Every finding on record at Visiting Nurse Association of Greater St. Louis

Observed in Individual Tracer. In 3 of 4 patient records reviewed, HHVRR4, HNHVRR1, HNHVRR2, the surveyor noted that patient care goals had been broad, not patient specific, not measurable. For example, HNHVRR1: patient's nutritional needs will be met as patient's condition /comfort allows; Family/caregiver verbalize/demonstrate measures to achieve optimum comfort level; Family/caregiver will verbalize understanding of falls prevention, home safety measures. HNHVRR, Patient maintains highest level of mobility possible; patient/caregiver can verbalize/demonstrate techniques to promote stasis ulcer healing appropriate for stage of disease. HHVRR4, goals stated: patient will maintain optimum level of functioning appropriate for disease process. Assess skin integrity and overall condition of skin including s/s breakdown; friction, shearing or pressure areas; CG will demonstrated improved safety awareness as evidenced by patient asking for assistance. This was discussed with the Hospice Director.

Observed in Individual Tracer. In 1 of 1 home visits conducted, HHV/RR 4. The patient had both Advil Liquigel 200 mg oral as needed for mild pain and Liquid Tylenol 650 mg orally as needed for mild pain. Both medications were indicated for mild pain without additional instruction regarding the sequence of taking the pain medication or which medications should be taken first. This was not compliant with the organization's policy and discussed with the Hospice Director.

Observed in Individual Tracer. In 1 of 1 home visits conducted, HHVRR4 during the home visit and subsequent record review the surveyor noted skin integrity and respiratory changes were documented in clinical note one week prior to the survey and during the home visit. The care plan was not updated to address altered respiratory status including the patient report he had to sit at bedside for 20 minutes before rising and needing to use his oxygen or changes in skin integrity which included blistering. The changes were discussed in the IDG meeting which occurred one week prior to the survey, however the plan of care was not updated to include these new conditions/symptoms. This was discussed with the Hospice Director.

Observed in Infection Control System Tracer. In 1 of 1 home visits conducted, HHV1, the nurse did not follow bag technique as she cleaned her equipment and placed it back on the same section of the barrier that she had previously placed the equipment after patient use. This was not compliant with policy. Discussed this with the Hospice Director.

Observed in Individual Tracer. In 1 of 1 home visits conducted, HHVRR4 during the home visit, the organization did not show evidence a list of medications, including dose, strength, frequency, route, date and time of administration for prescription and nonprescription medications, herbal products, and home remedies that relate to the patient's care, treatment, or services. For example HV1, during the home visit and record review, the medication list in the record stated Imodium 2 mg oral capsule. Take 1 capsule orally every 4 hours as needed for loose stools. The nurse and the patient stated the dosage was Imodium 2mg oral capsule take 2 capsules after the first loose stool then 1 capsule after each loose stool to a maximum of 8 capsules. The medication list in the record stated: Imodium 2 mg oral capsule take 1 capsule orally every 4 hours as needed as need for loose stool. In addition, the patient had over the counter Salonpas patches in the home which were not listed on the medication list in the record. This was discussed with the Hospice Director.

Observed in Record Review. In 4 of 10 patient records reviewed, of active patients, the Surveyor noted the Chaplain and/or Medical Social Worker (MSW) had not completed an initial assessment within five days after the election of hospice benefit (EOHB). In RRHV #3, the Medical Social Worker had an order to assess and evaluate; however, there had been no documented visit during the patients first 3 months of care. In RRNHV # 6 the Chaplain had not evaluated the patient until 35 days post EOHB. In RRNHV #7, the Chaplain had not documented a visit until 7 days post EOHB. In RRNHV #8 the Chaplain evaluated the patient 9 days post EOHB. This was validated with the Director of Hospice.

Observed in Record Review. In 1 of 14 patient records reviewed, the Surveyor noted an initial Bereavement Assessment had not been completed. RRNHV #6 and initial bereavement assessment had not been documented. This was validated with the Director of Hospice.

Observed in Record Review. In 7 of 10 patient records reviewed, of active patients, The Surveyor noted that patient care goals had been broad, not patient specific, not measurable and without an appropriate time frame for achievement. Examples include: Patient will be free of preventable complications; CG can describe techniques to prevent aspiration; Patient/caregiver verbalize/demonstrate proper skin care and what to report to RN; Patient will maintain optimum level of functioning appropriate for stage of disease process; Patient/family will express satisfactory control of symptoms; Continuity of care will be maintained as appropriate to patient /primary caregiver needs; : Patient will maintain optimum bowel functioning consistent with food intake and stage of disease process; Pt will be oriented to person and place; Caregiver will be able to demonstrate improved safety awareness as evidenced by: ; All Patient goals were to be achieved by the end of the Certification period and not specific to patient condition or need. This was found in RRHV #1, RRHV #2, RRHV #3, RRNHV #5, RRNHV #7, RRNHV #9 and RRNHV #10. This was validated with the Director of Hospice.

Observed in Record Review. In 3 of 10 patient records reviewed, of active patients, the Surveyor noted the Plan of Care (POC) had not been updated with the most current frequency orders. For example: RRHV #2 had Hospice Aide (HA) ordered for 1 to 3 times per week for 14 weeks at the beginning of the plan of care; however, the services had been declined by the care givers. The frequency orders had not been discontinued nor was the POC updated. In RRNHV #5, the Chaplain had orders to see the patient 1 to 3 times per month for 4 months. The Chaplain wrote a note that no further Chaplaincy was needed, but the order had not been discontinued and the POC had not been updated. In RRNHV #7, the HA had orders to begin services shortly after EOHB; however, the HA didn't begin seeing the patient until 30 days later. The family had initially declined the HA services, but the POC had not been updated and the frequency orders had not been discontinued. This was validated with the Director of Hospice.

Observed in Record Review. In 7 of 10 patient records reviewed, the Surveyor noted as needed medications had been incomplete and without clear indications for use. For example: in RRHV #1, the patient had Acetaminophen-Hydrocodone Bitartrate 325 mg-5 mg oral tablet every 6 hours as needed for moderate pain and morphine 20mg/ml concentrate every 4 hours as needed for pain/sob. In RRHV #2, The patient had both Advil Liquigel 200 mg oral as needed for mild pain and Liquid tylenol 650 mg orally as needed for mild pain. The patient in RRHV #3 had Dulcolax Laxative 5 mg oral delayed release tablet as needed for constipation and Dulcolax Laxative 10 mg rectal suppository as needed for constipation. In RRHV #4 the patient had multiple topical ointments that had not specified the area of application. For example, Polysporin Apply topically to affected areas as needed. Nystatin Topical Apply 1 application topical to affected areas as needed; Voltaren Arthritis Pain 1% topical gel; Apply 1 application topical as needed; to affected areas. In RRNHV #5, the patient had Acetaminophen Extra Strength Gelcaps 500 mg oral tablet every 6 hours as needed for mild pain and morphine 20 mg/mL oral every 4 hours as needed for moderate pain without identifying what was mild or moderate pain for this patient. RRNHV #7 lidocaine 5% film; Apply 1 patch transdermal once a day as needed for moderate pain; however, there had not been a location of application. The patient in RRNHV #8 had both docusate sodium 100 mg take 1 tab(s) oral daily as needed for constipation and Linzess 145 mcg oral capsule; Take 1 cap(s) orally once a day as needed for constipation. This was validated with the Director of Hospice. Observed in Record Review. In 6 of 10 patient records reviewed, of active patient records, the Surveyor noted the patient Plan of Care (POC) had not addressed all patient specific needs related to diagnosis and/or identified problems. For example: in RRHV #2 the patient had pain medications and was a high risk for falls; however, the POC had not contained interventions to support this. RRHV #3 Pain had not been included on the POC. In RRNHV #5, the patient had Lung Cancer frequent shortness of breath; however, this had not been added to the POC. RRNHV #7, the RN documented patient had frequent UTI's and was on new medications to treat, but it had not been included on the POC. In RRNHV #9, the patient had multiple pieces of DME, but the falls risk assessment had not been completed on initial evaluation, so it had not been addressed on the POC. The patient experienced a fall 1 month into POC. The patient also had a pressure ulcer, however, the risk assessment had not been completed on initial evaluation, so it had not been included on the POC. In RRNHV #10, the patient POC had not addressed pain. This was validated with the Director of Hospice. Observed in Record Review. In 6 of 6 patient records reviewed, where the patient had a wound being treated by the HCO, the Surveyor noted incomplete orders as the order had not defined who was to complete the wound care. For example: In RRHV #1 the patient had orders to: Scalp Tx: Cleanse skin Ca lesion with H2O2, apply thin layer of Neosporin ointment to open area and leave OTA until healed, clean lesion on top right forehead with soap and water, pat dry, apply fluorouracil topical per orders daily. Leave open to air; and Coccyx Tx: Cleanse with wound cleanser, pat dry. Cover with ABD pad and secure with tape once daily and PRN soilage/dislodgement; In RRHV #3 the patient had ‘Perform wound care/dressing change: LFA skin tear- cleanse with wound cleanser, pat dry, cover with bordered foam dressing. Change q 3 days/prn soiling; RRHV #4 had orders for stage 2 gluteal fold wound: daily, clean with wound cleanser, dry with gauze pads, apply barrier cream, leave open to air. In RRNHV #6: Perform wound care/dressing change: mid back wound: Cleanse with wound cleanser. Pat dry. Apply non adherent pad and secure with PAPER tape only. Change daily and prn soiling. RRNHV #7 Medial Inner Buttocks Coccyx Shearing Cleanse with wound cleanser and pat dry. Apply Mepilex Border dressing q3 days and PRN soilage/dislodgement, and Skin Tear / Left Anterior Arm Wrist Tx: Cleanse with wound cleanser and pat dry. Cover with Mepilex Border dressing every 7 days and PRN soilage/dislodgement. RRNHV #9 Had ‘wound care: Decubitus/Pressure Ulcer Stage II / Right Lateral Outer Foot Ankle Tx: Cleanse with wound cleanser and pat dry. Cover with Mepilex Border Dressing every 3 days and PRN soilage/dislodgement and Skin Tear / Left Outer Arm Elbow Cleanse with wound cleanser and pat dry. Cover with Mepilex Border dressing. Change every 5 days and PRN soilage/dislodgement. This was validated with the Director of Hospice.

Observed in Record Review. In 9 of 10 patient records reviewed, the Surveyor noted care had not provided according to hospice plan of care (POC). For example, in RRHV #1 the Medical Social Worker (MSW) had orders for 1-3 visits per month over 3 months; however, there had been no visits documented in the month of June, July or September. The Hospice Aide (HA) had orders to see the patient 2 times per week; however, there had been no visits documented the second week of August, and only 1 was made the last week of September and first week of October. In RRHV #2, the patient had an HA ordered for 1-3 visits per week for 14 weeks; however, no HA visits had been documented, and there had been no orders to discontinue services. The MSW and Chaplain both had orders to visit the patient monthly, but no documentation had been present for the month of September. RRHV #3, the MSW had orders to visit the patient at least monthly; however, there had been no MSW visits between January-June, then August and September. The HA had not documented any visits during the week of August. In RRNHV #4 the MSW had orders for 1-3m for 3 months, yet no visits had been documented in June, July, August or September. In RRNHV #5 there had been no documented MSW visit in July or September and the HA had not documented visits in the 2nd week of August. RRNHV #6 there had been not documented Chaplain visit in March and May. In RRNHV #7 the MSW had not documented a visit in August and September. RRNHV #9, the MSW had not documented a visit in August, and the Chaplain had not documented visits in June, July and August. In RRNHV #19 the MSW and Chaplain had not documented a visit in September. This was validated with the Director of Hospice.

Observed in Patient Home. In 2 of 3 home visits conducted, the Surveyor noted hand hygiene had not been followed according to HCO policy. For example, in RRHV #1, the HA changed her gloves x 7 without performing hand hygiene between glove changes. In HV #2, the clinician had been touching the patient and items in the immediate vicinity of the patient including medications without performing hand hygiene. This was validated with the Director of Patient Care Services.

Observed in Tracer Activities. The Surveyor noted the HCO has not performed analysis of hand hygiene compliance data since 2020 and therefore the HCO was not able to set a goal to improve hand hygiene compliance. This was validated with the director of Hospice and the QAPI administrator. Observed in Tracer Activities. The Surveyor noted the HCO had not performed an analysis of hand hygiene compliance data since 2020 and therefore the HCO was not able to set a goal to improve hand hygiene compliance. This was validated with the director of Hospice and the QAPI administrator.

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 a condition level finding at 418.56 and 418.60.

Observed in Patient Home. In 1 of 3 home visits conducted, the Surveyor noted the medication list in the HCO electronic medical record (EMR) had not contained all the medications the patient was being administered. In RRHV #3, the patient had Fleets Enema once a day as needed for constipation, Gerilanta 30 mg every 4 hours as needed for upset stomach, and Milk of Magnesia 30 ml once a day as needed for constipation all on the Skilled Nursing facility medication profile; however, the EMR with the HCO had not recorded these medications. The medications had been ongoing since June. This was validated with the Director of Patient Care Services.