Every finding on record at Starlight Hospice Inc.

Observed in Record Review. In 1 of 4 patient records reviewed, During RR#3 it was noted the patient was diabetic with prescribed medication. The initial RN evaluation lacked an assessment of the patient's diabetic status.

Observed in Record Review. In 2 of 4 patient records reviewed, During RR#2 and RR#3 it was noted the initial bereavement assessments were documented 6 days after the initial RN evaluation. This was discussed with the Administrator.

Observed in Record Review. In 1 of 4 patient records reviewed, During RR#1 it was noted the Braden assessment score indicated a high risk for skin breakdown. The POC lacked interventions related to strategies to reduce the risk of skin breakdown. This was discussed with the Administrator.

Observed in Record Review. In 4 of 4 patient records reviewed, During RRHV#1 and RR1-3 it was noted lack of the number and reasons for PRN visits for the spiritual counselor (SC) and the MSW. RR#1-3 lacked number and reason for PRN visits for the SC. RRHV#1 lacked the number and PRN reasons for the SC and the MSW. This was discussed with the Administrator.

Observed in Record Review. In 1 of 4 patient records reviewed, During review of RR#1 it was noted the hospice aide was ordered 2x/week the end of February 2025. The first attempted visit by the aide was documented the middle of March, 15 days after the assignment was completed. This was discussed with the Administrator.

Observed in Data Session. During review of the QAPI program data collection measures it was noted lack of contract monitoring activities to assess pharmacy, DME and other contractor services. This was discussed with the Administrator.

Observed in Data Session. During review of the QAPI program it was noted lack of clinical professional members attending the meetings. Those included the MSW, and the DPCS/Administrator designee. This was discussed with the Administrator.

Observed in Record Review. In 2 of 4 patient records reviewed, During RR#2 and RR#3 it was noted initial SC assessments were documented 6 days after the initial RN evaluation. This was discussed with the Administrator.

Observed in HR File Review. During review of the HR file for CHHA, it was noted lack of a documented competency for aide services. This was discussed with the Administrator. The administrator stated the competency assessment was scheduled to be completed at the next cycle. No competency completed to date after the survey in July 2024.

Observed in Patient Home. In 1 of 1 home visits conducted, During RRHV#1 it was noted the comfort kit medications: Morphine, Lorazepam, Ondansetron and Tylenol suppositories the patient had in the home were not listed on the current medication profile. This was reviewed and discussed with the SN during the visit and with the Administrator.

Observed in Individual Tracer. In 2 of 3 patient records reviewed, did not contain accurate information. The bereavement risk assessment was electronic and the clinician documented by exception if an issue was identified. For RR#2, The box for- if the family planned for the death defaulted to 0 however the narrative of the bereavement note reflected that the family had not began planning for the death. It was not clear from record review whether the box was truly assessed. This observation was discussed with the LPN who indicated if the box for a particular item is not checked then it is assumed that particular item was normal. The target date goals for RR#3 were not consistent. For the goal to resolve edema the target date to achieve the goal was dated two months after the resolved date for RR#3. In addition, for RR#3, the orders reflected that the patient had a comfort kit and per the RN the patient did not have a kit. This observation was discussed with the LVN

Observed in Individual Tracer. In 2 of 3 patient records reviewed, the goals identified on the care plan were not individualized and or measurable. RR#2 had the following goals listed; prevent discomfort throughout certification period, facilitate elimination/BM by xx/xx/xxxx which was within four weeks of the start of care, and pain would be reduced to comfortable levels. There was no further qualification of this pain goal. This observation was discussed with the LPN. Similarly, the goals listed for RR#1 were not measurable or individualized. The patient was placed on an antibiotic for three days for a UTI and the target date to achieve goal was within one month. RR#3 had issues with peripheral edema and the goal was for the edema to be resolved within a month with no other qualification. This observation was discussed with the LVN.

Observed in Record Review. In 2 of 3 patient records reviewed, did not have care plans that included specific orders and or treatments to manage the patients symptoms. RR#2 had a wound that required daily care. The comprehensive care plan did not include specifics related to the wound care and or the frequency of care. Similarly, RR#1 had a necrotic wound that required daily care. The comprehensive care plan did not include specifics related to the wound care related to the cleaning solution, the frequency of care, or if wound required an actual dressing or left open to air. Both RR#1 and RR#2 had orders in the records for the supplies to perform the care prior to the initiation of the care plans. This observation was discussed with the LVN.

Observed in HR File Review. In 1 of 2 HR files reviewed, that were aides, did not have orientation and or competency completed by an individual with the appropriate training. HR#1 who was an volunteer aide who was providing personal care to patients had her initial competency and orientation signed off by the owner who was an certified home health aide. This observation was discussed with the LVN.

Observed in Individual Tracer. In 1 of 3 patient records reviewed, In RR#1 was NPO and received gastrostomy feedings. The assessment of RR#1 did not reflect (did not check box) for dysphagia and or aspiration precautions. This observation was discussed with the LVN Observed in Individual Tracer. In 1 of 1 home visits conducted, the hospice medication profile was found to be inaccurate. Per the RN in RR#1 HV a prn medication used to treat excess secretions was substituted for another medication. The substitute medication was not listed on the profile and the original medication was still listed. Per the RN she was aware of the substitution but neglected to update the profile. This observation was discussed with the LPN.

Observed in Record Review. In 2 of 3 patient records that were admitted to service in the past 40 days, it was noted that the comprehensive assessment was not complete. For example, in record RRNHV#1 there was no initial bereavement assessment documented; on day 2 the spiritual counselor called and the patient stated not today and the spiritual counselor documented he would call the next day. 3 days later there was a blank bereavement assessment note in the record with only in and out times documented.

Observed in Record Review. In 3 of 3 patient records reviewed, it was noted that the written plan of care was not individualized for the patient. For example in record RRHV#1 7 of 9 goal's timeframes were 20 days in the past. In record RRNHV#1 the goals Diabetes medication management. Pt will maintain optimum peripheral circulation. were not individualized. This was discussed with the owner, supervisor, LVN and administrator present.

Observed in Data Session. During discussion with the administrator, owner, and supervisor and review of the QAPI program, it was noted that the organization had not documented written goals that included improving compliance with hand hygiene.

Observed in Emergency Management Session. During the Emergency Management session it was noted that the annual EOP drills did not include safety and security, communication disruption and staffing for 2021or 2022. This was confirmed and discussed with the Office Manager and Office nurse present.

Observed in HR File Review. In 10 of 10 HR files reviewed, it was noted that ongoing emergency management training was done every 3 years with competency and not every 2 years. This was confirmed with the CEO/owner, DPCS designee and Office Manager present

Observed in Emergency Management Session. During the Emergency Management session it was noted that the organization had not conducted one exercise per year to test the emergency operations plan. There was no documentation of drills or actual events in 2022 or 2021. This was confirmed and discussed with the DPCS designee, Office manager and office nurse present.

Observed in Patient Home. In 2 of 2 home visits conducted, with a nurse, it was noted that the hospice nurse failed to conduct a medication assessment. For example, during visits RRHV#1 and RRHV#2 the RN/NP did not complete a medication reconciliation. This was discussed with the CEO and office nurse.

Observed in Record Review. In 4 of 12 patient records reviewed, it was noted that the comprehensive assessment was not complete. For example, in record RRDC#1, there was no initial bereavement assessment documented. In record RRHV#2 the initial bereavement assessment was documented 24 weeks after admission. Record RRNHV#5, the initial bereavement assessment was documented 5 months after admission. Record RRNHV#1 there was no initial bereavement assessment documented. This was confirmed with the DPCS designee and Office nurse present.

Observed in Record Review. In 1 of 12 patient records reviewed, it was noted that the patient record was inaccurate or contains errors (i.e. conflicts with other documentation). For example, in record RRDC#2, the patient was discharged and the discharge summary and documents were completed. Two days after discharge the nurse documented on the IDG note No new changes, pt continues to decline slowly. Will continue with current POC. This was confirmed with the DPCS designee and Office nurse present.

Observed in Record Review. In 10 of 12 patient records reviewed, it was noted that the written plan of care was not individualized for the patient. For example in record RRHV#1 13/13 of goals target dates were 1 month in the past and the goals not measurable such as: Assess Pt. status for on-going care. -Blood sugar management for pt. comfort., meds take care of discomfort of GERD issues and psych meds will help with mental health  Promote rest and sleep patterns for pt/fam. In record RRHV#2 6/6 goals time frames were in the past and the patient had significant wounds of left foot and coccyx however there was no goal related to the wounds and the wound care was not documented in the plan of care. The patient also had a G tube and there was no goal related to site care. In record RRHV#3 the goal Reduce pain to below SIT level within 48 hrs of admission for comfort was still in place over 4 months after the admission with no update. In record RRNHV#6 6/6 goals time frames were in the past, 2 months or 9 months and the goal Reduce pain to below SIT level within 48 hrs of admission for comfort was active and not undated after 9 months. Additional records with the same or similar time frame issues and goals not being measurable. This was confirmed with the DPCS designee and Office nurse present.

Observed in Record Review. In 1 of 12 patient records reviewed, In record RRHV#2 the nurse notes charted SN provided wound care for the patient`s left foot ulcer as per the physician`s order. However, there was no order for wound care. Wound care was not included in the IDG documentation or Plan of Care. This was verified with the nurse present.

Observed in Record Review. In 5 of 12 patient records reviewed, it was noted that care was not provided according to the hospice plan of care. For example, in record RRNHV#6 the nurse frequency was order weekly however 6 weeks in the past 6 months there was no documentation of a visit or missed visit documentation. Record RRNHV#7 the nurse frequency was ordered 1 time a week and for 4 weeks in the past 6 months no SN visit was documented and no documentation of missed visits. Record RRNHV#5 the nurse frequency was 2 times a week and in the past 6 months there was no documentation for 18 SN visits and no missed visit documentation. Record RRNHV#4 SN frequency was 1 time a week and one week there was no documentation of visit or missed visit. Record RRNHV#2 SN frequency was 1 time a week and 3 as needed, for two months the as needed visits were used and an additional visit was documented with no supplemental order. This was discussed with the DPCS designee and Office Manager.

Observed in Record Review. In 1 of 2 patient records reviewed, that included aide services it was noted that the aide failed to contact the nurse related to receiving inadequate instructions. Record RRHV#3 the volunteer aide received inadequate instruction and failed to call the nurse to receive complete instructions. This was confirmed with the DPCS designee, Office Manager and Office nurse present.

Observed in Data Session. During the Data session it was noted that the QAPI program did not include issues related to palliative outcomes and hospice services. This was discussed with the Office Manager and Office nurse present.

Observed in Data Session. During the Data session the organization was unable to state the indicator data it used in the design of it's QAPI program.  This was discussed with the Office Manager and Office nurse present.

Observed in Data Session. During the Data session it was noted that the organization's governing body did not identify the frequency of patient satisfaction data collection. This was confirmed and discussed with the Office Manager and Office nurse present.

Observed in Data Session. During the Data session it was noted that the organization had not developed a data-based performance improvement program, hence leadership did not set priorities for data collection and the organization had not specified the frequency the organization would collect patient satisfaction data.  No data had been collected in the past year. This was confirmed with the Office Manager and Office nurse present.

Observed in Patient Home. In 2 of 3 home visits conducted, it was noted that the organization failed to implement its infection prevention and control activities. For example, during visit RRHV#1 and #2 the RN/NP placed the nursing bag on the couch between her and the patient and then placed equipment on the couch before and after use. The organization's policy stated that the bag and equipment were to be placed on a barrier or hard surface that could be cleaned. . This was discussed with the CEO and office nurse. Observed in Patient Home. In 2 of 3 home visits conducted, it was noted that the staff failed to perform hand hygiene consistent with the organization's policy. For example, during visits RRHV#1 and RRHV#2 the nurse accessed the nursing bag multiple times without performing hand hygiene and failed to perform hand hygiene after removing gloves multiple times. The organization's policy stated that hand hygiene was to be performed after removing gloves and prior to accessing the nursing bag. This was discussed with the CEO and office nurse.

Observed in Data Session. During the Data session it was noted that the organization could not provide evidence that the required infection prevention goals were documented as evidenced by: the written goals did not include improving compliance with hand hygiene guidelines. This was confirmed and discussed with the Office Manage and Office nurse present. Observed in Data Session. During the Data session it was noted that the organization could not provide evidence that the required infection prevention goals addressing prioritized risks were documented. This was confirmed and discussed with the Office Manage and Office nurse present. Observed in Data Session. During the Data session it was noted that there was no data collection to evaluate hand hygiene compliance. The documentation provided stated the most current data collection was greater than 3 years ago. This was confirmed and discussed with the Office Manager and Office nurse present.

Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement care, it was noted that the bereavement plan of care was incomplete. For example, in record RRBR#1 the bereavement POC included 2 interventions and no goal, the area to write the goal was left blank. In RRBR#2 there was no bereavement POC documented. This was confirmed with the DPCS designee and Office nurse present.

Observed in Record Review. In 1 of 2 patient records reviewed, for bereavement care, it was noted that the assessment post death was not done to assess bereavement risk in order to inform the decisions made by the IDG. For example, RRBR#2 there was no post death assessment documented. This was confirmed with the DPCS designee and Office nurse present.

Observed in HR File Review. In 2 of 2 HR files reviewed, for aides it was noted that the organization was unable to provide any documentation of at least 12 hours of in-service training during any 12 month period. This was confirmed with the DPCS designee, CEO/owner and Office Manager present.

Observed in Record Review. In 1 of 2 patient records reviewed, that included aide services it was noted that a registered nurse did not prepare written patient care instructions for the hospice aide. For example in RRHV#3 the aide services were provided by a volunteer aide who did not have access to the aide POC in Hospice MD. The volunteer aide received a volunteer POC that include 3 items to complete with the patient and the aide plan of care had over 20 items to complete. The volunteer aide received incomplete instructions as the Aide POC was not provided to the volunteer Aide. This was confirmed and discussed with the DPCS designee, CEO/owner, Office Manager and Office nurse.

Observed in Record Review. In 1 of 2 patient records reviewed, that included aide services it was noted that the RN failed to provide effective supervision of the aide services. In RRHV#3 the aide supervision area was completed timely in the record however it did not recognize that the HHA POC was not being followed or that there was no HHA documentation. This was confirmed with the Office Manager, Office nurse, and DPCS designee present.

Observed in Data Session. Leadership had not managed the implementation of their polices, which resulted in condition level deficiencies in leadership, provision of care, treatment and services, performance improvement. infection control and emergency management. Upon review of the Governing Board minutes for 2024 and 2023 it was noted that only finance issues and marketing were discussed. There was no documentation that clinical policy, plans, or procedures to guide and support patient care, treatment, or services were included. This was discussed with the Office Manager and the Office nurse present.

Observed in Record Review. In 1 of 2 patient records reviewed, that included aide services a lack of full and complete HHA documentation was noted. Record RRHV#3 the aide services were provided for 8 weeks by a volunteer aide and the documentation was in a volunteer note and incomplete for cares provided by a HHA. This was discussed with the DPCS designee, Office Manager and Office nurse.

Observed in HR File Review. In 2 of 10 HR files reviewed, it was noted that the initial competency had not been documented. For example, the volunteer aide had a volunteer competency documented, but no documentation for aide services. For example, the RN/NP worked in both roles in Hospice and Palliative Care and the HR file did not include competency for the NP roll in hospice or Palliative Care. This was confirmed with the CEO/owner, DPCS designee, and Office Manager present.

Observed in Record Review. In 1 of 12 patient records reviewed, it was noted that the patient record was incomplete. For example, in record RRHV#1 the medication list was inaccurate, it included Norco which had been discontinued and did not include Tylenol, Lisinoprol, and Zetia which the patient was taking. I. This was discussed with the nurse present.

Observed in Record Review. In 1 of 12 patient records reviewed, it was noted that entries in the patient record were not signed. For example in RRNHV#7 one IDG note was not signed by the RN and 7 IDG notes were not signed by the Spiritual Counselor. This was confirmed with the Office Manager and Office nurse present.

Observed in Patient Home. In 3 of 3 home visits conducted, it was noted that there was no education provided for individualized emergency plans. For example, in RRHV#1, #2, and #3 there was no individualized emergency plan in the patient's home record and on record review there was no individualized emergency plan in the patient record. The organization did have a document available for this use, however there was not documentation that it had been used. This was confirmed with the Office Manager and Office nurse present. Observed in Patient Home. In 1 of 2 home visits conducted, that included oxygen therapy in the home, it was noted that information on the safe and effective use of medical equipment was not provided. For example, during RRHV#1 there were multiple oxygen tanks were standing upright unsecured and education was not been provided during the visit to reinforce the safety of securing the tanks. This was discussed with the CEO and office nurse.

Observed in HR File Review. In 1 of 10 HR files reviewed, it was noted that the criminal background check was not conducted in a timely manner. For example, in the HHA file the background check was dated 15 months after hire. This was confirmed with the DPCS designee, CEO/owner and Office Manager present.