Every finding on record at United Hospice Care Services, LLC

Observed in Record Review. In 2 of 10 patient records reviewed, The organization failed to provide a complete, promptly and accurately documented patient record as evidenced in RRHV#1: HHA care plan had checked off oxygen safety precautions and to keep oxygen on during bath and patient is not using oxygen at this time RRHV#2: Nursing documentation states that foley was changed, 14 days ago, the foley change note was not in the record and should be submitted 48 hours following visit as per policy, this was observed and validated by the DON

Observed in Record Review. In 8 of 10 patient records reviewed, The organization failed when completing the written plan of care to create specific goals based on the patient’s needs and the time frames, settings, and services required to meet those goals as evidenced in RRHV#2: Constipation goals, no skin breakdown will be reported in next month and a nutrition/hydration goal: CG will verbalize understanding and instructed to notify hospice with any changes or concerns within next month. RRHV#3: Chaplain goal : patient will verbalize feeling spiritually supported. RRNHV#2: Goal, pain will be controlled at an acceptable level for patient/CG. RRNHV#3: Musculo/skeletal goal - patient/CG will understand disease process and endurance limitations. RRNHV#4: Goal- pain will be controlled at an acceptable level, neuro/emotional goal: care will be provided in a safe and trusting environment. RRNHV#5 and RRNHV#7: Musculo/skeletal goal: patient/caregiver will understand disease process and endurance limitations, this was observed and validated by the DON

Observed in Record Review. In 1 of 10 patient records reviewed, The organization failed to specify all services in the plan of care necessary to meet the patient an family needs as evidenced in RRHV#1: the patient was receiving homemaker services which were not ordered or in the plan of care, this was observed and validated by the QA/RN and DON

Observed in Record Review. In 3 of 10 patient records reviewed, The organization plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions as evidenced in RRHV#1; Tylenol # 3 was ordered 1 tab q 6-8 hours PRN with no indications, patient had a lt heel wound,the wound care and SNF RN was providing wound care and the patient is a diabetic with no specific instructions in the plan of care. RRNHV#1: Tylenol 500 mgs 1-2 tablets 6 every hours as needed for pain and patient is on Toujeo Solostar U-300 units 10 units SQ daily, no specific instructions in plan of care. RRNHV#2: patient is taking Toujeo Max U-300 Solostar 300units/ml ( 3mls) - 15 units SQ daily in evening - no diabetic instructions in plan of care, this is observed and validate by the DON

Observed in Record Review. In 2 of 10 patient records reviewed, The organization failed to plan the patient’s care as evidenced in RRNHV#1: there was conflicting information from the nurses assessment and the IDG notes. Pain issues mentioned in IDG 3 different times and nursing notes at that time did not have the same assessment, anxiety in nursing notes two times and order received for lorazepam and and not discussed in IDG. RRNHV#3: Patient has a wound which is documented in nursing notes, but no longer addressed in IDG in the last month, this was observed and validated by the DON

Observed in Data Session. The organization failed to select performance improvement activities that affect palliative outcomes, this was evidenced by no palliative project, this was validated by the DON and Administrator

Observed in Infection Control System Tracer. The organization failed to develop and implement necessary action plans to address infection control issues and improve its infection prevention and control program as evidenced by did not create any action plans or process improvement projects after gathering data, this was validated by the QA/LVN and Administrator

Observed in Record Review. In 1 of 10 patient records reviewed, The registered nurse failed to supervise the hospice aide during an on-site visit to the patient’s home no less frequently than every 14 days. As evidenced by in RRNHV#2: No HHA supervisory visit for 16 days, this was observed and validated by the DON

Observed in HR File Review. In 1 of 11 HR files reviewed, The organization failed to define the competencies it requires of its staff who provide patient care, treatment, or services. As evidenced in Volunteer HR File competencies not defined for Hospice volunteer staff, this was validated by the Administrator

Observed in Patient Home. In 1 of 3 home visits conducted, The organization failed to provide for a resident of a Skilled Nursing Facility the patient’s most recent hospice plan of care,the patient’s hospice election form, the physician certification and recertification of the patient’s terminal illness, the names and contact information of hospice staff involved in the care of the patient, instructions on how to access the hospice’s 24-hour on-call system as evidenced by in RRHV#1: Patient was recently transferred to SNF but all required documents were not sent to SNF, this was validated by the DON

Observed in Tracer Visit. The organization failed to have 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 as evidenced in the therapy and nurse practitioner contracts failed to require criminal background checks, this was observed and validated by the DON

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to ensure that the patient-specific comprehensive assessment and reassessment identified the patient's need for hospice care and services as related to the severity of symptoms and the palliation and management of the terminal illness and related conditions. For example: in review of RR#10 the patient was diabetic and medications included Lantus and Metformin. The initial comprehensive assessment and subsequent reassessments failed to assess the patient's endocrine system and any symptoms and their severity for diabetes, even with documentation that the patient's appetite was poor. The organization's policy for comprehensive assessment notes all complications and risk factors that affect care planning were to be addressed, however the patient's diabetes was not addressed in the record. This observation was reviewed with the Director of Nursing and the Administrator.

Observed in Record Review. In 5 of 11 patient records reviewed, the organization failed to ensure that the individualized written plan of care reflected the patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. For example: in HV#3 the patient assessment noted the presence of wounds and their treatment yet the current plan of care did not address skin integrity. The patient had a foley catheter yet the plan of care did not address genitourinary. Further, documentation noted issues with constipation and impaction yet the issues were not addressed on the plan of care. Example 2: In RR#8 the plan of care for GI had a goal but no interventions. For the cardiopulmonary care plan the goal states caregiver will verbalize understanding of possible complications related to shortness of breath within 2 weeks yet the intervention Pt/cg to notify hospice regarding changes does not address accomplishing the established goal. Further, documentation notes pain and edema as active issues for the patient yet these issues had no goals and interventions established to address the problem. Example 3: In RR#7 the documentation noted issues with blood pressure causing symptoms and requiring changes to the medications, and issues with lower extremity edema but no goals and interventions were established to address these problems. Example 4: In RR#10 the patient was a diabetic, taking insulin and oral hypoglycemic medication, and had documentation of poor appetite yet there were no goals and interventions to address diabetes. Example 5: In review of RR#4 the patient had wounds with changing treatment orders yet the plan of care goals and interventions did not reflect the current treatment of the wounds. These observations were reviewed with the Director of Nursing and Administrator.

Observed in Record Review. In 3 of 11 patient records reviewed, the organization failed to ensure that the frequency of services necessary to meet the specific patient and family needs was met. For example: in review on RR#7 the MSW and Chaplain had documented monthly visits with the patient yet there were no established frequency orders noted on the record for the MSW or Chaplain. Similar observation of no established frequency orders for the MSW and Chaplain but the services were being provided monthly were noted on RR#5 and RR#6. These observations were reviewed with the Administrator and the Director of Nursing.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to ensure that the patient's plan of care included all drugs and treatments necessary to meet the needs of the patient. For example: on review of RR#8 the nursing documentation during week 3 of care noted that the patient was started on multiple new medications to treat signs and symptoms of a respiratory infection yet orders for the fluticasone, zyxal, and Mucinex noted to be started during the visit could not be located in the patient record nor reflected in the plan of care. This observation was reviewed with the Director of Nursing and Administrator.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to ensure that care and services were provided in accordance with the hospice plan of care. For example: On review of RR#8 there was a physician order for a PRN SN visit to obtain a Covid test related to the patient's respiratory signs and symptoms. There was no documentation in the record that the Covid test was ever obtained as ordered. Example 2: in review of RR#4 the documentation notes 4 wounds with wound care orders early in the patient's care. The current plan of care orders continue to note wound care orders for the 4 wounds, however the current nursing visit notes document only wounds to the left heel and the sacrum. The orders on the plan of care for the sacrum read cleanse with normal saline, pat dry, apply medihoney, apply durafiber rope, cover with A6197 super absorbent dressing yet the recent SN documentation notes the dressing change of cleanse with normal saline, pat dry, apply medihoney, apply triad mixed with collagen , cover with 4x4 and secure with tape. For the left heel, the wound care order noted on the plan of care is not being carried out as the recent documentation notes treatment as caregiver to off load pressure. There is no order noted on the record that the wounds had resolved and wound care orders changed or discontinued. These observations were reviewed with the Administrator and Director of Nursing. Observed in Record Review. In 2 of 7 patient records reviewed, that were receiving hospice aide services, the care provided was not in accordance with the established aide plan of care. For example: during the home observation for HV#3 the hospice aide performed foley catheter care, and after the bath applied lotion to the patient extremities, however these tasks were not included on the plan of care that the aide had during the observation. However, upon further review of the hospice aide plan of care and documentation there were consistent discrepancies in the plan of care for tasks assigned versus the aides documentation of tasks completed for catheter care, moisturize, and record BM. Similar observations for discrepancies in the aide plan of care tasks assigned versus documentation of tasks completed was noted in RR#4 for recording BM's. These observations were reviewed with the Director of Nursing and the Administrator.

Observed in Data Session. Upon review of the data management program and QAPI summaries it was noted that the organization was not comparing internal data over time to compare levels of performance, patterns, trends and variations. Each quarter the QAPI summary contained data solely for the quarter reporting and did not compare data over time. This observation was reviewed with the Administrator, Director of Nursing, and QA staff.

Observed in Record Review. In 2 of 8 patient records reviewed, where hospice aide services were provided, the organization failed to ensure that the RN provide specific written patient care instructions for the hospice aide. For example: During the home observation on HV#3 the patient had dressings noted to the feet, yet there were no specific instructions on how the aide was to handle the dressings during the bath. In RR#4 the patient also had wound dressings, yet no specific instructions for the aide on how to handle the dressings while providing care. These observations were reviewed with the Administrator and Director of Nursing.

Observed in Record Review. In the one record reviewed for extended prognosis, the organization failed to ensure that the clinical record contained documentation in compliance with the organization's discharge process. For example: upon review of RR#10 for extended prognosis, the patient signed and dated the Notice of Medicare Non-Coverage on the day of discharge, not at least 2 days prior to discharge as required by regulation. The Director of Nursing and Administrator were able to articulate the organization's process of providing the Notice of Medicare Non-Coverage form at least 2 days prior to discharge, and noted an additional organization process of a 5 day prior notification, however all discharge documents for RR#10 were dated for the day of discharge. This observation was reviewed with the Director of Nursing and the Administrator.