Every finding on record at Tranquil Hospice, Inc.

Observed in Individual Tracer. In 8 of 8 patient records reviewed, The hospice nurse surveyor noted (RRHV#1) that the plan of care did not include any diet orders since the patient was admitted in October. The surveyor confirmed with the nurse that the patient was on a mechanical soft diet. Also, the surveyor noted that the other four active records (RRNHV#2-5) did not have any diet orders. In (RRNHV#5), the patient was diabetic and on both Metformin and Januvia; however, there was no information about dietary needs or restrictions. Also, there were no diet orders in the records for three discharged (RRNHV#6-8) patients. In discussion with the alternative administrator, the diet orders were not populating to the plan of care, and therefore were not reviewed by the physician and IDG.

Observed in Document Review. In 3 of 3 contracts reviewed, The hospice nurse surveyor noted that the DME contract included an addendum that listed the required elements of the contract agreement as stated in the standard; however, it did not include any specific information about the services to be provided, the manner in which the services will be coordinated, supervised and evaluated by hospice or a description of the role of both the hospice and the contractor. This was confirmed with the alternate administrator. Observed in Document Review. The hospice nurse surveyor noted that the SNF/NF contract included an addendum that listed the required elements of the contract agreement as stated in the standard; however, it did not include any specific information about the manner in which the services will be coordinated, supervised and evaluated by hospice. This was confirmed with the alternate administrator. Observed in Document Review. The hospice nurse surveyor noted that the Pharmacy contract included an addendum that listed the required elements of the contract agreement as stated in the standard; however, it did not include any specific information about the services to be provided, the manner in which the services will be coordinated, supervised and evaluated by hospice or a description of the role of both the hospice and the contractor. This was confirmed with the alternate administrator.

Observed in Document Review. In 1 of 3 contracts reviewed, The hospice nurse surveyor noted that the addendum to the written agreement did not describe the manner in which the SNF, NF, or ICF/IID and the hospice will communicate with each other and will document the communications to make sure the needs of the patients are met 24 hours a day. This was confirmed with the alternate administrator.

Observed in Emergency Management Session. The organization’s communications plan did not includes a method for sharing and/or releasing location information and medical documentation for patients under the organization’s care to the following individuals or entities, in accordance with law and regulation: Patient’s family, representative, or others involved in the care of the patient; Disaster relief organizations and relevant authorities; Other health care providers. This observation was reviewed with the Alternate Administrator. Observed in Emergency Management Session. The organization’s plan for providing patient care and clinical support did not include written procedures and arrangements with other health care providers for how it will share patient care information and medical documentation and how it will provide transportation to other health care facilities to maintain continuity of care. This observation was reviewed with the Alternate Administrator.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization failed to ensure the plan of care reflect the patient and family goals that are individualized, measurable and timebound. For example: on review of RRNHV#1 there were goals that were noted to not be measurable such as pain will remain in comfortable level during care and blood sugar management for patient comfort. All of the goals established had a achieve by date of the end of the benefit period. This observation was reviewed with the Alternate administrator.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness. For example: on review of RRNHV#1 the documentation noted disabling fatigue and constipation yet the issues were not reflected on the care plans. Further the MSW was visiting the patient every certification period yet there was no psychosocial care plan to guide the care. It was noted that throughout all 5 records reviewed the MSW was providing visits yet there was no psychosocial care plans established to guide care. In RRNHV#3 there was documentation of issues with nutrition yet there was no nutrition care plan. Further documentation noted increase in shortness of breath yet the changes were not reflected on the care plan. In RRNHV#4 the documentation noted patient weakness and lack of energy with education provided yet there was no reflection of the issues on the plan of care. In RRNHV#5 there was documentation of patient eating and drinking less and refusing to eat but no nutritional care plan. These observations were reviewed with the Alternate Administrator.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization failed to ensure the plan of care reflected the drugs and treatment necessary to meet the needs of the patient: For example: on review of RRNHV#2 the documentation noted the patient in pain and the SN administered Tylenol, however there was no physicians order for Tylenol noted on the plan of care. This observation was reviewed with the Alternate Administrator.

Observed in Record Review. In 4 of 5 patient records reviewed, the organization had not revised the plan and goals of care based on the updated comprehensive assessment. In the chart for RRNHV#5, the plan of care was not updated with progress toward goals. For example, Goal - Reduce discomfort related to symptoms of GERD with pharmacological and non-pharmacological interventions in 24-48 hours of start of care. remains on the current plan of care since admission. The achieve by date is adjusted each IDG meeting to the next IDG meeting, yet no documentation of the goal addressed. In RRNHV#2 there were goals such as family/PCG will verbalize understanding of fall precautions and safety interventions by end of the SN visit this goal continues IDG to IDG without documentation that the family had verbalized understanding. In RRNHV#4 an example was patient/PCG will verbalize understanding of functional limitations as part of terminal conditions and disease process through education of hospice philosophy by next IDG meeting The goal remains IDG to IDG without documentation of the progress toward resolution. In RRNHV#3 an example was Patient and PCG will verbalize understanding of infection control, how to identify COVID-19 symptoms, and reportable parameters by next IDG, yet there was no documentation of progress toward the goal even though the goals was in place unchanged since admission nearly 6 months ago. These observations were discussed with the Alternate Administrator.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization had not provided the patient with care, treatment, or services according to the patient's individualized plan of care. During RRHV#2, the RN was ordered per the plan of care visit every 14 days, however there were RN visits documented weekly in September and October. In week 3 of September there were 2 RN visits documented. One RN visit was made as supervisory only even though the RN visit was made the same week and week before. In the first week of October there were also two RN visits again one being a supervisory only and another RN visit. This was discussed with the Alternate Administrator.

Observed in Infection Control System Tracer. The organization's written infection prevention and control goals did not include the following: Goal addressing limiting the spread of infections associated with the use of medical equipment, devices, and supplies. This was discussed with the Alternate Administrator.

Observed in Record Review. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by Condition level observations at 418.56 and 418.104.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization failed to ensure all entries into the record were not clear and appropriately authenticated per policy. On review of RRNHV#2 it was noted the MSW September visit entry was not signed and dated. Further, the RN, LVN, and HA notes for September and October were noted to be not signed by the clinician. On review of RRNHV#3 the hospice aide visit notes for September and October were not signed. These observations were reviewed with the Alternate Administrator.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization failed to ensure the patient record was complete, promptly and accurately documented. For example: on review of RRNHV#2 it was noted that there were 3 patient visits were the RN and LVN made visits to the patient home on the same day. There was no indication in the record why the visits on the same day were necessary. On one visit in September the RN and LVN visit times overlapped with the RN from 1:15 pm to 2:15 pm and the LVN was 1:30 to 2:15 pm. In the LVN supervisory documentation it was indicated that the LVN was not present during the visit. In RRNHV#4 there was another example of the RN and LVN visiting on the same day. These observations were reviewed with the Alternate Administrator.

Observed in Emergency Management Session. The organization had not used its prioritized hazards from the hazard vulnerability analysis to identify and implement mitigation and preparedness actions to increase the resilience of the organization and help reduce disruption of essential services or functions. This was discussed with the Alternate Administrator.

Observed in Emergency Management Session. The organization did not have a written delegation of authority plan that provides the individual(s) with the legal authorization to act on behalf of the organization for specified purposes and to carry out specific duties. While the organization had an organizational chart, there was no further detail of specific functions or limitations of authority.

Observed in Emergency Management Session. The organization’s emergency operations plan did not include a process for cooperating and collaborating with other health care organizations, relevant community partners (such as fire, police, local incident command, public health departments), and relevant authorities (such as federal, state, tribal, regional, and local emergency preparedness staff), though the policy indicated one was required.

Observed in Emergency Management Session. The organization’s staffing plan did not address the management of all staff and volunteers as follows:Roles and responsibilities for essential functions; Integrating staffing agencies, volunteer staffing, or deployed medical assistance teams into assigned roles and responsibilities; Verifying the identity and licensures of volunteer practitioners.

Observed in Emergency Management Session. The organization had not maintained a contact list of individuals and entities that are to be notified in response to an emergency or disaster incident. The list of contacts did not include the following, based on the settings and services provided: Other hospices.

Observed in Emergency Management Session. The organization had not maintained a contact list of individuals and entities that are to be notified in response to an emergency or disaster incident. The list of contacts did not include the following, based on the settings and services provided: Relevant authorities (such as federal, state, tribal, regional, and local emergency preparedness staff).

Observed in Emergency Management Session. The organization’s plan for providing patient care and clinical support did not includes written procedures and arrangements with other health care providers for how it will share patient care information and medical documentation and how it will provide transportation to other health care facilities to maintain continuity of care. Observed in Emergency Management Session. The organization’s communications plan did not includes a method for sharing and/or releasing location information and medical documentation for patients under the organization’s care to the following individuals or entities, in accordance with law and regulation: Patient’s family, representative, or others involved in the care of the patient; Disaster relief organizations and relevant authorities; Other health care providers.

Observed in HR File Review. In 4 of 6 HR files reviewed, the organization had not provided on-going education and training consistent with roles and responsibilities at least every 2 years. There was no documented education about the EM plan in the files for more than two years in the files for HR#2, HR#3, HR#5, HR#8 as discussed with the Alternate Administrator.

Observed in Emergency Management Session. The organization’s emergency operations plan did not identify the patient population(s) that it will serve and the types of services it would have the ability to provide in an emergency or disaster event. The plan was not specific to hospice as it included identify those patients who could be discharged from home health earlier than anticipated. The plan did not include any plans for evacuating or relocating services if needed, safety and security of staff, etc.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization had not involved the patient in making decisions about their care, treatment or services. During the visit for RRHV#2, it was noted that the patient had a copy of the revocation document already signed, but not dated, in their informational packet in the home. This was confirmed with the RN during the visit.

Observed in Record Review. In 2 of 14 patient records reviewed, the patient record was not accurately documented. In the chart for RRHV#2, the POC indicated that Meclizine was to be given prn for memory/dementia. Upon discussion with the RN during the visit, she confirmed this was inaccurate as the patient takes it prn for dizziness. In the chart for RRNHV#7, 2 LVNs documented they saw the patient on the same day, approximately 1 month prior to the date of the survey with overlapping times. No indication why two clinicians made a visit to the same patient. One LVN documented the patient's oxygen saturation was 18% on room air with no respiratory distress. The other noted oxygen saturation at 96% with no respiratory distress. One of the visits was actually not for this patient as was discussed with the Alternate Administrator.

Observed in Record Review. In 3 of 14 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for RRDC#11, the patient developed constipation and the RN educated about fiber, hydration. No goals were added to the POC. In the chart for RRDC#12 and RRBR#13, the patients developed sleeping problems for which a medication was prescribed. The plans of care were not updated with a goal for this problem/intervention. This was discussed with the Alternate Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, the hospice’s interdisciplinary group had not updated the comprehensive assessment in collaboration with the patient’s attending physician, if any, as frequently as the patient’s condition requires. In the chart for RRDC#12, the patient fell and required a shoulder x-ray. At the next IDT, the documentation indicated the patient had no falls since the previous IDT. This was discussed with the Alternate Administrator.

Observed in Record Review. In 2 of 14 patient records reviewed, the plan of care did not include a frequency of services necessary to meet the patient's and families needs. In the chart for RRHV#2, the current plan of care included only 1 RN visit for recertification for the entire certification period. In the chart for RRNHV#5, there are no RN visits on the POC. Additionally, the MSW is seeing patient each benefit period, yet the plan of care does not include these visits.

Observed in Record Review. In 3 of 14 patient records reviewed, the organization had not updated the plan of care with changes in the patient's assessment. In the chart for RRHV#1, the patient was assessed to be at very high risk for PU development at the second RN visit, yet the POC was not updated with any interventions/goals. In the chart for RRHV#3, the RN documented teaching ice application to joints for pain management. There was no order for this treatment on POC. In the chart for RRDC#11, the patient developed constipation and the RN educated about fiber, hydration. No interventions were added to the POC. This was discussed with the Alternate Administrator.

Observed in Record Review. In 6 of 14 patient records reviewed, the organization had not revised the plan and goals of care based on the updated comprehensive assessment. In the chart for RRHV#1, the plan of care was not updated with progress toward goals. For example, Goal - Reduce discomfort related to symptoms of GERD with pharmacological and non-pharmacological interventions in 24-48 hours of start of care. remains on the current plan of care with a status of unresolved and a target date the last day of the previous benefit period. In the chart for RRHV#3, goals had not been updated and all have a target date as the last day of the admission benefit period and all continue say unresolved in the current benefit period, six months after admission. For example, Patient will remain free from fall and injury by next IDG -Family/PCG will verbalize understanding of increased risk of fall by next IDG. -Family/PCG will verbalize understanding of fall precautions and safety intervention by end of SN visit. The POC documentation does not indicate if the family ever was able to verbalize understanding of the teaching provided. In the chart for RRNHV#5, there was no progress toward goals in updated POC. All goals had target dates prior to the beginning of the previous benefit period. For example Reduce discomfort related to symptoms of GERD with pharmacological and non-pharmacological interventions in 24-48 hours of start of care. was on the current POC. The admission was more than 8 months ago. In the chart for RRNHV#6, the POC had not been updated. All target dates were the last day of the previous benefit period for all goals including Family/PCG will verbalize understanding of fall precautions and safety intervention by end of SN visit. -Pt/Family/PCG will verbalize understanding of increased risk of fall. In the chart for RRNHV#8, target dates for goals on the POC have not been updated. All target dates are the end of the initial episode of care, approximately 6 months prior to the survey, including educational goals of PCG about knowledge of medication use and schedule which remains unresolved on the POC. In the chart for RRNHV#10, all goals on the POC have a target date the last day of the previous benefit period; all are marked unresolved. This was discussed with the Alternate Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization had not provided services in accordance with the plan of care. In the chart for RRNHV#9, three weeks prior to the survey, the LVN frequency changed to weekly, yet the LVN continued to visit twice weekly since that time. Observed in Patient Home. In 1 of 3 home visits conducted, the organization had not provided the patient with care, treatment, or services according to the patient's individualized plan of care. During RRHV#2, it was observed that while oxygen was ordered on the POC, there was no oxygen concentrator or tanks in the patients home as confirmed with the RN. The RN confirmed that the patient did have oxygen delivered and does use oxygen prn. This was discussed with the Alternate Administrator.

Observed in Data Session. The Hospice QAPI program, failed to address DME, pharmacy, bereavement or volunteer services. This was discussed with the Alternate Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization had not implemented infection prevention and control activities when cleaning equipment. During RRHV#3, the LVN cleansed her equipment after use with Lysol wipes. The organization's bag technique policy required that equipment be cleansed with alcohol wipes after use. This was confirmed with the Alternate Administrator.

Observed in Data Session. The organization's written infection prevention and control goals did not include the following: Limiting the spread of infections associated with the use of medical equipment, devices, and supplies. This was discussed with the Alternate Administrator. Observed in Data Session. The organization's written infection prevention and control goals did not include the following: Limiting the spread of infections associated with procedures. This was discussed with the Alternate Administrator. Observed in Data Session. The organization's written infection prevention and control goals did not include the following: Addressing its prioritized risks. This was discussed with the Alternate Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization had not provided an individualized emergency plan to the patient. During RRHV#2 and RRHV#3, it was observed that the patient's copies of the forms were not completed, rather simply signed by the patient. This was discussed with the Alternate Administrator.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by Condition level observations at 418.56, 418.100, 418.104, 418.112, 418.113, 418.114, 418.58 and 418.60.

Observed in Document Review. In 2 of 3 contracts reviewed, the written agreement with an outside agency providing contracted services for the hospice did not include the following: A stipulation that services may be provided only with the authorization of the hospice. This stipulation was missing in the contracts for Pharmacy and DME services as discussed with the Alternate Administrator.

Observed in HR File Review. In 5 of 8 HR files reviewed, The organization's education and training did not comply with law and regulation. There was no documentation of annual OSHA/blood borne pathogen education in the HR files for HR#1, HR#3, HR#5, HR#7, HR#8.

Observed in Record Review. In 1 of 14 patient records reviewed, In the record for RRNHV#14, the recertification CTI from 4 months ago had not been electronically signed by the physician. This was discussed with the Alternate Administrator.

Observed in Record Review. In 9 of 14 patient records reviewed, the organization had not maintained complete records. In the chart for RRHV#1, there were multiple RN notes from up to 5 months prior to the survey which were still marked draft in the record which did not include any documentation of care provided, a systems assessment, narrative note, etc. Organizational policy Entries into the Clinical Record policy number 5-006.2 stated Entries in to the clinical record will be made on the day care is provided to the patient. In the chart for RRHV#2, the last documented supervisory visit/RN comprehensive reassessment occurred more than 2 months prior to the survey. Per discussion with the Alternate Administrator, this is missing documentation from the clinician, not actual missed visits. In the chart for RRHV#3, LVN visits are ordered weekly. The last documented LVN visit in the chart was 15 days prior to the day of the survey. In the chart for RRNHV#4, as of the date of the survey, there was no documented RN failed to document the comprehensive visit for 21 days, despite the plan of care requiring RN visits at least every 14 days. In the chart for RRNHV#5, in the 48th benefit period which began 11 days prior to survey there was no documented input from nursing in the most recent IDT, 8 days prior to survey. In the most recently documented LVN note, the diastolic BP was not documented. In the chart for RRNHV#6, the last documented RN visit/comprehensive assessment was more than six weeks prior to the date of the survey. In the chart for RRNHV#10, there are no notes for the LVN for the past two weeks at the time of survey. The ordered frequency is twice weekly. In the chart for RRDC#12, the patient had a shoulder x-ray ordered post fall. The result was not in the patient record. In the chart for RRBR#13, the death/disposal note did not indicate what staff member made the visit and pronounced the patient., etc. The IDG note indicated a visit had been made and the patient pronounced by hospice staff. This was discussed with the Alternate Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, all entries into the record were not clear and appropriately authenticated. In the chart for RRBR#13, the death note indicated that a hospice clinician pronounced the patient, however did not indicate which clinician made the pronouncement. The IDG note did indicate a visit was made and the hospice personnel pronounced the death, but again failed to indicate the clinician's name and credentials. This was discussed with the Alternate Administrator.

Observed in Document Review. Leaders had not monitored contracted services by evaluating these services in relation to the organization's expectations. There was no documented evaluation of contracted services; The contracts did not include the manner in which the hospice would evaluate services provided by the pharmacy and DME providers.

Observed in Document Review. In 1 of 1 contracts reviewed, the written agreement for SNF services did not include the following: A provision that the SNF, NF, or ICF/IID notifies the hospice immediately when there is a significant change in the patient’s physical, mental, social, or emotional status. This was missing in the contract for the SNF as discussed with Alternate Administrator.

Observed in Document Review. In 1 of 1 contracts reviewed, the written agreement for SNF services did not include the following: A provision stating the hospice assumes responsibility for determining the appropriate course of hospice care, including the decision to change the level of services provided.

Observed in Document Review. In 1 of 1 contracts reviewed, the written agreement for SNF services did not include the following: An agreement that it is the responsibility of the SNF, NF, or ICF/IID to furnish 24-hour room and board and meet the personal care and nursing needs that would have been provided by the primary caregiver at home. The level of care is the same as that provided before the patient elected hospice care.

Observed in Document Review. In 1 of 1 contracts reviewed, the written agreement for SNF services did not include the following: An agreement that it is the hospice’s responsibility to provide services at the same level as those services that would be provided if the SNF, NF, or ICF/IID resident were in the resident's own home

Observed in Document Review. In 1 of 1 contracts reviewed, the written agreement for SNF services did not include the following: A delineation of the hospice’s responsibilities, which include, but are not limited to, providing medical direction and management of the patient; nursing; counseling; social work; medical supplies; durable medical equipment; medications necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident’s terminal illness and related conditions.

Observed in Document Review. In 1 of 1 contracts reviewed, the written agreement for SNF services did not include: A provision that the hospice may use the SNF, NF, or ICF/IID nursing staff when permitted by state law and only to the extent that the hospice would routinely use the services of a hospice patient’s family in implementing the plan of care

Observed in Document Review. In 1 of 1 contracts reviewed, the written agreement for SNF services did not include: A provision stating that the hospice will report all mistreatment, neglect, or verbal, mental, sexual, and physical abuse to the SNF, NF, or ICF/IID administrator within 24 hours of the hospice becoming aware of the alleged violation, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice.

Observed in Document Review. In 2 of 3 contracts reviewed, the written agreement with an outside agency providing contracted services for the hospice did not include the following: A stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This stipulation was missing in the contracts for Pharmacy and DME services as discussed with the Alternate Administrator.

Observed in HR File Review. In 1 of 9 HR files reviewed, The organization had not obtained a criminal background check on the applicant as required by law and regulation. This was missing in the file for HR#8 as confirmed with the Alternate Administrator.