Every finding on record at Tranquility Hospice, LLC

It is required that the hospice conducts and documents a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. The assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by review of clinical records and interview with the Director of Nursing which revealed issues with completion of initial and comprehensive assessments of patients in the following areas: Failure of the hospice Interdisciplinary Group to document evidence of the review and update of patients’ comprehensive assessments and plans of care at least every 21 days to reflect changes that have taken place since the initial assessment was completed (HCPC.17.I/L533); and Failure of the hospice Interdisciplinary Group to demonstrate completion of the bereavement assessment, as part of the initial comprehensive assessment, within five (5) calendar days after the election of hospice care (HCPC.9.I/L523). The cumulative effect and scope of these deficiencies could negatively impact the organization’s ability to identify and meet the care needs of the patients and ensure continuity of care and service coordination.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by review of clinical records with the Director of Nursing and interview. In 3 of 6 (50%) clinical records, there was no documented evidence that the bereavement assessment, which is part of the initial comprehensive assessment, was completed by members of the Interdisciplinary Group within five (5) calendar days after the election of hospice care. Record #32611 - Patient was admitted to hospice on 9/8/21. There was no evidence of an initial Bereavement Assessment form in the electronic medical record. Record #19571 - Patient was admitted to hospice on 10/13/21. The initial Bereavement Assessment form in the electronic medical record was dated 10/16/21 and signed by the Social Worker however, the content of the Bereavement Assessment form was blank and there was no documented evidence of the findings of the initial bereavement assessment. Record #18249 - Patient was admitted to hospice on 8/15/21. The initial Bereavement Assessment form in the electronic medical record was dated 8/17/21 and signed by the Social Worker however, the content of the Bereavement Assessment form was blank and there was no documented evidence of the findings of the initial bereavement assessment. During interview, the Director of Nursing stated she could not locate the missing initial bereavement assessment form and confirmed that the initial bereavement assessment forms were dated and signed, however that the form content was blank and did not contain the bereavement assessment

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes: Information on the patient’s progress toward desired outcomes; and reassessment of the patient’s response to care. The assessment update is completed: As frequently as the condition of the patient requires; and no less frequently than every 15 days. This standard was not met as evidenced by review of clinical records with the Director of Nursing, document review, and interview. In 6 of 6 (100%) clinical records. there was no documented evidence that the review and update of the comprehensive assessment was completed by the hospice Interdisciplinary Group no less frequently than every 21 days, as defined by the public health emergency (PHE) time frame extension, and that the IDG review and update included information on the patients’ progress toward stated outcomes and reassessment of the patient’s plan of care. Record #98096 - Patient admitted on 10/15/21 and the first update of the comprehensive assessment was due no later than 11/5/21. The first "IDT Plan of Care and Review of Comprehensive Assessment" form was listed in the electronic medical record dated 10/25/21 and the Director of Nursing stated that she could not open the document for viewing during the site visit record review. The subsequent "IDT Plan of Care and Review of Comprehensive Assessment" forms dated 11/8/21 and 12/6/21 were able to be opened, however the forms only contained the patient's name and diagnoses and there was no documentation that described completion of a review and update of the comprehensive assessment by the IDG. During interview, the Director of Nursing confirmed the content of the forms were blank when opened and stated she did not know why the forms were blank. Record #19571 - Patient admitted on 10/13/21 and the first update of the comprehensive assessment was due no later than 11/3/21. The "IDT Plan of Care and Review of Comprehensive Assessment" forms dated 10/25/21 and 11/8/21 were missing documentation of a complete update to the comprehensive assessment. The section titled, "Current eligibility status" was left blank, and the section titled, "Since last IDT has care been provided according to the plan of care", with fields for responding “Yes” and “No” were also blank. Record #18249 - Patient admitted on 8/15/21. The "IDT Plan of Care and Review of Comprehensive Assessment" forms dated 11/8/21 and 11/22/21 were missing documentation of a complete update to the comprehensive assessment. The "Current eligibility status" sections were blank, and the "Social Worker Report" and "Spiritual Counselor Report" sections were blank. The sections, "Since last IDT has care been provided according to the plan of care”, with fields for responding “Yes” and “No” were also blank. Record #66934 - Patient admitted on 7/22/21. The "IDT Plan of Care and Review of Comprehensive Assessment" forms dated 10/25/21 and 11/8/21 were missing documentation of a complete update to the comprehensive assessment. The "Spiritual Counselor Report" section was blank. Record #26668 - Patient was admitted to hospice on 11/10/20 and expired on 3/16/21. The post death bereavement assessment was dated as completed on 3/16/21 and included, in part, "low risk bereavement level" and "continued bereaved contacts are refused". There was no documented evidence that the bereavement assessment was discussed with the IDG/IDT. Record #32611 - Patient was admitted to hospice on 9/8/21 and expired 9/27/21. The post death bereavement assessment was dated as completed on 9/27/21 and included, in part, "low risk bereavement level" and "continued bereaved contacts are refused". There was no documented evidence that the bereavement assessment was discussed with the IDG/IDT. The agency's policy, "Bereavement Services, 9-023", included, in part: "After death has occurred, the bereavement assessment will be updated, and the family/caregiver needs will be discussed at the next IDG meeting". During interview, the Director of Nursing stated that the patients' deaths were discussed at the next IDG/IDT meeting but confirmed that the "IDT Plan of Care and Review of the Comprehensive Assessment” form was not completed.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by review of clinical records, policies, and interview with the Director of Nursing which revealed the following issues with the development and implementation of patients’ interdisciplinary care plans: Failure of the hospice Interdisciplinary Group to ensure Hospice care and services were provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (HCPC.19.I/L543); Failure of the registered nurse to ensure that each patient and the primary caregiver(s) received education and training to complete treatments as ordered in the patients’ plan of care (HCPC.20.I/L544); Failure of the Interdisciplinary Group to ensure each patient’s individualized written plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments (HCPC.21.I/L545); and Failure of the Interdisciplinary Group to document review and revision of patients’ care plans as frequently as the patient's condition requires (HCPC.22.I/L553). The cumulative effect of these deficiencies could negatively impact the organization’s ability to develop, update, and implement plans of care to ensure services are provided that will meet the care needs of patients.

It is required that Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by review of clinical records with the Director of Nursing and interview. In 3 of 6 (50%) clinical records, review of visit notes revealed visits and treatments were not documented as completed as ordered in the Hospice plans of care and/or physicians orders. Record #18249 - The nursing visit frequency was ordered to be completed "two times a week". There was one nursing visit missing the week of 11/28/21. During interview, the Director of Nursing stated that she could not locate the missing nursing visit note or a missed visit report). Also, the spiritual counselor visit frequency was ordered to be completed "one time a month" and there was no evidence of a spiritual counselor visit completed during the month of November 2021. Record #19571 - The spiritual counselor visit frequency was ordered to be completed "one time a month” and there was no evidence of a spiritual counselor visit completed during the month of November 2021. A spiritual counselor visit form was present in the clinical record and dated 11/4/21, however the form was blank and there was no evidence of documentation completed by the spiritual counselor to confirm a visit had been made. In addition, at the time of admission on 10/13/21, the initial nursing assessment described the patient's skin status with "right and left toes bloody drainage", and "drainage serous" in the narrative summary section. The care plan problem of "impaired skin integrity" was established on 10/13/21 with care plan goals and interventions. Physician orders for wound care dated 10/13/21 stated, "apply Medihoney and apply gauze to wounds daily, caregiver may change dressings on non-SN visit days". The nursing visit note 10/21/21 did not include an assessment of the wounds or that the dressing change procedure was completed. During interview, the RN stated, "Yes, I see the missing wound assessments and that there is no documentation that the dressing change was done, but I did the wound care when I visited the patient". Record #32611 - At the time of admission on 9/8/21, the initial nursing assessment described the patient's skin status as, "impaired" with no documented assessment of a skin integrity impairment and stated "skin intact" in the narrative summary section. The care plan problem of "impaired skin integrity" was established on admission on 9/8/21. During interview, the Director of Nursing, who was also the RN who completed the nursing assessment, stated "The skin was not impaired and I do not know why I established the "impaired skin integrity" plan of care, and the wound was not present until 9/17/21". The nursing visit note 9/17/21 included, "wound left upper back" with documented assessment and measurement of the wound. Physician's orders 9/17/21 stated, "Wound left upper back, cleanse wound with cleanser, dry with gauze, apply Bacitracin and cover with oil emulsion and ABD, change daily, caregiver may change dressing on non-SN visit days". The nursing visit note 9/20/21 included, "abscess upper back drained large amount serosang drainage", with no documented dressing change procedure completed by the nurse. Nursing visit note 9/26/21 included no documentation of wound assessment and no documented dressing change procedure completed by the nurse. During interview, the RN stated "Yes, I see the missing wound assessments and that there is no documentation that wound care was done, but I did the wound care when I visited the patient". During interview, the Director of Nursing stated that she could not locate the missing spiritual counselor visit notes or missed visit reports.

It is required that the hospice ensures that each patient and the primary caregiver(s) receive education and training, provided by the hospice, as appropriate to their responsibilities for care as stated in the plan of care. This standard was not met as evidenced by review of clinical records with the Director of Nursing and interview. In 2 of 2 (100%) applicable clinical records of patients with wounds, there was no documented evidence that the nurse provided education and training to the primary caregiver for daily wound care. During interview, the Director of Nursing stated that she was the RN who made the nursing visits and that she did educate the caregiver on the daily wound care and that was not documented. Record #19571 - Patient admitted on 10/13/21 and the initial nursing assessment included wounds to the right and left toes with drainage. Physician's order dated 10/13/21 stated, "daily wound care, apply Medihoney and apply gauze, caregiver to perform on non-SN visit days". There was no documentation in the clinical record that the nurse provided education and training to the primary caregiver on the daily wound care. Record #32611 - Patient admitted on 9/7/21 and expired 9/27/21. The 9/17/21 Nursing visit note included a wound to the left upper back with drainage. Physician's order dated 9/17/21 stated, "daily wound care left upper back, cleanse wound with cleanser, dry with gauze, apply Bacitracin, cover with oil emulsion and ABD, caregiver to perform on non-SN days". There was no documentation in the clinical record that the nurse provided education and training to the primary caregiver on the daily wound care.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by review of clinical records with the Director of Nursing and interview. In 6 of 6 (100%) clinical records of patients receiving Social Worker and Spiritual Counselor services, the plans of care did not include the patient and caregiver goals or planned interventions based on the identified psychosocial, spiritual and/or initial bereavement needs identified in the initial comprehensive assessment. Record #19571 - Social Worker and Spiritual Counselor services were being provided to the patient. There were no plan of care problems, goals or interventions on the plan of care for the psychosocial and pre-bereavement needs identified in the initial Psychosocial and Bereavement Assessments. Record #98096 - Social Worker and Spiritual Counselor services were being provided to the patient. There were no plan of care problems, goals or interventions on the plan of care for the psychosocial, spiritual and pre-bereavement needs identified in the initial Psychosocial, Bereavement and Spiritual Assessments. Record #26668 - Social Worker and Spiritual Counselor services were being provided to the patient. There were no plan of care problems, goals or interventions on the plan of care for the psychosocial, spiritual and pre-bereavement needs identified in the initial Psychosocial, Bereavement and Spiritual Assessments. Record #32611 - Social Worker and Spiritual Counselor services were being provided to the patient. There were no plan of care problems, goals or interventions on the plan of care for the psychosocial, spiritual and pre-bereavement needs identified in the initial Psychosocial, Bereavement and Spiritual Assessments. Record #66934 - Social Worker and Spiritual Counselor services were being provided to the patient. There were no plan of care problems, goals or interventions on the plan of care for the psychosocial, spiritual and pre-bereavement needs identified in the initial Psychosocial, Bereavement and Spiritual Assessments. Record #18249 - Social Worker and Spiritual Counselor services were being provided to the patient. There were no plan of care problems, goals or interventions on the plan of care for the psychosocial and pre-bereavement needs identified in the initial Psychosocial and Bereavement Assessments. The spiritual plan of care identified interventions for only the "SN" to perform and did not include spiritual counselor interventions. During interview, the Director of Nursing stated the plans of care did not include the identified needs/problems, goals and interventions for services to be provided by Social Worker and Spiritual Counselor.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires. A revised plan of care includes information from the patient's updated comprehensive assessment and record of the patient's progress toward the progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by review of clinical records with the Director of Nursing and interview. In 1 of 6 (16%) clinical records there was no documented evidence that the hospice Interdisciplinary Group reviewed and revised the plan of care. Record #32611 - The Nursing visit note dated 9/17/21 identified a new wound and change in patient condition, stating "wound left upper back with bloody drainage". Physician orders were obtained on 9/17/21 which stated: "Daily wound care left upper back, cleanse wound with cleanser, apply Bacitracin, cover with oil emulsion and ABD, change daily, caregiver may change dressing on non-SN visit days". The hospice plan of care was updated to include the orders for wound care and identified a problem of "altered skin integrity", however there was no further updated documentation of new goals or interventions. During interview, the Director of Nursing stated that she established the care plan problem of "altered skin integrity" on admission 9/8/21 even though the skin was not altered and that the patient did not have a wound until 9/17/21. The Director of Nursing confirmed that the care plan was not updated after the wound was identified and that there were no goals or interventions under the care plan problem of "altered skin integrity".

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. The hospice has a means to authenticate entries or to identify the author of each entry. This standard was not met as evidenced by review of clinical records with the Director of Nursing, review of policies and procedures and interview. Agency policy, "Clinical/Service Data Collection", Policy No. 6-022, revised October 2019, included in part: "Signature authorization of clinical/service documentation will include the staff member's name and credentials (as specified on professional licenses and/or certification documents)"; and "The clinical/service note will include...signature of clinician/technician and his/her credentials". In 6 of 6 (100%) clinical records, there was no documented evidence that assessments and/or visit notes included the credentials of the nurse, hospice aide, social worker and/or spiritual counselor. During interview, the Director of Nursing confirmed that the credentials were missing after the signatures and that she would be in touch with the electronic medical record company to find out how to enter in the credentials. Record #98096 - The initial nursing assessment, nursing visit notes and hospice aide visit notes did not include the credentials after the electronic signature on the forms. Record #19571 - The initial nursing assessment, nursing, social worker and hospice aide visit notes, and the initial social worker, spiritual and bereavement assessments did not include the credentials after the electronic signature on the forms. Record #32611 - The initial nursing assessment, nursing, hospice aide and social worker visit notes, and the initial social worker and spiritual assessments did not include the credentials after the electronic signature on the forms. Record #18249 - The nursing, social worker and hospice aide visit notes did not include the credentials after the electronic signature on the forms. Record #66934 - The nursing, social worker, spiritual counselor and hospice aide visit notes did not include the credentials after the electronic signature on the forms. Record #26668 - The nursing, social worker and spiritual counselor visit notes did not include the credentials after the electronic signature on the forms.