Every finding on record at Scenic Healthcare Hospice LLC

Based on record review and interview, the agency failed to take into consideration an initial bereavement assessment as part of the comprehensive assessment in 7 (#1, #2, #3, #4, #5, #6, and #7) of 10 active patient records reviewed. The failure could impact the ability of the patient's family or other individuals to cope with a patient's death. --- Patient #1: Record review of Patient #1s record revealed a Plan of Care effective 6/27/2023. The Plan of Care indicated that Patient #1 was admitted to hospice services on 6/27/2023. Traumatic Hemorrhage of Cerebrum was listed as the terminal diagnosis. Patient #1 election for hospice was dated 6/27/23. Chaplain D conducted a visit on 7/3/2023. Chaplain D documented on an agency computerized form with ";Bereavement Admission" as the encounter type. Chaplain D documented that the bereavement risk was low. The comprehensive assessment failed to have an initial bereavement assessment. Patient #2: Record review of Patient #2s record revealed a Plan of Care effective 6/11/2023. The Plan of Care indicated that Patient #2 was admitted to hospice services on 6/11/2023. Senile Degeneration of the Brain was listed as the terminal diagnosis. Patient #2 election for hospice was dated 6/11/2023. Patient #2s record did not contain a bereavement assessment. The comprehensive assessment failed to have an initial bereavement assessment. Patient #3: Record review of Patient #3s record revealed a Plan of Care effective 6/7/2023. The Plan of Care indicated that Patient #3 was admitted to hospice services on 6/7/2023. Parkinsons Disease as the terminal diagnosis. Patient #3 election for hospice was dated 6/7/2023. Chaplain D conducted a visit on 7/3/2023. Chaplain D documented a ";Bereavement Admission" as the encounter type. Chaplain D documented that the bereavement risk was low. The comprehensive assessment failed to have an initial bereavement assessment. Patient #4: Record review of Patient #4s record revealed a Plan of Care effective 4/18/2023. The Plan of Care indicated that Patient #4 was admitted to hospice services on 4/18/2023. Senile Degeneration of the Brain was listed as the terminal diagnosis. Patient #4 election for hospice was dated 4/18/2023. Chaplain E conducted a visit on 4/24/2023. Chaplain D documented a ";Bereavement Admission" as the encounter type. Chaplain E documented that the bereavement risk was low. The comprehensive assessment failed to have an initial bereavement assessment. Patient #5: Record review of Patient #5s record revealed a Plan of Care effective 6/2/2023. The Plan of Care indicated that Patient #5 was admitted to hospice services on 6/2/2023. Cardiac Amyloidosis (stiff heart Syndrome) was listed as the terminal diagnosis. Patient #5 election for hospice was dated 6/2/2023. Chaplain F conducted a visit on 7/25/2023. Chaplain F documented a ";Bereavement Admission" as the encounter type. Chaplain F documented that the bereavement risk was low. The comprehensive assessment failed to have an initial bereavement assessment. Patient #6: Record review of Patient #6s record revealed a Plan of Care effective 6/15/2023 which included the Initial Plan of Care dated 6/10/2023. The Plan of Care indicated that Patient #6 was admitted to hospice services on 6/10/2023. Malignant Neoplasm of Unspecified Site of Unspecified Female Breast with metastasis to the bone, brain, liver, and lung as the terminal diagnosis. Chaplain D conducted a visit on 7/2/2023. Chaplain D documented a ";Bereavement Admission" as the encounter type. Chaplain D documented that the bereavement risk was not listed. The comprehensive assessment failed to have an initial bereavement assessment. Patient #7: Record review of Patient #7s record revealed a Plan of Care effective 6/29/2023. The Plan of Care indicated that Patient #7 was admitted to hospice services on 6/29/2023. Neurocognitive Disorder with Lewy Bodies was listed as the terminal diagnosis (type of progressive dementia that leads to a decline in thinking, reasoning and independent function). Patient #7 election for hospice was dated 6/29/2023. Chaplain D conducted a visit on 7/6/2023. Chaplain D documented a ";Bereavement Admission" as the encounter type. Chaplain D documented that the bereavement risk was low. The comprehensive assessment failed to have an initial bereavement assessment. During an interview on 7/28/2023 at 11:29 a.m. with the Administrator, Alternate Administrator, and Director of Nursing, the surveyor discussed the bereavement assessments. The Alternate Administrator informed the surveyor that the policy was that a bereavement assessment was done as part of the comprehensive assessment. The Alternate Administrator informed the surveyor that if the patient refused the Chaplain, then the Social Worker would do the assessment. If the patient refused both services, then the nurse would do it. The Alternate Administrator and Director of Nursing reviewed the records in the computer during record review. The Alternate Administrator stated, "No," when asked if the clinical records contained bereavement assessments. The Administrator and Alternate Administrator could not state why the bereavement assessments had not been conducted. The Alternate Administrator informed the surveyor that there was a new bereavement coordinator. The Bereavement Coordinator was on vacation. The agency had a policy titled ";Initial Assessment/Comprehensive Assessment" that was revised February 2022. The policy read in part: ";Policy Each patient admitted by Hospice will have an appropriate initial assessment and comprehensive assessment performed and documented which promote the patients well-being, comfort and dignity throughout the dying process. Purpose To define the scope and intensity of the initial assessment and comprehensive assessment...Procedure...3...An initial bereavement risk assessment of the needs of the patients family and other individuals focusing on the social, spiritual and cultural factors that may impact their ability to cope with the patients death. Information gathered from the initial bereavement assessment must be incorporated into the plan of care and considered in the bereavement plan of care...."

Based on record review and interview, the agency failed to follow the individualized written plan of care in 4 (#5, #8, #9, #13) of 14 patient records reviewed. The failure placed the patients at risk of poor symptom control and negative outcomes. --- Patient #5:Record review of Patient #5's record revealed a Plans of Care effective 6/5/2023, 6/15/2023, 6/29/2023, and 7/13/2023. The Plans of Care indicated that Patient #5 was admitted to hospice services on 6/2/2023. The Plans of Care listed Cardiac Amyloidosis (stiff heart syndrome) as the terminal diagnosis. The Plans of Care contained an order for hospice aide services two times each week. Hospice Aide H conducted an aide visit on 6/13/2023, the first aide visit conducted since Patient #5 was admitted on 6/2/2023. Patient #5 did not receive hospice aide visits the week of 6/4/2023. Hospice Aide H conducted hospice aide visits on 6/26/2023, 6/28/2023, 6/30/2023 which was three visits the week of 6/25/2023.Hospice Aide H conducted hospice aide visits on 7/3/2023, 7/5/2023, and 7/7/2023 which was three visits the week of 7/2/2023.Hospice Aide H conducted aide visits on 7/10/2023, 7/12/2023, and 7/14/2023 which was three visits the week of 7/9/2023. Patient #8:Record review of Patient #8's record revealed a Plan of Care effective 5/19/2023. The Plan of Care indicated that Patient #8 was admitted to hospice services on 1/8/2023. The Plan of Care listed Stage IV Breast Cancer with Metastasis to the Bone and Liver as the terminal diagnosis. The Plan of Care contained an order for skilled nursing services visits once each week. Patient #8's clinical record did not contain evidence that a skilled nurse visit was conducted the week of 5/28/2023. Patient #9:Record review of Patient #9's record contained a Plan of Care effective 6/1/2023. The Plan of Care indicated that Patient #9 was admitted to hospice services on 2/18/2023. The Plan of Care listed Congestive Heart Failure as the terminal diagnosis. The Plan of Care contained an order for hospice aide visits 3 times each week. Patient #9's clinical record did not contain evidence that a hospice aide conducted visits the week of 6/4/2023 and the week of 6/11/2023. The record contained Plans of Care effective 6/15/2023 and 6/29/2023. The Plans of Care contained orders for Patient #9 to receive hospice aide services 3 times each week. Hospice Aide I conducted hospice aide visits on 6/19/2023 and 6/22/2023, two visits the week of 6/18/2023.Hospice Aide I conducted hospice aide visits on 6/26/2023 and 6/29.2023, two visits the week of 6/25/2023.Hospice Aide I conducted hospice aide visits on 7/3/2023 and 7/6/2023, two visits the week of 7/2/2023.Hospice Aide I conducted hospice aide visits on 7/10/2023 and7/13/2023, two visits the week of 7/9/2023. Patient #13:Record review of Patient #13's record contained a Plans of Care effective 6/1/2023., The Plan of Care indicated that Patient #13 was admitted to hospice services on 10/27/2022. The Plan of Care listed the Parkinson's Disease as the terminal diagnosis. The Plan of Care contain an order for hospice aide services 3 times a week on Monday, Wednesday, and Friday. Patient #13's clinical record did not contain evidence that a hospice aide conducted visits the week of 6/4/2023 and the week of 6/11/2023. During an interview on 7/28/2023 at 11:29 a.m. with the Administrator, Alternate Administrator, and Registered Nurse C/Director of Nursing, the surveyor discussed that the aide did not provide services until 6/13/2023 for Patient #5 and that the Plans of Care contained orders for hospice aide services two times a week. The aide went 3 times a week starting the week of 6/25/2023. The Alternate Administrator and Registered Nurse C did not know why the aide was going 3 times each week. The Alternate Administrator and Registered Nurse C confirmed there was no order to increase the hospice aide frequency to 3 times each week. During an interview on 7/28/2023 at 11:29 a.m. with the Administrator, Alternate Administrator, and Registered Nurse C/Director of Nursing, the surveyor discussed that Patient #8 had not received a skilled nursing visit the week of 5/28/2023. The Alternate Administrator and Registered Nurse C/Director of Nursing verified that no visit was made by a nurse that week. The Alternate Administrator and Registered Nurse C did not know why a visit was not made. The Alternate Administrator informed the surveyor that the registered case manager had called in "sick the past few days and we cant call." During an interview on 7/28/2023 at 11:29 a.m. with the Administrator, Alternate Administrator, and Registered Nurse C, the survey discussed that the Plans of Care were not being followed regarding visit frequencies. The Administrator informed the surveyor that Hospice Aide I was on vacation from 6/5/2023 for two weeks. The Alternate Administrator and Registered Nurse C reviewed the records and verified that visits were not made to Patients #9 and #13 the weeks of 6/4/2023 and 6/11/2023. The patient records did not contain documentation of why the hospice aide visits were not provided. The Alternate Administrator stated, "I don't know, it wasn't documented," when asked why another hospice aide had not provided services when Hospice Aide I was on vacation. The Alternate Administrator informed the surveyor that there were no orders to hold aide services for Patients #9 and #13, or to reduce aide visits for Patient #9. The Administrator and Alternate Administrator informed the surveyor that the agency had back up services. The agency had a policy titled "IDG Care Planning Process" revised February 2022. The policy read in part: "Policy In order to assure that care provided is appropriately planned to meet each patient's specific needs and problems,...The Hospice IDG develops a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Purpose To define the IDG care planning process and documentation of care planning...Procedure...6. All care and services furnished to patient and their families follows an individualized written plan of care established by the IDG in collaboration with the attending physician (if any)..."

Based on record review and interview, the agency failed to include physician orders in the patient records for 2 (#3, #12) of 3 patients that had medication changes and for 4 (#5, #8, #11, #14) of 4 patients that were receiving wound care. The failure placed the patients at risk of negative outcomes and inadequate symptom control. --- Medications Patient #3: Record review of Patient #3's record revealed Plans of Care effective 6/15/2023, 6/29/2023, and 7/13/2023. The Plans of care indicated that Patient #3 started on the hospice services on 6/7/2023. The Plans of Care listed Parkinson's Disease as the terminal diagnosis. Registered Nurse C conducted a skilled nurse visit on 6/26/2023. Registered Nurse C documented "requested Lidocaine patches (used to treat pain), will order these and have delivered tonight. Will apply one patch topically daily." A home visit was conducted to Patient #3's home on 7/27/2023 at 11:50 a.m. The surveyor spoke with Patient #3 and Patient #3's Family Member about whether Patient #3 used Lidocaine patches. Patient #3's family member stated, "Yes, we use them as needed." Patient #3's clinical record did not contain an order for Lidocaine patches. Patient #12: Record review of Patient #12's record contained Plans of Care effective 3/22/2023 (Initial Plan of Care), 3/31/2023, and 4/6/2023. The Plans of Care indicated that Patient #12 was admitted to the agency's services on 3/22/2023. The Plans of Care listed Breast Cancer with metastasis to the bone, bladder, and thyroid as the terminal diagnosis. Registered Nurse C conducted a skilled nurse visit on 4/4/2023. Registered Nurse C documented that Patient #12's pain was not being controlled by Norco (used to treat pain) 5/325 milligrams, and the dose would be increased to Norco 10/325 milligrams today. Registered Nurse C conducted a skilled nurse visit on 4/6/2023. Registered Nurse C documented that Patient #12 complained of pain "even with Norco 10/325 milligrams every 6 hours, will change medication to Morphine (used to treat pain)15 milligrams every 12 hours...will have Norco for breakthrough pain if needed..." Registered Nurse C conducted a skilled nurse visit on 4/10/2023. Registered Nurse C documented that Morphine Sulfate 15 milligrams will be increased to every 8 hours instead of every 12 hours to assist with pain control. Registered Nurse C documented receipt of a phone call on 4/14/2023 from Patient #12's family member. Patient #12's family member informed Registered Nurse C that Patient #12 was unable to swallow. Registered Nurse C documented an order was sent to discontinue of all oral tablets and to start Fentanyl (used to treat pain) 25 micrograms/hour patch. Patient #12's clinical record did not contain orders for the changes in the dosages and frequency of administration of Norco; did not contain any orders for Morphine Sulfate 15 milligrams; and did not contain an order for Fentanyl patches. During an interview on 7/28/2023 at 11:29 a.m. with Alternate Administrator, the Alternate Administrator, and Registered Nurse C, the surveyor discussed the medication changes and that there were no orders in the clinical record for the medication changes that were made. Registered Nurse C informed the surveyor that Patient #3 had wanted to try the Lidocaine patches. Registered Nurse C stated, "I can't tell you," why the order for Lidocaine patches was not in the record. The Alternate Administrator and Registered Nurse C reviewed the clinical records. The Alternate Administrator stated, "Just prn (as needed) is all we have for Norco," (for Patient #12). The Alternate Administrator and Registered Nurse C "agree" that Patient #12's clinical record did not contain orders for Morphine Sulfate 15 milligrams, Fentanyl patch, and the changes in Norco dosage and frequency of administration. The surveyor asked about the process for ordering medications. The Alternate Administrator informed the surveyor that staff put the medication orders in a electronic system that would be sent to the physician to sign and then would be sent to the pharmacy. The staff will have to input the order in the electronic medical record. The system for getting prescriptions signed by the physician and to the pharmacy will not incorporate orders into the Patient records. Wound Care Patient #5: Record review of Patient #5's record revealed Plans of Care effective 6/29/2023 and 7/13/2023. The Plans of Care indicated that Patient #5 was admitted to hospice services on 6/2/2023. The Plans of Care listed Cardiac Amyloidosis (stiff heart syndrome) as the terminal diagnosis. The Plans of Care contained an order "May administer wound care as ordered." Registered Nurse C conducted a skilled nurse visit on 7/6/2023. Registered Nurse C documented that Patient #5 had multiple skin tears on the left arm and back. Registered Nurse C documented that the areas were cleaned with wound cleanser and applied xeroform (non-adhering dressing used on low draining wounds) to sites. Registered Nurse C conducted a skilled nurse visit on 7/14/2023. Registered Nurse C documented wound care to the left hip and left scapula area. Registered Nurse C documented cleaning the left hip with wound cleanser, applied Xeroform, applied pivot 4x4 dressing (dressing designed to protect wounds); Tegaderm (transparent dressing used to cover and protect wounds) applied to the upper left scapula area. Patient #5's record did not contain orders for wound care to the skin tears, left hip, and scapula area. Patient #8: Record review of Patient #8's revealed a Plan of Care effective 5/19/2023. The Plan of Care indicated that Patient #8 was admitted to hospice services 1/8/2023. The Plan of Care listed Stage IV Breast Cancer with Metastasis to the Bone and Liver as the terminal diagnosis. The Plan of Care contained an order "May administer wound care as ordered." Registered Nurse C conducted a skilled nurse visit on 5/25/2023. Registered Nurse C documented that Patient #8's bilateral lower extremities had 3+ swelling and "raised legs in recliner and applied wraps to bilateral Coban (a self-adherent elastic wrap used to compress) wraps." Patient #8's record did not contain orders for bilateral leg wraps. Patient #11: Record review of Patient #11's record revealed a Plan of Care effective 3/25/2023. The Plan of Care indicated that Patient #11 was admitted to hospice services on 3/25/2023. The Plan of Care listed Stage IV Metastatic Colon Cancer. The Plan of Care contained an order "May administer wound care as ordered." Registered Nurse C conducted a skilled nurse visit on 3/25/2023. Registered Nurse C documented a dressing was removed from the coccyx area. A 4x4 centimeter area of excoriation noted with a 2x2 nodule like protrusion that was attached to the skin. Cleansed with wound cleanser and applied xeroform gauze and sacral pivot dressing. Registered Nurse C conducted a skilled nurse visit on 3/27/2023. Registered Nurse C documented the dressing to coccyx was changed and a Xeroform and pivot dressing was applied. Registered Nurse C conducted a skilled nurse visit on 3/30/2023. Registered Nurse C documented the dressing to the coccyx area was changed. Registered Nurse C conducted a skilled nurse visit on 4/1/2023 due to family called about increased pain reported by the patient and thought wound was infected. Registered Nurse C documented the dressing to the coccyx area was changed and that the wound did not look infected. Registered Nurse C conducted a skilled nurse visit on 4/4/2023. Registered Nurse C documented the dressing to the coccyx area was changed. Patient #11's record did not contain wound care orders for the coccyx. Patient #14: Record review of Patient #14's record revealed a Plans of Care effective 5/19/2023, 6/1/2023, and 6/15/2023. The Plans of Care indicated that Patient #14 was admitted to the agency's services on 4/11/2023. The Plans of Care listed Alzheimer's Disease as the terminal diagnosis. The Plans of Care contained an order for wound care to the sacral area, clean with wound cleanser, pat dry, cover with 4x4 bordered gauze weekly and as needed. Registered Nurse C conducted a skilled nurse visit on 5/23/2023. Registered Nurse C documented that calf wounds were cleansed with cleanser, xeroform, ABD pad and wrapped with kerlix. Right hip wound cleansed, xeroform, and pivot 4x4. Registered Nurse G conducted a skilled nurse visit on 5/30/2023. Registered Nurse C documented performing wound care to the bilateral calves and right hip. The bilateral calf wounds were cleaned with wound cleanser, xeroform dress and ABD pad (gauze pads used to absorb drainage from heavily draining wounds), wrapped with kerlix (rolled gauze dressing) and tape. The right hip was cleansed with spray, xeroform, and covered with 4x4 gauze, and tape. Registered Nurse C conducted a skilled nurse visit on 6/7/2023. Registered Nurse C documented wound care to calf wounds, applied xeroform, non adherent dressing, ABD pad, and wrapped with gauze only. Right hip with no dressing was required on top of it at this time. Registered Nurse C conducted a skilled nurse visit on 6/13/2023. Registered Nurse C documented wound care to calf wounds, cleansed with wound spray, xeroform, non-adherent dressing (a wound dressing that does not stick to wound bed), gauze, and Coban to heels and calves. Right pressure wound (site not specified) was cleansed (not specified), xeroform, and gauze. Registered Nurse C conducted a skilled nurse visit on 6/21/2023. Registered Nurse C documented wound care to calf wounds, applied xeroform, nonadherent dressing, ABD pad, and wrapped with gauze only. The right hip, xeroform and gauze only were applied. Registered Nurse C conducted a skilled nurse visit on 6/26/2023. Registered Nurse C documented that Patient #14's family member was at bedside to assist with wound care (wound care and sites not specified). Patient #14's record did not contain wound care orders for the right hip and bilateral calves. During an interview on 7/28/2023 at 11:29 a.m. with the Administrator, Alternate Administrator, and Registered Nurse C, the surveyor discussed that wound care orders were not in the patient records. The Alternate Administrator and Registered Nurse C reviewed the patient records during record review. Registered Nurse C informed the surveyor that there were verbal orders for the wound care. Registered Nurse C informed the surveyor that the Plans of Care had an order that wound care may be provided as ordered; "Didn't realized needed to be specific." When asked whether the agency knew why the orders were not included in the record, Registered Nurse C stated, "No, but they will be from now on." During the interview on 7/28/2023 at 11:29 a.m. with the Administrator, Alternate Administrator, and Registered Nurse C/Director of Nursing, the surveyor asked about the policy regarding receipt of verbal orders. The Alternate Administrator informed the surveyor that the orders were to be written into the record the day the order was received. The agency had a policy titled "Physician Orders - Verbal Orders" that was revised June 2019. The policy read in part: "Policy Drugs and Treatment are administered by Hospice staff only as ordered by the physician. Only authorized staff receives and record verbal orders... Verbal orders are put in writing and signed and dated...Purpose To document verbal orders received from the patient's physician...4...A copy will remain in the patient's record until the signed order is returned..."