Every finding on record at Sdkj Forever, LLC

Based on interview and record review, the hospice agency failed to review and revise the emergency preparedness plan annually and provide emergency preparedness training to the staff. This failure had the potential to place the patients at risk in the event of an emergency or disaster. --- Based on interview and record review, the hospice agency failed to review and revise the emergency preparedness plan annually and provide emergency preparedness training to the staff. This failure had the potential to place patients at risk in the event of an emergency or disaster. A review of the hospice policy and procedure titled "Emergency Management Plan" , indicated the policy had not been revised since 11/15/2019, with corresponding signatures by the governing body. Further review of the Disaster Drill training indicated no documented evidence it was provided to the staff as required.During an interview with the DPCS (Director of Patient Care Services) on 7/16/23, at 11 a.m., DPCS stated she was aware the policy should be reviewed annually, but could not provide the signatures of the governing body's participation. The Administrator stated she could not provide evidence of a disaster drill and emergency preparedness training for all the staffs.

Based on observation, interview, and record review, the hospice agency (HA) failed to maintain an accurate, current medication profile for two of 14 sampled patients (Patients 1 and Patient 8). 1. For Patient 1, the agency did not update current medication profile. 2. For Patient 8, the agency did not provide a comfort kit as ordered and the visiting nurse was not aware of it. This failure had the potential to place the patients at risk for medication errors and adverse drug reactions. --- b. A review of Patient 8's (P8) Plan of care (POC) dated 7/14/23 indicated P8 is an 85 year old female admitted on 6/16/21 with the diagnosis of alzheimer's disease unspecified (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A review of P8's POC indicated frequency of visits for hospice aide(HA) 3 times a week, Bereavement one initial, social worker (SW) visits one initial and as needed, Registered nurse (RN) as needed and every 14 days for supervisory visits, recertification, and any change of condition and symptom management Spiritual counselor 1 initial and 2x as needed and skilled nurse (SN) 1 every other week and as needed plus 2 visits. Volunteer declined. On 7/15/23 at 11:15 a.m., a joint home visit was conducted at the P8's residence with the Licensed Vocational Nurse 1 (LVN 1). Son was present at bedside. LVN 1 started his home visit. During an interview of P8's son at the same date and time, Son expressed that his mom has episodes of delirium and delusions and wakes up confused late at night at least once a week. When asked if how he manages the patients terminal symptoms , son stated " I talk to my mom until she is no confused. Son stated he reported it to the hospice agency, he stated he tells the nurse every time the nurse comes to visit. During a review of P8's home medication with the LVN 1 and the son, observed there was no comfort kit listed for this patient. On concurrent interview with the son, he stated he does not know what a comfort kit is and its use. During an interview with the licensed vocational nurse 1 (LVN 1) on 7/15/23 during the home visit, LVN 1 stated it should be offered and explained by the case manager for use when terminal symptoms arise and should be always available for the family to use. During an interview with the DON on 7/16/23 at 10:15 a.m. DON stated she received the report from LVN 1 yesterday after the home visit. DON stated she will coordinate with the son, the case manager and the doctor to revise a plan of care for the patients safety and management of terminal symptoms. A review of the HA's policy titled "Patient Education" revised 2014 indicated that based on the patient's condition, IDG care plan, physician ordered care and assessed needs, patient/family will receive education ,as appropriate, about: medications , including safe and effective use, pain and symptom assessment and management. Treatment and disease management education. the patient education will be documented. a. A review of Patient 1's clinical record indicated she was admitted to the hospice agency on 6/15/23, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation. A review of Patient 1s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 6/15/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus 3 prn (as needed) visits for pain and symptoms management, and the Hospice aid (HA) to visit two times a week. The skilled nurse was to instruct the patient and/or caregiver regarding new medications or treatments, monitor for side effects, to monitor and assess effectiveness of the current and any new medications or treatments. There was a physician's order included in the plan of care to administer Ondansetron 8 mg (milligrams) one tab every eight hours as needed. On 7/15/2023, at 2 p.m., a joint home visit was conducted to Patient 1's residence, with the DPCS (director of patient care services). Patient 1 was observed lying in bed awake, alert, and oriented. On 7/15/2023, at 2:30 p.m., during a review of Patient 1s current medications, there was a bottle of Ondansetron 4 mg (fill date- 6/2/23) one tab every 8 hours as needed. During an interview with the patients caregiver (PCG 1), she stated Patient 1 was taking Ondansetron 4 mg one tab when needed. On 7/16/2023 at 11:00 a.m., during an interview with the DPCS), she stated the visiting nurse should be reviewing the patients current medication on every visit and update the medication profile in the patients clinical record. A review of the hospice agencys undated policy and procedure titled, ";Medication Profile", indicated patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.

Based on interview and record review, the Hospice Agency (HA) failed to follow their policy for documentation of discharge orders for four out of 14 sampled patients (Patient 6, Patient 7, Patient 13, and Patient 14) after discharge from the HA. This failure resulted in incomplete documentation and communication of the patient's plan of care on record. --- b. A review of Patient 13's Patient Information indicated, a start of care (SOC) date of 5/14/21, with diagnosis of heart disease unspecified (Impairment of health or a condition of abnormal functioning of the heart) During a review of Patient 13's electronic medical record (EMR) indicated that Patient 13's "Discharge Summary" indicated that patient was discharged from the HA care on 8/16/22 due to death under routine level of care. There was no discharge order on record. c. A review of Patient 14's Patient Information indicated an SOC of 2/1/22 with the diagnosis of atherosclerosis of the aorta (a progressive build up of plaque in the largest artery in your body). During a review of Patient 14's EMR indicated that Patient 14's "Discharge Summary" indicated that patient was discharged from the HA care on 2/3/22 due to death under routine level of care. There was no discharge order on record. During an interview with the Director of Nursing (DON) on 7/16/23 at 10:15 a.m., DON stated it is in the policy that a discharge order should be documented in the patient's record. A review of the HA's policy titled "Discharge Criteria" revised 2015, indicated that prior to discharge, a patient for any reason, the interdisciplinary group (IDG) will obtain a written discharge order form from the medical director. If a patient has an attending physician involved in his/her plan of care, the physician will be consulted before discharge and the attending physician's review and decision included in the discharge note. a. A review of Patient 6's Patient Information indicated, a start of care (SOC) date of 7/24/23, with diagnosis of congestive heart failure (chronic condition in which the heart does not pump blood as well as it should). During a review of Patient 6's electronic medical record (EMR) indicated that Patient 6's "Discharge Summary" indicated that patient was discharged from the HA care on 7/26/23 due to death under routine level of care. There was no discharge order filed in the clinical record. b. A review of Patient 7's Patient Information indicated, a start of care (SOC) date of 6/3/23, with diagnosis of heart disease unspecified (Impairment of health or a condition of abnormal functioning of the heart) During a review of Patient 7's electronic medical record (EMR) indicated that Patient 7's "Discharge Summary" indicated that patient was discharged from the HA care on 7/8/23 due to revocation of hospice benefit. However, there was no discharge order filed on the clinical record.