Every finding on record at St. Claire Medical Center, Inc.

Observed in Record Review. In 1 of 3 bereavement records reviewed, the organization had not documented an initial post-death bereavement assessment as per the organization's Bereavement Policy. The bereavement plan of care did not include an assessment of bereavement needs. This finding was discussed with the Bereavement Coordinator at the time of the visit.

Observed in Record Review. In 4 of 14 patient records reviewed, it was noted that the organization did not ensure that the plan of care goals included outcome measures for specific care activities. For example, during a review of the medical record for HosRRHV#1, the following was identified: 1) The plan of care included the following goal statement: “Patient will achieve and maintain regular bowel elimination and skin integrity”. The goal statement did not include a method to measure the effectiveness of problem interventions. 2) The falls risk assessment indicated the patient was at risk for falls. During an interview, the patient’s caregiver stated the patient had experienced a fall during week 1 of the 2nd benefit period. The plan of care was not updated with a goal statement to evaluate the response to care, treatment and services related to fall prevention interventions. 3) During week 3 of the 1st benefit period, an updated comprehensive assessment documented the presence of moderate pain at the buttocks. The plan of care did not include a goal statement to evaluate the response to care, treatment, and services related to pain management. Example #2: During a review of the medical record for HosRRHV#2, it was noted that the patient’s primary diagnosis was Idiopathic normal pressure hydrocephalus. The plan of care did not include outcome measures related to the care, treatment, and services of the patient’s primary diagnosis disease process. Example #3: During a review of the medical record for HosRRHV#3, it was noted that the patient’s primary diagnosis was Protein Calorie Malnutrition. The plan of care did not include outcome measures related to the care, treatment, and services of the patient’s primary diagnosis disease process. Example #4: During a review of the medical record for HosRRNHV#5, an updated comprehensive assessment documented the presence of pain at the stomach area. The plan of care did not include outcome measures related to pain management. This observation was reviewed with the Assistant Director of Hospice/Quality and Compliance Hospice and the Director of Home Health and Hospice.

Observed in Record Review. In 4 of 14 patient records reviewed, it was noted that the organization did not ensure the plan of care was revised when the patient’s condition changed. For example, a review of the medical record for HosRRHV#1, revealed that the falls risk assessment indicated the patient was at risk for falls. During an interview, the patient’s caregiver stated the patient had experienced a fall during week 1 of the 2nd benefit period. The plan of care was not updated with interventions to maintain patient safety, and strategies to prevent injury. In addition, during week 3 of services an updated comprehensive assessment documented the presence of moderate pain at the buttocks. The plan of care did not include interventions related to pain management. Example #2: In 1 of 14 patient records reviewed, it was noted that the plan of care did not include interventions based on problems identified in the comprehensive assessment. For example, during a review of the medical record for HosRRHV#2, it was noted that the patient’s primary diagnosis was Idiopathic normal pressure hydrocephalus. The plan of care did not include interventions related to the care, treatment, and services of the patient’s primary diagnosis disease process. Example #3: During a review of the medical record for HosRRHV#3, it was noted that the patient’s primary diagnosis was Protein Calorie Malnutrition. The plan of care did not include interventions related to the care, treatment, and services of patient’s primary diagnosis disease process. Example #4: During a review of the medical record for HosRRNHV#5, an updated comprehensive assessment documented the presence of pain at the stomach area. The plan of care did not include interventions related to pain management. This observation was reviewed with the Assistant Director of Hospice/Quality and Compliance Hospice and the Director of Home Health and Hospice.

Observed in Individual Tracer. In 1 of 4 individual tracers, it was noted that the organization did not ensure that required information was included in the patient record. For example, during home visit activities for HosRRHV#1, it was noted that the patient had an oxygen concentrator in the home. The plan of care did not include orders for oxygen therapy. This observation was reviewed with the Hospice Clinical Manager.

Observed in Data Session. The organization did not have documentation demonstrating that its quality assessment and performance improvement program (QAPI) included all provided services. There was no evidence that the volunteer program and the bereavement program were included in the program. This finding was discussed with the Director of Home Care at the time of discovery.

Observed in Record Review. In 1 of 5 patient records reviewed, for patient's receiving Hospice Aide services, it was noted that the organization did not ensure the plan of care included orders for Hospice Aide services. For example, a review of the medical record for HosRRHV#2, revealed that the Hospice Aide was visiting the patient two times per week, starting week 1 of hospice services. The plan of care did not include a description of visit frequency for hospice aide services. This observation was reviewed with the Assistant Director of Hospice/Quality and Compliance Hospice.

Observed in Record Review. In 1 of 5 patient records reviewed, for patients receiving Hospice Aide services, it was noted that the organization did not ensure Hospice Aide supervision was effective. For example, during the review of the medical record for HosRRHV#2, it was noted that a Hospice Aide supervision visit was not documented by the Registered Nurse every 14 days during the first benefit period. The first supervision visit was documented during week 6 of hospice services. This observation was reviewed with the Director of Home Health and Hospice.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization did not ensure that the requirement for a written Certification of Terminal Illness statement was implemented. For example, a review of the medical record for HosRRHV#1, revealed that a CTI statement for benefit period #2 was not present in the medical record. The 2nd benefit period of hospice services started 12 days before the start of survey activities. Documentation to support the medical prognosis and recertification of hospice services was not present in the medical record. This observation was reviewed with the Director of Home Health and Hospice.

Observed in Individual Tracer. In 1 of 4 individual tracers, it was noted that the organization did not ensure the medication list included accurate information. For example, during home visit activities for HosRRHV#1, it was noted that the medication list included the following information: Buspirone HCL 5mg 1 tab 2 times per day. An interview with the patient’s caregiver revealed that Buspirone HCL 5mg was being administered 1 tab 3 times a day. This observation was reviewed with the Hospice Clinical Manager.

Observed in Record Review. In 13 of 13 patient records reviewed, the hospice surveyor noted that the plans of care did not include individualized measurable goals. Some of the goals noted were as follows:keep patient comfortable during hospice care, patient oriented to extent possible, promote dignified death for patient and optimal family coping skills during dying process, patient will achieve optimal breathing patterns, airway patency and comfort, pain goal was that the patient will achieve and maintain optimal physical comfort. This was confirmed with the Hospice Leadership Team.

Observed in Record Review. In 3 of 13 patient records reviewed, the hospice surveyor noted that the plan of care did not include all services/orders needed for management of the terminal illness and related conditions. Following record review (HOS RR#2) of a patient in a skilled nursing facility who had a foley catheter on admission, the surveyor noted there was an order to discontinue the foley catheter on the day of admission. When reviewing ongoing skilled nursing visit documentation, it was noted that the catheter was never discontinued per the facility until weeks after the order was written. No additional orders were written to cover this. Following record review (HOS RR#3) of a patient that had multiple skin tears, the surveyor noted there was documentation that stated changed bandages to arms and replaced xeroform and allevyns to skin tears, 2 on right arm and 3 on left. There were no orders or plan of care opened related to this care. Following record review (HOS RR#6) of a patient in a skilled nursing facility, the surveyor noted in the documentation that there were steri strips in place on a new skin tear following a recent fall and that the patient had a stage 2 on his coccyx with foam dressing in tact. There were no orders related to this or care plan problem opened. This was confirmed with the Hospice Leadership Team.

Observed in Record Review. In 13 of 13 patient records reviewed, the hospice surveyor noted that when reviewing all the patient records that there was no documentation of progress towards goals. The IDT documentation was very vague and did not review the patients' current goals of care nor did the documentation address what progress was being made against the established goals. When observing the IDT meeting, this is being discussed with all the team members but the documentation does not support or show that. This was confirmed with the Hospice Leadership Team.

Observed in Record Review. In 3 of 6 patient records reviewed, of patients ordered home health aide services, the hospice surveyor noted that the Hospice Aide Care Plan did not accurately reflect written instructions required to care for the patient. Following record review of (HOS HV#2, HOS RR#1 and HOS RR#3) of patients on oxygen as needed or continuous, the surveyor noted that the home health aide plan of care did not include the information that the patient was on oxygen and/or if it can be removed during the bath. This was confirmed with the Hospice Leadership Team.

Observed in Record Review. In 5 of 6 patient records reviewed, of patients ordered home health aide services the hospice surveyor noted that the registered nurse did not supervise the hospice aide every 14 days as required. Following record review of (HOS HV#2, HOS RR#1, HOS RR#3, HOS RR#4 and HOS RR#10), the surveyor noted that the aide supervision was not completed every 14 days as required. The surveyor noted on most of the supervisory visits that were completed in the section labeled: Supervisory Visit General Details the only documentation in that section was check boxes that the form was completed by the RN completing the visit. There was no other information as to what was assessed. This was confirmed with the Hospice Leadership Team.

Observed in Record Review. In 3 of 3 patient records reviewed, of patients currently residing in a skilled nursing facility, the hospice surveyor noted that the hospice plan of care did not identify which provider was responsible for performing the care and services included on the hospice plan of care. Following record review of (HOS HV#1,HOS RR#2 and HOS RR#6) the surveyor noted there was no collaborative care plan outlining what tasks the skilled nursing facility was to complete and what the hospice was responsible for. For example one patient (HOS RR#2) had a foley catheter and there was nothing noted in the plan of care who was changing it or managing it. Another patient (HOS RR#6) had a skin tear with steri strips applied and a stage 2 wound on his coccyx that a foam dressing was applied and intact. No instructions/orders as to who was doing these treatments. This was confirmed with the Hospice Leadership Team.

Observed in Record Review. Following home visit (HOS HV#1) to a patient that currently resides in a skilled nursing facility, the hospice surveyor noted that the agency did not provide the facility with the patient's most current plan of care and the physician's recertifications of the patients current terminal illness. This was confirmed with the nurse on site and discussed with the Hospice Leadership Team.