Every finding on record at Traditions Hospice of Seminole, LLC

Observed in Record Review. In 1 of 1 patient records reviewed with discharge for extended prognosis, During D/C# 2's patient record review it was noted the organization had not ensured it respected the patient's right to participate in decisions about their care, treatment, or services For example: review of D/C# 2's patient record revealed D/C# 2 was discharged due to extended prognosis. Further review of D/C# 2's patient record revealed no documentation of a Notice of Medicare Non-Coverage (NOMNC). This was reviewed, discussed, and validated with the Branch Manager.

Observed in Record Review. In 2 of 6 patient records reviewed with wound, During RRHV# 3 and RRNHV# 6's patient records review it was noted the organization had not ensured staff followed the organization policy Wound Assessment, Document Number 213 that included wound measurements and appearance of the wound bed, periwound tissue, odor, and drainage weekly. For example: review of RRHV# 3's patient record revealed documentation that RRHV# 3 had a terminal diagnosis of skin cancer of the left ear with an open lesion. Review of RRHV# 3's patient record revealed wound measurements five days after the start of care and the next documented wound measurement was dated approximately 26 days later. Review of RRHV# 3's skilled nurse visit notes revealed the wound had been inactivated approximately 70 days prior to the surveyor review of the record with two documented wound measurements over the last 70 days. Further review of RRHV# 3's patient record revealed the Skilled Nursing Facility continued to provide wound care during the last 70 day. Review of RRNHV# 6's patient record revealed a wound to the coccyx at start of care. Further review of RRNHV# 6's patient record revealed no wound measurements for 23 days. This was reviewed, discussed, and validated with the Branch Manager and Clinical Team Lead.

Observed in Record Review. In 14 of 14 patient records reviewed, During RRHV# 1, RRHV# 2, RRHV# 3, RRHV# 4, RRNHV# 1, RRNHV# 2, RRNHV# 3, RRNHV# 4, RRNHV# 5, RRNHV# 6, RRNHV# 7, RRHV# 8, RRNHV# 9, and RRNHV# 10's patient records review it was noted the organization had not ensured the plan of care was based on the patients' goals and the time frames, setting, and services required to meet those goals. For example: review of the patients' plans of care revealed the same goals that included pain will be managed at a level acceptable to the patient with no indication what each individual patient's acceptable level of pain was. Further review of the patients plans of care revealed Patient will have safety needs met with no indication what safety need. RRNHV# 1 had a Pleurx in place, RRNHV# 2 has a G-tube and was bed bound, and all the patients were assessed as fall risks. In addition, review of the recertification plans of care revealed goals for Medical Social Worker and/or Chaplain to develop a plan of care and no goals for the patients. This was reviewed, discussed, and validated with the Branch Manager.

Observed in Record Review. In 2 of 14 patient records reviewed, During RRNHV# 1 and RRNHV# 9's patient records review it was noted the organization had not ensured the patient's plan of care included all services needed for the palliation and management of the terminal illness and related conditions to include medications and treatments necessary to meet the patient's needs. For example: review of RRNHV# 1's patient record revealed a start of care RN comprehensive assessment with documentation RRNHV# 1 had a Pleurx drain in place in the right upper quadrant (RUQ). Further review of RRNHV# 1's patient record revealed five skilled nurse visits with documentation the nurse drained the Pleurx and completed dressing changes to the Pleurx. Review of the plan of care revealed no documentation of a Pleurx drain or Pleurx drain dressing change. Review of the physician orders revealed an order to drain the Pleurx for comfort dated 19 days after the start of care and after the five skilled nursing visits were completed. Review of RRNHV# 9's patient record revealed a start of care RN comprehensive assessment dated 325 days prior to the surveyor review of the record with documentation that RRNHV# 9 had a terminal diagnosis of pancreatic cancer. Further review of the start of care RN comprehensive assessment revealed RRNHV# 9 was diabetic and performed blood sugar finger sticks daily for insulin administration. Review of the medication profile revealed an order Levemir U-100 20 units administer per directions per sliding scale, dated 325 days prior to the surveyor review of the record. Further review of RRNHV# 9's patient record revealed no documentation of a sliding scale or clarification regarding 20 units or sliding scale. This was reviewed, discussed, and validated with the Branch Manager and Clinical Team Lead.

Observed in Record Review. In 2 of 3 bereavement patient records reviewed, During RRBR# 1 and RRBR# 3's patient records review it was noted the organization had not ensured it provided care, treatment, or services according to the patient's individualized plan of care. For example: review of RRBR# 1's post death bereavement assessment revealed RRBR# 1 was assessed as high risk. Review of RRBR# 1's bereavement plan of care revealed the interventions for a visit at two weeks post death, a follow up visit one month post death, a visit three months post death, and a call four months post death. Review of RRBR# 1's patient record revealed RRBR# 1's day of death was approximately five months prior to the surveyor review of the record. Further review RRBR# 1's patient record revealed no documentation of a visit at two weeks post death, a follow up visit one month post death, a visit three month post death, or a phone call four months post death. Review of RRBR# 3's patient record revealed RRBR# 3's day of death was approximately two months prior to the surveyor review of the record. Review of RRBR# 3's bereavement post death risk assessment revealed a minimal risk. Review of RRBR# 3's bereavement plan of care revealed the intervention of a phone call 72 hours post death. However, review of RRBR# 3's patient record revealed the 72-hour phone call was completed seven days post death. This was reviewed, discussed, and validated with the Branch Manager and Clinical Team Lead. Observed in Record Review. In 1 of 14 patient records reviewed, During RRNHV# 2's patient record review it was noted the organization had not ensured it provided care, treatment, or services according to the patient's plan of care. For example: review of RRNHV# 2's patient record revealed a wound care order to clean the right and left buttock wound and apply Calmoseptine. However, review of the skilled nurse visit notes revealed wound care was provided and Calazime was applied. This was reviewed, discussed, and validated with the Branch Manager.

Observed in Patient Home. In 4 of 4 home visits conducted, During RRHV# 1, RRHV# 2, RRHV# 3, RRHV# 4's home observations it was noted the organization had not ensured staff followed the organization's policies Hand Hygiene” and Bag Technique that included, hand hygiene would be performed prior to entering the bag, after removing gloves, rubbing hands until the hand sanitizer is completely dry, and using soap and water or hand sanitizer to perform hand hygiene. For example: during RRHV# 1's home observation the LPN shared she did not have hand soap, paper towels, or hand sanitizer and used alcohol wipes to clean her hands. During the home observation the LPN used alcohol wipes to wipe her hands. The LPN was observed cleaning the vital sign equipment and then continued to assess the patient without wiping her hands with alcohol wipes and entered the nurse bag to retrieve the alcohol wipes throughout the observation. During RRHV# 2's home observation the Home Health Aide (HHA) was observed leaving the RRHV# 2's room with gloves on and came back with no gloves on. The HHA was observed putting hand sanitizer into the hands and rubbed the hands together then shook the hands to dry the alcohol prior to putting on the new gloves. During RRHV# 3's home observation the LPN was observed entering the bag multiple times without performing hand hygiene. In addition, the LPN was observed assessing the patient then charting on the phone without performing HH and then continuing to assess the patient without performing hand hygiene after touching the phone on multiple occasions. During RRHV# 4's home observation the registered nurse (RN) was observed assessing RRHV# 4 and then removing gloves and then picking up the tablet to chart without performing hand hygiene after removing gloves. This was observed, discussed, and validated with the Clinical Team Lead. Observed in Patient Home. In 2 of 3 home visits conducted with medical equipment, During RRHV# 3 and RRHV# 4's home observations it was noted the organization had not ensured staff followed the organization policy “Bag Technique” that included cleaning reusable equipment with alcohol, disinfectant wipe and/or antimicrobial soap and water as appropriate, to reduce the risks of infections associated with medical equipment, devices, and supplies. For example: during RRHV# 4's home observation the registered nurse (RN) was observed wiping down the stethoscope, electronic B/P cuff, pulse oximetry, and thermometer with a Good and Clean Disinfectant Wipe. The RN shared she had purchased the wipes. Review of the manufacturers IFU revealed the product was approved for hard non-porous surfaces only. During RRHV# 3's home observation the licensed practical nurse (LPN) was observed using a phone to chart findings during the home visit. The phone was not cleaned prior to use, during use, or prior to leaving RRHV# 3's room. The LPN shared that the phone was cleaned three or four times during the day. This was observed, discussed, and validated with the Clinical Team Lead.

Observed in Record Review. In 10 of 11 patient records reviewed with Hospice Aide, During RRHV# 1, RRHV# 2, RRHV# 3, RRHV# 4, RRNHV# 1, RRNHV# 2, RRNHV# 3, RRNHV# 4, RRNHV# 5, and RRNHV# 6's patient records review it was noted the organization had not ensured the registered nurse (RN) who is a member of the interdisciplinary group is responsible for hospice aide supervision prepared complete written patient care instructions for the hospice aide. For example: during RRHV# 1's the home observation RRHV# 1 shared the bilateral hearing aids needed new batteries and removed the bilateral hearing aids for the licensed practical nurse (LPN) to change the batteries. Review of RRHV# 1's patient record revealed patient written instructions for the hospice aide that included the task of shower. Further review of the patient written instructions revealed no documentation that RRHV# 1 had hearing aids or if the hearing aids needed to be removed prior to showering. During RRHV# 2’s home observation the hospice aide was observed transferring RRHV# 2 with the assistance of the skilled nurse facility aide with the use of a gait belt. Review of RRHV# 2’s patient record revealed documentation that RRHV# 2 was unable to bear weight for transfers. Review of RRHV# 2’s patient written instructions revealed no documentation regarding transfer instructions. Review of RRHV# 3’s patient record revealed RRHV# 3 had a wound to the left ear with a dressing. Review of RRHV# 3’s patient written instructions revealed the task of a shower with no documentation regarding the wound or wound dressing. Review of RRHV# 4’s patient record revealed RRHV# 4 was on continuous oxygen at 2-4 lpm. Review of RRHV# 4’s patient written instructions revealed the task of a shower with no documentation regarding the use of oxygen or if the oxygen should be removed during the shower. Review of RRNHV# 6's patient record revealed RRNHV# 6 had a wound to the coccyx with a border dressing. Review of RRNHV# 6's patient written instructions revealed the task of shower with no documentation regarding the wound or the wound dressing. Review of RRNHV# 5's patient record revealed RRNHV# 5 was on continuous oxygen at 2-4 lpm. Review of RRNHV# 5's patient written instructions revealed the task of a shower with no documentation that RRNHV 5 was on continuous oxygen or whether to remove the oxygen for the shower. Review of RRNHV# 4's patient record revealed RRNHV# 4 had a stage IV pressure ulcer to the coccyx with and dressing. Review of RRNHV# 4's patient written instructions revealed the task of a bed bath with no documentation of a wound or a dressing. Review of RRNHV# 3's patient record revealed documentation the RRNHV# 3 was to be transferred with a Hoyer lift. Review of RRHV# 3's patient written instructions revealed no documentation of a Hoyer lift. Review of RRNHV# 2's patient record revealed RRNHV# 2 had a G-tube. Review of RRNHV# 2's patient written instructions revealed the task of a bed bath with no documentation regarding the G-tube or directions regarding the head of the bed height. Review of RRNHV# 1's patient record revealed RRNHV# 1 had a Pleurx drain inserted in the right upper quadrant. Review of RRNHV# 1's patient written instructions revealed the task of bed bath with no documentation of a Pleurx drain. This was observed, reviewed, discussed, and validated with the Clinical Team Lead and Branch Director.

Observed in Patient Home. In 2 of 3 home visits conducted with mediation reconciliation, During RRHV# 1 and RRHV# 4's home observations it was noted the organization had not ensured the patient's records included information that reflected the patients' care, treatment, or services. For example: review of RRHV# 1's assisted living facility (ALF) medication administration record (MAR) revealed Lasix 20mg daily and the organization's medication list revealed Lasix had been discontinued approximately 12 days prior to the surveyor’s home observation. In addition, the ALF staff asked if the potassium should also be daily since the Lasix is daily and the organization's list revealed that the potassium was discontinued at the same time as the Lasix. During RRHV# 4's home observation the registered nurse (RN) was observed completing a medication reconciliation. During the medication reconciliation it was noted the organization's medication list was inaccurate, as RRHV# 4 shared she had not taken alendronate 70 mg weekly since admission to hospice approximately 14 months prior to the home observation. In addition, RRHV# 4 was taking Clopidogrel 75mg daily for approximately the last two months. This was observed, discussed, and validates with the Clinical Team Lead. Observed in Record Review. In 1 of 14 patient records reviewed, During RRHV# 2's patient record review it was noted the organization had not ensured the patient's record included information that reflected the patient's care, treatment, or services. For example: review of RRHV# 1's election of benefit (EOB) revealed it had been signed by the patient's representative approximately seven months prior to the surveyor review of the record. Further review of the EOB revealed no documentation of the diagnosis, name of the hospice or the EOB date as this lines were all blank. This was reviewed, discussed, and validated with the Branch Director and Clinical Team Lead.

Observed in Record Review. In 13 of 14 patient records reviewed, During RRHV# 1, RRHV# 2, RRHV# 3, RRHV# 4, RRNHV# 1, RRNHV# 2, RRNHV# 3, RRNHV# 4, RRNHV# 6, RRNHV# 7, RRNHV# 8, RRNHV# 9, and RRNHV# 10's patient records review it was noted the organization had not ensured all entries in to the patient record were appropriately authenticated with currently accepted standards of practice and organization policy Verification of Physician Licensure and Order that included The individual receiving the order must record and sign it immediately and have the prescribing person sign it in accordance with state and federal regulations... For example: review of RRHV# 1, RRHV# 2, RRHV# 3, RRHV# 4, RRNHV# 1, RRNHV# 2, RRNHV# 3, RRNHV# 4, RRNHV# 6, RRNHV# 7, RRNHV# 8, RRNHV# 9, and RRNHV# 10's Medical Director's verbal order Certificate of Terminal Illness (CTI) revealed documentation that the admission registered nurse received the verbal order CTI. However, the signature line Verbal Certificate Taken By was not signed by the admission nurses it was signed by the Branch Director or the Clinical Team Lead. This was reviewed, discussed, and validated with the Branch Director and Clinical Team Lead.

Observed in Patient Home. In 2 of 2 home visits conducted in a SNF, During RRHV# 2 and RRHV# 3's home observation it was noted the organization had not ensured the most current plan of care for the patient were provided to the Skilled Nursing Facility (SNF). For example: review of RRHV# 2's hospice binder in the SNF revealed an initial plan of care that ended approximately 132 days prior to the surveyor home observation and an update to the plan of care dated 168 days prior to the surveyor home observation. Review of RRHV# 3's hospice binder in the SNF revealed an updated plan of care and a medication list dated approximately 25 days prior to the surveyor home observation. This was reviewed, discussed, and validated with the Clinical Team Lead.

Based on record review and interview, the hospice failed to ensure the plan of care was fully developed to include all services necessary for the palliation and management of the terminal illness for three (Patient #4, 5 and 6) of 11 patients reviewed. Findings: Patient #4 A review of the plan of care dated 10/30/21 to 01/27/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #5 A plan of care dated 01/04/22 to 04/03/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #6 A plan of care dated 11/30/21 to 02/27/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. On 03/10/22 at 11:20 am, Staff A and B stated the plans of care for Patients #4, 5 and 6 failed to include services necessary for the palliation and management of the terminal illness.