Every finding on record at Sunrise Hospice Inc

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #5, No evidence of patient signature on copy of Bill of Rights confirming they received the Bill of Rights.

Upon patient record review, 7 of 14 (Patient #1,2,3,5,7,8,9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1,2, No evidence of mortuary in MSW assessment. No evidence of no mortuary on psych social care plan. Patient #3,SC documents powerlessness and loss of independence on initial assessment. No evidence this was addressed on the spiritual care plan. Patient #5,6,8,9, MSW initial assessment documents patient is a full code. No evidence this was addressed on psych social care plan.

Upon client record review, 6 of 14 (Patient #1,3,6,7,8,9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, LVN frequency 1x/week, no evidence of LVN visit the week of 6/7 and 7/1. Patient #3, LVN frequency 1x/week, no evidence of LVN visit the week of 6/24 and 7/8. MSW frequency 1x/month, visits completed on 12/30/23, 3/24/24, 6/22/24. No evidence of monthly visits. Patient #6, MSW frequency 1x/month, No evidence of visits for the month of May and June. Visits completed on 4/7 and 5/31 completed as telephone visits, no evidence of order for telephone visits. Patient #7, SC visit on 7/3 completed as telephone visit. No evidence of order for telephone visit. Patient #8, MSW frequency 1x/month visits made on 3/19 and 6/14 completed as telephone visit. No evidence of telephone order for telephone visits. No evidence of monthly visits completed. Patient #9, MSW visit on 2/4 completed as telephone visit. No evidence of order for telephone visit.

Upon patient record review, 3 of 14 (Patient #1,3,7) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1,3,7, Aide care plan documents to take vital signs. No evidence of parameters for vital signs documented on care plan.

Upon patient record review 3 of 14 (Patient #2,3,7) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #2,3, RN supervisory visit completed for LVN only on 6/11, 6/25, 7/9, aide visits 1x/week. No evidence aide was supervised every 14 days. Patient #7, RN supervisory visit completed for LVN only on 5/7, 5/21, 6/4, aide visits 1x/week. No evidence aide was supervised every 14 days.

Observed in Patient Home. The organization failed to provide information in the language the patient could understand. During the home visit for HOS 1 the surveyor noted that the documents in the home folder which the patient signed at the start of care including the Election of Medicare Hospice Benefit and the Release of Information & Consent for Treatment were in English and not provided in the patient's native language of Armenian. Additionally, the educational materials in the home folder including materials on COVID 19, Infection Control, Medication Disposal and the Rights and Responsibilities were also all in English. The LVN confirmed that the patient did not speak or read English nor did the caregiver.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization failed to complete the comprehensive assessment no later than five calendar days after the election of hospice care in accordance with their policy no. 2-036.1 Spiritual Assessment which states that an in-depth spiritual assessment will be completed for each patient/family by the Hospice Chaplain. For example, in review of the medical record for HOS 1 the surveyor noted that the Registered Nurse completed the Spiritual Assessment/Care Plan at the time of the Hospice Initial Comprehensive Nursing Assessment and the Chaplain contacted the patient/son 4 days later to offer spiritual care services which were declined. Also, for example, in review of the medical record for HOS 2 the surveyor noted that the Registered Nurse completed the Spiritual Assessment/Care Plan at the time of the Hospice Initial Comprehensive Nursing Assessment and the Chaplain contacted the family 3 days later to offer spiritual care services which were declined. And in review of the medical record for HOS 3 the surveyor noted that the Registered Nurse completed the Spiritual Assessment/Care Plan at the time of the Hospice Initial Comprehensive Nursing Assessment and the Chaplain contacted the daughter 3 days later to offer spiritual care services which were declined. Finally, in review of the medical record for RR 1 the surveyor noted that the Registered Nurse completed the Spiritual Assessment/Care Plan at the time of the Hospice Initial Comprehensive Nursing Assessment and the Chaplain contacted the caregiver/family 4 days later to offer spiritual care services which were declined and in review of RR 2 the surveyor noted that the Registered Nurse completed the Spiritual Assessment/Care Plan at the time of the Hospice Initial Comprehensive Nursing Assessment and the patient/family was not contacted and offered Spiritual Care services. This was confirmed by the Admin/DPCS.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization had not included measurable outcomes that were anticipated from implementing and coordinating the plan of care. For example, for HOS 1 the plan of care included a problem on musculoskeletal status with a goal that the patient will maintain optimal mobility during care within 2 weeks period of time however failed to identify what optimal mobility was for HOS 1. Additionally, for the problem of Integumentary Status the organization documented a goal that skin integrity will be maintained during care however failed to identify what that meant for HOS 1, or include time frames and interventions for meeting the goal. Also in review of the record for HOS 2 the care plan included the problem of Integumentary Status with a documented goal that skin integrity will be maintained during care however failed to identify what that meant for HOS 2, or include time frames for meeting the goal. And for HOS 3 there was a problem of Integumentary Status with a documented goal that skin integrity will be maintained during care however failed to identify what that meant for HOS 3, or include time frames and interventions for meeting the goal. Finally, in review of RR 1 and RR 2 the organization documented a problem of Integumentary Status and a goal that skin integrity will be maintained during care however failed to identify what that meant for either patient or include time frames and interventions for meeting the goal. This was confirmed by the Admin/DPCS.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to implement planned activities of their COVID 10 plan which stated that; patients should wear their own cloth mask (if tolerated) upon arrival of the personnel to and throughout the entire visit and if they do not have a face covering, they should be offered a facemask or cloth mask. The surveyor noted that for HOS 1 and HOS 2 that the patients did not have face coverings on and the LVN did not offer facemasks to either patient. This was discussed with the Admin/DPCS.

Observed in Record Review. In 2 of 5 patient records reviewed, the patient record was found to be inaccurate. Upon review of the medical record for HOS 2 the surveyor discovered a Hospice Nursing Clinical Note dated 33 days prior to the Election of Medicare Hospice Benefit by the patient. Additionally, in review of the medical record for RR 2 the surveyor discovered a Communication Note to alert the physician of serious medication interactions for Cyclobenzaprine oral and Cymbalta, however in review of the medical record it was noted that the patient was not on either of those medications. Patient medications include; Aspirin, Omeprazole, Quetiapine, Atenolol, Namenda, Donepezil, Amlodipine, Tylenol. This was confirmed by the Admin/DPCS

Observed in HR File Review. In 4 of 9 HR files reviewed, the organization had not verified credentials of staff. For example in review of HR 1 for the Volunteer Coordinator the qualifications on the job description require a college degree or an advanced degree in human services preferred however in review of the personnel file there was no documentation or evidence that the Volunteer Coordinator met those requirements. Additionally, in review of HR 2 for the Volunteer there was no evidence in the personnel file of completion of volunteer training program as required by job description. Also, the job description for the DPCS and DPCS Designee requires an RN with a baccalaureate or higher degree in nursing or another health related field however in review of the personnel files for HR 8 - the DPCS and HR 5 - the DPCS Designee there was no documentation of evidence such as a diploma or transcripts of the degree. This was verified with the Admin/DPCS.