Every finding on record at The Medical Team, Inc. (Hebbronville)

Observed in Record Review. In 1 of 3 patient records reviewed, the surveyor observed that the hospice did not complete the comprehensive assessment no later than five calendar days after the election of hospice care. In the record of RR#3 the Chaplain did not document a comprehensive assessment. This observation was verified with the Administrator/DPCS and the alternate Administrator/DPCS.

Observed in Record Review. In 3 of 3 patient records reviewed, the surveyor observed that the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. Interventions to manage pain and symptoms were the same for each patient; the scope and frequency of services necessary to meet the patient’s and family’s needs were not individualized; and the identified outcomes were not measurable. This observation was verified with the Administrator/DPCS and the alternate Administrator/DPCS.

Observed in Record Review. In 3 of 3 patient records reviewed, the surveyor observed that patient plans of care were not individualized as they did not reflect patient or family goals and interventions based on problems identified in the assessment. Goals were generic in every record. Time frames for completion were all 14 days in one record; two weeks in another record; and not indicated in another record. These observations were reviewed with the Administrator/DPCS and the alternate Administrator/DPCS

Observed in Record Review. In 3 of 3 patient records reviewed, the surveyor observed that the interdisciplinary group did not review and revise the plan of care as frequently as the patient’s condition required, or at least every 15 calendar days. Nursing interdisciplinary meeting notes did not reflect changes in comprehensive reassessments. Entries by social and spiritual counselors were non-specific for each individual patient and repeated the same information. For example, while reviewing the record of RR#1 the surveyor was told that the patient fell, went to an emergency room for treatment, had surgery for a hip fracture and then came back to hospice. None of this was documented in the patient record. And in the record of RR#2 the nurse noted that the patient had a burn on the lower back caused by a heating pad. These changes of condition were not reviewed, revised, or documented. These observations were verified with the Administrator/DPCS and the alternate Administrator/DPCS.

Observed in Record Review. In 3 of 3 patient records reviewed, the surveyor observed that the plan of care did not include revisions based on updated comprehensive assessments and progress toward goals and outcomes. There was no documentation of progress toward goals and outcome in any record. This observation was verified with the Administrator/DPCS and the alternate Administrator/DPCS.

Observed in Record Review. In 3 of 3 patient records reviewed, the surveyor determined that the organization's governing body did not assume full legal authority and responsibility for the overall operation of the organization. As evidenced by continuing Condition Level deficiencies at the following COPs: §418.104 and §418.56. This observation was reviewed with the Administrator/DPCS and the alternate Administrator/DPCS.

Observed in Record Review. In 3 of 3 patient records reviewed, the surveyor observed that entries were not entered timely in the patient records. Late entries were noted from several days to several weeks in every record reviewed. According to the Administrator/DPCS, agency policy requires documents to be submitted the same day the visit was completed. This observation was verified with the Administrator/DPCS and the alternate Administrator/DPCS.

Observed in Record Review. In 3 of 3 patient records reviewed, the surveyor observed that the plan of care did not includes all services needed for the palliation and management of the terminal illness and related conditions, including the following: - Interventions to manage pain and symptoms - A statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs - Measurable outcomes anticipated from implementing and coordinating the plan of care - Medications and treatment necessary to meet the patient’s needs - Medical supplies and appliances necessary to meet the patient’s needsObserved in RR#1, #2 and #3 the goals were not specific and were generic pain will be at an acceptable level to the patient; pt /verbalized /demonstrate appropriate pain control; patient will safety needs met; but there were no specific safety needs identified; Additionally there were no goals for all Disciplines. such as MSW and Chaplain. For RR#1 and 2, the notes documented anxiety, but there were no specific goals or intervention related to anxiety. Additionally, the goals were not measurable. This observation was verified with the DPCS who was also the navigator for the Electronic Medical Record review.

Observed in Record Review. In 3 of 3 patient records reviewed, the surveyor observed that patients plans of care were not individualized. The plan of care did not reflect patient or family goals and interventions based on problems identified in the patient assessment. For RR#1, 2 and #, the goals were generic and not patient specific. For RR#1, the was a pain goal however the assessment documented no pain. record review #2, the nurse documented increased anxiety but there were no goals or interventions. All three (3) records had a goal patient safety needs will be met, however, there was no documentation of any safety needs specific to the individual patients. None of the patients' goals had time frames. These observations were verified with the DPCS who was the electronic medical record navigator for the records reviewed.

Observed in Record Review. In 3 of 3 patient records reviewed, the surveyor observed that the interdisciplinary group, in collaboration with the patient’s attending physician, if any, did not review and revises the plan of care as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. These reviews were not documented. During review of the record for IDG notes there was no documentation of goals or of any discussion with team of care plan and patient condition. There were no documented notes from the MSW or Chaplain. The RN notes were part of a template, but did not describe the care, treatment or services provided or progress for any specific goals of care. These observations were verified with the DPCS who was the electronic record navigator for the record review.

Observed in Record Review. In 3 of 3 patient records reviewed, the surveyor observed that the plan of care did not include revisions are based on information from updates to the patient’s comprehensive assessment and address the patient’s progress toward goals and outcomes. There was no documentation of progress toward goals and outcome in any record. There was information the RN reassessment related to anxiety, however, there were no patient specific goals or interventions related to anxiety. Additionally, there were pain goals for all three (3) patients but the assessments documents that the patients did not have pain. These observations were verified with the DPCS who was the electronic record navigator for the surveyor.

Observed in Leadership Session. During discussion with the ADM/DPCS and review of volunteer cost reports, the surveyor observed that the cost reports reviewed for September and October did not document the percentage of volunteer time to direct care hours. The hours were reported , but the forms were not completed to show a minimum of 5 percent of the total patient care hours of all paid hospice employees. The form was not completed showing the total patient care time. This observation was verified with the ADM/DPCS.

Observed in Record Review. the surveyor determined that the organization's governing body did not assume full legal authority and responsibility for the overall operation of the organization. As evidenced by continuing Condition Level deficiencies at the following COPs: 418.100,418.104 and 418.56.

Observed in Record Review. the surveyor observed that entries were not entered timely in the patient records. Observed in Record review #1, Spiritual Assessment was documented as completed on time but was not submitted for 14 days . The notes were submitted during survey when the DPCS called the staff to request they submit the visit note. According the DPCS, agency policy requires documents to be submitted within 48 hours . This observation was verified with the DPCS who was also the electronic record navigator.

Observed in Record Review. In 8 of 11 patient records reviewed, the organization failed to provide a comprehensive assessment in accordance with their policy PE. 3 Initial Patient Assessment/Patient Admission which states, the initial comprehensive health assessment includes the following forms; initial nursing assessment, social worker assessment, spiritual assessment, initial bereavement assessment and medication profile. In review of the medical records for HOS 3, RR 1, RR 3, RR4, RR 7 and RR 8 there was no evidence of the social worker assessment and in review of the medical records for HOS 2, HOS 3 and RR2 there was no evidence of the spiritual assessment.

Observed in Record Review. In 3 of 5 patient records reviewed, for the bereavement program the organization failed to comply with their policy PC. 26 which requires a bereavement risk assessment to be performed on admission and after death. For example in review of the medical records for BR 2 and BR 3 there was no evidence that a bereavement risk assessment had been completed at the time of admission to the hospice program or post death and in review of BR 4 there was no evidence of a bereavement risk assessment post death as required by policy.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization failed to individualize the plan of care for hospice patients. In review of the medical record and care plans every two weeks the surveyor noted that goals and time frames for achieving goals and the IDG summary notes were the same on each plan of care. Goals were not measurable for example there was a problem of ascites with the goal, free of complications and goals for each problem on the care plan were to be achieved by time of death/discharge. Additionally, the IDG team note on in every record was the same stating, IDG Summary: IDG MD, MSW, RN, SCC and Volunteer SVC Coord met to review patients POC and revise as appropriate. RN reviewed progress towards goals and patient hospice metrics and discussed symptom management needs with hospice MD and team. MSW reviewed psychosocial support and advanced care planning status as well as anticipated issues with team members. SCC updated team on spiritual support status and evolving bereavement care plan. Volunteer services coordinator reviewed whether patient/caregiver has requested volunteer support and the status of same. DME needs were discussed and reviewed. Medication orders received where deemed appropriate by hospice physician. All team members signed IDG sign in sheet attesting to attendance. This was discussed with and validated with the Administrator/DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, the interdisciplinary group failed to meet at least every 15 days to review and revise the plan of care. In review of the medical record for HOS 2 there was no documentation that the IDG team had met and updated the plan of care for a 28 day period. This was discussed and confirmed with the Administrator/DPCS.

Observed in Record Review. In 10 of 11 patient records reviewed, the organization failed to document the patient’s progress toward goals and outcomes. For example in review of the medical record for RR 2 the surveyor noted that in 18 of 18 IDG team meeting notes/care plans reviewed there was no documentation of progress towards goals. Goals, interventions and time frames for goals all remained the same for all notes reviewed. This was also noted in review of RR 3, RR 4, RR 5, RR 6, RR 7 and RR 8.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to enforce standard precautions consistent with their COVID 19 Agency Plan which requires all employees to mask at all times and utilize appropriate handwashing, PPE and general infection control procedures when in a client's home regardless of vaccination status and exposure risk. For HOS 1 the Hospice Chaplain failed to wear a mask during the visit for the hospice patient. This was discussed with and validated with the Administrator/DPCS. Observed in Pharmacy. In 1 of 2 home visits conducted, the organization failed to implements its infection prevention and control activities. The nurse did not follow the organization's bag technique policy which states that after hand cleansing, supplies and/or equipment needed for the visit are removed from the bag. During the wound care procedure, the nurse re-entered the nursing bag with gloved hands to retrieve wound cleanser, continued performing wound care and subsequently entered a plastic bag of wound care supplies with gloved hands. This issue was discussed and confirmed with the Administrator/DPCS.

Observed in Infection Control System Tracer. In review of the organization's Infection Control Plan IC. 2 the plan did not include a goal on improving compliance with hand hygiene guidelines. Observed in Infection Control System Tracer. in review of the organization's Infection Control Plan IC.2 the plan did not include a goal on how it would limit unprotected exposure to pathogens. Observed in Infection Control System Tracer. in review of the organization's Infection Control Plan IC. 2 the plan did not include a goal on how it would limit the spread of infections associated with the use of medical equipment, devices, and supplies. Observed in Infection Control System Tracer. in review of the organization's Infection Control Plan IC.2 the plan did not include a goal on how it would limit the spread of infections associated with procedures. Observed in Infection Control System Tracer. in review of the organization's Infection Control Plan IC.2 the plan did not include how it would address prioritized risks.

Observed in Document Review. The organization failed to document their efforts to recruit and train volunteers. The Volunteer Coordinator provided a verbal report of efforts over the past three years to recruit volunteers however had failed to document those recruitment activities.

Observed in Document Review. the organization had not documented the cost savings achieved through the use of volunteers. In review of the Volunteer Program and in discussion with the Volunteer Coordinator who had been in her position for more than three years the surveyor was informed that the hospice had been unable to recruit and train volunteers and therefore there had been no cost savings achieved with the exception of the hours the Administrative Assistant/Volunteer Coordinator had documented of her time. This had also been the situation during the organization's initial deemed survey 3 years ago.

Observed in Document Review. the organization had not achieved at least a 5% cost savings through the use of volunteers. The hospice had been unable to recruit, train and provide or utilize volunteer services for the past 3 years. This was validated through discussion with the Volunteer Coordinator.

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 discussions with staff; 418.60 , 418.60 (a), 418.78, 418.78 (c).

Observed in Record Review. In 4 of 11 patient records reviewed, the organization failed to assure that care was documented accurately. In review of the documentation of the IDG team meeting/care plan updates every two weeks the surveyor noted that records included documentation of interventions/activities for future dates. For example, in review of RR 3 the care plan/IDG meeting note included interventions/activities dated for the next day, one week and two weeks in the future. This was also observed in review of RR 5, RR 7 and RR 8.