Every finding on record at United Hospice, Inc.

Based on record reviews and staff interviews, the Hospice failed to ensure that all plans of care include all services necessary including the scope and frequency of services, and that standing orders are individualized to address the specific needs of the patients. This was evident for four (4) of four (4) clinical records reviewed. (Patients #1, #2, #3, and #4). Failure to ensure that all plans of care include all services, including the scope and frequency of services, and that standing orders are individualized to address the specific needs of the patients has the potential for negative patient outcomes. The findings are: --- 4. Patient #4 has a start of care date of 7/28/2023 with diagnoses that include Heart Failure, Chronic Obstructive Pulmonary Disease, Essential Hypertension, Anemia, Pressure Ulcer of Unspecified Site, Gastrointestinal Reflux without Esophagitis as documented on the ";Physicians Plan of Care for the Certification Period of 7/28/2023 to 10/25/2023. The "Physician's Plan of Care" for the Certification Period of 7/28/2023 to 10/25/2023 documents:" Authorization/initiation of Care Plan. Scope of Hospice Care and Services: Hospice Care IDT (Interdisciplinary Team) members to provide care and services as appropriate to address the ongoing needs of this patient and family including: Collaborative pain and symptom management, Patient/family education, Physician consult services, Skilled and supportive Nursing Care, Hospice Aide Services/Personal Care, Homemaking services, Social Work services, Volunteer services, Spiritual Support, Case Management, Care at time of death, Hospice Community resource assistance, Clinical Pharmacology consult, Patient/Family/Children BV (Bereavement) counseling, Pharmacy, Infusion, DME (Durable Medical Equipment), Physical, Occupational and Speech Therapy,, Respiratory Therapy, Dietary Counseling, and Transportation". The ";Registered Nurse (RN) Admission Assessment" dated 7/28/2023 documents: ";Compound fracture of right leg covered in dressing. Report erythema to right heel covered with gauze. Patient has fracture to right femur. Patient previously in hospice with family revoking hospice on 7/24/2023 due to compound right femur fracture. Patient fell to the ground and was brought to the hospital with right femur fracture with bone protruding through skin. Staff reports foley to be inserted prior to discharge to alleviate movement of right leg during hygiene care. Patient currently has female" WICK with clear amber urine draining". The ";Physicians Plan of Care" for the Certification Period of 7/28/2023 to 10/25/2023 lacks documented evidence of the frequency and duration of services Skilled Nursing and Hospice Health Aide, Medical Social Worker, Chaplain, Volunteers specific to meet the patients needs. The ";Standing orders" dated 7/28/2023 documents, ";Skilled Nursing (NP/RN/LPN): 1to 4 visits/week and 6 PRN (as needed) visits/cert period; Social Work (MSW): 1to 4 visits/month and 2 PRN visits/cert period; Health Aide (CHHA): 1to 5 visits/week and 6 PRN (as needed) visits/cert period; Spiritual care, Volunteer, Massage/Music/Pet Therapy PRN as per IDG (Interdisciplinary Group) and patient family". May insert #16 urinary catheter with 5 cc balloon. Change every 8 weeks and as needed for blockage, leakage or dislodgement. May irrigate with 30 cc sterile normal daily as needed for blockage". The ";RN comprehensive assessment" dated 7/29/2023, documents:" Durable Medical Equipment required for transfer. Totally bedbound unable to perform any activity. Nurse frequency once a week". The ";RN comprehensive assessment dated 7/31/2023, and 8/8/2023 documents:" Mobility: total dependence. Dependent in all IADLs. Hospice aide initiated". There is no documented evidence the ";Standing orders" are individualized to address the specific needs of the patient. There is no documented evidence the ";Physicians Plan of Care" has visit frequency of services necessary to meet the specific needs of the patient and family. On 8/8/23 at 3:00PM, the Chief Operating Officer, the Physician and the Director of Performance Improvement and Initiatives were interviewed. the physician states, ";the Standing orders are just routine for all patients". no further explanation was provided. 3. Patient # 3 has a Start of Care date of 7/6/23 and a discharge date of 7/15/23 diagnoses "Malignant Neoplasm of Unspecified Ovary; Secondary Malignant Neoplasm of Retroperitoneum and Peritoneum, Malignant Neoplasm of Liver and Intrahepatic Bile Duct, Unspecified Malignant Neoplasm of Lymph Node, Aortic Aneurysm of Unspecified site without Rupture" as documented on the "Physician's Plan Of Care", for the Certification Period of "7/06/2023 to 10/03/2023". The "Physician's Plan of Care" for the Certification Period of "7/06/23 to 10/03/23" documents, "Scope of Hospice Care and Services: Hospice Care IDT (Interdisciplinary Team) members to provide care and services as appropriate to address the ongoing needs of this patient and family: Collaborative pain and symptom management, Patient/family education, Physician consult services, Skilled and supportive Nursing Care, Hospice Aide Services/Personal Care, Homemaking services, Social Work services, Volunteer services, Spiritual Support, Case Management, Care at time of death, Hospice Community programs referral/support, Community resource assistance, Clinical Pharmacology consult, Patient/Family/Children BV (Bereavement) counseling, Pharmacy, Infusion, DME (Durable Medical Equipment), Physical, Occupational and Speech Therapy, Respiratory care, Dietary Counseling, and Transportation". The ";Physicians Plan of Care" for the Certification Period of "7/06/23 to 10/03/2023" lacks documented evidence of the frequency and duration of services for the following: Skilled Nursing, Hospice Health Aide, Medical Social Worker, Chaplain, and Volunteer. The "Standing Orders" dated "7/6/23", documents "Services: Skilled Nursing NP/RN/LPN (Nurse Practitioner, Registered Nurse, Licensed Practical Nurse) 1-4 visits/week and 6 prn (as needed) visits/cert period for change in status. Social Work MSW (Medical Social Worker) 1-4 visits/month and 2 prn (as needed) visits/cert period for emotional crisis, Health aide (CHHA: Certified Home Health Aide) 1-5 visits/week and 6 prn (as needed) visits/cert period for personal care assistance, Spiritual care, Volunteer, Massage/Music/Pet Therapy prn (as needed) as per IDG (Interdisciplinary Group) and patient/family. There is no documented evidence the ";Physicians Plan of Care" has visit frequency of services necessary to meet the specific needs of the patient and family. There is no documented evidence the ";Standing orders" are individualized to address the patient's specific needs. During an interview on 8/9/23 at 11:45 am, the above findings were reviewed, the Hospice Medical Director stated, "standing orders are routine for all patients, for this patient the IDG Meeting has the frequency of services". 2. Patient #2 has a start of care date of 5/10/23 with diagnoses of unspecified Kidney Failure, Hypertension, Major Depressive Disorder, recurrent, unspecified, Degenerative Disease of Nervous System and Anemia documented on the ";Physicians Plan of Care" dated 5/10/2023. The ";Physicians Plan of Care" dated 5/10/2023 documents, ";Authorization/Initiation of Care Plan: Start Date: 5/10/2023 ; End Date 08/07/2023; Scope of Hospice Care and Services: Hospice Care IDT (Interdisciplinary Team) members to provide care and services as appropriate to address the ongoing needs of this patient and family including: Collaborative pain and symptom management, Patient/family education, Physician consult services, Skilled and supportive Nursing Care, Hospice Aide Services/Personal Care, Homemaking services, Social Work services, Volunteer services, Spiritual Support, Case Management, Care at time of death, Hospice Community resource assistance, Clinical Pharmacology consult, Patient/Family/Children BV (Bereavement) counseling, Pharmacy, Infusion, DME (Durable Medical Equipment), Physical, Occupational and Speech Therapy,, Respiratory Therapy, Dietary Counseling, and Transportation. Medical Treatment Orders: Medical Treatment Orders: Activity as tolerated, DME as needed; Bowel Regimen; Nutrition/Diet; Oxygen Order" The Standing orders dated 5/10/23 documents, ";Skilled Nursing (NP/RN/LPN): 1to 4 visits/week and 6 PRN (as needed) visits/cert period; Social Work (MSW): 1to 4 visits/month and 2 PRN visits/cert period; Health Aide (CHHA): 1to 5 visits/week and 6 PRN (as needed) visits/cert period; Spiritual care, Volunteer, Massage/Music/Pet Therapy PRN as per IDG (Interdisciplinary Group) and patient family" On 8/9/23 at 11:47 AM, the Hospice Physician states, ";the Standing orders are just routine for all patients" The "Physicians Plan of Care" and "Standing Orders" lack documented evidence of the specific/individualized services the patient is to receive. There is no documented evidence the ";Physicians Plan of Care " has visit frequency of services necessary to meet the specific needs of patient and family. On 8/09/2023 at 4:25 PM, the Chief Executive Officer, Chief Operations Officer, Physician, and Director of Performance Improvement were interviewed and did not provide any explanation for the findings. 1. Patient #1 has a start of care date of 06/19/2023 with diagnoses of Non-Hodgkin Lymphoma, Unspecified Kidney Failure, Essential Hypertension, Hyperlipidemia and Polyosteoarthritis as documented on the "Physician's Plan of Care" for authorization period 06/19/2023 - 09/16/2023. The "Physician's Plan of Care" for authorization/initiation of Care Plan, start date 06/19/2023 end date 09/16/2023, documents: "Scope of Hospice Care and Services: Hospice Care IDT (Interdisciplinary Team) members to provide care and services as appropriate to address the ongoing needs of this patient and family including: Collaborative pain and symptom management, Patient/family education, Physician consult services, Skilled and supportive Nursing Care, Hospice Aide Services/Personal Care, Homemaking services, Social Work services, Volunteer services, Spiritual Support, Case Management, Care at time of death, Hospice Community resource assistance, Clinical Pharmacology consult, Patient/Family/Children BV (Bereavement) counseling, Pharmacy, Infusion, DME (Durable Medical Equipment), Physical, Occupational and Speech Therapy,, Respiratory Therapy, Dietary Counseling, and Transportation. Skilled Nurse services are dated 06/19/23, 06/20/23, 06/21/23, 06/29/23, 07/06/23, 07/14/23 and 07/18/23. Social Work services are dated 06/20/23, 06/26/23, 07/11/23, and 07/25/23. Physical Therapy evaluation is dated 07/25/23. Spiritual/Pastoral Care was declined 06/20/23. The "Physician's Plan of Care" lacks documentation of the frequency/range of visits of Hospice services for Skilled Nurse, Social Work, Spiritual Support, and Physical Therapy services. The Hospice failed to ensure that the Physician's Plan of Care include range of visits and PRN orders for visit frequencies to ensure the most appropriate level of service is provided to the Hospice patient. Survey findings and interview were conducted on 08/09/2023 at 11:50 AM with the Chief Executive Officer (CEO), Chief Operations Officer (COO), Physician, and Director of Performance Improvement (PDI). No explanation was given for the Physician's Plan of Care not including range of visits for services.

Observed in Record Review. In 6 of 6 patient records reviewed, During the patient file review the surveyor noted that in the IDT notes which is considered the MD order, the term and PRN was being used by the nurse, MSW and chaplain with no number or qualifier/indication. This was verified in a discussion with and observation by the DON.

Observed in Record Review. In 6 of 6 patient records reviewed, During the patient file review the surveyor noted that in the plan of care, the terms pain is relieved, improved ventilation and regular bowel function were being used which is not measurable. This was verified in a discussion with and observation by the DON.

Observed in Individual Tracer. During HV 4, the nurse surveyor observed that the aide performed a bed bath and when finished with the posterior perineal area did not change her gloves before applying cream to the patient's back. This was verified in a discussion with and observation by the DON.

Observed in HR File Review. In 2 of 11 HR files reviewed, During the Competency Assessment Process and subsequent file review the surveyor noted that in RN 2 the license expired on 8/31/22 and was not verified until 2/28/23. IN LPN 1 the license expired on 8/31/22 and was not verified until 2/2/23. This was verified in a discussion with and observation by the Chief of Staff and HR Manager.

Observed in Individual Tracer. The hospice nurse surveyor noted (HV#1) that the patient plan of care did not include outcome measures or time frames for managing symptoms particularly dyspnea and risk for falls. The surveyor noted that the patient was on continuous oxygen at 3 LPM; Morphine as needed (twice per day) and that she was just started on methadone three times a day (ordered yesterday). The last falls risk assessment indicated that the patient was high risk for fall; however there were no outcome measures or time frames for managing fall risk. The surveyor also noted that all the goals had time frames that read ongoing. This was confirmed with the educator.

Observed in Building Tour. The hospice nurse surveyor noted that the gap under the south wing fire door in the hospice inpatient unit was greater that 3/4 inch. This was corrected on site and reduced to less than 3/4 inch by the facilities manager. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.