Every finding on record at Superior Care Hospice Inc.

Observed in Infection Control System Tracer. It was determined that the organization’s documentation of clinical contraindications, as required by Infection Control CoP 418.60(d)(3)(viii)(B), did not include a statement by the authenticating practitioner recommending that the staff member be exempted from the organization’s COVID-19 vaccination requirements for staff based on recognized clinical contraindications, as evidenced by lack of a policy and process. Observed in Infection Control System Tracer. It was determined that the organization’s documentation of clinical contraindications, as required by Infection Control CoP 418.60(d)(3)(viii)(A), did not include information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications, as evidenced by lack of policy and process. Observed in Infection Control System Tracer. It was determined that the organization, as required by Infection Control CoP 418.60(d)(3)(viii) did not have a process for ensuring that all documentation that confirms recognized clinical contraindications to COVID-19 vaccines and supports staff requests for medical exemptions from vaccination had been signed and dated by a licensed practitioner who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable state and local laws as evidenced by lack of a policy and process. Observed in Infection Control System Tracer. It was determined that the organization, as required by Infection Control CoP 418.60(d)(3)(vi) did not have a process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable federal law as evidenced by lack of a policy and process. Observed in Infection Control System Tracer. - It was determined that the organization, as required by Infection Control CoP 418.60(d)(3)(x) did not have contingency plans for staff who are not fully vaccinated for COVID-19 as evidenced by lack of a policy and process. Observed in Infection Control System Tracer. It was determined that the organization, as required by Infection Control CoP 418.60(d)(3)(ix), did not have a process for ensuring the tracking and securing of documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, as evidenced by lack of a policy and process. Observed in Infection Control System Tracer. It was determined that the organization, as required by Infection Control CoP 418.60(d)(3)(iii) did not have a process for ensuring the implementation of additional precautions, intended to mitigate the transmission, and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19 as evidenced by lack of a policy and process. Observed in Infection Control System Tracer. It was determined that the organization, as required by Infection Control CoP 418.60(d)(3)(vii) did not have a process for tracking and securely documenting information provided by those staff who have requested, and for whom the organization has granted, an exemption from the staff COVID-19 vaccination requirements based on recognized clinical contraindications or applicable federal laws as evidenced by lack of a policy and process. Observed in Infection Control Tracer. It was determined that the organization, as required by Infection Control CoP 418.60(d)(3)(v) did not have a process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC as evidenced by lack of a policy and process. The organization vaccination rate is 100% with no exemptions as reviewed by surveyor.

Observed in Infection Control System Tracer. During review of the organization emergency management plan it was noted lack of a description of the patient population served by the organization and the extent to which additional populations may be cared for during an emergency based on the organization’s capabilities.

Observed in Document Review. During review of the organization consent it was noted lack of the notification, “Patient Notification of Hospice Non-Covered Items, Services, and Drugs addendum, that lists conditions, items, services, and drugs that the hospice has determined to be unrelated to the terminal illness and related conditions, and that will not be covered by the hospice effective October, 2020.

Observed in Patient Home. In 2 of 11 patient records reviewed, During review of HV#1 record review it was noted lack of documentation of the patient's response to care during IDG meetings and in visit notes. It was noted during the IDG meeting the beginning of May 2022 the RN summary did not include the clinical summary of the prior 2 weeks. During HV #2 record review it was noted during the IDG the beginning of May 2022 the MSW did not include a summary of psychosocial findings since the previous IDG. The MSW summary was the same as the summary from the previous IDG meeting. The RN assessment prior to the IDG meeting documented changes with increased confusion, forgetfulness and difficulty comprehending due to slurred speech that were not included in the IDG summary the beginning of May 2022. Observed in Record Review. During RR#8, it was noted the middle of July 2021, the patient developed a pressure sore on buttock. The RN summary during the IDG 3 days later lacked a description of pressure ulcer. The note stated wound care had been initiated. Wound assessment, interventions and goals were not updated on the POC.

Observed in Record Review. In 5 of 11 patient records reviewed, During HV#1 record review it was noted the goals on the POC were not individualized or measurable. For example: pt/family/PCG will verbalize having urinary elimination needs met at an acceptable level, increase strength/energy for optimal functional activities, and patient needs will be met on a day to day basis as communicated. During HV#3 record review it was noted goals without measure to assess if achieved. For example: Pt needs will be met on a day to day basis as communicated. Pt will have optimum level of oxygen and Increase strength/energy for optimal functional activities. During RR#2 it was noted lack of documentation of measurable goals on the POC. For example: Pt will maintain optimum peripheral circulation, Pt needs will be met on a day to day basis as communicated, Reduce pain to below SIT level within 48 hrs. of admission for comfort Pt will have optimum level of oxygen. During RR#3 it was noted lack of documentation of measurable goals. For example: Pt will have optimum level of oxygen, Increase strength/energy for optimal functional activities, Pt will maintain optimum peripheral circulation. During RR#4 the following goals were documented that were not measurable: Pt will have optimum level of oxygen. Reduce pain to below SIT level within 48 hrs of admission for comfort pain assessment at admission was 0, Pt will have adequate food and fluids to maintain comfort as exhibited by expressed verbal and non-verbal communication, Pt needs will be met on a day to day basis as communicated.

Observed in Record Review. In 10 of 11 patient records reviewed, During HV#1 record review it was noted interventions related to pain control that included: Resolve pain with medications ordered. Teach Pt/Family/PCG on immediate use, efficacy and precautions. The assessment of pain during 2 SN notes in April 2022 documented a pain level of 4 in one part of the note and 0 pain in the pain assessment addendum. The patient medication profile did not include a pain medication order. The patient has an E kit that contains Roxanol but during the HV it was noted the kit had not been opened. During RR#1 it was noted during an IDG meeting in April 2022 by the RN that constipation was also addressed. The POC during the IDG meeting was note updated to include ongoing assessments, interventions and goals associated with constipation. During the IDG meeting the beginning of May 2022 it was noted in the RN summary, for the past two weeks patient is more declined evidenced by agitation and restlessness, per MD order started Lorazepam for anxiety and restlessness. The POC was not updated to reflect assessment, interventions and goals associated with agitation and restlessness. During RR#5 it was noted the frequency for the MSW is once a month and for the SC initial assessment and as family requests. There was lack of interventions and goals related to psycho social and spiritual issues on the POC. During RR#7 although the frequency for MSW and SC were on the POC, it was noted lack of interventions and goals related to the MSW and SC assessments on the POC. During HV#1 record review it was noted although the SC frequency was monthly, The POC lacked psychosocial and spiritual interventions and goals. During HV#2 record review it was noted although the SC frequency was monthly, the POC lacked spiritual interventions and goals. During HV#3 record review and RR#2 and #3 it was noted although the MSW and SC frequencies were monthly, the POC lacked psychosocial or spiritual interventions and goals. During RR#1 it was noted the MSW frequency on the POC was monthly. The POC lacked psychosocial interventions and goals.

Observed in Record Review. In 4 of 11 patient records reviewed, During HV#1 record review it was noted the frequency for RN: 1 supervisory visit every 14 days, re certification and as needed, and for the chaplain: SC: 1 One-time then PRN. The frequencies lacked the number of PRN visits needed and the reason for the PRN visits to be performed. During RR#1 it was noted the following frequency of visits, MSW: 1 per Month + 1 PRN Visits and RN: 1 per 2 Week + 1 PRN Visits, without the reason for the PRN visits. During RR#4 it was noted the following frequency of visits for the MSW and RN: MSW: 1 per Month + 1 PRN Visits, RN: 1 per 2 Week + 1 PRN, without reasons for the PRN visits. During RR#7 it was noted the following frequencies for SN, MSW and SC: MSW: 1 per Month + 1 PRN Visits, RN: 1 per 2 Week + 1 PRN Visits, SC: 1 Onetime then PRN. The order lacked the reason for the PRN visits.

Observed in Record Review. In 1 of 11 patient records reviewed, During RR#4 it was noted on the RN initial assessment the documentation of IDDM with blood sugar 104. There was no further documentation of the diabetic status on the assessment. There were no insulins listed on the medication profile. The diagnosis was not added to the POC as a related condition. Cerebral infarction is documented as the primary Dx on the POC. The RN summary at the first IDG documented the following dx and related conditions: Primary Diagnosis of End stage Alzheimer`s Disease and Secondary diagnosis of Essential unspecified hypertension. Patient has comorbidities of HTN, Constipation, insomnia, depression, GERD, seizure disorder, unspecified psychoses.

Observed in Patient Home. During HV#1 it was noted the SN did not adhere to the contact time when cleaning equipment used during the visit. Observed in Patient Home. During HV#1 it was noted the SN did not follow the organization bag technique and hand hygiene policy twice during multiple entries into her bag to remove items for use. She entered her bag with her gloves on after providing direct patient care on one occasion and took off her gloves at another occasion, entered her bag to retrieve a clean pair of gloves without hand disinfection prior to retrieving the gloves, then disinfected her hands and donned the gloves.

Observed in HR File Review. During HR#6 review it was noted the current certification in the employee HR file was not validated through source verification. A copy of the CHHA certification was in the file.