Every finding on record at Upmc Western Maryland Corporation

Observed in Record Review. the organization failed to plan the patient's care. During record review for HOSRRNHV#10, it was identified that the plan of care was not based on assessed identified need. The plan of care included foley catheter; however, the patients did not have issues with urinary function at the time of the assessment. This was confirmed with the Hospice Clinical Manager. Observed in Record Review. In 13 of 14 patient records reviewed, the surveyor noted during record reviews that the established plan of care was not based on assessed identified needs. For example, In HOSRRHV#1 and HOSRRHV#3 the plan of care included foley catheter; however, the patients were not identified to have any issues with urinary function at the time of the assessment. This was confirmed with the hospice clinical manager.

Observed in Record Review. the organization failed to plan the patient's care. During record review for HOSRRNHV#10, the Hospice Nurse Surveyor observed the care plan did not contain all items needed. For example in HOSRRNHV#10, the nursing and HHA documented on several visits education related to bilateral lower extremity edema but there were no goals for edema on the plan of care. This was discussed and reviewed with the Hospice Leadership Team. Observed in Record Review. the organization failed to plan the patient's care. During the wound care visit (HOSHVRR#2) the wound care plan included wound treatment interventions rather than patient specific goals. Example Problem statement patient has a stage 3 wound to coccyx with a goal statement coccyx to be cleansed with wound wash and treated with medihoney to the wound bed.; second goal family may change wound on non-nurse days. This was discussed with the Clinical Manager.

Observed in Record Review. In 8 of 14 patient records reviewed, The surveyor noted in (HOSRRHV#1,HOSRRHV#2, HOSRRHV#3,HOSRRHV#4, HOSNHV#3, HOSRRNHV#5, HOSRRNHV#6)) that patient goals and outcomes anticipated from implementing and coordinating the plan of care were not measurable by all disciplines. Examples nursing care plan goal for anxiety documented, reduced anxiety; spiritual care plan for spiritual comfort and utilization of resources documented, provide emotional support. MSW care plan for Coping with difficulties due to expected decline documented, for patient and family to be emotionally stable and working through their grief in a healthy way. Nursing goal for Deficit related to anxiety, Patient self esteem will improve , Anxiety will be managed.

Observed in Patient Home. In 2 of 19 patient records reviewed, The surveyor noted during record reviews that the individualized plan of care did not address all active problems including (HOSRRHV#1) Medication management, Medication Safety, Oxygen Safety, and Pain pertinent to source and diagnoses, and in (HOSRRNHV#2) Oxygen safety. Reviewed with Clinical Director.

Observed in Patient Home. In 2 of 4 home visits conducted, The surveyor noted (HOSRRHV#2 and HOSRRHV#4) that the plan of care did not accurately reflect the medication orders necessary to meet patient needs. Examples, an order for gabapentin for pain with a prescribed frequency had not been discontinued despite not being given since admission and Levothyroxine and levetiracetam still listed as current yet not being given to the patient. Reviewed with Clinical Director.

Observed in Record Review. In 2 of 13 patient records reviewed, It was noted during record review of HOSRRNHV#7 and HOSRRNHV#9 that a complete comprehensive spiritual assessment was not performed as the section for spiritual care was not addressed. This was confirmed with the Clinical Manager.

Observed in Record Review. In 1 of 15 patient records reviewed, the surveyor noted (HOSRRNHV#1) that the aide care plan had not been updated to reflect aspiration precautions following the recommendations from the Speech Therapist. Reviewed with Clinical Manager.

Observed in Tracer Activities. During the Hospice Volunteer Tracer, the surveyor noted that for calendar year 2024 volunteers provided 3% of total administrative and patient care hours in relation to those of all paid staff. This was discussed with the volunteer coordinator and hospice manager who described significant efforts underway to enhance volunteer recruitment and utilization.

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 significant issues identified in the provision of care resulting in a condition level finding at 418.56. Reviewed with Clinical Manager.

Observed in Record Review. In 2 of 13 patient records reviewed, it was noted that the organization did not ensure when multiple medications were ordered to address the same symptom that the order included which medication should be given first. For example, during a review of the medical record(s) for HosHV#2, it was noted that the patient's medication list included the following medication's: Tylenol arthritis pain oral tablet extended release 650mg 2 tabs every 8 hours as needed for pain; Ibuprofen oral tablet 200mg 2 tabs every 6 hours as needed for pain; Morphine Sulfate (Concentrate) oral solution 20mg/ml 0.25ml every 4 hours as needed for pain/dyspnea. The order(s) for these medications did not indicate which medication should be given first. The organization's medication order policy did not specify which medication should be given first. Example #2: During a review of the medical record(s) for HosHV#3, it was noted that the patient's medication list included the following medication's: Tramadol HCL oral tablet 50mg 1 tab every 6 hours as needed for pain; Morphine Sulfate (Concentrate) oral solution 20mg/ml 0.25ml as needed for pain/shortness of breath; Tylenol PM Extra Strength oral tablet 500-25mg 1 tablet nightly as needed for sleep/pain; Tylenol Extra Strength oral tablet 500mg 2 tabs every 6 hours as needed for pain/fever. The order(s) for these medications did not indicate which medication should be given first. The organization's medication order policy did not specify which medication should be given first. This observation was reviewed with the Senior Manager of Clinical Operations - Hospice. Example #3: During a review of the medical record for HosRR#4, it was noted that the patient’s medication list included the following medication’s: Tramadol HCl oral tablet 50mg 1 tab every 6 hours as needed for pain; Tylenol 8-hour oral tablet extended release 650mg 1 tab every 4 hours as needed for pain; Morphine Sulfate (Concentrate) oral solution 20mg/ml 0.25ml as needed for pain/shortness of breath. The order(s) for these medications did not include which medication should be given first. This observation was reviewed with the Senior Manager of Clinical Operations - Hospice.

Observed in Record Review. In 1 of 13 patient records reviewed, it was noted that the organization did not ensure the plan of care specified the care and services necessary to meet the needs identified in the comprehensive assessment. For example, during a review of the medical record for HosRR#7, it was noted that the patient’s falls risk assessment indicated the patient was at risk for fall. In addition, the falls risk assessment indicated the patient had experienced falls in the last 3 months. The patient’s plan of care did not include interventions to maintain patient safety, strategies to prevent injury, and a goal statement to evaluate response to care, treatment and services related to fall prevention interventions.

Observed in Record Review. In 1 of 8 patient records reviewed, for patient's receiving hospice aide services, it was noted that the organization did not ensure aide supervision was completed every 14 days.. For example, during the first benefit period an aide supervision visit was completed in week 2. The next aide supervision visit was completed 21 days later. This observation was reviewed with the Senior Manager of Clinical Operations - Hospice.