order for this patient reads, "Sacral wound Pressure ulcer stage 3 - Cleanse around wound edges and peri wound using Vashe wash or antimicrobial wound cleanser. Do not put anything on the wound bed. Cover with silicone bordered foam dressing. Change superficial dressing daily and as needed for the loss of integrity/soiling. The order does not specify who will change the dressing.

Upon client record review, 2 of 14 (Patient #3,4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: The MSW is seeing the patient monthly, without evidence of an order for monthly visits. Patient #4: The POC states SC is declined, however, SC is seeing the patient monthly without an order.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that the hospice has offered and/or provided spiritual counseling in accordance with the patient/family's desires which include: •Providing an assessment of the patient's and family's spiritual needs (individual comprehensive assessments missing the spiritual assessment is cited under L524) •Providing spiritual counseling to meet these needs in accordance with the patient's and family's acceptance of this service and in a manner consistent with their beliefs and desires •Making all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or other individuals who can support the patient's spiritual needs to the best of their ability •Advising the patient and family of this service Patient #5: The RN noted in the initial assessment that spiritual care was needed and there was no evidence of a spiritual visit up to day of survey.

Upon patient record review, 7 of 14 (Patient #1,2,3,6,7,9,10) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: The Aide POC states to encourage fluids and diet as tolerated. The patient is on a mechanical soft diet. The patient is on oxygen, though oxygen and oxygen precautions are not on the aide POC. Patient #2: The aide POC states diet as tolerated. The patient is on a mechanical soft diet. The patient has prn oxygen, though it is not listed with oxygen precautions on the aide POC. Patient #3: The patient has DME of a Hoyer lift. This is not included in the Aide POC. Patient #6: The aide POC does not contain bleeding precautions as patient is on anticoagulants. Patient #7: The aide POC is blank. There are no tasks included in the Aide POC. Patient #9: The aide POC states patient uses wheel chair and Geri-chair. This needs to specify which will be used, there cannot be a choice for the aide. The aide POC does not include bleeding precautions despite patient being on anticoagulants. The patient has oxygen. Oxygen and Oxygen precautions are not included in the aide POC. Patient #10: The aide POC states to encourage fluids, however, there is no diet listed. The patient has seizures, though seizure precautions are not included in the aide POC.

Observed in Record Review. In 5 of 6 patient records reviewed, the bereavement assessment was not completed by the social worker as required by policy. The organization's policy no. 2-010.1 Bereavement Services, states, a bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. In review of the medical record for HOS 1 the surveyor noted that the bereavement assessment had been completed by the spiritual counselor. This also occurred in review of the medical records for HOS 2, RR 1, RR 2 and RR 3. This was validated by the Administrator/DPCS.

Observed in Record Review. In 6 of 6 patient records reviewed, the organization had not completely implemented its infection prevention and control activities to minimize, reduce, or eliminate the risk of infection of COVID 19. The organization's Infection Control Program included a requirement that clinical staff perform COVID 19 screening of patients prior to home visits and that the screening be documented in the patient's clinical record. In review of 6 of 6 patient records for HOS 1, HOS 2, HOS 3, RR 1, RR 2 and RR 3 there was no evidence in the medical record that screenings had been completed. Family members and caregivers for HOS 1, HOS 2 and HOS 3 confirmed when questioned by the surveyor that staff do call and conduct the screening prior to visiting the home. The Administrator/DPCS and QAPI RN explained that staff were conducting the screening however there had not been a process in place to document the results of the screening. Additionally, for HOS 1 the nurse did not follow the organization's bag technique policy.  The nursing bag remained open and on the patient's floor throughout the visit.  The organization's policy included that the bag should not be placed on the patient's floor and should be closed during the visit when not being accessed. This was validated by the Administrator who also observed the visit.

Observed in Record Review. In 2 of 2 patient records reviewed, bereavement care plans did not include specific, individualized interventions, and the timing and frequency were the same exactly for all levels of bereavement risk and did not include interventions in accordance with the organization's Bereavement Program which states, Standard bereavement services are as follows for all clients: a). One week after death, Letter sent and bereavement visit scheduled, b). One month after death, Phone call to loved one, c). Three months after death, letter, pamphlet on grief, invitation to bereavement group, d). Six months after death, letter, phone call and invitation to bereavement group, e). Twelve months after death, letter and phone call. On going one-on-one bereavement counseling for a short term nature will be offered to all loved ones. All survivors will be encouraged to join the hospice bereavement group or will be referred to another group. For example in review of BR 1 the care plan included Bereaved will receive regular scheduled mailing of letters x 13 months and was not individualized. Additionally, in review of the medical record there was no evidence of phone calls or visits by the Bereavement Coordinator as stated in policy. Also in review of BR 2 the care plan stated the bereaved will receive regular scheduled mailing of letters x 13 months and the care plan was not individualized. In review of the medical record for BR 2 there was no evidence of phone calls or visits by the Bereavement Coordinated in accordance with the organization's policy. This was validated by the Administrator/DPCS.

Observed in Document Review. In 1 of 4 contracts reviewed, the contract failed to include all required elements. For example, the contract for general inpatient care and respite care with the skilled nursing facility did not include a stipulation that services may be provided only with the authorization of the hospice or the manner in which contracted services will be supervised, and evaluated by the hospice. This was validated by the QAPI RN.

Observed in Patient Home. In 1 of 3 home visits conducted, with patients on oxygen, the organization failed to take action to minimize identified safety and security risks. For example, for HOS 1 the surveyor observed an e-tank stored in the back of a closet behind clothing with the door closed and there was also no evidence that the Oxygen in Use/No Smoking Sign had been posted. This was validated by the Administrator/DPCS who also observed the visit.