Every finding on record at The Monroe Clinic

Observed in Record Review. In 3 of 5 patient records reviewed, patients with wound care, the organization failed to assess and reassess its patients'. During record review and home visit for RRHV#1, RRNHV#5, and RRNHV#6, reassessment documentation did not contain all needed elements. For example in RRHV#1, the Hospice Nurse Surveyor observed the patient had a wound documented 6 weeks prior to survey but no documentation or measurement per policy since. During the home visit with the surveyor, the nurse assessed and provided wound care during the observed visit. The organizational policy stated they would measure and assess at least weekly. In RRNHV#5, the patient did not have wound measurements for a 2 month period and for two weeks prior to survey. In RRNHV#6, the patient wound measurements were not completed for 21 days, which was outside the organizational policy stating it would be done weekly. This was discussed and reviewed with the Hospice Clinical Supervisor.

Observed in Record Review. In 6 of 16 patient records reviewed, the organization failed to assess and reassess its patients. During record review for RRHV#1, RRHV#3, RRNHV#3, RRNHV#5, RRNHV#6, and RRNHV#7, the plan of care was not updated with progress towards goals and desired outcomes. For example in RRHV#1, the Hospice Nurse Surveyor observed the patient had entered his second certification but the goals and target dates entered by the SW had not been updated with current information from the comprehensive assessment. For example one of the goals was pt will have funeral plans by 6/01 which was almost 8 weeks prior to survey. The patient also had a goal of SW will provide emotional support by 7/01 which was 4 weeks prior to survey. In RRHV#3, the patient skilled nursing goal for pt/ cg will implement strategies to reduce fall risk by 7/30 had been carried over each certification since start of care. In RRNHV#7, the goals were carried over certification after certification with no progress documented and just the goal timeframe adjusted. This was discussed and reviewed with the Hospice Clinical Supervisor.

Observed in Record Review. In 6 of 16 patient records reviewed, the organization failed to plan the patient's care. During record review for RRHV#2, RRHV#3, RRHV#4, RRNHV#6, RRNHV#7, and RRNHV#9, the Hospice Nurse Surveyor observed the plan of care did not contain all needed elements. For example in RRHV#2, the patient had a goal of wishes to stay home until EOL. This goal was not measurable and the timeframe was not individualized. In RRHV#3, the patient had a goal of pt receives appropriate emotional support which was not measurable. In RRHV#4, all nursing goal target dates were set for by IDT which was not individualized. In RRNHV#6, the patient had a call for a PRN visit from nursing with new onset of weakness and fatigue but this was not reflected on the plan of care. In RRNHV#7, the chaplain goals did not contain goal timeframes. In RRNHV#9, the patient had new orders for oxygen with oxygen in the home but it was not added to the plan of care. This was discussed and reviewed with the Hospice Clinical Manager.

Observed in Record Review. In 8 of 16 patient records reviewed, the organization failed to maintain medication orders that were clear and accurate. During record review for RRHV#1, RRHV#2, RRHV#3, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#8, and RRNHV#9, the plan of care did not contain all needed order elements. In RRHV#1, RRHV#2, and RRHV#3, the Hospice Nurse Surveyor observed the patient's had two PRN medication orders ( Acetaminophen and Morphine for all) for pain management but the order did not specify which medication to use first. RRNHV#2, had PRN medications for pain which included Morphine, Tylenol and Tramadol. The tramadol did not included when the patient should take it. In RRNHV# 2, RRNHV#3, RRNHV#4, and RRNHV#9, the patients had incomplete orders for oxygen. There was no route or frequency with the order. For RRNHV#8, the patient had oxygen in the home, which their physician prescribed. The nurse had been education on the oxygen but there were no orders in place for use. This was discussed and reviewed with the Hospice Clinical Supervisor.

Observed in Patient Home. In 2 of 2 home visits conducted, in private homes, the organization failed to provide patient education and training. During home visit for RRHV#1 and RRHV#2, the Hospice Nurse Surveyor observed the patient did not have an individualized emergency plan in the home. This was discussed and reviewed with the Hospice Clinical Supervisor.

Observed in Record Review. In 7 of 10 patient records reviewed, with aide services, the organization failed to plan the patient's care. During record review for RRHV#1, RRHV#2, RRHV#3, RRHV#4, RRNHV#2, RRNHV#4, and RRNHV#10, the Hospice Nurse Surveyor observed the aide care plan did not contain all needed precautions. For example in RRHV#1, the aide care plan did not contain fall risk and the patient was a high fall risk. For RRHV#2, the patient was a high risk for fall and had oxygen ordered PRN but these were not on the aide plan of care. In RRHV#3, the patient had bleeding precautions and oxygen precautions but they were not visible on the aide care plan. For RRHV#4, the patient had bleeding precautions and fall precautions but they were not visible on the aide care plan. In RRNHV#2, the aide care plan did not contain precautions for falls or oxygen. In RRNHV#4, the aide care plan did not contain precautions for falls or oxygen. In RRNHV#10, the patient did not have fall risk on the aide care plan. This was discussed and reviewed with the Hospice Clinical Supervisor.

Observed in HR File Review. In four out of four records, volunteers had not been supervised as defined by the Volunteer Services Policy in the last three years. Examples of supervision activities in the policy included: joint home visits, observations made when providing services, observations in IDT and evaluations of performance. This observation was confirmed with the Volunteer Coordinator.

Based on record review and interview, the agency failed to obtain a written acknowledgment of receipt of patients rights and responsibilities upon admission to hospice in 19 of 19 patient records reviewed (Patients #1 – Patient #19). --- Record review for Patient #16 with start of care date 07/25/2023 revealed no evidence of written acknowledgement of receipt of the patient's rights and responsibilities. Record review for Patient #17 with start of care date 02/20/2024 revealed no evidence of written acknowledgement of receipt of the patient's rights and responsibilities. Record review for Patient #18 with start of care date 02/20/2024 and discharged 02/28/2024 revealed no evidence of written acknowledgement of receipt of the patient's rights and responsibilities. Record review for Patient #19 with start of care date 11/09/2023 revealed no evidence of written acknowledgement of receipt of the patient's rights and responsibilities. During an interview with Office Manager C on 04/10/2024 at 12:00 PM, when asked about evidence of signing acknowledgement that the patient received their rights and responsibilities, Office Manager C replied, "I don't think we have them sign anything. We always provided it as part of the admission packet but I don't see they sign anything." The above findings were reviewed and confirmed for Patients #1 - #19 during an interview with Hospice Manager A and Hospice Supervisor B on 04/11/2024 at 10:15 AM. Record review for Patient #13 with start of care date 01/04/2024, revealed no evidence of written acknowledgement of receipt of the patient's rights and responsibilities. Record review for Patient #14 with start of care date 10/20/2023, revealed no evidence of written acknowledgement of receipt of the patient's rights and responsibilities. Record review for Patient #15 with start of care date 11/06/2023, revealed no evidence of written acknowledgement of receipt of the patient's rights and responsibilities. Record review for Patient #11 with start of care date 12/02/2022 and discharged 01/11/2024 revealed no evidence of written acknowledgment of receipt of the patients rights and responsibilities. Record review for Patient #12 with start of care date 11/15/2023 and discharged 12/12/2023 revealed no evidence of written acknowledgment of receipt of the patients rights and responsibilities. Findings include: Review of agency policies and procedures titled "Patient Rights and Responsibilities" dated 02/2024 revealed "Process: I. Procedure F. An Admission Consent Form is obtained from the patient, activated Power of Attorney, and/or guardian confirming receipt of the Rights and Responsibilities in a manner they could understand. The signed consent form acknowledges review of the Patient Rights and Responsibilities." Record review for Patient #1 with start of care date 01/15/2024, revealed no evidence of written acknowledgement of receipt of the patient's rights and responsibilities. Record review for Patient #2 with start of care date 10/25/2023, revealed no evidence of written acknowledgement of receipt of the patient's rights and responsibilities. Record review for Patient #3 with start of care date 03/05/2024, revealed no evidence of written acknowledgement of receipt of the patient's rights and responsibilities. Record review for Patient #4 with start of care date 04/05/2024, revealed no evidence of written acknowledgement of receipt of the patient's rights and responsibilities. Record review for Patient #5 with start of care date 02/22/2024, revealed no evidence of written acknowledgement of receipt of the patient's rights and responsibilities. Record review for Patient #6 with start of care date 03/20/2024, revealed no evidence of written acknowledgement of receipt of the patient's rights and responsibilities. Record review for Patient #7 with start of care date 03/07/2024, revealed no evidence of written acknowledgement of receipt of the patient's rights and responsibilities. Record review for Patient #8 with start of care date 03/18/2024, revealed no evidence of written acknowledgement of receipt of the patient's rights and responsibilities. Record review for Patient #9 with start of care date 01/24/2024, revealed no evidence of written acknowledgement of receipt of the patient's rights and responsibilities. Record review for Patient #10 with start of care date 08/08/2023, revealed no evidence of written acknowledgement of receipt of the patient's rights and responsibilities.

Based on observation, record review and interview, the agency failed to ensure the plans of care were individualized and contained orders for all medications and treatments to meet the needs of the patients in 1 of 19 (Patient #18) medical records reviewed. --- Findings Include: Review of the agency policy titled "Assessment of Patient" revised 01/24/2024 revealed "Hospice Initial and Comprehensive Assessment: The medication profile is part the patient-specific comprehensive assessment. All patient's prescriptions, over the counter medications and alternate treatments are reviewed and documented on the plan of care. This includes, but not limited to: The need for non-pharmacological interventions for pain and other symptom management." During an observation and interview on 04/10/2024 at 10:35 AM at the Residential unit for Patient #18, observed Patient #18 having oxygen on, resting comfortably in a recliner, and observed an oxygen concentrator located in Patient #18's bathroom set at 4LPM (liters per minute). Patient #18 denied "any shortness of breath, has used oxygen since admission, and reported the need for morphine recently which helps with breathing." Record review of Patient #18's Plan of Care with start of care 02/24/2024 revealed admitting hospice diagnoses were Chronic Heart Failure, Chronic Stage 4 Kidney disease, Anxiety and Dyspnea. Under Problems: Dyspnea (shortness of breath), started 02/24/2024. Interventions:1) Instruct on breathing and relaxation techniques at each visit. 2) Evaluate effectiveness of oxygen therapy at each visit. Under Equipment/Supplies ordered by hospice- Oxygen concentrator and oxygen kit set-up, dated 02/26/2024. Record review of Patient #18's medication list as part of the patient plan of care revealed no oxygen was ordered. During an interview with Hospice Supervisor B on 04/10/2024 at 4:30 PM, when asked about orders on the plan of care or medication list for oxygen, Supervisor B replied, "The oxygen orders are in, but do not automatically transfer onto the plan of care or medication list for residential patients. Oxygen orders are manually entered on the treatment plans and medication lists and should be reviewed every 2 weeks with care plan updates." The above findings were reviewed during an interivew with Hospice Supervisor B on 04/11/2024 at 10:20 AM. When asked what the hospice expectations are for medication orders as part of the patient medication list, Hospice Supervisor B replied, "The patient is located at the Hospice Home. The order might be in Hyperspace but not in the remote client as part of our hospice documentation. I know there is a gap with this."

Based on record review and interview, the agency failed to establish a QAPI (Quality Assurance and Performance Improvement) hospice-wide committee that utilized quality indicator data, including patient care and other relevant data in its overall design of the hospice quality program in 1 of 1 QAPI programs reviewed. --- Findings include: Review of agency plan titled ";QAPI Plan 2023" revealed ";The quality committee reports to the Board on a quarterly basis and recommends to the Board policies, processes and procedures related to quality and safety...The quality committee also supports and oversees an ongoing quality and safety program, including reviewing, evaluating, and monitoring quality, cost and appropriateness of health care services." Review of hospice agency QAPI meeting minutes dated 05/12/2022 revealed this was the last dated hospice-wide agency QAPI Committee conducted that evaluated quality indicator data and safety program. This hospice agency had no evidence of hospice agency quarterly committee meetings as per the QAPI plan policy. During an interview with Hospice Supervisor B on 04/11/2024 at 8:50 AM, when asked about proof of a hospice agency wide QAPI committee and actions taken in 2023, Hospice Supervisor B replied, ";I have not done anything with QAPI." During an interview with Chief Nursing Officer F on 04/11/2024 at 8:55 AM, when discussing QAPI in that while this agency has oversight from an SSM Health leadership level, does this agency specifically have a hospice wide QAPI committee to review the quality and safety and meet quarterly, Chief Nursing Officer F replied, ";I dont believe there is. Do we need to have it? Absolutely. We need to revisit priorities, but does it formally exist, no. There was a change in leadership and we need to regroup. We had staff on leave. Theres been work done just didnt capture it all in meeting minutes." During an interview with Hospice Supervisor B on 04/11/2024 at 9:15 AM, when asked about the leadership change and who was responsible for QAPI for calendar year 2023, Hospice Supervisor B replied, ";There was another supervisor who left in October 2023 and was in charge of QAPI."

Based on record review and interview, the agency QAPI (Quality Assurance and Performance Improvement) hospice-wide committee failed to identify opportunities and priorities for improvement with an agency multi-disciplinary approach to review the safety and quality of patient care in 1 of 1 QAPI programs reviewed. --- Findings include: Review of agency plan titled ";QAPI Plan 2023" revealed in part, ";Scope of Activities: The scope of the quality and safety program includes all activities that have a direct or indirect impact on reliability, improvement, the quality-of-care patients receive, and safety of our ministries. Ministry leaders, along with Ministry multidisciplinary teams, are responsible for identification, prioritization, implementation, and monitoring of all quality and patient safety initiatives." Review of hospice agency QAPI meeting minutes dated 05/12/2022 revealed this was the last dated hospice-wide agency QAPI Committee that included a hospice-wide multi-disciplinary team approach to review of quality and safety activities. During an interview with Hospice Supervisor B on 04/11/2024 at 8:50 AM, when asked about proof of a hospice agency wide QAPI committee and actions taken in 2023, Hospice Supervisor B replied, ";I have not done anything with QAPI." During an interview with Chief Nursing Officer F on 04/11/2024 at 8:55 AM, when discussing QAPI in that while this agency has oversight from an SSM Health leadership level, does this agency specifically have a hospice wide QAPIT committee to review the quality and safety and meet quarterly, Chief Nursing Officer F replied, ";I dont believe there is. Do we need to have it? Absolutely. We need to revisit priorities, but does it formally exist, no. There was a change in leadership and we need to regroup. We had staff on leave. Theres been work done just didnt capture it all in meeting minutes." During an interview with Hospice Supervisor B on 04/11/2024 at 9:15 AM, when asked about the leadership change and who was responsible for QAPI for calendar year 2023, Hospice Supervisor B replied, ";There was another supervisor who left in October 2023 and was in charge of QAPI."

Based on record review and interview, the agency failed to evaluate QAPI (Quality Assurance and Performance Improvement) hospice-wide performance improvement project activities for the effectiveness of the actions taken in order to improve quality of care and patient safety with a multi-disciplinary approach in 1 of 1 QAPI programs reviewed. --- Findings include: Review of agency plan titled ";QAPI Plan 2023" revealed in part, ";Scope of Activities: Ministry leaders, along with Ministry multidisciplinary teams, are responsible for identification, prioritization, implementation, and monitoring of all quality and patient safety initiatives... All information and data related to the activities delineated in the QAPI Plan is used to evaluate and improve performance and the quality and safety of care, treatment, and services." Review of this agencys Performance Improvement Project to improve Top Box Score included a hospice-wide education PowerPoint for calendar year 2023 titled ";EVIE: Every Visit is Exceptional." Review of agency meeting minutes dated 05/12/2022 revealed this was the last dated hospice-wide agency QAPI multi-disciplinary Committee conducted that evaluated overall effectiveness of agency performance activities. There was no evidence that a hospice agency wide QAPI committee evaluated the overall effectiveness of the Performance Improvement Project activities in calendar year 2023 to evaluate the agencys overall outcomes, patient safety and quality indicators. During an interview with Hospice Supervisor B on 04/11/2024 at 8:50 AM, when asked about proof of a hospice agency wide QAPI committee and actions taken in 2023, Hospice Supervisor B replied, ";I have not done anything with QAPI." During an interview with Chief Nursing Officer F on 04/11/2024 at 8:55 AM, when discussing QAPI in that while this agency has oversight from an SSM Health leadership level, does this agency specifically have a hospice wide QAPIT committee to review the quality and safety and meet quarterly, Chief Nursing Officer F replied, ";I dont believe there is. Do we need to have it? Absolutely. We need to revisit priorities, but does it formally exist, no. There was a change in leadership and we need to regroup. We had staff on leave. Theres been work done just didnt capture it all in meeting minutes." During an interview with Hospice Supervisor B on 04/11/2024 at 9:15 AM, when asked about the leadership change and who was responsible for QAPI for calendar year 2023, Hospice Supervisor B replied, ";There was another supervisor who left in October 2023 and was in charge of QAPI."

Based on record review and interview agency staff failed to provide evidence of completed hospice orientation for 11 (Staff A, B, C, G, H, I, J, K, L, M, and N) of 12 staff personnel files reviewed. --- Findings Include: Review of agency policy titled, "Annual Employee Requirements" (last revision date 11/02/2022) revealed in part, "III. New employees will meet compliance as part of their new employee orientation program and job-specific orientation." Record review of personnel file for Administrator/Hospice Manager A, date of hire 08/26/2022, revealed no evidence of completed hospice orientation at hire. Record review of personnel file for Hospice Supervisor/Substitute Administrator B, date of hire 02/19/2018, revealed no evidence of completed hospice orientation at hire. Record review of personnel file for Volunteer Coordinator C, date of hire 11/12/2018, revealed no evidence of completed hospice orientation at hire. Record review of personnel file for Medical Director G, date of hire 07/31/1997, revealed no evidence of completed hospice orientation at hire. Record review of personnel file for Bereavement Coordinator H, date of hire 12/13/2021, revealed no evidence of completed hospice orientation at hire. Record review of personnel file for Social Worker I, date of hire 01/01/1997, revealed no evidence of completed hospice orientation at hire. Record review of personnel file for Registered Nurse J, date of hire 03/12/2018, revealed no evidence of completed hospice orientation at hire. Record review of personnel file for Registered Nurse K, date of hire 12/28/2015, revealed no evidence of completed hospice orientation at hire. Record review of personnel file for Registered Nurse L, date of hire 08/03/1977, revealed no evidence of completed hospice orientation at hire. Record review of personnel file for Hospice Aide M, date of hire 09/12/2022, revealed no evidence of completed hospice orientation at hire. Record review of personnel file for Hospice Aide N, date of hire 01/21/2019, revealed no evidence of completed hospice orientation at hire. During an interview with Hospice Manager A on 04/10/2024 at 12:15 PM, when asked about orientation being part of the personnel files, Hospice Manager A replied, "Orientation is housed by our manager who is no longer here. She would have had those." During an interview with Hospice Supervisor/Substitute Administrator B on 04/10/2024 at 1:52 PM when asked about evidence of staff orientation, Hospice Supervisor/Substitute Administrator B replied, "We have forms we fill out, but they haven't been done. The prior supervisor may have that, but I don't have access to them. I have one from when I was a preceptor that I used but not everyone uses them." When asked since the orientatation files were done by another supervisor no longer here and confirming they are not available, Hospice Supervisor/Substitute Administrator B replied, "Yes, that is accurate. We don't have those."