Every finding on record at Tram Hospice Care, Inc

Observed in Record Review. On 1 of 1 records reviewed for discharge for extended prognosis, the organization failed to involve the patient in making decisions about their care. During record review of a patient with a discharge for cause diagnosis, the Hospice Nurse Surveyor observed the patient given the NOMNOC with information related to when their benefits for hospice would end due to extended prognosis but it was given and signed one day before discharge versus the minimum 2 day notice. This was discussed and reviewed with the Hospice Leadership Team and further education provided.

Observed in Patient Home. In 1 of 2 active record reviews, the hospice nurse surveyor noted medication assessment was not clear and accurate. On RRHV # 1 the physician''s orders in the plan of care documented Tylenol q 6 hours PO prn for mild/mod pain and Tylenol q 6 hours SUPP prn for mild/mod pain; however there was no indication when to use each of the duplicate therapy. The organization's policy Medication Profile documented that all duplicate therapy will be address duplicate therapy and include special instructions for use for the family. This was discussed and confirmed by Hospice Agency Leadership.

Observed in Record Review. In 1 of 2 active records reviewed, the organization failed to plan the patient's care. During record review for RRHV #1, it was noted that the goals were not measurable and specific to the patient. For example patient using oxygen for comfort yet the goal was not measurable or specific to the patient, it stated oxygen for optimal treatment. Reviewed and discussed finding and current progress with Hospice Leadership.

Observed in Patient Home. In 1 of 1 home visits conducted, the hospice nurse surveyor noted that the organization had not implemented its infection prevention and control activities. Agency policy (9-014.1) states equipment will be cleaned with alcohol or soap/water. On RRHV #1, the nurse surveyor observed that the RN cleaned her vital sign equipment with Clorox and did not observe the 4 minute wet time per manufacturer and did not follow agency policy to clean with alcohol or soap/water. This was discussed and confirmed by Hospice Agency Leadership.

Observed in Record Review. In 1 of 1 patient records reviewed with start of care after 11/3/23, During RR# 1's patient record review it was noted the organization had not ensured the registered nurse completed a patient-specific comprehensive assessment. For example: RR# 1's start of care was approximately seven days prior to the surveyor review of the record. Review of RR# 1's patient record revealed a blank RN start of care comprehensive assessment. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed with recertification, During RR# 2's patient record review it was noted the organization had not ensured patient and family goals were based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. For example: review of RR# 2's recertification plan of care and subsequent IDG/plan of care updates revealed all goals with the date at the end of the first certification. This was discussed, reviewed, and validated with the Administrator.

Observed in Record Review. The organization failed to implement its policies and procedures that guide and support patient services. During records review, documents review, and interviews, it was noted the organization had not implemented processes related to clinical records, specifically promptly documented and complete patient records. In addition, the organization had not ensured the registered nurse completed a start of care comprehensive assessment within five days. This resulted in Condition Level Deficiencies that included: 418.54 Initial and Comprehensive Assessment; and repeated 418.104 Clinical Records and 418.100 Organization and Administration. This was discussed and reviewed with the Administrator.

Observed in HR File Review. In 2 of 2 physician HR files reviewed, Review of HR# 1 and HR# 2's HR files revealed the organization had not ensured the Medical Director and alternate Medical Director had their competence assessed as part of the orientation to the organization. For example: review of the HR files revealed the organization had not completed initial competence assessment of the physicians. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed with recertification, During RR# 2 and RR# 3's patient records review it was noted the organization had not ensured the Medical Director or alternate Medical Director signed the certification of terminal illness (CTI) at the time of recertification. For example: review of RR# 3's patient record revealed a recertification CTI for the certification period beginning approximately three days prior to the surveyor review of the record with no documentation of a verbal order or a physician signature. Review of RR# 2's patient record revealed a recertification CTI with no verbal order and a physician signature dated the day of the new certification period. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. In 3 of 3 patient records reviewed, During RR# 1, RR# 2, and RR# 3's patient records it was noted the organization had not ensured entries into the patient record were complete and promptly documented. For example: review of RR# 1's patient record revealed an initial psychosocial assessment dated approximately six days prior to the surveyor review of the record with no signature. Further review of RR# 1's patient record revealed an initial bereavement assessment and spiritual care assessment dated approximately two days prior to the surveyor review of the record with no signatures. Review of RR# 2's patient record revealed 12/12 Skilled Nurse visit notes with no signatures since last survey or approximately 40 days. Review of RR# 3's patient record revealed a recertification RN comprehensive assessment dated approximately 19 days prior to the surveyor review of the record with no signatures. This was reviewed, discussed, and validated with the Administrator.

Observed in Tracer Activities. the organization failed to have a comprehensive emergency management program. During tracer activities for Emergency Management, the Hospice Nurse Surveyor observes the EOP listed the previous owner/ CEO as the leader for Administrator and Leader for Emergency Planning and listed a previous VP home as the back up location for office operations in case of an emergency. These individuals no longer work for the organization and the EOP was not updated to reflect the new leadership. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Tracer Activities. the organization failed to maintain a list of needed contacts it would need in the event of a disaster scenario. During tracer activities for Emergency Management, the Hospice Nurse Surveyor observed the EOP contained an employee call tree from the previous owners and staff. The organization had a recent ownership change and a complete staff change which was not reflected in the EOP. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 1 of 1 patient records reviewed, the organization failed to involve the patient in making decisions about their care. During record review for RRDC#1, the Hospice Nurse Surveyor observed the patient was not given the NOMNOC with information related to when their benefits for hospice would end due to extended prognosis. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. The organization failed to assess patient wounds. D The wound care was being documented but the assessment of the wound was not. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to assess and reassess its patient's. During home visits for RRHV#1 the Hospice Nurse Surveyor observed the hospice nurse had conducted a medication assessment previously but the organizational medication list contained medications that were in the home and expired. In RRHV#1, the caregiver stated that it's still okay to give to him. It was unclear if either patient was given the expired medications. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 2 of 3 patient records reviewed, the organization failed to assess and reassess its patient's. During record review for RRHV#1 and RRHV#2, the Hospice Nurse Surveyor observed assessments were not completed according to policy. For example in RRHV#1, the bereavement assessment was not documented or completed, the psychosocial assessment was only partially completed and documented and the volunteer needs was not assessed or documented. In RHV#2, the need for volunteer services was not assessed. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 12 of 12 patient records reviewed, the organization failed to plan the patient's care. During record review for all records, the Hospice Nurse Surveyor observed the plan of care goals were all to be achieved by the last day of the certification for all goals and all records. For example in RRHV#1, the patient had a goal of Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects. This goal was placed at SOC and the timeframes were extended into each certification with no updates to the goal. For RRHV#2, the patient had a goal for pain management with a goal date at the end of the first certification. In RRNHV#1, the patient had a goal of Pt/family/pcg will verbalize confidence in the management of patients pain with a goal target date at the end of the first certification. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 5 of 14 patient records reviewed, the organization failed to plan the patient's care. During record review for RRNHV#1, RRHV#2, RRHV#3, RRNVH#6, RRNHV#7, the Hospice Nurse Surveyor observed not all items needed were included in the Plan of Care. For example in RRNHV#1, the patient had a wound on the right medial back for which he was receiving wound care but the wound was not addressed on the Plan of Care. In RRHV#2, the patient had no mortuary picked out but this was not addressed on the POC. In RRHV#3, the patient had goals and interventions for skin breakdown but it was not updated to include the open pressure ulcers to the right heel and right lower leg. In RRNHV#6, the patient had a UTI, constipation and orders for eye medication from itching and dry eyes but these were not addressed on the POC. In RRNHV#7, the patient had increased pain, anxiety and showed decline last few days of life but the POC was not updated to reflect these items. For RRHV#3, the patient was taking Enalapril from a previous hospitalization but the hospice had Clonidine on the medication list ordered by the hospice physician. This had not been provided. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 1 of 2 patient records reviewed, the organization failed to provide care, treatment, or services. During record review for RRBR#2, the Hospice Nurse Surveyor observed the Bereavement Care Plan listed multiple mailings including one for the first month but no mailings were ever sent. The Bereavement Care Plan was not followed. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Tracer Activities. In 1 of 1 HR files reviewed, for an Aide, the organization failed to document ongoing education and training for its hospice aides. During tracer activities for document review, the Hospice Nurse Surveyor observed the organization had a training program in place, but the Aide had not participated in the training program and there was no documentation they received the necessary in-services. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 1 of 3 patient records reviewed, the organization failed to plan the patient's care. During record review for RRHV#1, the Hospice Nurse Surveyor observed the Aide Care Plan did not contain shaving but the HHA documented shaving during one visit. This was discussed and reviewed with the Hospice Leadership Team.

Observed in HR File Review. In 1 of 10 HR files reviewed, the organization failed to document orientation to staff. During HR file review, the Hospice Nurse Surveyor observed HR #9 ( volunteer) did not have documentation of orientation about the hospice philosophy. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Tracer Activities. The organization failed to review, approve, and manage the implementation of policies and procedures that guide and support patient services. During tracer activities and record reviews, the Hospice Nurse Surveyor observed the organization had not implemented processes related to regulation, law and policy. For example the organization had no process in place for notice of non-coverage at discharge, they had not alerted The Joint Commission of new ownership, the CLIA certificate was not updated related to the new Medical Director and the organization had no wound care policy or process in place. The organization also failed to follow the discharge summary policy related to who would write the discharge summary. This resulted in Condition Level Deficiencies. This was discussed and reviewed with the Hospice Leadership Team.

Observed in HR File Review. In 1 of 10 HR files reviewed, the organization failed to document orientation to staff. During HR file review, the Hospice Nurse Surveyor observed HR #9 ( volunteer) did not have documentation of orientation to specific policies and procedures, specific job duties or infection control. There was no documentation of orientation in the HR file. This was discussed and reviewed with the Hospice Leadership Team.

Observed in HR File Review. In 2 of 10 HR files reviewed, the organization failed to document staff competence. During HR file review for HR#1 and HR#2, the Hospice Nurse Surveyor observed the staff did not have documented 90 day competencies as required by the organizational policy. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 1 of 1 patient records reviewed, for aide services, the organization failed to maintain a complete and accurate patient record. During record review for RRHV#1, the Hospice Nurse Surveyor observed the Aide Care Plan stated vitals at every visit. The Aide was documenting that vitals completed but the vitals were not documented. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 1 of 1 patient records reviewed, the organization failed to provide a written discharge summary in accordance with their policy. During record review for RRDC#1, the Hospice Nurse Surveyor observed the discharge summary was written and signed off by office personnel and not by the Care Manager as required by organizational policy. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to have qualified staff receive and record verbal orders. During record review for all records, the office personnel were entering verbal orders for the DON and then the DON would sign. The policy states verbal orders will be spoken to, taken and documented only by professional, licenses hospice personnel. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to supervise patient's and families competency of administering medications. During home visits for RRHV#1 and RRHV#3, the Hospice Nurse Surveyor observed the caregivers were not competent to administer medications and there was not documentation to support their competency. For example in RRHV#1, the medication list contained Midodrine, Tylenol suppositories and Hycosamine which the patient was not currently taking. The medications were in the home and were all expired. The caregiver stated she would give the Midodrine for high blood pressure if needed because that doctor told me expiration dates don't matter. The LPN did remove the medications from the home and ordered new one's. In RRHV#3, the patient was also scheduled to take Seroquel 2x daily but the caregiver had been giving it PRN. The LPN did call the physician for new orders and the caregiver was to be educated at the next visit. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Patient Home. In 1 of 1 patient records reviewed, the organization failed to comply with law and regulation. During record review for RRDC#1, the Hospice Nurse Surveyor observed the organization did not have a process in place for managing or implementing the NOMNOC for discharge. The patient did not have an NOMNOC in place for discharge related to extended prognosis and during conversation with the Hospice Leadership Team they were unaware of the requirement. This was discussed and reviewed with the Hospice Leadership Team. Observed in Tracer Activities. The organization failed to update their CLIA certificate with the appropriate individual. During document review, the Hospice Nurse Surveyor observed the CLIA certificate contained the previous Medical Director. After conversation with the hospice new owner, the new owner stated they were waiting to submit the paperwork until the full change of ownership and change of location took place ( organization working on moving to a new location). The new Medical Director had been in place for 7 months. The governing body failed to provide oversight for policy implementation and licensure changes as evidenced by non-compliance with 418.100, 418.104, 418.116 and 418.56. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Individual Tracer. In 2 of 2 patient records reviewed, HV1, RR2, during the home visit and record review, the surveyor noted the organization had not demonstrated the written plan of care was based on the patient’s goals and the time frames, settings, and services required to meet those goals. For example, HV1, RR2, all goals had the time frame of achieving them as 90 days, regardless of the problem or goal. This was validated by the DPCS Designee.

Observed in HR File Review. In 2 of 2 hospice aide personnel files, HR3, HR6 during record review and personnel file review, the surveyor noted the organization failed to show evidence it had evaluated the following areas by observing the hospice aide's performance of the tasks with a patient or pseudo-patient as part of a simulation: Appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination; Safe transfer techniques and ambulation; Normal range of motion and positioning. For example, HR 3 clinical competency evaluation was noted to be in lab setting. However during discussion with the Administrator, Administrator designee and DPCS designee, they indicated it was a verbal discussion, not an observed evaluation. HR6, the personnel file noted the aide was observed on 4/3/21 in the patient's home. However, upon review of the patient record (aide plan date of 4/8/21), there was no documentation of onsite supervisory visits conducted with the aide. The supervisory visit notes in the patient record dated 4/19, 5/3, 5/17 and 5/31 stated the aide was not present during the supervisory visit. This was validated by the Administrator and DPCS designee.

Observed in Individual Tracer. In 1 of 1 home visits conducted, HV1, during the home visit and record review the surveyor noted the organization had not shown evidence it had provided overall coordination of the patient’s hospice care with the board and care caregivers including communication, coordination and education with the owner/nurse/caregiver and other providers participating in provision of care. For example, the caregiver at the home presented medications for the nurse to reconcile, however there were multiple duplicate medications and expired medications. Upon interview, the owner/medication nurse indicated they were stored with the hospice medications. In addition, during the discussion, the provider, stated she never accessed the Hospice home folder which contained current plan of care, orders, the current medication list, visit information documented by the hospice, as the folder belonged to hospice. In addition, the clinical notes and orders indicated the patient's bedtime Quetiapine had been increased three weeks prior to the visit, however the owner/medication nurse stated she had just learned about the change and implemented the new medication five days prior to the visit. This discrepancy in communication and coordination was validated by the DPCS designee and the hospice nurse.

Observed in HR File Review. HR 5 during the personnel file review, the surveyor noted the organization had not shown evidence it verified and documents the credentials of the Chaplain. For example there was no verification by telephone or secured electronic file obtained upon hire by the organization. This was validated by the Administrator.

Observed in Leadership Session. In 1 of 19 vaccinated employees, During review of COVID policies and personnel files and discussion with the Administrator designee, the surveyor noted the organization failed to provide care, treatment, or services in accordance with licensure requirements, laws, and rules and regulations. For example, the organization did not show evidence to had complied with the 100% vaccinated staff or accepted religious exemption by February 28, 2022. The organization failed to demonstrate it had requested documentation from employee requesting religious exemption or that documentation had been completed and returned for Governing Body approval by February 28, 2022. In addition, there was no process in place to track the weekly testing required by the organization for the unvaccinated employee. This was validated by the Administrator Designee.