Every finding on record at The Ambient Hospice Inc

Upon patient record review, 1 of 14 (Patient #6) did not have evidence in the patient record that a complete review was completed of all prescription and non-prescription medications that could affect drug therapy. Patient #6-The medication profile includes Fleets enema to be administered daily. The correct order is Fleets enema daily prn constipation if Bisacodyl is not effective. The medication profile also includes 2 duplicative dosages of Ativan without differentiation for administration. 04/06/23 Ativan 2mg/ml .25 ml q6h prn anxiety and Ativan .5 mg 1 tablet twice daily as needed for anxiety and agitation. (corrected on site)

Upon patient record review, 2 of 14 (Patient #5, #6) did not have evidence the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including specific orders for medications and treatments. Patient #5- On 04/25/23 the plan of care was updated with orders to cleanse the wound with wound cleanser, pat dry with gauze sponge, apply tetracyte and hydrogel to wound bed followed by gauze and cover with bordered dressing three times weekly. The orders are not specific for the wound location. (corrected on site) Patient #6-The 04/05/23 plan of care includes orders for a Fleets enema to be administered daily. The correct order is Fleets enema daily prn constipation if Bisacodyl is not effective. The plan of care also includes 2 duplicative dosages of Ativan without differentiation for administration. 04/06/23 Ativan 2mg/ml .25 ml q6h prn anxiety and Ativan .5 mg 1 tablet twice daily as needed for anxiety and agitation.

Upon client record review, 1 of 14 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3-The Spiritual Counselor documents performing a visit via telehealth on 3/17/23. The plan of care was not updated with orders for Telehealth. (corrected on site)

Upon patient record review, 3 of 14 (Patient #2, #5, #6) did not have evidence that all entries are complete/accurate, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #2-The LVN documents performing 2 routine visits on 04/09/23 within 1.25 hours. Upon interview, one visit was a documentation error regarding the date as the visit was performed on 04/04/23 (corrected on site). Patient #5-The Aide visits on record do not contain an electronic signature. (corrected on site.) Patient #6-On 04/27/23 the nurse documented wound care was provided. The documentation is not specific for the actual wound care rendered.

Observed in Record Review. In 1 of 5 patient records reviewed, During RR#3 it was noted lack of documentation of an initial bereavement assessment completed within 5 days of the SOC the end of September 2022 and to date. This was discussed with the Administrator and Administrator designee.

Observed in Record Review. In 5 of 5 patient records reviewed, During RR#3-#6 and HV#1 record review it was noted lack of outcome measures/goals on the POCs for the MSW and Chaplain. This was discussed with the Administrator and Administrator designee.

Observed in Record Review. In 5 of 5 patient records reviewed, It was noted the organization had not ensured the patient plan of care included all the services needed for palliation and management of the terminal illness and related conditions, including interventions to management pain and symptoms. During RR#6 it was noted documentation from a wound care provider who was participating in the patient's care along with the Hospice SN to provide wound care and dressing changes. The IDG/POC did not include the orders for wound care from the wound care center. In addition during the RN comprehensive assessment it was documented that the patient had a stage lV coccyx pressure ulcer that was not added to the POC as a related condition. During RR#3-#5 and HV#1 record review it was noted lack of interventions for the MSW and Chaplain on the POCs. This was discussed with the Administrator and Administrator designee.

Observed in Record Review. In 5 of 5 patient records reviewed, During RR#3-#6 and HV#1 it was noted frequency of visits for the MSW and Chaplain on the POC for 1x/cert +PRN. The order lacked the number and reason for the PRN visits. This was discussed with the Administrator and Administrator designee.

Observed in Patient Home. In 1 of 1 home visits conducted, The organization did not implement its infection prevention and control activities when cleaning and performing disinfection of medical supplies. During HV#1 it was noted although the SN disinfected her equipment according to manufacturer's guidelines she placed the equipment after disinfecting the items on the same barrier used to place the equipment after use. The equipment used were BP machine, thermometer and pulse oximeter. This was discussed with the Administrator and Administrator designee.

Observed in Record Review. In 1 of 5 patient records reviewed, It was noted the organization had not ensured the registered nurse (RN) prepared patient specific written care instructions for the hospice aide. During RR#5 it was noted the home health aide care plan revealed the task of recording the patient's temperature and blood pressure measurement with no documentation of parameters on when to notify the RN. This was discussed with the Administrator and Administrator designee.

Observed in Record Review. In 1 of 5 patient records reviewed, It was noted that the home health aide had not provided care based on the plan of care. During RR#5 it was noted the Hospice aide did not follow the care plan order to take the patient's vital signs each visit. The notes reviewed were the end of October and beginning of November 2022 to date. This was discussed with the Administrator and Administrator designee.

Observed in Record Review. In 1 of 5 patient records reviewed, The patient record did not contain the following clinical information on medications administered including the dose. During HV#1 the patient stated she takes Tylenol for pain. The SN notes document that the patient takes pain medication as needed for pain. Tylenol including dose and frequency were not on the medication profile reviewed in the home or in the patient medical record. This was discussed with the Administrator and Administrator designee.

Observed in Record Review. In 1 of 4 patient records reviewed, During RR#3 it was noted during the RN initial comprehensive assessment of the integumentary system the patient had BLE wounds and multiple bruises all over her body There was no further description of the wounds or bruises in the assessment. This was discussed with the Administrator/DPCS and designee.

Observed in Record Review. In 2 of 4 patient records reviewed, During RR#2 it was noted an LVN visit the beginning of August 2022 documented basic wound care done and documented the pressure ulcer was stage 1. All other SN notes documented the pressure ulcer as stage 3 to the coccyx. During RR#3 it was noted on multiple RN assessments prior to IDG meetings the following documentation: BLE wounds and multiple bruises on all over the body. In between the RN visits the LVN documentation of the patient's skin was skin is dry and intact. No signs of skin breakdown or impairment observed during the visit. Reinforced proper skin care. This was discussed with the Administrator/DPCS and designee.

Observed in Record Review. In 1 of 4 patient records reviewed, During RR#2 it was noted a goal Confusion/anxiety: In 4-5 weeks, patient/family will verbalize understanding re: natural course of disease process eventually affecting patient’s neuro-mental status associated with episodes of confusion/anxiety without interventions other than to assess dementia, to accomplish the goal. In addition the goal Patient will have optimal bowel movement lacked the method that will be used to measure progress and there was lack of interventions other than to assess bowel status. This was discussed with the Administrator/DPCS and designee.

Observed in Record Review. In 3 of 4 patient records reviewed, During RR#1-2, it was noted lack of interventions established by the MSW and the chaplain on the initial and updated POCs. During RR#3 it was noted lack of interventions for the MSW, the chaplain assessment was refused by the patient/family. This was discussed with the Administrator/DPCS and designee.

Observed in Record Review. In 1 of 4 patient records reviewed, During RR#1 it was noted at the first IDG meeting after the SOC there was lack of a frequency of visits for the MSW noted on the POC even though the MSW initial visit was completed within 5 days of the initial RN assessment. This was discussed with the Administrator/DPCS and designee.

Observed in Record Review. In 1 of 4 patient records reviewed, During RR#2 it was noted although the IDG met every 14 days the comprehensive assessment during the IDGs was not consistently updated. A wound care order was not added to the POC when ordered the middle of August 2022. At the IDG meeting the end of August 2022 the SN documented in the summary of clinical findings a wound care order that was changed after the IDG the middle of August. In addition during the initial RN comprehensive assessment it was noted the presence of a stage 3 pressure ulcer on the coccyx. This was not added as a comorbidity on the POC. This was discussed with the Administrator/DPCS and designee. Observed in Record Review. In 1 of 4 patient records reviewed, During RR#2 it was noted incomplete wound care orders to the coccyx. The initial order the middle of August 2022 was: Cleanse with NSS, pat dry, apply collagen particles and cover with bordered foam dressing; Change dressing every 2-3 days or PRN for loss of integrity/Soiling. The order lacked who was to perform the wound care. Also in the middle of August 2022 an order change was obtained to Clean the wound with dermal wound cleanser pat dry with gauze sponge apply tetracyte and therahoney to the wound bed followed by cuticerin. The order lacked the frequency of the change and who would perform the wound care. This was discussed with the Administrator/DPCS and designee.

Observed in Record Review. In 1 of 4 patient records reviewed, During RR#1 it was noted an oxygen safety assessment was completed with interventions related to oxygen use and safety. The POC lacked an order for oxygen therapy and SN notes lacked the identification of oxygen use in the home. The POC included a problem identified as potential for cardiac disease which was not listed as a comorbidity to the terminal dx of protein calorie malnutrition. Two RN updated comprehensive assessments documented the patient took Tylenol 500 mg every 6 hours as needed for pain. The medication profile lacked an order for Tylenol for pain. This was discussed with the Administrator/DPCS and designee.

Observed in Emergency Management Session. During review of the Emergency Operations Management Plan it was noted the organization had not determined an alternate site where staff would go for a temporary location. This was reviewed, discussed, and validated by the Director of Patient Care Services and the Administrator designee.

Observed in Emergency Management Session. During review of the Emergency Operations Management Plan it was noted the organization had not ensure the plan included names and contact information of the following: Staff, Physicians, or Volunteers. This was reviewed, discussed, and validated by the Director of Patient Care Services and the Administrator designee.

Observed in Patient Home. In 2 of 2 home visits conducted with home folders, During review of the Admission Packet, review of HV# 1 and HV# 2's patient home folders, it was noted the organization had not provide written policies and state specific laws on Advanced Directives. This was reviewed, discussed, and validated by the Administrator.

Observed in Record Review. During RR# 6's patient record review it was noted the organization had not ensured it respected the patient's right to revoke in accordance with Medicare hospice regulations. For example: review of the RR# 6's record revealed no documentation of a revocation statement. This was reviewed, discussed, and validated by the Administrator designee.  Observed in Record Review. In 3 of 3 patient records reviewed with revocation, Although the patient revoked hospice, the revocation statement could not be found. During HV#2's patient record review, it was noted that the revocation form was not obtained. This was reviewed and validated with the Hospice the Director of Patient Care Services and the Director of Patient Care Services Designee.

Observed in Record Review. During RR# 2, RR# 4, RR# 5, RR# 6's patient record review it was noted that the comprehensive assessment was not completed within five days. For example: review of RR# 6's patient record revealed RR# 6 was discharged 71 days after start of care. Further review of RR# 6's patient record revealed no initial assessment from the MSW or Chaplain. Review of RR# 2's patient record revealed RR# 2's start of care was 69 days prior to the surveyors review of the record with no documentation of an initial assessment from the Chaplain. Review of RR# 4's patient record revealed RR# 4 start of care was 19 days prior to the surveyor review of the record with no documentation of an initial assessment from the Chaplain. Review of RR# 5's patient record revealed RR# 5 start of care 27 days prior to the surveyor review of the record with no documentation of an initial assessment from the Chaplain. Observed in Record Review. In 7 of 11 patient records reviewed, the chaplain failed to complete their initial assessments within five days after the election of hospice. During HV#1, HV#2, and HV#3's patient records review, it was noted that the chaplain's initial assessment was not completed. This was reviewed and validated with the Director of Patient Care Services and the Director of Patient Care Services Designee.

Observed in Record Review. In 11 of 11 patient records reviewed, During RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, RR# 6, RR# 7, and RR# 8's patient records review it was noted the organization had not ensure the initial bereavement assessment completed. For example: review of the patients records revealed no initial bereavement assessment completed. This was reviewed, discussed, and validated by the Director of Patient Care Services and Director of Patient Care Services Director designee. Observed in Record Review. During HV#1, HV#2, and HV#3's patient records review, it was noted that the initial bereavement assessment was not completed. This was reviewed and validated with the Director of Patient Care Services and the Director of Patient Care Services Designee.

Observed in Record Review. In 4 of 11 patient records reviewed, During RR# 3, RR# 4, RR# 5, and RR# 6's patient record review it was noted the organization had not ensured the interdisciplinary group updated the comprehensives assessment no less than every 15 days. For example: Review of RR# 3's patient record revealed no documentation of a RN update to comprehensive assessment until 70 days after the start of care RN comprehensive assessment. Review of RR# 5's patient record revealed a start of care 27 days prior to the surveyor review of the record. Further review of the record revealed no documentation of the RN update to the comprehensive assessment. Review of RR# 6's patient record revealed no documentation of a RN update to the comprehensive assessment until 38 days after the start of care. Review of RR# 4's patient record revealed a start of care 19 days prior to the surveyor review of the record. Further review of RR# 4's patient record revealed no documentation of the RN update comprehensive assessment. This was reviewed, discussed, and validated by the Director of Patient Care Service and Director of Patient Care Service designee.

Observed in Record Review. In 2 of 8 patient records reviewed, During RR# 2 & RR# 3's patient record review it was noted the organization had not ensured the patient plan of care included all the services needed for palliation and management of the terminal illness and related conditions, including a statement of the scope and frequency of services and interventions to management pain and symptoms. For example: review of RR# 2's plan of care and subsequent update to the plan of care/IDG revealed no Skilled Nurse (SN) frequency. However, review of RR# 2's patient record revealed the SN had completed twice a week visits. In addition, review of RR# 2's plan of care revealed RR# 2 was receiving eloquis. Further review of the plan of care and subsequent update to the plan of care/IDG revealed no documentation of bleeding precautions interventions. Review of RR# 3's patient record revealed RR# 3's diet was puree with honey thickened liquids. However, review of RR# 3's plan of care and subsequent updates to the plan of care/IDG revealed no documentation of aspiration precaution interventions. This was reviewed, discussed, and validated with the Director of Patient Care Services and the Director of Patient Care Services designee.

Observed in Patient Home. In 2 of 3 home visits conducted, During HV#1 and HV2's home observation it was observed that the nurses did not follow the organization's Hand Hygiene Policy No. 9-009.1 that included decontaminating hands prior to entering patient's home, after removing gloves or prior to putting on gloves glove changes, and not using alcohol based hand sanitizer. For example, during HV#1 home observation the nurse was observed using patient's used bar of soap to wash her hands and changed gloves multiple times without decontaminating. During HV#2's home observation, the LVN was observed closing faucet with her bare hands and using toilet paper to dry her hands. This was observed, discussed, and validated by the Administrator Designee. Observed in Patient Home. In 2 of 2 home visits conducted with nurse bag, During HV#1 and HV#2's home observation it was observed that the nurses did not follow the organization's Bag Technique Policy No. 9-014.1 that included decontaminating hands prior to entering the nurse bag. For example, during HV#1 home observation the nurse was observed on multiple occasions entering the nurse bag without decontaminating hands. During HV#2's home observation, the LVN was observed on multiple occasions entering the nurse bag without decontaminating her hands. This was observed, discussed, and validated by the Administrator Designee.

Observed in Record Review. Bereavement care plan not initiated. During BR#1 patient record review, it was noted that bereavement post assessment and post death care plan was not found in the record. This was reviewed, discussed, and validated with the Director of Patient Care Services and the Director of Patient Care Designee.

Observed in Competency Session. In 2 of 2 home health aide HR files, During HR# 1's personnel record it was noted the organization had not ensured the initial home health aide competency assessment was complete on an actual patient or a qualified pseudo patient. For example: review of the initial home health competency assessment revealed documentation the competence assessment was verbally completed. This was discussed with the Director of Patient Care Services and validated. Observed in HR File Review. Home Health Aide did not have competencies completed upon hire. During HR#9 personnel file review, it was noted that aide's competency packet was checked off by aide, but not signed off by RN. This was reviewed, discussed, and validated with Director of Human Resources.

Observed in Record Review. In 3 of 9 patient records reviewed with Home Health Aide services, During RR# 2, RR# 3, and RR# 5's patient record review it was noted the organization had not ensured the registered nurse (RN) prepared patient specific written care instructions for the hospice aide. For example: review of RR# 2, RR# 3, and RR# 5's home health aide care plan revealed the task of blood pressure measurement with no documentation of systolic or diastolic parameters on when to call the RN. This was reviewed, discussed, and reviewed with the Director of Patient Care Services and Director of Patient Care Services designee.

Observed in Record Review. In 5 of 9 patient records reviewed with Home Health Aide services, During RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, it was noted that the home health aide had not provided care based on the plan of care. For example: review of RR# 1, RR# 2, RR# 3, and RR# 5's home health aide plan of care, the aide;was required to obtain vital signs however there were missing vital signs on multiple visits in the patient records. Review of RR# 4's home health aide visit notes revealed vital signs documented. However, review of RR# 4's home health aide plan of care revealed no vital sign task. This was reviewed, discussed, and validated by the Director of Patient Care Services and the Director of Patient Care Services designee.

Observed in Record Review. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.100 Organization and Administration of Services, §418.52 Patient's Rights, §418.54 Initial & Comprehensive Assessment of the Patient, and §418.104 Clinical Records.

Observed in HR File Review. In 1 of 12 HR files reviewed, During HR# 3's personnel record it was noted the organization had not ensured the alternate Medical Director completed an initial competency assessment. For example: review of HR# 3's personnel record revealed no documentation of a competency assessment. This was reviewed, discussed, and validated with the Director of Human Resources and the Administrator designee. Observed in Competency Session. During HR# 2's personnel record it was noted the organization had not ensured the Medical Director completed a competency assessment every three years. For example: HR# 2 had been contracted with the organization for the last six years. Review of HR# 2's personnel record revealed the last documented competency assessment was approximately five years from the day of the surveyor review of the record. This was reviewed, discussed and validated by the Director of Human Resources.

Observed in Record Review. In 2 of 11 patient records reviewed, During RR# 1's patient record review it was noted the organization had not ensured the patient record was complete, promptly and accurately documented. For example: review of the patient's record revealed two Home Health Aide Visit notes with the same visit date and time with conflicting documentation regarding vital sign assessment on three separate dates. Review of RR# 3's patient record revealed a Home Health Visit note dated the day the surveyor reviewed the record and the signature dated a future date. This was reviewed, discussed, and validated by the Director of Patient Care Services, the Director of Patient Care Services designee, and the Administrator designee.

Observed in Patient Home. In 6 of 12 patient records reviewed, During HV#1 and HV#2's home observation it was noted that the organization had not ensured that the patient record contained information that reflected the patient's care and treatment. For example, during HV#1 medication reconciliation it was noted that the medication profile had Levothyroxine 50 mg, however the medication bottle had the dose as Levothyroxine 50 mcg. This was observed, discussed, and validated with the RN. During HV#2's home observation, it was noted that the medication profile was missing Tramadol 50 mg which was listed on the facility's medication administration record. This was observed, discussed, and validated with the LVN. Observed in Record Review. In 4 of 8 patient records reviewed, During RR# 1, RR# 2, RR# 3, and RR# 4's patient record review it was noted the organization had not ensure the patient record contained information that reflects the patient's care, treatment, or services. For example: review of RR# 1's patient record revealed a terminal diagnosis of protein-calorie malnutrition. Review of the RN comprehensive assessment revealed no documentation under Nutrition/Hydration of the patient's weight, height or mid-arm circumference. Review of RR# 2's patient record revealed a terminal diagnosis of protein-calorie malnutrition. Review of the RN comprehensive assessment revealed no documentation under Nutrition/Hydration of the patient's weight, height, or mid-arm circumference. Review of RR# 3's patient record revealed the start of care RN comprehensive assessment with documentation RR# 3 had an indwelling urinary catheter that was last changed approximately six days prior to the start of care, or 155 days prior to the surveyor review of the record, and it was to be changed at a minimum every 30 days. Further review of the patient's record revealed the last date the indwelling urinary catheter had been changed was 155 days. Review of RR# 4's patient record revealed no documentation of an update to the plan of care/IDG notes for 19 days. In addition, review of RR# 4's start of care RN comprehensive assessment revealed no documentation under Nutrition/Hydration of the patient's weight, height, or mid-arm circumference. This was validated by the Director of Patient Care Services and the Director of Patient Care Services designee.

Observed in Record Review. In 11 of 11 patient records reviewed, During RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, RR# 6, RR# 7, and RR# 8's patient record review it was noted the organization had not ensured the patient records were authenticated to include a signature and a title (occupation). For example: all patients records included documentation by the Director of Patient Care Services designee. Review of the Director of Patient Care Services designee's signature revealed no documentation of registered nurse. This was reviewed, discussed, and validated by the Director of Patient Care Services and the Director of Patient Care Services designee. In addition, review of RR# 1's patient record revealed multiple Skilled Nurse Visit notes, the Home Health Aide written assignment and multiple Home Health Aide Visit notes with no signatures. Review of RR# 2's patient record revealed a start of care RN comprehensive assessment completed 69 days prior to the surveyor review of the record. Review of the start of care RN comprehensive assessment revealed no signature. This was reviewed, discussed, and validated by the Director of Patient Care Services and the Director of Patient Care Services designee.

Observed in Record Review. In 1 of 11 patient records reviewed, During RR# 5's patient record review it was noted the organization had not ensured it maintained the security and integrity of health information. For example: information was added to the form after the form was acknowledged by the patient's representative. Review of RR# 5's patient notification of hospice covered items electronically signed by RR# 5's patient representative revealed white out over the typed patient name and documentation of a hand written patient name. This was reviewed, discussed, and validated by the Administrator designee.

Observed in Patient Home. In 2 of 2 home visits conducted with home folders, During review of the Admission packet, review of HV# 1 and HV# 2's home folder revealed no documentation of the organization's written policies and procedures on the management and disposal of controlled drugs for the patient or patient or patient's representative and family. This was reviewed, discussed, and validated by the Administrator designee and the Director of Patient Care Services.

Observed in Competency Session. During HR# 3's personnel record it was noted the organization had not ensured a criminal background check had been completed on the alternate Medical Director. For example: review of the personnel record revealed no documentation of a criminal background check. This was reviewed, discussed, and validated with the Director of Human Resources and Administrator Designee.

Observed in Record Review. In 1 of 1 patient record reviewed discharged for extended prognosis, During RR# 7's patient record review it was noted the organization had not ensured the Notice of Medicare Non-coverage was provided to the patient or patient representative two calendar days prior to discharging RR# 7 for extended prognosis. This was reviewed, discussed, and validated by the Administrator designee.