Every finding on record at Together Hospice Care, LLC

Observed in Emergency Management Session. During review of the emergency management plan it was noted lack of the method to be used to inform state and local officials of any on-duty staff or patients that the organization was unable to contact. This was discussed with the organization leadership.

Observed in Record Review. In 2 of 14 patient records reviewed, During RR#1 it was noted lack of an initial bereavement assessment in the patient record 18 days after the comprehensive assessesment without documentation of the reason. During RR#8 it was noted the SC called to set up a visit to complete the bereavement assessment on the 6th day after the RN initial assessment. This was discussed with leadership.

Observed in Record Review. In 1 of 14 patient records reviewed, During RR#3 it was noted goals that were not individualized or measurable. They included patient will maintain peripheral circulation, patient will have BM managed with bowel care regimen, Pt/Family/PCG will verbalize having urinary elimination needs met at an acceptable level and Pt will have adequate food and fluids as tolerated or desired. This was discussed with the organization leadership.

Observed in Record Review. In 9 of 14 patient records reviewed, During HV#2 record reivew it was noted an order for physical therapy (PT) 1x/week x 3 weeks in August 2023. The POC was not updated to include PT interventions and goals. During HV#3 record review, RR#1, RR#3, and RR#5 record reviews it was noted on the RN comprehensive assessments the patient was at risk for aspiration. Aspiration precaution interventions were not added to the POC. During reivew of RR#8, RR#6, RR#5, RR#3 the fall risk assessment results were rated as high. The POCs lacked interventions and goals related to the risks identified on the fall risk assessments. During RR#9, RR#7, RR#6, and RR#5 it was noted lack of instruction on oxygen use and safety on the POC. During HV#4 record review it was noted the patient developed a UTI with antibiotic therapy documented during an IDG meeting. The POC was not updated to include GU interventions and goals. This was discussed with organization leadership.

Observed in Record Review. In 11 of 14 patient records reviewed, During HV#1 and #4 record review, RR#1, RR#2, RR#3, RR#4, RR#8, RR#7, RR#6, RR#5, RR#9 it was noted an oxygen therapy order for 2-5 L/NC, titrate for comfort PRN SOB. The order lacked the parameters to increase the liter flow. This was discussed with the leadership. This was discussed with the leadership.

Observed in Data Tracer. During review of the QAPI program it was noted lack of reivew of bereavement services, and contracted services including pharmacy, DME, therapy, and hospice care in contracted skilled nursing facilities. This was discussed with leadership.

Observed in Data Session. During review of the organization QAPI program it was noted lack of documentation of annual program reviews for 2022, and 2023. The QAPI team provided the surveyor with an updated QAPI plan for 2024 during the survey. This was reviewed with leadership.

Observed in Infection Control System Tracer. During reivew of the organization infection control plan it was noted the infection prevention and control goals did not include limiting unprotected exposure to pathogens. This was discussed with leadership. Observed in Infection Control System Tracer. During review of the infection control plan it was noted lack of a goal limiting the spread of infections associated with the use of medical equipment, devices, and supplies. This was discussed with leadership. Observed in Infection Control System Tracer. During review of the infection control plan it was noted lack of a goal limiting the spread of infections associated with procedures. This was discussed with the leadership.

Observed in Data Session. During review of the sign in forms for QAPI meetings, it was noted the participants were the Administrator, QAPI Coordiantor and DPCS. The QAPI committee lacked other professionals members such as the MSW, Chaplain, and Medical Director. This was discussed with the Administrator.

Observed in Record Review. In 11 of 12 patient records reviewed, who were receiving hospice aide serivce. During HV#1- HV#4 record review, RR#1, RR#2, RR#4, RR#8, RR#6, RR#5, RR#9 it was noted the hospice aide assignment form contained ranges for oxygen therapy, prepared by the RN. The assignments included use of oxygen at 2-5 L/NC PRN SOB. This was discussed with leadership.

Observed in Record Review. In 1 of 2 patient records reviewed, who were discharged from hospice. During Live D/CRR#2 it was noted the completed d/c summary lacked documentation that a copy was sent to the hospital where the patient was admitted. This was discussed with leadership.

Observed in Document Review. During reivew of the organization admission packet and in discussion with the DPCS, although there was information on disposal of medications, it was noted lack of a copy of the hospice's written policies and procedures on the management and disposal of controlled medications has been given to the patient or the patient’s representative and family during care.

Observed in Regulatory Review. During review of the admission packet and in discussion with the leadership it was noted lack of a written individualized disaster preparedness form in the patient medical record or in the home. This was discussed and verified with the organization leadership.

Observed in HR File Review. In 1 of 12 HR files reviewed, During HR#1 review it was noted the employee did not meet the experience requirement in the job description of a minimum one year experience in health care. This was discussed with the organization leadership.

Observed in Document Review. In 2 of 4 contracts reviewed, During reivew of the pharmacy, and DME contracts it was noted lack of a stipulation that the outside agency will complete criminal background checks on employees who provide direct patient care or have access to patient records. This was discussed with organization leadership.

Based on inetrview and record review, the agency failed to ensure a clinical record was complete for 1 of 2 sampled residents (1). As a result, Patient 1's clinical records data entry was unclear and unverified. --- Findings: Patient 1 was admitted to the agency on 8/5/23 with diagnoses which included Alzheimer's disease (a gradual decline in memory, thinking, behavior, and social skills). A review of Patient 1's clinical record was conducted. Per the Visit Note, dated 8/7/23, indicated this visit was in person, and the caregiver reported that Patient 1 was in pain. The screening for highly infectious respiratory disease, pain assessments, vital signs, and narrative notes were left blank. In addition, the signature and date were also left blank. On 10/19/23 at 1:30 P.M., a joint interview and record review was conducted with the Director of Patient Care Services (DPCS). The DPCS stated entries to clinical records must be complete, signed, and dated. The DPCS recalled that on 8/5/23, Patient 1 was admitted, and on 8/7/23, the caregiver called to report that Patient 1 was in pain. The DPCS stated she did not perform a home visit for Patient 1. It was a phone call, and they addressed the concern over the phone. The DPCS said Patient 1's clinical note should have been completed, signed, and dated. Per the agency's policy and procedure, titled Entries Into The Clinical Record, dated 10/19, "...Entries into the clinical record will be clear, concise, and specific statements of fact...Signature authorization of clinical document...All entries into the clinical record will reflect the date..."