Every finding on record at St Luke Home Health Services, LLC

Based on medical record review, staff interview, and policy and procedure review, the facility failed coordinate care to support and manage the needs of the patient and the family and has the potential to affect other patients by not following the written plan of care dated 07/06/2023 which included Home Health Aide service for assistance with personal care, hygiene and activities daily living and failing to provide appropriate and timely on-call assistance on three (3) of three (3) days of survey. Findings Include: --- Review of Patient #1s medical record confirmed the Plan of Care dated 07/06/2023 contained an order for Home Health Aide services, but failed to include the frequency of services, resulting in the failure to coordinate care and provide services to meet Patient #1s needs. There is no documentation to confirm a visit was made by an Aide. Review of the medical record, skilled nursing note dated 07/12/2023 for visit made on 07/09/2023 by Registered Nurse (RN) #3 revealed the family needed and requested assistance for personal care of the patient. Documentation from RN #3 states, ";...on weekends hospice nurse does not come out unless there is a change in status or for a death..." On 10/04/2023 at 2:48 p.m., during an interview with facility Administrator, it was confirmed Home Health Aide services were ordered for Patient #1 and a home health aide visit was not scheduled as ordered on Plan of Care. Review of facility policy and procedure, ";Initial Assessment/Comprehensive Assessment," dated February 2022, confirms ";...Each patient admitted by hospice will have appropriate initial assessment...which promote the patients well-being, comfort and dignity throughout the dying process...Support with activities of daily living...". Review of the facilitys policy and procedure, ";After Hour Accessibility," revision date June 2019, confirmed ";...The director and/or Manager of Patient Services is on-call 24 hours per day on a rotation weekly basis...". During the exit conference on 10/05/2023 at 12:00 p.m. with Administrator, RN, Case Manager, RN of Quality Assessment and Performance Improvement (QAPI), and Administrative Assistant, survey findings were discussed, and no further documentation was submitted for review.

Based on medical record review, staff interview, and policy and procedure review, the facility failed coordinate care to meet the needs of the patient by not following the written plan of care dated 07/06/2023 which included Home Health Aide service for assistance with personal care, hygiene and activities daily living on three (3) of three (3) days of survey Findings Include: --- Cross refer to L536/418.56 for the facilitys failure to follow the written plan of care dated 07/06/2023 for Home Health Aide services. During the exit conference on 10/05/2023 at 12:00 p.m. with Administrator, RN, Case Manager, RN of Quality Assessment and Performance Improvement (QAPI), and Administrative Assistant, survey findings were discussed, and no further documentation was submitted for review.

Based on medical record review of the plan of care, staff interview, and policy and procedure review, the facility failed document the frequency of Home Health Aide services to coordinate care to meet the needs of the patient assistance with personal care, hygiene and activities daily living on three (3) of three (3) days of survey. Findings Include: --- Cross refer to L536/418.56 for the facilitys failure to include the frequency of Home Health Aide services in the written plan of care dated 07/06/2023. During the exit conference on 10/05/2023 at 12:00 p.m. with Administrator, RN, Case Manager, RN of Quality Assessment and Performance Improvement (QAPI), and Administrative Assistant, survey findings were discussed, and no further documentation was submitted for review.

Based on medical record review of the plan of care, staff interview, and policy and procedure review, the facility failed coordinate the services of the Home Health Aide and ensure the care and services were provided based on the plan of care dated 07/06/2023 for on three (3) of three (3) days of survey. Findings Include: --- Cross refer to L536/418.56 for the facilitys failure to coordinate the Home Health Aide services as ordered in the written plan of care dated 07/06/2023. During the exit conference on 10/05/2023 at 12:00 p.m. with Administrator, RN, Case Manager, RN of Quality Assessment and Performance Improvement (QAPI), and Administrative Assistant, survey findings were discussed, and no further documentation was submitted for review.

Based on medical record review of the plan of care, staff interview, and policy and procedure review, the facility failed ensure reasonable and necessary services to meet the needs of the patient and the family were provided based on the plan of care and the failure to address the patient and familys needs on 24-hour basis 7 days a week for three (3) of three (3) days of survey. Findings Include: --- Cross refer to L536/418.56 for the facilitys failure to provide services to meet the needs of the patient and family. Cross refer to L653/418.100(c) for the facilitys failure to ensure the patients and familys needs were met on 24-hour basis seven (7) days a week. During the exit conference on 10/05/2023 at 12:00 p.m. with Administrator, RN, Case Manager, RN of Quality Assessment and Performance Improvement (QAPI), and Administrative Assistant, survey findings were discussed, and no further documentation was submitted for review.

Based on staff interview, review of the facilitys on-call log, medical record review, and facility policy and procedure review the facility failed to ensure they addressed the patient and familys needs on 24-hour basis seven (7) days a week for three (3) of three (3) days of survey. Findings Include: --- An interview with the Administrative Assistant on 10/04/2023 at 1:12 p.m. confirmed there is no skilled nursing documentation available in the medical record for Patient #1 family members call to the on-call service on 07/08/2023 at 10:01 a.m. Review of the facility on-call log dated 07/08/2023 at 10:01 a.m. confirms family member could not reach the office. Review of Patient #1 medical record confirms there is no documentation available in the medical record on 07/08/2023 for the call made to the facility's on-call service by Patient #1's family at 10:01 a.m. Review of Patient #1's medical record skilled nursing note, incorrectly dated 07/12/2023, for visit made on 07/09/2023 at 5:28 p.m. for a change in status by RN #3 revealed the family needed and requested assistance for personal care of the patient on 07/08/2023 at 10:51 a.m. Documentation from RN #3 states, ";...on weekends hospice nurse does not come out unless there is a change in status or for a death...". Review of the on-call log dated 07/10/2023 confirmed Patient #1s family called the on-call service on 07/10/2023 at 1:55 a.m. to report the patient was deceased. Review of Patient #1s Skilled Nurse visit note by RN #3, incorrectly dated 07/12/2023, for a visit made on 07/10/2023 confirms the skilled nurse incorrectly documented the date of the death visit and documents the time of death as 3:25 a.m. The visit was recorded on 07/12/2023 for a visit that was made on 07/10/2023, unable to confirm the correct time of the visit based on the documentation in the visit note. During the exit conference on 10/05/2023 at 12:00 p.m. with Administrator, RN, Case Manager, RN of Quality Assessment and Performance Improvement (QAPI), and Administrative Assistant, survey findings were discussed, and no further documentation was submitted for review.

Based on staff interview, Quality Assessment Performance Improvement (QAPI) documentation review and policy and procedure review, the facility, failed to ensure hospice wide, data driven QAPI program was developed and implemented on three (3) of three (3) days of survey. Findings Include: During an interview on 02/10/2022 at 2:10 p.m., the Administrator confirmed there was no documented evidence of the facility's QAPI program except for the medical record data completed in July 2021, August 2021, September 2021, October 2021, and November 2021; with a combined total of 15 medical records audited; infection control log of 13 patients dated 03/25/2021 through 09/22/2021, and QAPI meeting agenda dated 07/20/2021. Further review of the QAPI documentation revealed no documented evidence of data analysis from the medical record audit data dated July 2021 through November 2021 or from the infection control log dated 03/25/2021 through 09/22/2021; and no documented evidence of ongoing data collection for infection control or patient adverse events for the period reviewed, 02/01/2021 through 02/10/2022. Further review of the QAPI data for the period reviewed, 02/01/2021 through 02/10/2022 revealed no documented evidence of facility action plans implemented for identified improvement needs. No further QAPI documentation was submitted for review. During an interview on 02/10/2022 at 3:00 p.m., the Regional Director confirmed no QAPI data had been tracked for patient adverse events for the period reviewed, 02/01/2021 through 02/10/2022. No further documentation was submitted for review concerning patient adverse events. Review of the facility's "(QAPI data) dated July 2021" revealed: " ...auditing of 4 (four) charts ...noted to be a trend that we need to improve immediately ...making sure IDG (Interdisciplinary Group) MD's (Medical Director) are signing the plans of care every 14 days for compliance." No further documentation was submitted for review. Review of the facility's "(QAPI data) dated August 2021" revealed: " ...auditing of 2 (two) charts ...noted to be a trend ...to make sure CTI's (Certification of Terminal Illness) are obtained within 1 (one) day and completed by MD (Medical Director) ...". No further documentation was submitted for review. Review of the facility's "(QAPI data) dated September 2021" revealed: " ...auditing of 2 (two) charts ...noted to be a trend ...to make sure CTI's (Certification of Terminal Illness) are obtained within 2 (two) day and completed by MD (Medical Director) ...". No further documentation was submitted for review. Review of the facility's "(QAPI data) dated October 2021" revealed: " ...auditing of 4 (four) charts ...noted to be a trend ...on continuing to make sure we have an updated plan of care every 15 days ...". No further documentation was submitted for review. Review of the facility's "(QAPI data) dated November 2021" revealed: "review of 2 (two) charts ...noted we need to improve making sure consents are signed and dated appropriately ...". Review of the facility's "Hospice Documentation Audit Tool" data from July 2021 through December 2021 revealed no quality indicators for infection control or patient adverse events. Review of the facility's "QAPI Plan" policy, revision date of June 2019, revealed: " ...section 10.1.1. Hospice has established an ongoing program of quality assessment and performance improvement. Purpose to define the QAPI program. Objectives to collect and analyze data to improve identified processes and outcomes of care. To educate and involve appropriate staff in QAPI activities ...To endeavor to meet the needs/expectations of our internal and external customers and suppliers ...To meet federal CMS requirements for QAPI ...Scope of Care: Types of patients served ...Diagnosis and conditions treated ...Patient care disciplines providing care ...Responsibility/Accountability: The Governing Body is ultimately responsible for QAPI and implementation of the QAPI plan ...The QAPI committee will meet on a regular basis and will report findings to the Administrator/Director, who, in turn, will report to the Governing Body ...Data collection will include established priorities for improvement with major processes include: ...Infection Prevention and Control ...Medication Management ...". Review of the facility's "Adverse Event" policy, revision date of June 2019, revealed: " ...10.2.1 Hospice will measure, analyze and track defined adverse events. Purpose to define adverse events ...Hospice will investigate any incident or injury ...Any action or inaction by hospice that caused harm to a hospice patient will also be investigated ...The investigation will be initiated by the Director within 24 hours after hospice becomes aware of an adverse event ...The investigation will be documented in an incident/variant report ...changes in systems or processes are needed ...When adverse event monitoring reveals a problem area, hospice will implement changes designed to decrease occurrences of the adverse event. Hospice will assure that the new process is implemented hospice-wide and that it is effective in reducing that adverse event." Review of the facility's "Quarterly Record Review Process" policy, revision date of June 2019, revealed: " ...10.4.1 Hospice will collect data quarterly on quality indicators ...purpose to define quality indicators ...Frequency Method: Quarterly review of 10 active and closed patient records ...Acceptable Limits: 90% for each quality indicator." During Exit Conference on 02/10/2022 at 4:09 p.m. survey findings were discussed, and no further documentation was submitted for review.