Every finding on record at Sanford Home Care Hospice

Based on observation, record review, policy review, and staff interview, the Hospice failed to develop and update the plan of care to include the patient's needs and identification of treatments and services for 6 of 14 sampled patients (Patient #1, #2, #3, #8, #10, and #12) currently receiving hospice services and for 2 of 2 closed record patients (Patient #15 and #16) reviewed. Failure to develop individualized and patient-specific plans of care, including revisions with information reflected in the patient's updated comprehensive assessments limited the staff's ability to communicate treatment approaches and interventions to ensure continuity of care. Findings include: --- -Review of Patient #16's medical record occurred on 06/26/24. A nurse's note, dated 01/03/24, indicated a left shin laceration with orders for wound care received. [The hospice record lacked treatment for the wound in their medication orders.] A nurse's note, dated 01/25/24, indicated the wound to the left shin was assessed and healing with a new perineal wound noted and facility staff doing dressing changes to the area. The patients POC, finalized 01/29/24, failed to reflect the patients wounds or orders for wound care. During an interview on 06/26/24 at 3:24 p.m., an administrative staff member (#1) confirmed clinical staff failed to update the POC to reflect the patients wound care. - Observation on 06/24/24 at 11:50 a.m. showed a hospice nurse (#2) completed a skilled nurse (SN) visit with Patient #1. During the visit the nurse checked the urine collection bag hanging on the bed frame of the patients bed. Review of Patient #1s medical record occurred on all days of survey. The POC, finalized 06/14/24, stated. ";. . . SN Perform supervisory visits of the HHA [home health aid] every 14 days or less. . . ." The POC identified HHA supervisory visits, the record lacked an indication of HHA visits and lacked a problem, goal, or interventions related to Patient #1s indwelling catheter During an interview the afternoon of 06/25/24, an administrative nurse (#1) confirmed Patient #1 did not receive HHA visits, staff should not have included supervisory visits, and staff failed to include the indwelling catheter on the POC for Patient #1. - Review of Patient #10s medical record occurred on all days of survey. The POC, updated 06/12/24, stated, ";. . . Problem: Speech language pathology SLP starting 2/27/2024 . . . PLAN: RECOMMEND SKILLED ST [speech therapy] 1 x [time] PER WEEK FOR 60 MINUTES PER SESSION FOR 5 WEEKS . . ." Patient #10s problem, goal and interventions related to SLP have been achieved and hospice staff failed to update/remove from the POC. - Review of Patient #15s medical record occurred on all days of survey. A nurses note dated 05/15/24 at 10:10 a.m. identified the patient had an indwelling catheter. The POC, dated 05/15/24, lacked a problem, goal, or interventions related to Patient #15s indwelling catheter. Review of the Hospice policy titled "Plan of Care" occurred on 06/26/24. This policy, dated 12/28/23, stated, ". . . The POC [Plan of Care] identifies the care, treatment, and services provided to the patient based on his/her needs identified by the IDG [Interdisciplinary Group] and the Comprehensive Assessments and Reassessments. Diagnostic and therapeutic orders are obtained from the attending physician/designee . . . PROCEDURE: . . . The POC, treatment, services, and goals are revised based on the patient's needs. . . . Factors which contribute to the reviewing/updating the POC and therapeutic orders are, but not limited to: * Changes in the patient's physical and/or psychosocial condition * Outcomes/treatments have changed and/or been achieved . . . the staff and IDG develop a list of patient problems and needs with corresponding goals and interventions . . ." - Review of Patient #3's medical record occurred on all days of survey. The POC, updated 06/12/24, stated, ". . . IDG Notes: . . . Massage Therapy: declined . . . Problems: . . . Problem: Ongoing Hospice Services . . . Intervention: Massage Therapy . . . Starting: 5/3/2024. Frequency: Each Visit. Provide massage interventions to accomplish individualized goals by licensed massage therapist. Visit frequency once a week. . . ." Patient #3's POC contained conflicting information regarding the intervention of massage therapy. During an interview on 06/24/24 at 4:45 p.m., an administrative nurse (#1) stated the staff may have thought the resident wanted massage therapy and placed it on the care plan on admission, but when the resident declined, the staff never removed the massage therapy from the care plan problems. - Review of Patient #8's medical record occurred on all days of survey. The POC, updated 06/12/24, stated, ". . . IDG Notes: . . . He is on a soft diet with thin liquids. . . . will pocket food in his mouth. He has difficulty with swallowing which is managed with small bites and small sips. . . . Deep pressure injury to right heel remains unchanged. There is a new small opening to right side of penile shaft that is draining pus. There is a stage 2 pressure ulcer to coccyx in which SNF [skilled nursing facility] staff is cleansing [with] NS [normal saline], medihoney [wound ointment], and covering with a mepilix [absorbent foam dressing], 3x/wk [three times weekly]. . . ." The POC's problem list included the following: *Problem: Orders and Wound Therapy: ". . . Intervention: Wound cares orders . . . Starting: 6/3/2024. Frequency: PRN [as needed]. Wound care provided by nursing home, location of wound coccyx, type of wound pressure ulcer, cleansing agent saline or soap and water, dressing instructions clean area, apply medihoney and cover with mepilex . . ." *Problem: Physical: ". . . Intervention: Educate/implement nutrition and hydration . . . Starting 4/30/2024 . . . [Name of Patient #8] is NPO [nothing per mouth]. . . ." A prior POC, updated 05/15/24, identified Patient #8 took minimal bites of food, had difficulty with swallowing, and had a deep pressure injury to the right heel, but the problem list indicated Patient #8 as NPO and failed to include a heel ulcer. A nurse's note, dated 05/20/24, indicated a right penile wound with purulent drainage, cleansed with a cleansing wipe, and the treatment per the medication administration record (MAR). [The hospice record lacked treatment for the wound in their medication orders.] A nurse's note, dated 05/31/24, indicated a new stage 2 pressure ulcer to the mid coccyx, the penile wound and a deep tissue pressure injury to the heel from 04/30/24 treated with a foam border dressing (Mepilex) and offloaded feet on a pillow. A nurse's note, dated 06/17/24, stated Patient #8 "was changed to a pureed diet." The current POC contained conflicting information and an incomplete problem list (care plan) regarding Patient #8's diet and wound orders/status. During an interview on 06/26/24 at 11:38 a.m., an administrative nurse (#1) agreed staff failed to update Patient #8's POC Problems with the current diet and heel and penile wounds including treatments/interventions. - Review of Patient #12's medical record occurred on 06/26/24. The POC, updated 06/12/24, stated, ". . . IDG Notes: . . . Flower Delivery: declined. . . . Volunteer services declined; receives weekly flower delivery. . . ." Patient #12's POC contained conflicting information regarding the intervention of flower delivery.

Based on record review, policy review, and staff interview, the Hospice failed to ensure a registered nurse (RN) completed an on-site supervisory visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide for 5 of 7 sampled patients (Patient #3, #5, #7, #8, and #10) receiving hospice aide services. Failure to perform the supervisory visits limited the Hospices' ability to ensure hospice aide services met the patients' needs. Findings include: --- -Review of Patient #3's medical record occurred on June 24-26, 2024. The patient's plan of care for the certification period 05/03/24 to 07/31/24 identified hospice aide visits twice a week. The record showed the aide visits occurred as scheduled and an RN completed a supervisory visit (SV) on May 10, 21, and 24, 2024. Patient #3s record lacked evidence an RN performed two on-site SV required in the weeks between 05/24/24 and 06/21/24. During an interview on 06/24/24 at 4:15 p.m., an administrative nurse (#1) stated "supervisory visits should be every 14 days" and verified Patient #3's record lacked a SV after 05/24/24. -Review of Patient #8's medical record occurred on June 24-26, 2024. The patient's plan of care for the certification period 04/30/24 to 07/28/24 identified hospice aide visits twice a week. The record showed the aide visits occurred as scheduled and showed no supervisory visits. Patient #8s record lacked evidence an RN performed four on-site SV required in the weeks between 04/30/24 and 06/24/24. During an interview on 06/26/24 at 2:30 p.m., an administrative nurse (#1) verified Patient #8's record lacked any SV. Review of the facility policy titled "Aide Services, Hospice" occurred on 06/26/24. This policy, dated December 2023, stated, ";. . . The RN arranges the Aide services, assigns the care, and supervises the Aide, . . . An on-site supervisory visit will be done by the RN at least every 14 days. If an area of concern is noted during the supervisory visit, the RN must make an on-site visit to the location where the patient is receiving care in order to observe and assess the Aide during the performance of care. . . . All supervisory visits will be documented in the medical record, . . ." - Review of Patient #5s medical record occurred on June 24-26, 2024. The patient's plan of care for the certification period 04/16/24 to 07/14/24 identified hospice aide services started the week of 04/21/24 with a visit frequency of two times a week. The record showed the aide visits occurred as scheduled and a RN supervisory visit (SV) completed on 05/07/24, the next SV completed on 05/23/24 (two days late). Patient #5s record lacked evidence an RN performed two on-site SV required in the weeks between 05/24/24 and 06/24/24. - Review of Patient #7s medical record occurred on June 24-26, 2024. The patient's plan of care for the certification period 04/24/24 to 07/22/24 identified hospice aide visits one time a week. The record showed the aide visits occurred as scheduled and a RN supervisory visit completed on 05/09/24. Patient #7s record lacked evidence an RN performed three on-site SV required in the weeks between 05/23/24 and 06/20/24. - Review of Patient #10s medical record occurred on June 24-26, 2024. The patient's plan of care for the certification period 02/02/24 to 05/01/24 and recertification period 05/02/24 to 07/30/24 identified hospice aide visits two time a week and decreased to one time a week starting the week of 05/05/24. The record showed the aide visits occurred as scheduled and RN supervisory visits completed on 03/21/24, 03/29/24, 04/18/24, and 04/23/24. Patient #10s record lacked evidence an RN performed seven on-site SV throughout Patient #10's certification period and recertification period up to the week of 06/23/24. During an interview on 06/26/24 at 11:20 a.m., an administrative nurse (#1) confirmed Patient records lacked evidence an RN completed the required supervisory visits.

Based on review of information provided from the Hospice regarding the use of volunteers and staff interview, the Hospice failed to ensure volunteers provided services which equaled five percent or more of the total patient care hours of all paid hospice employees and contract staff within a one-year period (05/01/23 to 04/30/24). This resulted in the failure to use volunteers to the extent required for administrative and/or direct patient care. Findings include: --- Review of information regarding volunteers occurred on 06/26/24. The information showed the Hospice employed 11 volunteers and provided 71.49 volunteer hours and 4,353.74 direct patient care hours from 05/01/23 to 04/30/24. The division of these hours identified a value of 1.64 percent and did not equal the required five percent minimum. During an interview on 06/26/24 at 3:10 p.m., an administrative nurse (#1) confirmed the number of volunteer hours in direct patient care or administrative activities did not meet the required 5 percent.

Based on record review, policy review, and staff interview, the Hospice failed to ensure the medical record accurately reflected the current physician's orders for 2 of 14 sampled patients (Patient #8 and #10) currently receiving hospice services and 2 of 2 closed record patients (Patient #15 and #16) reviewed. Failure to obtain orders and/or accurately transcribe physician's orders has the potential for patients to experience complications and ineffective management of their conditions. Findings include: --- - Review of Patient #10s medical record occurred on all days of survey. The plan of care (POC), effective 04/17/24, indicated skilled nurse (SN) visits twice a week and home health aide (HHA) visits once a week. Review of visit frequency identified a missed SN visit on 05/17/24, and a missed HHA visit the week of 05/26/24. The record lacked a physician order for the missed visits. - Review of Patient #15s medical record occurred on all days of survey. A nurses note dated 05/16/24 visit time 2:19 p.m. to 3:39 p.m. ";. . . the Novolog [short-acting insulin] was discontinued with the long acting remaining and blood sugars will be checked in the morning. . . ." A nurses note dated 05/17/24 at 7:31 a.m. indicated a call regarding a blood sugar of over 500 and the patient had not received the long-acting insulin the night before, the note included Patient #15 was treated with 10 units of Novolog and 8 units of Novolog prior to lunch. The medical record lacked the Provider orders for the Novolog insulin. During an interview the afternoon of 06/26/24, an administrative staff member (#1) confirmed the medical records lacked provider orders for Patient #10's missed visits and Patient #15's insulin orders. - Review of Patient #8's medical record occurred on all days of survey. The POC, updated 06/12/24, stated, ". . . IDG Notes: . . . He is on a soft diet with thin liquids. . . . Deep pressure injury to right heel remains unchanged. There is a new small opening to right side of penile shaft that is draining pus. There is a stage 2 pressure ulcer to coccyx in which SNF [skilled nursing facility] staff is cleansing [with] NS [normal saline], medihoney [wound ointment], and covering with a mepilix [absorbent foam dressing], 3x/wk [three times weekly]. . . ." The POC's problem list included the following: *Problem: Orders and Wound Therapy: ". . . Intervention: Wound cares orders . . . Starting: 6/3/2024. Frequency: PRN [as needed]. Wound care provided by nursing home, location of wound coccyx, type of wound pressure ulcer, cleansing agent saline or soap and water, dressing instructions clean area, apply medihoney and cover with mepilex . . ." *Problem: Physical: ". . . Intervention: Educate/implement nutrition and hydration . . . Starting 4/30/2024 . . . [Name of Patient #8] is NPO [nothing per mouth]. . . ." A nurse's note, dated 05/20/24, indicated a right penile wound with purulent drainage, cleansed with a cleansing wipe, and the treatment per the medication administration record (MAR). [The hospice record lacked treatment orders for the wound in their medication orders.] A nurse's note, dated 05/31/24, indicated a new stage 2 pressure ulcer to the mid coccyx and a deep tissue pressure injury to the heel from 04/30/24 treated with a foam border dressing (Mepilex) and offloaded feet on a pillow. A nurse's note, dated 06/17/24, stated Patient #8 "was changed to a pureed diet." The medical record failed to contain physician/health care provider orders for the following diets and treatments for Patient #8 as noted in the POC, problem list, or nurses' notes: NPO, soft diet, pureed diet, and treatments for the heel ulcer, coccyx ulcer, and penile wound. During an interview on 06/26/24 at 11:40 a.m., an administrative nurse (#1) agreed the record lacked physician/provider orders for Patient #8's diet and treatments. Review of the Hospice policy titled "Provider Orders: Order Entry Modes Releasing Signed Held Orders and Phases of Care" occurred on 06/26/24. This policy, dated 01/24/24, stated, "PURPOSE: . . . To provide for consistent, accurate and safe recording of provider orders for implementation and discontinuation related to phases of care. . . Provider orders received by clinical staff will be entered electronically using the appropriate Order Entry Mode. . ." -Review of Patient #16's medical record occurred on all days of survey. A nurse's note, dated 01/03/24 at 2:11 p.m., stated ". . .wound to left shin observed. . .orders faxed to SNF [skilled nursing facility] for a normal saline cleanse to the left shin laceration, pat dry, and cover with Xeroform, Telfa, and paper tape." The record lacked evidence to show an order for wound care had been received and/or entered to the patient's record. In an interview on 06/26/24 at 3:24 p.m., an administrative staff member (#1) confirmed staff failed to accurately enter the order for wound care to the medical record.

Based on record review and staff interview, the Hospice failed to ensure coordination of Volunteer services for 2 of 2 active patients (Patient #1 and Patient #6) reviewed who were determined to have a need for Volunteer visits. This failure has the potential to limit the Hospice from meeting the needs of the patients and their caregivers. Findings include: - Review of Patient #1's active medical record occurred on February 23-24, 2022 and showed election of Hospice on 01/02/22. The initial Plan of Care did not include Volunteer visits, but a Volunteer Care Plan, dated 01/03/22, identified weekly flower delivery. A Master of Social Work (MSW) note, dated 01/18/22 at 12:35 p.m., stated, ". . . [name of Patient #1] stated that she has noticed she is tiring more easily. [Name of Patient #1] also mentioned that she is having some pain in her neck. SW [Social Worker] offered to have volunteer assist with apply [sic] cream and rubbing neck/shoulders. [name of Patient #1] stated that this would be nice and she would like to try this. SW will follow up with Volunteer coordinator. . . ." MSW added this note and a Volunteer Referral to the Plan of Care on 01/18/22. The Hospice Interdisciplinary Group (IDG) notes from a meeting on 02/15/22 stated, "Case Manager note . . . Volunteer services: Volunteer to come 3x weekly when available and does received [sic] weekly flower deliveries. . . . Volunteer Coordinator note . . . Patient receives weekly flower delivery. Has requested a volunteer-one will be assigned this week. The record did not include documentation/follow up from the Volunteer Coordinator regarding volunteer visits after the referral from MSW on 01/18/22, volunteer visits were not added to the Plan of Care, and the record did not show Patient #1 received volunteer visits. During an interview on the morning of 02/24/22, the Volunteer Coordinator (#2) stated the MSW spoke to her about utilizing a volunteer. She stated volunteer visits were attempted, but Patient #1's clinical condition changed to the point where a volunteer visit was not appropriate. The Volunteer Coordinator (#2) acknowledged she failed to document this coordination of care. - Review of Patient #6's active medical record occurred on February 23-24, 2022 and showed election of Hospice on 12/19/21. The initial Plan of Care did not include volunteer visits, but a Volunteer Care Plan, dated 12/20/21, identified weekly flower delivery. An MSW Note, dated 12/31/21 at 3:23 p.m., stated, " . . . (husband) and . . . (son) requested hospice volunteer to bring weekly flower and provide companionship once a week for [name of Patient #6]. Family had requested the volunteer walk with her in the wheelchair in the facility's hallways and provide comfort. SW informed Hospice Volunteer Coordinator to arrange services for [name of Patient #6]. . . ." MSW added this note and a Volunteer Referral to the Plan of Care on 12/31/21. The Hospice IDG notes from a meeting on 02/01/22 stated, ". . . Volunteer Coordinator note created . . . on 1/31/2022 Patient receives weekly flower delivery. Volunteer as needed-attempt [sic] have been made by volunteer to visit but Patient does not wake up." The record did not include documentation/follow up from the Volunteer Coordinator regarding volunteer visits after the referral from MSW on 12/31/21, Volunteer visits were not added to the Plan of Care, and the record did not show Patient #1 received volunteer visits. During an interview on the morning of 02/24/22, the Volunteer Coordinator (#2) stated the MSW spoke to her about utilizing a volunteer. She stated volunteer visits were attempted, but Patient #6's clinical condition changed to the point where a volunteer visit was not appropriate. The Volunteer Coordinator (#2) acknowledged she failed to document this coordination of care. During an interview on the afternoon of 02/24/22, an administrative staff member (#1) stated the Hospice staff members should document all coordination of care in the patient's medical record.

Based on record review, review of the Agreement for the Provision of Hospice Services, and staff interview, the Hospice failed to develop a plan of care reflecting participation of the hospice for 2 of 9 active patients (Patient #1 and #2) who resided in a skilled nursing facility (SNF). Failure of the Hospice and SNF to coordinate the plan of care does not ensure delineation of duties by each facility, does not ensure the interventions reflect the patient's choices and preferences, and does not ensure the patient will receive all the interventions required to care for his/her needs and meet his/her goals. Findings include: Review of the "Agreement for the Provision of Hospice Services" occurred on 02/24/22. This agreement dated August 2014, stated, ". . . Plan of care must 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. Plan of care must reflect participation by Hospice, Facility, resident, and family to the extent possible. . . . Hospice shall . . . (iii) provide Facility with the following information: (A) the most recent hospice plan of care specific to each resident; . . . " - Review of Patient #1's active medical record occurred on February 23-24, 2022 and showed election of Hospice on 01/02/22. The most recent Plan of Care, dated 02/15/22, identified Chaplain visits one to four times a month, Medical Social Work visits one to four times a month, Skilled Nursing visits two times a week, and Home Health Aide visits one time a week for one week, then five times a week. The Hospice Interdisciplinary Group (IDG) meeting notes, dated 02/15/22, stated, ". . . Pain: Pain continues in her neck and bilateral feet. Morphine is scheduled every 6 hours and can be given every 2 hours PRN (as needed) for breakthrough pain. Bio Freeze and Lidocaine Patch 5% can be used as well for pain control. . . . Respiratory: Currently on 2L[liters] of oxygen. . . . did have her oxygen off for 2 weeks and just recently put it back on due to increased shortness of breath. . . . Gastrointestinal: . . . Constipation has been an issue . . . Senna was increased to 2 senna tablets BID [twice a day]. . . . Volunteer services: Volunteer to come 3 x [times] weekly when available and does received [sic] weekly flower deliveries. . . . Home Health Aides will start coming week of 02/13/22 once and then the following weeks they will be coming 5x weekly for additional aide services and companionship. . . . PS [pastoral services] is providing spiritual support . . . SW [social work] following 1-4 times a month or as needed to provide grief support. . . . [name of skilled nursing facility] is sending meals ground; however, this is too chunky for [name of Patient #1] to eat. Daughter requested to have food pureed. . . ." The Hospice Care Plan, started 01/02/22, identified a goal for Hospice staff to effectively collaborate with facility/agency staff and stated, ". . . Collaboration with [name of skilled nursing facility] staff, discuss/review Plan of Care . . ." A home visit with Patient #1 occurred on 02/22/22 at 11:05 a.m. with the Hospice Chaplain. After the visit, a SNF staff nurse (#4) provided Patient #1's most recent Care Plan. Review of Patient #1's Care Plan failed to include the care and services provided by the Hospice. When asked about whether the Hospice added information to the Care Plan or provided the Hospice Plan of Care to the facility, the staff nurse (#4) stated she did not know and confirmed Patient #1's record did not include the Hospice Plan of Care. During a telephone interview on 02/24/22 at 10:25 a.m. a SNF nurse manager (#5) stated she completed the care plans for patients on hospice and included the information in a binder along with the patient's SNF care plan. The nurse (#5) confirmed she had not updated Patient #1's Care Plan to reflect hospice services until 02/22/22 and confirmed the Hospice did not provide the SNF with Patient #1's Hospice Plan of Care. During an interview on 02/24/22 at 1:30 p.m., an administrative nurse (#1) confirmed the hospice should provide the SNF with the Hospice Plan of Care. - Review of Patient #2's medical record occurred on February 22-23, 2022. Diagnoses included adult failure to thrive. The IDG notes, dated 02/15/22, stated, ". . . Nutrition: poor appetite and intake; needs assistance. Bites only. . . . Hospice aides coming in 5 times a week to assist with lunch meal. . . ." A home visit with Patient #2 occurred on 02/22/22 at 1:30 p.m. After the visit, a SNF staff nurse (#6) provided the SNF care plan for Patient #2. The SNF care plan identified, ". . . Problem: Terminal illness secondary to failure to thrive. . . . Approach: Coordinate with Hospice service provider ongoing to ensure coordination of care. . . ." The SNF care plan failed to include the Hospice aide coming five times a week to assist with the lunch meal. During an interview on 02/24/22 at 1:30 p.m., an administrative nurse (#1) confirmed staff failed to include in the SNF care plan the hospice services provided and the disciplines involved in the patient care.