Every finding on record at Supreme Healthcare, Inc.

Observed in Record Review. In 1 of 1 patient records reviewed, for extended prognosis discharge it was noted that the patient and caregiver did ot participate in decisions about their care. For example, in RRDC#1 the Notice of Medicare Non-Coverage was signed and dated the day of discharge, not 2 days prior as required. This was discussed with the Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement services it was noted that the post death assessment was not done to assessment bereavement risk in order to inform the decisions made by the IDG in a timely manner. During the Bereavement Program session with the bereavement coordinator he stated that post death bereavement assessments were to be completed within 48 hours of a patient's death. In RRBR#1 the post death bereavement assessment was completed 5 days after death and in RRBR#2 it was completed 3 days after death. This was discussed with the Administrator.

Observed in Record Review. In 10 of 10 patient records reviewed, it was noted that the written plan of care was not individualized and did not reflect patient and family goals and interventions. For example, in record RRNHV#7 the social worker documented monthly visits however there were no goals or interventions for social services documented on the POC. In record RRHV#1 the goal Reduce pain to below SIT level within 48 hrs of admission for comfort. Pain will remain in comfortable level during care. had been updated at last IDG however the patient had been admitted 8 months prior. RRNHV#6 Pt will be assessed for urinary issues every visit and educate Cg to understand elimination needs while providing proper care every diaper change. Discussed and confirmed with Administrator.

Observed in Record Review. In 1 of 1 patient records reviewed, that included volunteer services, it was noted that the POC did not include a complete statement of the scope and frequency of the services necessary to meet the patient's need. For example In record RRNHV#6 there was documentation that volunteer visits had been made, but no frequency of volunteer visits. This was discussed the Clinical Manager present.

Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement services it was noted that while a post death assessment had been completed there was no documentation of the interdisciplinary group reflecting on the bereaved and bereavement plan of care. For example, in records RRBR#1 and RRBR#2 there was no documentation of an IDG discussion taking place after the patient death. In both cases the last IDG documentation was prior to death. This was discussed and confirmed with the Administrator.

Observed in Record Review. In 1 of 1 patient records reviewed, that included volunteer services it was noted that the services provided were not based on the individualized plan of care. In record RRNHV#6 there was no POC developed for the volunteer. There was a check list of items to complete during a visit and the volunteer documented completion of 5 of 7 items and documented providing 1 additional item that had not been identified. This was discussed and confirmed with the Clinical Manager present.

Observed in Data Session. During the Data session it was noted that the hospice had collected a large amount of data, however there was no data analysis performed over time to determine trends in performance. For example, hand hygiene data had been collected monthly, but there was no analysis or trending completed. This was discussed with the Administrator, Assistant Administrator, Alternate Administrator and Clinical Manager present.

Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement services it was noted that the hospice had not developed a bereavement plan of care that specified the type of bereavement services to be offered and the frequency of service delivery. For example in RRBR#1 and RRBR#2 the comment Follow usual Bereavement POC. was documented in the area for the plan of care with no goals or interventions. This was discussed with the Administrator.

Observed in Record Review. In 1 of 7 patient records reviewed, that included aide services it was noted that the patient care instructions for the hospice aide were incomplete. For example, in record RRHV#3 the patient had a wound dressing on his right heel, but the aide POC did not provide directions regarding the dressing. This was discussed with the Administrator.

Observed in Record Review. In 1 of 7 patient records reviewed, it was noted that the patient care and services provided were not according to the patient's plan of care. For example, in record RRHV#3 the hospice aide did not follow the POC that required the patient's teeth to be brushed at each visit, and hair to be shampooed and blow dried each visit, however these were not completed. This was discussed with the Administrator.

Observed in Record Review. In 1 of 7 patient records reviewed, it was noted that the patient care and services provided were not according to the patient's plan of care. For example, in record RRHV#3 the hospice aide did not follow the POC order If the patient is experiencing pain and/or change in condition notify RN. Upon entering the patient's home the aide stated to the surveyor that she was aware the patient had pain in left shoulder and right lower extremity and may become agitated. During the aides care the patient yelled out in pain at multiple times and became agitated. There was no documentation that the aide had notified the RN of the situation. This was discussed with the Administrator.

Observed in Record Review. In 1 of 7 patient records reviewed, that included aide services it was noted that the hospice aide supervision was not done every 14 days. For example, in record RRHV#1 during the past 4 months aide supervision was documented at 15 days twice and at 20 days once. This was discussed with the Administrator.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by condition level finding at 418.64.

Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement service it was noted that the hospice had not developed a bereavement plan of care and as a result had not made bereavement services available to the family and other individuals specified in the bereavement plan of care. This was discussed and confirmed with the Administrator.

Observed in HR File Review. In 1 of 7 HR files reviewed, it was noted that staff competence was not initially assessed and documented. For example in file HR-SC/BR Coordinator it was noted that a competency was documented for Spiritual Counselor, but no competency was documented for Bereavement Coordinator. This was discussed with the Administrator and HR employee.

Observed in Patient Home. During 1 of 1 visits that included medication disposal it was noted that the nurse did not follow the organization's policy for disposal of medications. During visit HOS RRHV#1 the nurse placed tablets in a bag and mixed with water and disposed and the organization's Medication Disposal policy stated that the medication was to be placed in cat litter or coffee grounds. This was discussed with the administrator.

Observed in Record Review. In 3 of 3 patient records reviewed, During hospice record review #1-3, it was noted the POC goals were not individualized and not measurable. For example: RR#1 goals identified on the POC in July 2022 were: optimal bowel elimination and comfort. Patient's symptoms of anemia will be controlled with palliative approach: fatigue, weakness, shortness of breath. Will prevent exacerbation of disease. Increase strength/energy for optimal functional activities. Pt will have adequate food and fluids as tolerated or desired RR#2 goals identified on the POC in July 2022 Pt will have blood pressure within normal limits.Pt's behavior will be in control for better rest periods. RR#3 goals identified on the POC in July 2022. Diuresis will be titrated as needed to prevent patient from developing edema and worsening fluid overload. Patient's edema will not increase from +1 pitting edema. Patient's edema will not result in fluid overload. Reduce discomfort.

Observed in Record Review. In 1 of 3 patient records reviewed, During Hospice RR#1, it was noted the organization had not ensured the plan of care included a statement of scope and frequency of services necessary to meet the patient's and family's needs. The MSW frequency was one time and PRN for crisis management. The order lacked the number of PRN visits needed and the schedule for the PRN visits.

Observed in Record Review. In 1 of 11 patient records reviewed, During HOSRR# 4's patient record review it was noted the initial comprehensive assessment was not completed within five calendar days of the patient electing the hospice benefit. For example: review of the patient's record revealed the MSW's initial assessment was completed 12 days after the start of care. This was reviewed, discussed, and validated by the Director of Patient Care Services Designee and the Office Manager.

Observed in Record Review. In 7 of 11 patient records reviewed, During HOSHV# 1, HOSRR# 3, HOSRR# 4, HOSRR# 5, HOSRR# 6, HOSRR# 7, and HOSRR# 8 records review, it was noted the organization had not ensure the patients' plans of care were measurable and included all the services required to meet those goals. For example: review of HOSHV# 1's plan of care goals included optimal bowel elimination and comfort, minimize risk of pressure injury, pain will remain in comfortable level during care. Review of HOSRR# 3's plan of care goals included patient will verbalize any instances of pain, Increase strength/energy for optimal functional activities, and under Nutrition, patient will prioritize her sleeping medication along with her eye drops.. Review of HOSRR# 4's plan of care goals included patient will maintain optimal peripheral circulation, reduce discomfort, and optimal bowel elimination and comfort. Review of HOSRR# 5's plan of care goals included reduce discomfort patient will report any feelings of pain, and urinary elimination needs met at an acceptable level. Review of HOSRR# 6's plan of care goals included promote optimal rest status for patient and patient will remain in comfortable level during care. Review of HOSRR# 7's plan of care goals included patient will take sleeping medication at night to promote adequate rest and comfort and help keep patient awaken during the day. Review of HOSRR# 8's plan of care goals included increase strength/energy for optimal functioning and optimal bowel elimination and comfort. In addition, review of HOSRR# 5's plan of care revealed the Chaplain frequency for two times monthly. However, further review of the plan of care revealed no goals or interventions for the Chaplain. This was reviewed, discussed, and validated with the Director of Patient Care Services Designee and the Office Manager

Observed in Record Review. In 11 of 11 patient records reviewed, During patient records review, it was noted the organization had not ensured the plan of care included a statement of scope and frequency of services necessary to meet the patient's and family's needs. For example: review of the 11 patient records revealed the discipline specific SN, MSW, and SC PRN visit orders had no indication as to when a needed visit should be completed. This was reviewed, discussed, and validated with the Director of Patient Care Services Designee

Observed in Leadership Session. During the Leadership and Data Management Session it was noted the organization had not ensured that data collected was analyzed and compared with internal data over to time. This reviewed, discussed, and validated with Leadership.

Observed in Patient Home. In 2 of 3 home visits conducted, During HOSHV#1's home observation nurse did not follow the organization's Exposure Control Plan-OSHA Regulation Policy, related to nurse bag technique. For example: the nurse was observed going in and out of nursing bag multiple times without performing hand hygiene per policy. This was discussed with the Director of Patient Care Services Designee and validated. Observed in Patient Home. In 2 of 3 home visits conducted, During HOSHV# 2 and HOSHV# 3's home observations, it was noted the organization did not follow accepted standards of practice to prevent the transmission of infection and communicable diseases. For example: During HOSHV# 2 and HOSHV# 3's home observation the nurses did not follow the organization's policy, Exposure Control Plan-OSHA Regulation related to Methods of Disinfection of vital sign equipment. The organization's policy directed staff to clean the thermometer with alcohol. During both home observations the nurse used bleach to clean the thermometers. This was observed, discussed, and validated with the Director of Patient Care Services Designee. During HOSHV# 3's home observation the nurse did not follow the policy related to the Nurse Bag Technique. For example: the nurse was observed entering the nurse bag multiple times without performing hand hygiene prior to entering the nurse bag. This was observed and discussed with the Director of Patient Care Services Designee and validated. Observed in Patient Home. In 2 of 3 home visits conducted, During HOSHV# 1, and HOSHV# 3's home observation, it was noted staff failed to perform hand hygiene consistent with the organization's Hand Hygiene policy. For example: during HOSHV# 1's home observation the Home Health Aide was observed completing a bed bath with the same pair of gloves to include peri-care with a small bowel movement and then applying A&D ointment. This was discussed with the Director of Patient Care Services Designee and validated. During HOSHV# 3's home observation the nurse was observed removing gloves and putting on new gloves multiple times without performing hand hygiene after removing the gloves. This was observed, discussed, and validated with the Director of Patient Care Services Designee

Observed in Leadership Session. During the Leadership and Data Management session it was noted the organization had not identified infection risks based on its geographic location. This was reviewed, discussed, and validated by Leadership.

Observed in Patient Home. In 1 of 10 patient records reviewed, During HOSHV# 1's home observation it was noted the registered nurse had not ensured the written patient care instructions for the home health aide (HHA) were complete. For example: during the home observation the HHA applied A & D ointment to the patients peri-area. Review of the patient record revealed a physician order for A & D ointment to be applied after each incontinence episode. However, review of the HHA written instructions revealed no documentation of A&D ointment. This was reviewed and discussed with the Director of Patient Care Services designee and validated.

Observed in Leadership Session. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: - §418.60, §418.100, and §418.56.

Observed in Record Review. During HOSHV# 3's patient record, it was noted the organization had not ensured it maintained the security and integrity of health information. For example: review of the election of benefit signed and dated by the patient's representative revealed, the original date written on the date of election of benefit line had been handwritten over after the EOB was signed to reflect the next day. This was reviewed, discussed, and validated by the Office Manager and Director of Patient Care Services Designee. Observed in Record Review. During HOSRR# 3's patient record review, it was noted the organization had not ensured it maintained the security and integrity of health information. For example: review of HOSRR# 3's plan of care revealed documentation the patient had experienced suicide risk with passive ideation of suicide approximately two months prior to the Medical Social Worker (MSW) documented visit note addressing the risk. This was reviewed and discussed with the MSW, Office Manager, and Director of Patient Care Services Designee that shared the goal on the plan of care was supposed to be the dated the day of the documentation and the date was not accurate. This was discussed with the Office Manager and the Director of Patient Care Services Designee and validated. Observed in Record Review. In 4 of 11 patient records reviewed, During HOSHV# 1 and HOSRR# 8's patient records review, it was noted the organization had not ensured it maintained the security and integrity of health information. For example: review of HOSHV# 1's initial Certificate of Terminal Illness (CTI) revealed a signature from the Medical Director signed 365 days prior to the start of care. Review of HOSRR# 8's initial (CTI) revealed a signature from the Medical Director signed 20 days prior to the start of care. This was discussed with the Office Manager and Director of Patient Care Services Designee that shared the date of the signature in the electronic medical record could be manipulated.