Every finding on record at Traditions Hospice of Winfield, LLC

Observed in Record Review. In 14 of 14 patient records reviewed, for active hospice patients, the nurse surveyor noted that the goals were not measurable. For example, “Facility staff will verbalize understanding of measures to prevent bleeding.” “ Caregiver will verbalize understanding of nonverbal indicators of pain.” Additionally, all time frames for completion were either for the end of Hospice service or did not have a completion date at all. All findings were discussed and verified with the RN Clinical Team Manager, Executive Director over Illinois, the Regional Clinical Director, and the V.P. of Clinical Operations. Observed in Record Review. In 4 of 4 patient records reviewed, the noted that the organization did not ensure the individualized plan of care included all required information related to patient goals. For example, in HOSRRHV#3, HOSRRHV#4, HOSRRHV5 and HOSRRHV6, goals for all ordered disciplines did not include an expected to be achieved time frame. For example, Patient/caregiver will verbalized understanding off potential skin breakdown. “Patient at risk for skin integrity will maintain skin integrity. This was reviewed and discussed with the agency’s Clinical Team Leader, Regional Clinical Director and VP of Operations. Observed in Record Review. In 14 of 14 patient records reviewed, for active hospice patients, the nurse surveyor noted that the goals were not measurable. For example, “Facility staff will verbalize understanding of measures to prevent bleeding.” “ Caregiver will verbalize understanding of nonverbal indicators of pain.” Additionally, all time frames for completion were either for the end of Hospice service or did not have a completion date at all. All findings were discussed and verified with the RN Clinical Team Manager, Executive Director over Illinois, the Regional Clinical Director, and the V.P. of Clinical Operations.

Observed in Record Review. In 1 of 20 patient records reviewed, for active records, it was noted by the nurse surveyor that orders were not clear or complete. For HOSRRHV#1, the medication orders were unclear. Acetaminophen 320mg 2 tabs tid was ordered for pain, there was an additional order for Acetaminophen 320mg 2 tabs was ordered prn for pain ordered along with an order for prn Acetaminophen suppositories, the order was unclear when the PRN doses should be given. Finding was discussed with the Executive Director Over Illinois. Observed in Record Review. In 1 of 20 patient records reviewed, for active records, it was noted by the nurse surveyor that orders were not clear or complete. For HOSRRHV#1, the medication orders were unclear. Acetaminophen 320mg 2 tabs tid was ordered for pain, there was an additional order for Acetaminophen 320mg 2 tabs was ordered prn for pain ordered along with an order for prn Acetaminophen suppositories, the order was unclear when the PRN doses should be given. Finding was discussed with the Executive Director Over Illinois.

Observed in Data Tracer. The organization had not documented performance improvement projects, the reasons for conducting the projects and the measurable progress achieved on them. This was evidenced by the lack of an improvement project identified for the Decatur (FOP) branch. This was discussed with the VP of Operations.

Observed in Record Review. In 3 of 19 patient records reviewed, for patients with a hospice aide, it was noted by the nurse surveyor that the hospice aide care plans did not include the information necessary for the hospice aide to effectively care for the patients. For HOSRRHV#1 (Peoria office), there were no instructions to notify the nurse for a change in the patient’s condition or for skin breakdown. For HOSRRHV#2 (Peoria Office), the patient had an elbow abrasion covered by an elbow pad. There were no instructions to the hospice aide as to what she should do regarding the elbow pad (remove or not remove) during the bath. Additionally, there were no instructions to notify the nurse for a change in the patient’s condition or increased or new skin breakdown. For HOSRRNHV#10 (Decatur Office), the patient was on continuous oxygen and there were no orders as to what to do with the oxygen during the patient’s shower nor when to notify the registered nurse. Findings were discussed and verified with the RN Clinical Team Manager, Executive Director over Illinois, the Regional Clinical Director, and the V.P. of Clinical Operations. Observed in Record Review. In 3 of 19 patient records reviewed, for patients with a hospice aide, it was noted by the nurse surveyor that the hospice aide care plans did not include the information necessary for the hospice aide to effectively care for the patients. For HOSRRHV#1 (Peoria office), there were no instructions to notify the nurse for a change in the patient’s condition or for skin breakdown. For HOSRRHV#2 (Peoria Office), the patient had an elbow abrasion covered by an elbow pad. There were no instructions to the hospice aide as to what she should do regarding the elbow pad (remove or not remove) during the bath. Additionally, there were no instructions to notify the nurse for a change in the patient’s condition or increased or new skin breakdown. For HOSRRNHV#10 (Decatur Office), the patient was on continuous oxygen and there were no orders as to what to do with the oxygen during the patient’s shower nor when to notify the registered nurse. Findings were discussed and verified with the RN Clinical Team Manager, Executive Director over Illinois, the Regional Clinical Director, and the V.P. of Clinical Operations. Observed in Patient Home. In 1 of 6 home visits conducted, it was noted by the nurse surveyor that the patient was on continuous oxygen and the care plan did not address whether the oxygen could be removed for the bath was not a useful medication list in the home. This was reviewed and discussed with the agency’s Clinical Team Leader, Regional Clinical Director and VP of Operations.

Observed in Document Review. The organization's volunteer staff did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff. The volunteers' hours comprised 1.83% (all 3 branches combined) of all paid hours. This finding was discussed with the volunteer coordinators at the time of discovery.

Observed in Patient Home. In 1 of 6 home visits conducted, it was noted by the nurse surveyor that the medication profile was inaccurate. For HOSRRNHV#1, during the visit, the patient asked the nurse where her hemorrhoid cream was, the nurse replied that the patient had run out of it. The nurse assured the patient that she would talk to the patient’s daughter to pick up some more. The Medication Profile did not include the hemorrhoid cream. Findings were discussed and verified with the RN Clinical Team Manager, Executive Director over Illinois, the Regional Clinical Director, and the V.P. of Clinical Operations. Observed in Patient Home. In 1 of 6 home visits conducted, it was noted by the nurse surveyor that the medication profile was inaccurate. For HOSRRNHV#1, during the visit, the patient asked the nurse where her hemorrhoid cream was, the nurse replied that the patient had run out of it. The nurse assured the patient that she would talk to the patient’s daughter to pick up some more. The Medication Profile did not include the hemorrhoid cream. Findings were discussed and verified with the RN Clinical Team Manager, Executive Director over Illinois, the Regional Clinical Director, and the V.P. of Clinical Operations.

Observed in Record Review. In 1 of 11 patient records reviewed, for active patients, the nurse surveyor noted that for HOSRR#10PEP, the Chaplain did not complete the comprehensive assessment within five calendar days of the election of hospice care. There was no documentation in the electronic medical record to indicate why this was not completed within the required timeframe. Finding was verified by the Executive Director.

Observed in Record Review. In 11 of 11 patient records reviewed, for active hospice patients the nurse surveyor noted that the goals were not measurable. For example, “Indwelling urinary catheter will remain in patient,” and “Patient/caregiver will feel relief from spiritual concerns.” Additionally, there were no short-term goals at start of care to address issues of immediate needs such as understanding medication management, symptom management, pain management, mobility, or safety, most did not have a timeframe for completion. Findings were verified by the Branch Director and the Executive Director.

Observed in Record Review. In 1 of 11 patient records reviewed, for active patients, it was noted by the nurse surveyor that the plan of care did not contain the information necessary to meet the patient’s needs. For HOSRR#11PEP the plan of care did not include a complete order regarding the type, diameter, and balloon size of the foley catheter to be inserted, how often to change it, and specific protocol for irrigating it needed. Findings were verified by the Branch Director and the Executive Director.

Observed in Tracer Activities. During bereavement record review for Forsyth, the administrator confirmed that the plan of care had not been followed after the first post death visit by the chaplain. Observed in Tracer Activities. During bereavement record review for Winfield, the administrator confirmed that the plan of care had not been followed after the first post death call and visit by the chaplain. Observed in Tracer Activities. During bereavement record review for Peoria, the administrator confirmed that the plan of care had not been followed after the first month post death. Specifically, they did not complete the phone calls or visits required for moderate risk at two months, three months, four months and six months.

Observed in Patient Home. In 3 of 4 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned per policy “Hand Hygiene – IC15 Policy and Procedure” and “Bag Technique - IC60 Policy and Procedure”. For example, during HOSHV#1/RR#1WNP the Hospice Aide grabbed clean linens out of the linen closet on the way to the patient room without hand sanitizing. Once in the patient room, she then washed her hands with soap and water and donned gloves. She then set everything up to give the patient a bath. She did change gloves prior to starting the bath but did not hand sanitize between glove changes per policy. During HOSHV#2/RR#2WNP the skilled nurse did not consistently perform hand hygiene between glove changes per policy. Additionally, she did not clean her scissors prior to returning them to her nursing bag. The Branch Director was present during the visits and observed the infection control breaches. During HOSHV#4/RR#4FOP the social worker washed her hands upon entering the nursing home, then missed opportunities to hand sanitize prior to sitting down to talk to the patient and after leaving the patient to document. The hospice aide who was also present with the patient assisting her was noted to have artificial nails that violated agency policy. The Executive Director for the Northern Part of the State was present during the visit and observed the infection control breaches.

Observed in HR File Review. In 1 of 15 HR records review, the Forsyth Bereavement Coordinator's (also a chaplain) file did not have experience or education in grief or loss counseling. This was confirmed with the regional HR representative. Observed in HR File Review. In 1 of 15 HR records review, the Bereavement Coordinator's (also a chaplain) file did not have experience or education in grief or loss counseling. This was confirmed with the regional HR representative.

Observed in Tracer Activities. During bereavement record review for Winfield, the administrator confirmed that the record did not have the anticipatory (pre-death) risk assessment.

Observed in HR File Review. In 1 of 15 HR records review, the backup Winfield Medical Director did not have competencies for the year 2022 as required by the organization's annual competency policy. This was confirmed with the regional HR representative.

Observed in Tracer Activities. At the time of survey, the organization was not able to show how they were evaluating contracted services in relation to the organization's expectations in 4 of 4 contracts reviewed. The administrator confirmed this observation.

Observed in HR File Review. In 1 of 15 HR records review, the Peoria nurse's license had not been validated through primary source verification upon hire.