Every finding on record at United Hospice Inc

Based on review of the hospice's Emergency Preparedness (EP)/Operational Plan and staff interview, the hospice had no documentation or policies regarding communication to authorities regarding the hospice's ability to provide assistance during an emergency and specific facility needs during an emergency. --- On 8/24/2023 at 8:51 AM, review of the hospice's Emergency Preparedness/Operational Plan revealed the hospice had no policies or letters of communication to local Emergency Preparedness authorities that showed the hospice's ability to provide assistance in an emergency. There was no documented communication to authorities regarding the hospice's needs during an emergency. On 8/24/2023 at 1:45 PM, Interim Administrator verified the findings.

Based on record reviews and interview, the hospice failed to ensure the Interdisciplinary Team (IDT) completed the patient's initial comprehensive assessment within 5 days of the patient's notice of election (NOE) for the hospice benefit for 12 of 10 patient charts reviewed. (Patient 1,3, 5, 6, 7, 8, 9,10, 11,12, 13 and 14) --- Record review on 08/22/23 at 9:42 AM for Patient 1 revealed the patient was admitted on 08/18/22 for Malignant poorly differentiated neuroendocrine tumors. Review of the patient's chart revealed no IDT (Interdisciplinary Team) comprehensive assessment within 5 days of admission. The first IDT meeting for the patient was on 08/24/22 which was 6 days after the patient's Notice of Election (NOE) for the hospice benefit. During an interview on 08/24/23 at 12:12 PM, the Interim Administrator verified the findings. Record review on 08/23/23 at 9:15 AM for Patient 7 revealed the patient was admitted on 04/12/23 for Cirrhosis of the liver. Review of the patient's chart revealed no IDT comprehensive assessment within 5 days of the patient's NOE. The first IDT meeting for the patient was on 04/19/23 which was 7 days after the NOE. During an interview on 08/24/23 at 12:35 PM, the Interim Hospice Administrator verified the findings. Record review on 08/23/23 at 10:56 AM for Patient 8 revealed the patient was admitted on 01/27/23 for Alzheimer Disease. Review of the patient's chart revealed there was no IDT comprehensive assessment within 5 days of admission as the first IDT meeting for the patient was on 02/01/23 which was completed with no collaboration by the Chaplain. During an interview on 08/24/23 at 12:52 PM, the Interim Administrator verified the findings. Record review on 08/23/23 at 11:39 AM for Patient 9 revealed the patient was admitted on 04/06/23 for Senile Degeneration of the Brain. Review of the patient's chart revealed there was no IDT comprehensive assessment within 5 days of admission. The first IDT meeting for the patient was on 04/12/23 which was 6 days after the patient's NOE. During an interview on 08/24/23 at 1:01 PM, the Interim Administrator verified the findings. Record review on 08/22/23 at 3:34 PM for Patient 10 revealed the patient was admitted to the hospice on 07/20/23 for Malignant neoplasm of unspecified bronchus or lung. Review of the patient's chart revealed there was no IDT comprehensive assessment within 5 days of the patient's admission as the first IDT meeting for the patient was on 07/25/23 which was completed with no collaboration by the Chaplain on 07/25/23. During an interview on 08/24/23 at 1:14 PM, the Interim Administrator verified the findings. Record review on 08/23/23 at 2:00 PM for Patient 12 revealed the patient was admitted on 11/28/22 for Chronic Obstructive Pulmonary Disease (COPD). Review of the patient's chart revealed there was no IDT comprehensive assessment within 5 days of admission as the first IDT meeting for the patient was on 11/30/22 which was completed with no assessment by the Master of Social Worker. During an interview on 08/24/23 at 1:27 PM, the Interim Administrator verified the findings. Record review on 08/23/23 at 2:34 PM for Patient 13 revealed the patient was admitted on 11/23/22 for Kidney Cancer. Review of the patient's chart revealed there was no IDT comprehensive assessment within 5 days of admission. The first IDT meeting for the patient was on 11/30/22 which was 7 days after the patient's NOE. During an interview on 08/24/23 at 1:30 PM, the Interim Administrator verified the findings. Record review on 08/22/23 at 3:42 PM for Patient 3 revealed the patient was admitted on 01/23/2023 for Chronic Obstructive Pulmonary Disease. Review of the patient's chart revealed no IDT (Interdisciplinary Team) comprehensive assessment within 5 days of admission. The first IDT meeting for the patient was on 02/01/2023 which was 6 days after the patient's Notice of Election (NOE) for the hospice benefit. During an interview on 08/24/2023 at 11:30 AM, the Interim Administrator verified the findings. Record review on 08/23/2023 at 10:13 AM for Patient 5 revealed the patient was admitted on 12/21/2022 for Congestive Heart Failure. Review of the patient's chart revealed no IDT comprehensive assessment within 5 days of admission. The first IDT meeting for the patient was on 01/04/2023 which was 12 days after the patient's NOE for the hospice benefit. During an interview on 08/24/2023 at 11:45 AM the Interim Administrator verified the findings. Record review on 08/23/2023 at 12:55 PM for Patient 6 revealed the patient was admitted on 11/23/2022 for Cancer of the Kidney and Renal Pelvis. Review of the patient's chart revealed no IDT comprehensive assessment within 5 days of admission. The first IDT meeting for this patient was on 11/30/2023 which was 6 days after the patient's NOE for hospice benefit. During an interview on 08/24/2023 at 11:47 AM the Interim Administrator verified the findings. Record review on 08/23/2023 at 1:30 PM for Patient 11 revealed the patient was admitted on 02/10/2023 for Acute on congestive heart failure and aortic stenosis. Review of the patient's chart revealed no IDT comprehensive assessment within 5 days of admission. The initial assessment by the social worker did not occur until 02/27/2023. During an interview on 08/24/2023 at 11:48 AM the Interim Administrator verified the findings. Record review on 08/24/2023 at 9:30 AM for Patient 14 revealed patient was admitted on 02/17/202 for Alzheimer's disease. Review of the patients's chart revealed no IDT comprehensive assessment within 5 days of admission. The intial assessment by the social worker did not occur until 02/27/2023. During an interview on 08/24/2023 at 11:55 AM the Interim Administrator verified the findings.

Based on record reviews, interviews, and review of the hospice's policy and procedure, the hospice failed to ensure reconciliation of the patient's hospice medication profile with the skilled nursing facilitys medication administration record (MAR) for 1 of 1 patient in a nursing care facility (Patient 9) and the patients home medications compared to the hospices medication administration record (MAR) (Patient 10). --- The findings include: Observations on 08/22/23 from 1:15 PM to 1:55 PM for Patient 9 revealed the patient's skilled nursing facility's MAR contained the following medication that were not listed on the hospices MAR: Derma gran B cream, topical, apply Derma Gran B twice a day to buttocks. During an interview on 08/24/23 at 1:01 PM, the Interim Administrator verified the findings. Observations on 08/22/23 from 11:43 AM to 12:25 PM for Patient10 revealed the patient's home medications had the following medication that were not listed on the hospice MAR: Hydrocodone -Acetaminophen 5/325 mg (milligrams), 1 tablet 4 times a day as needed for pain and Metoprolol 25 mg, 1 tablet every morning. The following medications on the hospices MAR which the patient does not take: Ativan 0.5 mg, 1 tablet every 6 hours as needed for anxiety, Hydrocodone 10 mg, 1 tablet orally 4 times a day as needed for severe pain, dyspnea, or other end of life symptoms and Senna 8.6 mg, 1 tablet 1 time as needed for constipation. During an interview on 08/24/23 at 1:14 PM, the Interim Administrator verified the findings.

Based on record review, interview and review of facility policy and procedure, the hospice failed to ensure Registered Nurses (RN) completed comprehensive assessments for 6 of 14 patient records reviewed. (Patients 7, 8, 9, 10, 12 and 13). --- The findings include: Record review on 08/23/23 at 9:15 AM of P 7 revealed P 7 was admitted to the hospice on 04/12/23 for Cirrhosis of the liver. Review of the RN assessments for certification period 04/12/23 to 07/10/23 revealed no comprehensive assessments completed by the RN since the initial assessment on 04/12/23 for the following dates: 04/18/23, 04/20/23, 04/24/23, 04/27/23, 05/01/23, 05/04/23, 05/08/23, 05/11/23, 05/15/23, 05/18/23, 05/22/23, 05/25/23, 05/29/23, 06/01/23, 06/05/23 and 06/08/23. During an interview on 08/24/23 at 12:35 PM, the Administrator of Hospice B verified the findings. Record review on 08/23/23 at 10:56 AM of P 8 revealed P 8 was admitted to the hospice on 01/27/23 for Alzheimers Disease. Review of the RN assessments for certification period 07/26/23 to 09/23/23 revealed no comprehensive assessments completed by the RN for the following dates: 07/27/23, 07/31/23, 08/03/23, 08/08/23, 08/10/23, 08/15/23, 08/17/23 and 08/23/23. During an interview on 08/24/23 at 12:52 PM, the Administrator of Hospice B verified the findings. Record review on 08/23/23 at 11:39 AM of P 9 revealed P 9 was admitted to the hospice on 04/06/23 for Senile Degeneration of the Brain. Review of the RN assessments for certification period 07/05/23 to 09/02/23 revealed no comprehensive assessments completed by the RN for the following dates: 07/06/23, 07/11/23, 07/13/23, 07/18/23, 07/20/23, 07/24/23, 07/26/23, 08/01/23, 08/03/23, 08/07/23, 08/11/23, 08/14/23, 08/18/23 and 08/22/23. During an interview on 08/24/23 at 1:01 PM, the Administrator of Hospice B verified the findings. Record review on 08/22/23 at 3:34 PM of P 10 revealed P 10 was admitted to the hospice on 07/20/23 for Malignant neoplasm of unspecified bronchus or lung. Review of the RN assessments for certification period 07/20/23 to 10/17/23 revealed no comprehensive assessments completed by the RN since the initial assessment on 07/20/23 for the following dates: 07/24/23, 07/26/23, 07/31/23, 08/02/23, 08/04/23, 08/07/23, 08/10/23, 08/11/23, 08/14/23, 08/16/23, 08/18/23 and 08/22/23. During an interview on 08/24/23 at 1:14 PM, the Administrator of Hospice B verified the findings. Record review on 08/23/23 at 2:00 PM of P 12 revealed P 12 was admitted to the hospice on 11/28/22 for Chronic Obstructive Pulmonary Disease (COPD). Review of the RN assessments for certification period 05/27/23 to 07/25/23 revealed no comprehensive assessments completed by the RN for the following dates: 06/01/23, 06/06/23, 06/13/23, 06/17/23, 06/18/23, 06/19/23, 06/23/23, 06/26/23, 07/03/23, 07/04/23, 07/07/23, 07/08/23, 07/09/23, 07/10/23 and 07/12/23. During an interview on 08/24/23 at 1:27 PM, the Administrator of Hospice B verified the findings. Record review on 08/23/23 at 2:34 PM of P 13 revealed P 13 was admitted to the hospice on 11/23/23 for Kidney cancer. Review of the RN assessments for certification period 05/22/23 to 07/20/23 revealed no comprehensive assessments completed by the RN for the following dates: 05/25/23, 05/30/23, 06/01/23, 06/06/23, 06/08/23, 06/12/23, 06/15/23, 06/19/23, 06/21/23, 06/26/23, 06/29/23, 07/03/23 and 07/06/23. During an interview on 08/24/23 at 1:05 PM, the Administrator of Hospice B verified the findings.

Based on record review and interview, the hospice failed to ensure the Aide, Volunteer and Master of Social Worker (MSW) completed home visits per the ordered frequency on the patient's plan of care for 8 of 14 patient charts reviewed. (Patients 7, 8, 9, 10, 11, 12 and 14). --- The findings include: Record review on 08/23/23 from 9:15 AM for Patient 7 revealed the patient was admitted on 04/12/23 for Cirrhosis of the liver. Review of the certification period 04/12/23 to 07/10/23 revealed Volunteer visit frequency was 1 time a month. Review of Volunteer visits revealed 1 missed Volunteer visit the month of May 2023. During an interview on 08/24/23 at 12:35 PM, the Interim Administrator verified the findings. Record review on 08/23/23 at 10:56 AM for Patient 8 revealed the patient was admitted on 01/27/23 for Alzheimer Disease. Review of the certification period 07/26/23 to 09/23/23 revealed Volunteer visit frequency was 1 time a week. Review of the volunteer visits revealed 1 missed volunteer visit the week of 07/26/23, 07/30/23, and 08/13/23. During an interview on 08/24/23 at 12:52 PM, the Interim Administrator verified the findings. Record review on 08/23/23 at 11:39 AM for Patient 9 revealed the patient was admitted on 04/06/23 for Senile Degeneration of the Brain. Review of the certification period 07/05/23 to 09/02/23 revealed Volunteer visit frequency was 2 times a month. Review of the volunteer visits revealed 2 missed volunteer visits during the month of July 2023. During an interview on 08/24/23 at 1:01 PM, the Interim Administrator verified the findings. Record review on 08/22/23 at 3:34 PM for Patient 10 revealed the patient was admitted on 07/20/23 for Malignant neoplasm of unspecified bronchus or lung. Review of the certification period 07/20/23 to 10/17/23 revealed the Volunteer visit frequency was 1 time a week. Review of the Volunteer visits revealed 1 missed volunteer visit during the week of 07/30/23, 08/06/23, and 08/13/23. During an interview on 08/24/23 at 1:14 PM, the Interim Administrator verified the findings. Record review on 08/23/23 at 2:00 PM for Patient 12 revealed the patient was admitted on 11/28/22 for Chronic Obstructive Pulmonary Disease (COPD). Review of the certification period 05/27/23 to 0725/23 revealed the Volunteer visit frequency was 1 time a week and the hospice aide visit frequency was 3 times a week for 8 weeks. Review of the volunteer visits revealed 1 missed volunteer visit during the week of 05/28/23, 06/04/23, 06/11/23, 06/18/23, 06/25/23, 07/02/23, 07/09/23, and 07/16/23 and the Hospice aide had 3 missed visits the week of 05/28/23, 06/04/23, and 06/11/23. During an interview on 08/24/23 at 1:27 PM, the Interim Administrator verified the findings. Record review on 08/23/23 at 10:54 AM of Patient 11 revealed the patient was admitted on 02/10/23 for Acute congestive heart failure with aortic stenosis. Review of the certification period 02/10/23 to 05/10/23 revealed Licensed Medical Social Work visit frequency was 1 time a month for two months. Review of the LMSW visits revealed 1 missed social worker visit the week of 02/12/23 and 05/16/23. During an interview on 08/24/23 at 11:52 AM, the Interim Administrator verified the findings. Record review on 08/23/23 at 11:39 AM for Patient 14 revealed the patient was admitted 02/17/23 for Alzheimer Disease. Review of certification period 02/17/2023 to 05/17/23 revealed Licensed Medical Social Worker visit frequency was 1 time a month. Review of the LMSW visits revealed 1 missed social worker visit the week of 02/20/23. During an interview on 08/24/23 at 11:55 AM, the Interim Administrator verified the findings.

Based on record review and interview, the hospice failed to provide ongoing sharing of information between all disciplines providing care and services for patients in all settings whether provided directly or under arrangement for 1 of 1 assisted living facility patient chart reviewed. (Patient 9). --- The findings include: Observations on 08/22/23 from 2:09 PM to 2:15 PM of Patient 9s (facility) hospice chart revealed the chart had no current contact name for hospice personnel and/or hospice or attending physician orders. During an interview on 08/24/23 at 1:01 PM, the Interim Administrator verified the findings.

Based on record review, interview and review of facility policy and procedure, the hospice failed to ensure measurable outcomes were documented in the Quality Assessment Performance Improvement (QAPI) minutes for the facility. --- The findings include: Record review on 08/24/23 at 10:20 AM of QAPI minutes revealed no documentation of measurable outcomes for quality indicators for the hospice. During an interview on 08/24/23 3:40 PM, the Administrator stated, ";We discuss it, but its not documented". Facility policy, entitled ";Hospice QAPI Policy" revealed, ";The Hospice QAPI Committee, in collaboration with Hospice leadership, establishes a framework for determining appropriate quality indicators to monitor clinical and non-clinical components of the hospices operations...".

Based on record review, interview, and review of the hospice's policy and procedure, the hospice failed to perform analysis of adverse events with documentation identified in the Quality Assessment Performance Improvement (QAPI) minutes. --- The findings include: Record review on 08/24/23 at 10:23 AM of the hospice's QAPI minutes revealed there was no documentation of analysis of adverse events identified in the QAPI minutes. During an interview on 08/24/23 at 3:40 PM, the Interim Administrator stated, ";We discuss it, but its not documented." Hospice policy, entitled ";Hospice QAPI Policy revealed, ";The Hospice QAPI Committee is responsible for reviewing and analyzing data that may impact patient/family care, which may include but not be limited to: Quality Metrics—related to improving clinical outcomes and reducing adverse outcomes...".

Based on record review, staff interview, and policy and procedure review, the hospice failed to follow the bereavement plan of care for two of fourteen patient charts reviewed. (Patient 1 and 2) --- The findings include: Record review on 08/22/23 at 9:42 AM for Patient 1 revealed the patient was admitted on 08/18/22 for Malignant poorly differentiated neuroendocrine tumors and expired on 09/06/22. Review of Patient 1s chart revealed there was no documentation that the bereavement plan of care was completed for the family/power of attorney. During an interview on 08/24/23 at 12:12 PM, the Interim Administrator verified the findings. Record review on 08/23/23 at 1:13 PM for Patient 2 revealed the patient was admitted on 07/13/22 for Malignant neoplasm ovary and expired on 11/24/22. Review of Patient 2s chart further revealed no documentation that the bereavement plan of care was completed for Patient 2s daughter. During an interview on 08/24/23 at 11:30 AM, the Interim Administrator verified the findings. Hospice Policy, "Bereavement Care Planning for Hospice," reads, " Appropriate interventions, care, and support of the primary bereaved(s) will be made by the Bereavement Coordinator and the plan of care updated accordingly."

Based on observations, interviews, and review of the hospice's policy, the hospice failed to ensure expired supplies were removed from the patient supply room and were not available for patient use. --- The findings include: Observations on 08/21/23 at 10:33 AM in the supply room revealed (29) Provon Antimicrobial lotion soap 16 fluid ounce (oz) expired on 03/22. On 08/21/23 at 10:35 AM, the findings were verified by the Administrative Assistant. Hospice policy, entitled, ";Medical Supplies for Hospice", revealed, ";6. Expiration dates (if applicable) are checked prior to use and are checked periodically by the hospices administrative support staff. Outdated medical supplies are discarded...".

Based on record review and interview, the Registered Nurse followed the hospice's procedure for disposal of narcotic drugs for 1 of 1 patient charts reviewed. (Patient &) --- The findings include: Record review on 08/23/23 at 9:15 AM for Patient 7 revealed the patient was admitted on 04/12/23 for Cirrhosis of the Liver and expired on 08/21/23. Review of the Registered Nurse's (RN) drug disposal documentation for narcotics revealed Lorazepam 1 mg (milligram) tablet (22 pills) and Morphine 100 mg/5 ml, 15 ml (milliliters) combined with the mixed solution poured into a Chux pad. During an interview on 08/24/23 at 12:41 PM, the Interim Administrator stated, ";That is not an approved method of disposal of narcotics."