Every finding on record at Seasons Hospice & Palliative Care of Maryland, LLC

Observed in Record Review. In 3 out of 24 records, reassessments related to the palliation and management of the terminal illness and related conditions were not documented. Examples: In RRNHV#9, RRNHV#10, and RRHV#19, reassessments related to the tube feeding formula, rate, and tolerance was not assessed and documented during routine nursing visits. This was confirmed by the Director of Operations. Observed in Individual Tracer. In 3 of 20 patient records reviewed, The surveyor noted (RRHV#4) that there was no evidence that the severity of the patient's diabetes was assessed. The surveyor noted that the patient's son indicated that he was monitoring her blood sugar and reported that her level was 300 on Sunday. He also noted that she had fainted that day. The patient was also prescribed two oral hypoglycemics. Also, ( in RRCR#24) there was no evidence that the severity of the patients ascites was assessed. The patient revoked the benefit to seek treatment for the ascites. Also, in (RRIPU#27), there was no assessment of the function or patency of the supra-pubic catheter documented on admission or since. This was confirmed with the leadership team.

Observed in Individual Tracer. In 4 of 24 patient records reviewed, The surveyor noted (RRHV#4) that the patient was admitted with a diagnosis of Diabetes managed with two oral hypoglycemics with Blood glucose levels recorded by the son above 200 since admission. The patient did not speak English and her primary language was Cantonese; however, this was not indicated on the care plan. Also, in (RRHV#5), the patient was admitted with COPD, dyspnea at rest on continuous oxygen an there was no respiratory care plan. In (RRIPU#26), there was no care plan for managing the midline central catheter. Also, in (RRIPU#27), there was no care plan for managing the patients supra-pubic catheter or urinary output and insertion site.

Observed in Record Review. In 24 out of 28 records, goals did not include outcome measures or timeframes for achievement. Examples: In RRHV#2, RRHV#3, RRNHV#7, RRNHV#8, RRNHV#9, RRNHV#11, RRNHV#13, RRNHV#16, RRNHV#17, RRNHV18, and RRNHV#20, there was a goal for pain to be managed at an acceptable level without identification of the target level. In RRHV#1, RRNHV#7, RRNHV#8, 10, RRNHV#12, RRNHV#14, RRNHV#15, RRNHV#17, and RRNHV#18, there was a goal stating that nutrition will be managed within the context of the expected decline and expressed desires. In RRHV#3, there was a goal stating patient/daughter will verbalize understanding of need for transmission based precautions within the scope of her disease process. In RRNHV#20, there was generic coordination of care goal that lacked definition of who (facility or agency) would be responsible for carrying out interventions within the plan of care. This was confirmed with the Director of Operations. Observed in Tracer Visit. In 8 out of 24 records, the written plan of care was not individualized to reflect the patient and family goals and interventions based on the problems identified in comprehensive assessments. For example: In RRNHV#9, patient had a diagnosis of Diabetes with routine insulin listed on the medication profile. However, there were no goals or interventions related to this diagnosis on the plan of care. In RRNHV#13, patient had a surgical wound with identified interventions on the plan of care. However, there were no were associated goals. Observed in Individual Tracer. In 7 of 24 patient records reviewed, The surveyor noted (RRHV#4) , that the goals did not include outcome measures or time frames for achievement. For example, the goal for pain was patient at an acceptable level. Also, in (RRHV#5) there were no outcome measures for managing pain. In (RRHV#6), the social work assessment indicated psychological needs to be monitored; however there was no outcome measure for managing the psychological needs. In (RRIPU#29) the goals: acceptable level for N/V, agitation and dyspnea were not measurable and did not include any time frames. In (RRDR#24) the goal for edema acceptable level of edema/ascites was not measurable and timed. This was confirmed with the director.

Observed in Record Review. In 4 out of 24 records, the agency did not have interventions identified to manage care. Examples: In RRNHV#10 there were no orders for the PEG tube feedings on the plan of care. In RRNHV#13 benefit periods 1 and 2, there are no orders indicating who would provide the daily wound care on the non-hospice visit days. This was confirmed by the Director of Operations.

Observed in Record Review. The surveyor noted (RRNHVIPU#26), that the plan of treatment did not include orders for care of the midline catheter in place on admission and utilized to administer medications daily. In (RRIPU#27), there were no interventions ordered to manage the patient's Supra-pubic catheter. This was confirmed with the director. Observed in Record Review. The surveyor noted that (RRIPU#26) and (RRIPU#27) the medication orders were incomplete. The medication order template use by the physician did not specify the route for PO medications and indicated either oral/Macey catheter. Also, the orders for Morphine injection 2 mg/ml did not specify which route either IV or SQ. Also the oxygen orders did not include a frequency. The order only stated 5LNC. This was confirmed with the manager.

Observed in Tracer Visit. In 1 out of 1 aide visits, the hospice aide did not provide services that were ordered by the physician or allowed practitioner in the plan of care. Example: In RRHV#2, the aide performed a bed bath. However, the plan of care indicated a bathing - shower seated every visit. In interviewing the aide, she reported offering a bath or shower during each visit. This was confirmed by the Team Leader who accompanied the Surveyor on the home visit.

Observed in Individual Tracer. In 1 of 6 home visits conducted, The surveyor noted (RRHV#6) that hand hygiene policies were not followed. The nurse used a large amount of hand sanitizer and instead of rubbing until dry, shook his hands to remove it. Also, he failed to sanitize his hands after two glove changes. This was confirmed with the team director. Observed in Tracer Visit. In 1 out of 3 home visits, the hospice did not follow accepted standards of practice to prevent the transmission of infections per their bag technique policy. Example in RRHV#3, the clinician was observed using sanitizer and shaking their hands to remove excess sanitizer prior to gloving. Also during RRHV#3, the total contact time as defined by the manufacturer of the product of 2 minutes for the disinfectant wipe was not followed as evidence by the clinician being observed wiping down and immediately placing equipment used during the visit back into their clinical bag. This was confirmed by the Director of Clinical Operations. Observed in Building Tour. In 1 of 2 IPU tours, The surveyor noted (IPU#1) that several medical supplies had expired including three packages of glucometer strips, an aqua-cell dressing, hydrogel dressing, and five straight catheters all had expiration dates greater than 30 days ago. One of the catheters expired in 2023. This was confirmed with the IPU nurse. Observed in Medication Management Tracer. In 1 of 2 medication tracers IPU, The surveyor noted (IPU Medication Tracer) that the nurse failed to sanitize the multi-use pill cutter after splitting a tablet of Dexamethasone. This was confirmed with the director.

Observed in Individual Tracer. In 1 of 15 HHA records, The surveyor noted that (RRHV#6) the HHA supervision had not been completed for a period of 23 days. This was confirmed with the director.

Observed in Leadership Session. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by a condition level finding at 418.104 (Clinical Records) as significant issues were observed in the following areas: 1. The scribing of medication orders in the inpatient unit 2. The use of white out within the inpatient unit medical records. 3. Inaccurate medication profiles within the medical record 4. The absence of a discharge summary being sent to the primary care provider after revocation. These findings were confirmed with the Clinical Directors.

Observed in Tracer Visit. In 2 of 6 home visits, the medication profile within the medical record was inaccurate. Example: In RRHV#1, patient reported taking Tylenol every day. However, the medication profile within the medical record only indicated Acetaminophen prn via suppository. In RRHV#3, the medication profile was inaccurate. In the home, the daughter reported the patient also taking Tylenol prn, Dayquil prn, and routinely taking Vitamin D and B12. These medications were not new for the patient and had not been included in the medical record profile. These inaccuracies were confirmed by the Nurses being observed during the home visits .

Observed in Record Review. In 2 of 4 IPU patient records reviewed, The surveyor noted (RRIPU#27) that three medication orders were scribbled over and unclear including a morphine dose and three frequency .orders. Also, in (RR#28) white out was used to correct a physician order. This did not comply with agency policy to draw a line through the entry, initial it and re-write the correction. This was confirmed with the director.

Observed in Record Review. In 1 of 4 patient records reviewed, (RRDR#24) no discharge summary sent to MD or hospital after revocation

Observed in Individual Tracer. In 1 of 2 SNF hospice patient records, The surveyor noted (RRHV#5) that there was no care plan that identified the care and services that are needed and identified which provider was responsible for performing the functions that have been agreed upon and included in the plan of care. The required form facility integration form was not available to the facility or hospice. This was confirmed with the team director.

Observed in Building Tour. There was an electric portable space heater within the smoke compartment containing sleeping rooms located underneath the Hospice's Main Nurse Station desk. This was acknowledged by the Director of Clinical Operations. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.

Observed in Emergency Management Session. In 4 of 4 locations, The hospice nurse surveyor noted that the emergency operation's plan required a minimum of two (2) exercises annually, at all locations; however, the organization did not have documentation to confirm that all sites were involved or that two exercises were completed. The only documents on file for 2020 was a Covid event for all locations, and in 2021 there was one tabletop exercise that did not indicate who was involved in the exercise or the extent of the exercise to include all staff, including volunteers. The actual events that were documented were power outages in the office only and did not evaluate how the organization managed staff and patients. Also, there was no evidence that the inpatient facilities participated or that they participated in the hospital exercises or events. This was confirmed with Director of Business Operations.

Observed in Record Review. In 3 of 20 patient records reviewed, The hospice nurse surveyor noted (RR#3) that the updated nursing assessment indicated that the patient was experiencing pain in the ilium; however the pain assessment was incomplete and did not include an intensity rating of the pain. This was confirmed with the manager. Observed in Record Review. In 2 of 11 patient records reviewed, it was noted that the organization did not ensure that a pain assessment that included its defined criteria was completed. For example, a review of the medical record for RR#7, revealed an admitting diagnosis of uncontrolled pain. The comprehensive pain assessment did not include the documentation of the following information as required by organization policy: location, duration, description, frequency, functional and psychosocial impact, onset, current treatment plan, and response to treatment. Example #2: A review of the medical record for RR#9, revealed that during week 10 of services the clinician documented the onset of right shoulder pain. The pain assessment did not include the documentation of the following information as required by organization policy: duration, description, frequency, functional and psychosocial impact, and response to treatment. This observation was reviewed with the Clinical Director of Operations.

Observed in Record Review. In 2 of 20 patient records reviewed, The hospice nurse surveyor noted (RR#1) that the patient assessment indicated that the patient was agitated and combative; however, there was no assessment of the severity of the symptoms. In (RR#2), the surveyor noted that the patient assessment indicated that the patient was experiencing psychosis and hallucinations; however, there was no assessment of the severity of the symptoms. This was confirmed with the manager.

Observed in Record Review. In 6 of 20 patient records reviewed, The hospice nurse surveyor noted (RR#1) that the patient assessment indicated that the patient was agitated and combative; however, the plan of care did not include goals, outcome measures or time frames to manage the symptoms. In (RR#2), the surveyor noted that the patient assessment indicated that the patient was experiencing psychosis and hallucinations; however, there were no goals, interventions, expected outcomes or time frames to manage the symptoms. In (RR#4), the plan of care did not include any measurable outcomes or timeframes and (RR#5), the patient plan of care goals did not include outcome measures. This was confirmed with the manager. Observed in Record Review. In 2 of 11 patient records reviewed, it was noted that the organization did not ensure that the plan of care goals included specific assessed needs and outcome measures for specific care activities. For example, during a review of the medical record for RR#7, it was noted that the care plan included the following goal statement(s): Pain is currently managed at a level acceptable to patient; Patient exhibits reduction/relief of any cardiopulmonary symptoms. The goal statemen(s)t did not include the specific patient goal and a method to measure the effectiveness of problem interventions. Example #2: A review of the medical record for RR#15, revealed that the plan of care included the following goal statement: Pain is currently managed at a level acceptable to patient. The goal statement did not include the specific patient goal and a method to measure the effectiveness of problem interventions. This observation was reviewed with the Clinical Director of Operations.

Observed in Record Review. In 1 of 11 patient records reviewed, it was noted that the organization did not ensure that the plan of care was revised when the patient’s condition changed For example, a review of the medical record for HV#5 revealed that the patient experienced a fall during week 6 of services, the plan of care was not updated with interventions to maintain patient safety, and strategies to prevent injury. This observation was reviewed with the Clinical Director of Operations.

Observed in Individual Tracer. In 4 of 20 patient records reviewed, The hospice nurse surveyor noted (HV#1) that the plan of care was not updated to include updated information. The surveyor noted that there was a new order for Lexapro and an early October visit note indicated that the patient was tearful and was assessed as a three on a depression scale. The surveyor noted that the interdisciplinary plan of care and team meeting notes did not indicate a change to the plan of care or provide information about the outcome expected from the new medication. The surveyor also noted that there was no indication in the notes that the change in condition had not been communicated to the physician, as it was not documented. Also, in (HV#3), the surveyor noted that the patient assessment indicated that the patient had dysphagia and was ordered a pureed diet; however there were no interventions on the plan of care to manage the risk for aspiration. Also, the surveyor noted that the patient had an oxygen concentrator in the room; however, there were no goals or interventions on the plan of care to manage respiratory symptoms except for ordered medication. In (RR#3), the surveyor noted that the interdisciplinary team notes indicated that constipation and edema are now an issue; however, the plan of treatment was not updated to include goals and interventions to manage those symptoms. This was confirmed with the manager.

Observed in Record Review. In 4 of 20 patient records reviewed, The hospice nurse surveyor noted (RR#1) that there was no evidence that the interdisciplinary team evaluated the patient's progress toward goals. The surveyor noted that the patient assessment indicated that the patient was agitated and combative; however, in review of the interdisciplinary team notes and the plan of care the surveyor noted that there was no indication of goals and interventions to manage the symptoms and therefore no evidence of progress toward a goal. In (RR#3), the surveyor noted that the patient had developed a wound on the sacrum; however, the plan of care was not updated and there was no interdisciplinary evaluation of the progress toward healing. In (HV#2) and (HV#3), the surveyor noted that the patients had been on service for ten months; however, there was no identified outcome measure and therefore no assessment of progress toward goals. This was confirmed with the manager.

Observed in Individual Tracer. In 3 of 20 patient records reviewed, The hospice nurse surveyor noted (HV#1) that the psycho-social plan of care was not followed. The surveyor noted that the plan of care and treatment orders indicated that the social worker was to visit once every two weeks; however, only one visit per month was completed in August and September, and no visit was completed in October. Also, the plan of care indicated that the purpose of the visits was to assess the patient and caregiver's psycho-social needs; however, there was no evidence that the caregiver's (spouse) needs were assessed, other than the bereavement risk assessment, which did not identify the actual person assessed. The surveyor noted that previous contacts were made with the daughter. Also, in (HV#2), the surveyor noted that the October recertification social services order/plan was for one visit every 2 weeks for 4 weeks; however only one visit was completed in October and the next visit was three weeks later in November. In (RR#3), the surveyor noted that the social services assessment indicated that the patient did not want to see the social worker and indicated to contact her in a few weeks as she was overwhelmed with so many people visiting. There was no indication that the social worker had followed up for a period of seven weeks. This was confirmed with the manager.

Observed in Competency Session. The hospice nurse surveyor noted that there was no evidence in the personnel file that skills competence was assessed on hire in 2017 or since. The documentation was not available on site. This was confirmed with the regional HR director.

Observed in Individual Tracer. In 1 of 2 hospice aide care plans reviewed, The hospice nurse surveyor noted (HV#1) that the aide care plan did not include instructions about how to transfer the patient. The surveyor noted that the assessment indicated that the patient was chair bound. During the visit, the paid caregiver had indicated that they were going to need to use the Hoyer lift, as the patient was become less able to participate in the transfer. This was confirmed with the manager.

Observed in Record Review. In 2 of 6 discharge records, The hospice nurse surveyor noted (RR#5) that the patient was transferred to the hospital emergency room and then to a psychiatric facility; however, there was no evidence that the organization gave the information about the care, treatment, or services provided to the patient to the other service providers who will provide the patient with care, treatment, or services. Also, in (RR#6) there was no indication that the patient information was provided the other hospice when the patient was transferred. This was confirmed with the manager.

Observed in Record Review. In 1 of 5 skilled nurse facility care plans, The hospice nurse surveyor noted (RR#3) that the plan of care did not specify the care needs of the patient receiving respite care in a contracted skilled nursing facility. This was confirmed with the manager/