Every finding on record at Traditions Hospice of Ennis, LLC

Observed in Record Review. In 2 of 14 patient records reviewed, During RRBR# 1 and RRBR# 2's patient record review it was noted the organization had not ensured the initial bereavement assessment was completed no later than five calendar days after the election of benefit (EOB). For example: review of RRBR# 1's patient record revealed the initial bereavement assessment was completed approximately two months after the EOB. Review of RRBR# 2's patient record revealed the initial bereavement assessment was completed approximately 40 days after the EOB. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, During RRNHV# 1's patient record review it was noted the organization had not ensured staff assessed and reassessed the patient per psychosocial comprehensive assessment procedure. For example: review of RRNHV# 1's patient record revealed RRNHV# 1 was alert, oriented and had a history of depression with suicidal ideations and was hospitalized approximately eight months prior to hospice for depression and suicidal ideations. Further review of RRNHV# 1's patient record revealed documentation that RRNHV# 1 had been removed from his home by Adult Protective Services due to financial exploitation by family members and placed in a skilled nursing facility and had suffered multiple losses. Review of RRNHV# 1's Psychosocial comprehensive assessment revealed under Depression/Suicide Risk Assessment completed documentation No and under Why was a Depression/Suicide Risk Assessment not completed documentation not applicable. This was reviewed, discussed, and validated with the Administrator. Observed in Record Review. In 7 of 14 patient records reviewed, During RRHV# 1, RRHV# 2, RRNHV# 2, RRNHV# 4, RRNHV# 5, RRNHV# 6, and RRNHV# 7's patient records review it was noted the organization had not ensured it assessed the need for volunteer services. For example: review of RRHV# 1, RRHV# 2, and RRNHV# 2's patient records revealed no evidence that the need for volunteer services was assessed. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, During RRNHV# 3's patient record review it was noted the organization had not ensured an initial bereavement assessment was completed. For example: review of RRNHV# 3's patient record revealed an election of benefit dated approximately 30 days prior to the surveyor review of the record. Further review of RRNHV# 3's patient record revealed no documentation of an initial bereavement assessment. This was reviewed, discussed, and validated with the Administrator. Observed in Record Review. In 4 out of 14 records reviewed, the organization failed to assess its patients. For example, in record review of RRHV#2, RRHV#3, RRDC#1, and RRDC#2, there was no evidence that the organization assessed for the need for volunteer services. This was reviewed, discussed, and validated with the branch manager.

Observed in Record Review. In 2 of 14 patient records reviewed, During RRNHV# 2 and RRNHV# 3's patient records review it was noted the organization had not ensured the update to the comprehensive assessment included information about the patient's progress toward desired outcomes and the patient's response to volunteer care. For example: review of RRNHV# 2's updates to the plan of care/Interdisciplinary (IDG) meeting notes revealed documentation by the Volunteer Coordinator that RRNHV# 2 had a volunteer visit 1-3 visits a month. Further review of the updates to the plan of care/IDG meeting notes revealed no documentation of the discussion at the IDG meetings that the volunteer visited or progress toward desired outcomes. Review of RRNHV# 3's updates to the plan of care/IDG meeting notes revealed documentation by the Volunteer Coordinator that RRNHV# 3 had a volunteer visit two times a month. Further review of the updates to the plan of care/IDG meeting notes revealed no documentation of the discussion at the IDG meetings that the volunteer visited or progress toward desired outcomes. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. In 4 of 14 patient records reviewed, During RRNHV# 1, RRNHV# 2, RRNHV# 3, and RRNHV# 5's patient records review it was noted the organization had not ensured the plan of care was based on the patient's goals and time frames required to meet those goals. For example: review of RRNHV# 2's patient record revealed Volunteer visit notes. However, review of the plan of care revealed no goals for the Volunteer services. Further review of RRNHV# 2's plan of care revealed wound care orders for the left inner buttocks with no goals for the wound. Review of RRNHV# 3's plan of care revealed a new antibiotic order for an infection to the left great toenail. Review of RRNHV# 3's plan of care revealed no goal for the infected toenail. Further review of RRNHV# 3's plan of care revealed a Chaplain non-measurable goal with no time frame that included Help [patient first name] recall assurance in Christ and see it evidenced in his body language and speech. Review of RRNHV# 1's plan of care revealed a Chaplain goals that were not measurable and had no time frames that includedHelp [patient first name] know how to pursue spiritual encouragement; and Help [patient first name] experience lasting and true forgiveness toward his children. Review of RRNHV# 5's Interdisciplinary (IDG)/update to plan of care meeting notes revealed the Volunteer Coordinator documentation that RRNHV# 5 had a volunteer visit 3-4 times a month. However review of the plan of care revealed no goals for Volunteer Services. This was reviewed, discussed, and validated with the Administrator. Observed in Record Review. In 3 out of 14 records reviewed, the organization failed to plan the patient's care. For example, in record review for RRHV#2, RRHV#3, and RRDC#1, the organization had provided multiple volunteer visits during the course of care, however, there was no evidence of patient-specific volunteer goals on the plan of care. This was reviewed, discussed, and validated with the branch manager.

Observed in Record Review. In 3 of 14 patient records reviewed, During RRNHV# 2, RRNHV# 3, and RRNHV# 5's patient records review it was noted the organization had not ensured the patient's plan of care included interventions to manage pain and symptoms. For example: review of RRNHV# 2's patient record revealed Volunteer visit notes. However, review of RRNHV# 2's plan of care revealed no Volunteer services interventions. Review of RRNHV# 3's Interdisciplinary (IDG)/update to plan of care meeting notes revealed the Volunteer Coordinator's documentation that RRNHV# 3 had volunteer visits two times a month. However, review of RRNHV# 3's IDG/update to plan of care revealed no interventions for the Volunteer. Review of RRNHV# 5's IDG/update to plan of care meeting notes revealed the Volunteer Coordinator's documentation that RRNHV# 5 had volunteer visits 3-4 times a month. However, review of RRNHV# 5's IDG/update to plan of care revealed no interventions for the Volunteer. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. In 3 of 14 patient records reviewed, During RRNHV# 2, RRNHV# 3, and RRNHV# 5's patient records review it was noted the organization had not ensured the plan of care included a statement of the scope and frequency of services necessary to meet the patient's and family's needs. For example: review of RRNHV# 2's Interdisciplinary (IDG) meeting notes revealed documentation by the Volunteer Coordinator that a volunteer was to visit RRNHV# 2 one to two times a month. However, review of RRNHV# 2's Plan of Care and Updates to Plan of care revealed no documentation of Volunteer or Volunteer frequency. Review of RRNHV# 3's IDG meeting notes revealed documentation by the Volunteer Coordinator that a volunteer was to visit RRNHV# 3 two times a month. However, review of RRNHV# 3's plan of care revealed no documentation of Volunteer or Volunteer frequency. Review of RRNHV# 5's IDG meeting notes revealed documentation by the Volunteer Coordinator that a volunteer was to visit RRNHV# 5 3-4 times a month. However review of RRNHV# 5's plan of care revealed no documentation of Volunteer or Volunteer frequency. This was reviewed, discussed, and validated with the Administrator. Observed in Record Review. In 3 out of 14 records reviewed, the organization failed to plan the patient's care. For example, in record review for RRHV#2, RRHV#3, and RRDC#1, the organization had provided multiple volunteer visits during the course of care, however, there was no evidence of a volunteer scope or frequency listed on the plan of care. This was reviewed, discussed, and validated with the branch manager.

Observed in Record Review. In 2 of 14 patient records reviewed, During RRHV# 1 and RRNHV# 3's patient records review it was noted the organization had not ensured the plan of care included interventions to manage symptoms. For example: review of RRNHV# 3's patient record revealed RRNHV# 3 had bilateral lower extremity +4 pitting edema and had tubular elastic bandages from toe to below the knee that was to be removed at night. However, review of RRNHV# 3's plan of care revealed no documentation of tubular elastic bandages. Review of RRHV# 1's hospice aide written patient care instructions revealed RRHV# 1 the task of applying Barrier Cream to the perianal area after each brief change. Review of RRHV# 1's patient record revealed documentation that Thick Barrier cream was applied to RRHV# 's perianal area. However, review of RRHV# 1's plan of care revealed no Barrier Cream. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. In 2 of 14 patient records reviewed, During RRNHV# 1 and RRNHV# 3's patient records review it was noted the organization had not ensured the registered nurse prepared compete written patient care instructions for the hospice aide. For example: review of RRNHV# 1's patient record reveled RRNHV# 1 had oxygen 1-4 Lpm via nasal cannula as needed. However, review of RRNHV# 1's hospice aide written patient care instructions revealed no documentation of oxygen or oxygen precautions. Review of RRNHV# 3's patient record revealed RRNHV# 3 had bilateral lower extremity +4 pitting edema and had tubular elastic bandages from toes to just below the knees to be removed at night. Review of RRNHV# 3's hospice aide patient written instructions revealed the task of a shower with no documentation of the tubular elastic bandages or what to do if they bandages were to get wet. Further review of RRNHV# 3's patient record revealed RRNHV# 3 had oxygen as needed. However, review of the hospice aide patient written instructions revealed no documentation of oxygen or oxygen precautions. This was reviewed, discussed, and validated with the Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, in two of two home visits with medication reconciliation; during RRHV# 1's home observation it was noted the organization had not ensured the patient record contained information that reflected the patient's care, treatment, or services. For example: during RRHV# 1's home observation the registered nurse (RN) was observed completing a medication reconciliation that included reviewing RRHV# 1's prescription bottle of Famotidine 40 mg tablet daily with prescription dates approximately four months prior to the surveyor home observation. However, review of RRHV# 1's medication profile revealed Famotidine 20mg tablet 1 tablet daily. This was observed, reviewed, discussed, and validated with the Administrator. Observed in Patient Home. In 1 out of 2 home visits conducted with a medication reconciliation, the organization failed to ensure that the patient record contains information that reflects the patient's care treatment, or services. For example, in RRHV#3, during the home visit, it was observed that the patient's medication profile included several medications that were not present or currently being taken including; Azelastine 137 mcg nasal spray, Diclofenac 1% gel, Restasis 0.05% drops, Memantine 10 mg, Donepezil 10 mg, and Alendronate 35 mg. Upon further review, it was observed that the patient had several medications not listed on the profile that they had been taking for several months including Trazadone 75 mg, and Buspirone 7.5 mg. Furthermore, the patient's medication profile indicated a prescription for Buspirone 5 mg to be taken twice daily, however, the medication label in the home had instructions to take only once daily. This was reviewed, discussed, and validated with the branch manager.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization did not respect the patient's right to participate in decisions about their care, treatment, or services. In the record of RR#5 the surveyor read that the patient was discharged for extended prognosis, however there was no signed Medicare Notice of Non-Coverage found. The organization did have a policy requiring that the patient be informed, and the document signed five days prior to discharge. This was reviewed with the Regional Director of Operations and the Administrator.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to complete bereavement assessments as part of the initial comprehensive assessment in the hospice records of RR#1 and RR#6. This was reviewed with the Regional Director of Operations and the Administrator.

Observed in Record Review. In 10 of 11 patient records reviewed, where the interdisciplinary group met more than twice, the organization did not update comprehensive assessments to reflect changes that had occurred since the initial assessment. The surveyor found that most notes did not document on-going patient decline, progress toward goals, and plans for the next two weeks. This was reviewed with the Regional Director of Operations and the Administrator.

Observed in Record Review. In 11 of 11 patient records reviewed, the hospice did not develop plans of care that were based on the patient’s goals and the time frames, settings, and services required to meet those goals. For example, most plans were not individualized with measurable goals and identified target dates for completion. This was confirmed by the Administrator.

Observed in Record Review. In 11 of 11 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. In the record of HV#2 the RN documented that the patient had a wound on the lower left leg, but there was no order for wound care found in the documentation. In the record of RR#3 it was noted that the patient did not have an advance directive for a DNR. This was not addressed in the plan of care. And in most records reviewed, there was limited correlation between problems identified in the notes and interventions and goals created in plans of care. For example, every patient was identified as being high risk for falls using the MAHC-10 scale, but few had interventions and goals to address the risk. This was reviewed with the Regional Director of Operations and the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not implement the infection prevention and control activities it had planned. During HV#2 the surveyor observed that an RN donned gloves without washing her hands, which did not comply with standard precautions practice. This was reviewed with the Regional Director of Operations and the Administrator. Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not implement the infection prevention and control activities it had planned. For example, at HV#2 the surveyor observed that the RN used a Sani Wipe to clean a pulse oximeter, digital blood pressure cuff and digital thermometer. However, she did not keep the items wet for two minutes as required in the instructions for use to achieve low level disinfection before placing them back into the clean section of her visit bag. This was reviewed with the Regional Director of Operations and the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the hospice did not provide the SNF with the following information: The patient’s most recent hospice plan of care - The patient’s hospice election form and any advance directives - The physician certification of the patient’s terminal illness - The names and contact information of hospice staff involved in the care of the patient - Information on the hospice medications for the patient - Orders from the hospice physician and attending physician, if any, for the patient. At HV#2 the surveyor observed that the SNF had not yet received this information for a patient admitted four days prior to this visit. According to the Administrator this should have been given to the facility at today’s visit.