Every finding on record at Traditions Hospice of Portland, LLC

Observed in Record Review. In 2 of 3 patient records reviewed, The surveyor found in 2/3 records reviewed that the organization had not measured wounds weekly as required by HCO policy. The surveyor reviewed 3 records with wounds and 2/3 records reviewed with wounds did not have wound measurements. The dates of issue related to lack of documented wound measures were between 12/15/2023 and 1/5/2024. The surveyor discussed and confirmed the issue with organization leaders.

Observed in Record Review. In 10 of 19 patient records reviewed, the organization did not ensure that comprehensive assessments and reassessments adequately evaluated patients' needs for care and services. For example, in RRHV#1 an RN did not document the presence of an indwelling foley catheter, nor a feeding tube. And the stoma was not evaluated. In RRNHV#1 an RN documented that a wound on the left side of the patient’s jaw was open through to the mouth cavity. Measurements were not recorded. In RRHV#4, RRNHV#2, RRNHV#3, RRNHV#5, RRNHV#8, RRBR#1, RRBR#2, and RRBR#3 bereavement, psychosocial, and/or spiritual assessments were not documented. This RFI was reviewed with the Administrator, Clinical Specialist, and Branch Director.

Observed in Proficiency Testing. In 2 of 19 patient records reviewed, the organization did not document completion of the initial comprehensive assessment within five days of election of the hospice benefit. For example, in RRNHV#1, and RRNHV#8 bereavement, psychosocial and/or spiritual assessments were not documented within the specified time frame. This RFI was reviewed with the Administrator, Clinical Specialist, and Branch Director.

Observed in Record Review. In 15 of 19 patient records reviewed, where the interdisciplinary group met two or more times for patients receiving services, the organization did not update comprehensive assessments to reflect changes that occurred since the initial assessment. Interdisciplinary notes did not consistently document patient decline, for example, decreased ambulation, decreased appetite, weight loss, or use or change in use of opioids; progress toward goals; and plans for the next two weeks. These omissions were noted in records RRHV#2, RRHV#3, RRHV#4, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#9. RRNHV#10, RRDC#1, and RRBR#3. This RFI was reviewed with the Administrator, Clinical Specialist, and Branch Director.

Observed in Record Review. In 19 of 19 patient records reviewed, the organization did not develop plans of care that were based on patient’s goals and the time frames, settings, and services required to meet those goals. In all records reviewed most goals were not specific, measurable, and did not identify targeted dates for completion. For example: Pain will be managed at a level acceptable to the patient; patient/caregiver will have decreased fear/anxiety regarding death and dying process; laboratory results will guide hospice IDT in the provision of providing comfort care and system management; patient/caregiver will express an increased sense of closure and peacefulness at the end of life; caregiver will experience a sense of accomplishment at having supported the dying person; medications will be managed appropriately as evidenced by steady symptom control. And few identified when completion would occur. This RFI was reviewed with the Administrator, Clinical Specialist, and Branch Director.

Observed in Record Review. In 1 of 19 patient records reviewed, the plan of care did not include all medications and treatments necessary to meet the patient’s needs. For example, in record RRHV#3, and RRNHV#2 an RN documented in the initial comprehensive nursing assessments that these patients were using oxygen, however, there were no orders found in the plans of care. This RFI was reviewed with the Administrator, Clinical Specialist, and Branch Director.

Observed in Record Review. In 2 of 3 patient records reviewed, the organization did not provide services according to the individualized plan of care. In RRBR#1 bereavement services were provided for just three months. In RRBR#2 no bereavement services were provided. There was no documentation that families requested the service to end. This RFI was reviewed with the Administrator, Clinical Specialist, and Branch Director.

Observed in Tracer Activities. leaders did not manage implementation of patient care policies and procedures governing the provision of care. Documentation failures were identified in the following: required assessments and reassessments; plan of care revisions; patient goals; and provision of bereavement services. This RFI was reviewed with the Branch Director and reviewed with the Administrator and Clinical Specialist.

Observed in Record Review. In 1 of 19 patient records reviewed, the patient record did not contain the following clinical information: - A list of medications, including dose, strength, frequency, route, date and time of administration. In record RRHV#1 Morphine Sulfate concentrate 20mg/ml to be given orally was listed. There were additional directions to give the drug via peg tube every hour as needed for pain, which contradicted the oral route of administration. The documentation should have instructed that the drug be given by sublingual route. This RFI was validated by the Clinical Specialist and Branch Director.

Observed in Record Review. In 1 of 19 patient records reviewed, the organization did not ensure that all entries in the patient record were complete, and appropriately authenticated in accordance with organization policy, and currently accepted standards of practice. For example, in record RRHV#3 the Election of Benefits was not signed by a clinician. This RFI was reviewed with the Administrator, Clinical Specialist, and Branch Director.

Observed in Patient Home. In 1 of 4 home visits conducted, the organization 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 and recertification of the patient’s terminal illness - The names and contact information of hospice staff involved in the care of the patient - Instructions on how to access the hospice’s 24-hour on-call system - Information on the hospice medications for the patient - Orders from the hospice physician and attending physician, if any, for the patient. During home visit RRHV#1 there was no folder containing the above information in the skilled nursing facility. The Administrator stated that he had never seen a folder for this patient. And at home visit RRHV#2 there also no folder for the surveyor to review in the foster home. The caregiver did not know where it was located. This RFI was reviewed with the Administrator, Clinical Specialist, and Branch Director.

Based on interview and medical record review, it was determined the agency failed to include individualized measurable outcomes anticipated from implementing and coordinating the plan of care for 19 of 19 patient care plans reviewed (Patients #1- #19). --- Findings: 1. Review of the medical records of Patients #1, #3, #4, #5, #7, #8, #13, and #16 revealed a document titled "Hospice POC Report." A section of this document titled "Pathway: HOSPICE CHAPLAIN," listed a care goal of "PATIENT/CAREGIVER EXHIBIT IMPROVED COPING STATEGIES [sic]/SKILLS." The care plan lacked individualized information regarding what "EXHIBIT IMPROVED COPING STATEGIES [sic]/SKILLS" meant for each patient and how this goal would be measured. 2. Review of the medical records of Patients #10, #11, #13, #15, and #18 revealed a document titled "Hospice POC Report." A section of this document titled "Pathway: HOSPICE SKILLED NURSING," listed a care goal of "PATIENT'S CONSTIPATION IS CONTROLLED." The care plan lacked individualized information regarding how constipation is or would be controlled and how this goal would be measured for each patient. 3. Review of the medical records of Patients #2, #6, #7, #9, #10, #11, #12, #15, #18, and #19 revealed a document titled "Hospice POC Report." A section of this document titled "Pathway: HOSPICE SKILLED NURSING," listed care goals of " PAIN IS CURRENTLY MANAGED AT A LEVEL ACCEPTABLE TO PATIENT," "PATIENT/CAREGIVER UNDERSTANDS NEED TO REPORT CHANGES IN PAIN LEVEL TO HOSPICE STAFF," and "PATEINT/CAREGIVER UNDERSTANDS NEED TO REPORT INEFFECTIVE PAIN MANAGEMENT TO HOSPICE NURSE." The care plan lacked individualized information regarding what "LEVEL ACCEPTABLE TO PATIENT, CHANGES IN PAIN LEVEL," and "INEFFECTIVE PAIN MANAGEMENT" is to the patient, and how these goals would be measured. During the preliminary deficiencies review with the Administrator/Executive Director on 4/3/2023 at 10:00 AM the above findings were presented and discussed. The Administrator/Executive Director acknowledged the goal statements did not have measurable goals that were unique to the patient with the problem.

Based on review of education records for 6 hospice aides, it was determined that the agency failed to ensure that 4 of 6 Hospice Aides (Employees #14, #15, #17, and #18), received at least 12 hours of in-service training over a 12-month period. --- Review of the agency policy and procedure titled "Agency In-services," last reviewed on 10/01/2021, revealed, "Policy ... B. All Hospice Aides are required to have at least 12 hours of in-service training during each 12-month period. Training may be based on the individual's employment anniversary as long as the in-service training requirement is met ... Procedure ... Vl. An individual record of in-service attendance is maintained on each employee and is kept in the employee personnel file." Review of education records for 6 Hospice Aides (Employees #14 - #19) revealed that education records for 4 Hospice Aides (Employees #14, #15, #17, and #18) lacked the required 12 hours of in-service training during a 12-month period. During an interview with the Executive Director/Administrator on 04/03/2023 at 10:00 AM, they were informed that education records lacked the required 12 hours of in-service training during a 12-month period on several of the hospice aides. The Executive Director/Administrator stated that they may not have sent all of the records and additional time was requested to locate them. On 04/03/2023 at 11:40 AM and again on 04/04/2023 at 2:01 PM, additional education documentation was received via email. Education records on 5 of the 6 employees (Employees #14, #15, #16, #17, and #19) met compliance with the 12 hours of in-service training during a 12-month period. Education records for Employee #18 revealed they had 4 hours of in-service training from 04/2022 thru 03/2023. The education records lacked the required 12 hours of in-service training during a 12-month period.

Based on observation, interview, and document review, it was determined the Agency failed to provide documentation that demonstrates the requirements of this standard is met. --- Refer to Tag L0620.