Every finding on record at Spectrum Health Continuing Care

It is required that the comprehensive assessment includes consideration of the following factors: Symptoms and symptom severity, including skin integrity. This standard was not met as evidenced by clinical record review and interview. In 1 of 27 (4%) records reviewed it was revealed that the hospice agency did not ensure the comprehensive assessment was completed every fifteen days and included skin integrity. Clinical Record 15: The election of benefit was dated 07/11/2023. The care plan dated 12/08/2023-02/05/2024 had an intervention that stated in part, "Patient's skin will be assessed for impaired integrity at admission, recertification, routine visits, and as needed." The patient received an RN assessment on 01/18/2024. The care plan intervention stating in part, "Patient's skin will be assessed for impaired integrity at admission, recertification, routine visits, and as needed," and was marked "completed" by the RN. The patient received RN assessments on 01/22/2024, 01/24/2024, and 01/29/2024, and the RN did not document the assessment of the PEG tube insertion site on those dates. Signs and symptoms of an infection were identified to the skin surrounding the PEG tube insertion site on 02/05/2024. The RN visit note dated 02/05/2024 narrative note stated in part, "Area around PEG tube is reddened, and per caregiver (name), the patient has had pussy draining oozing over the weekend. Encouraged to keep the area clean and dry. Nystatin ordered." The intervention was not marked as "completed" on 02/05/2024. The surrounding skin of the PEG tube was not assessed by the RN for eighteen (18) days from 1/18/2024 to 2/5/2024, and the patient developed an infection during this time. A joint record review and interview with the Nurse Manager (staff 1) on 02/05/2024 confirmed the skin surrounding the PEG tube was not assessed for eighteen (18) days from 01/18/2023 to 02/05/2024.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 27 (4%) records reviewed it was revealed that the hospice did not ensure the plan of care contained interventions to meet the needs of the patient based on problems identified in the initial and updated comprehensive assessments. Document 4: Policy # 161, titled Hospice-Plan of Care, (revised 02/09/2021) sub-section seven (7), stated in part, "The plan of care may include the following: (d) reflects patient and family goals. (e) Identified planned interventions based on problems identified on the initial and updated comprehensive assessments." Clinical Record 14: The benefit election date was 04/15/2023. The patient that had a tracheostomy identified on admission had an initial plan of care from 04/15/2023-06/15/2023 that did not contain any problems, goals, or interventions related to the tracheostomy. A joint record review and interview with the Nurse Manager (staff 1) on 02/08/2024 confirmed that the hospice agency did not ensure the care plan dated 04/15/2023-06/15/2023 contained goals and interventions based on problems initially identified.

It is required that each patient’s individualized written plan of care includes all medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, interview and observation. In 1 of 6 (17%) home visit observations it was revealed that the hospice agency did not ensure all appliances necessary to meet the patient's needs were included in the plan of care. Document 4: Policy #7161 titled Hospice-Plan of Care, (revised 02/09/2021) sub-section seven (7) stated in part, "The plan of care may include the following: (f) Includes all services necessary for the palliation and management of the terminal illness, including the following: medical supplies and appliances". Clinical Record 2: The home visit (Home Visit 4) was conducted on 02/06/2023 for a patient with a hospice benefit election date of 3/4/2023. The patient resided in an Assisted Living Facility (ALF) and had a terminal diagnosis of chronic combined systolic and diastolic heart failure. The home visit revealed a Bi-PAP machine was present directly beside the patient's bed in the home for daily use and contained a sticker with the correct patient's name to identify who the Bi-PAP machine belonged to. The room was a single occupancy ALF room. A sign above the patient's bed stated, "Please do not fill the Bi-PAP machine with water." The ALF provided a patient care flow sheet from 01/06/2024-present, that identified the ALF and verified daily the Bi-PAP was present and in use. The ALF document stated in part, "Bi-PAP and O2 (oxygen) in use. The updated Interdisciplinary Group (IDG) care plan was effective 02/01/2024-02/15/2024 for the benefit period of 12/29/2023-02/26/2024 and did not contain any reference to a Bi-PAP machine. The plans of care dated 03/04/2023-06/01/2023, 06/02/2023-08/30/2023, 08/31/2023-10/29/2023, 10/30/2023, 12/29/2023 -02/26/2024 did not contain any reference to a Bi-PAP machine. The Nurse Manager (staff 11) phoned the DME company listed on the Bi-PAP machine to clarify Bi-PAP use and settings. The DME provider stated the patient had the Bi-PAP machine since 2019, and now owned the machine. The Pulmonologist updated the most recent settings on April 2, 2020. The Certificate of Terminal Illness (CTI) dated 03/04/2023 stated in part, "Wears Bi-PAP at night." The Initial Interdisciplinary Group (IDG) meeting on 03/09/2023 contained the RN admission notes, which stated in part, "Obstructive Sleep Apnea (OSA)-wearing Bi-PAP consistently at night." The IDG meetings following admission dated 03/16/2023, 03/30/2023, 04/13/2023, 04/27/2023, 05/11/2023, 05/25/2023, 06/8/2023......2/1/2023 did not contain any evidence of the IDG discussing the Bi-PAP usage. During a joint record review, and interview with the Nurse Manager (staff 11) on 02/06/2024, she confirmed the Bi-PAP machine had not been on any care plan since admission. In addition, the nurse manager confirmed there was no physician order for the BiPAP machine settings. The Nurse Manager stated, "The physician is aware the patient uses Bi-PAP because we discussed it at the first Interdisciplinary (IDG) meeting after admission."

It is required that a patient's clinical record includes, at a minimum physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 27 (7%) records reviewed it was revealed that the hospice agency did not ensure the patient's clinical record contained all physician's orders. Document 9: Policy #9897, titled Content of Record, stated in part, "The patient's clinical record includes 4.11, appropriate, current, and signed medical orders by the physician, in compliance with regulatory and accrediting bodies." Clinical Record 14: The election of benefit date was 04/15/2023. The patient had a tracheostomy on admission and had a plan of care signed and dated 12/11/2023-02/08/2024 that contained an intervention for tracheostomy care that stated in part, "Caregiver to complete tracheostomy care. Care is to be completed daily. SN may complete tracheostomy care as needed (PRN)." The record did not contain a physician's order to specify the type of solution/medication used for cleaning the tracheostomy site. In addition, the plan of care dated 12/11/2023-02/08/2024 contained an intervention for PEG tube feedings but did not contain a physician's order for PEG tube insertion site care. Clinical Record 15: The election of benefit was dated 07/11/2023. The patient had a PEG tube identified on the Initial RN assessment and the Certificate of Terminal Illness. The record did not contain a physician's order for PEG tube insertion site care. The care plan dated 07/11/2023-10/08/2023, 10/09/2023-12/07/2023, and 12/08/2023-02/05/2023 contained no PEG tube insertion site care interventions. A joint record review and interview with the nurse manager (staff 1) on 02/08/2024 confirmed that the hospice agency clinical record did not s contain a physician's order for the tracheostomy or PEG tube insertion site care.