Every finding on record at Wecare Hospice and Palliative Services Inc

Observed in Emergency Management Session. During the Emergency Management session the plan did not include hazards that are likely to impact the organization’s geographical region, community, facility, and patient population. For example, the organization's plan included a list of potential hazards with prioritization , however the list was labeled Sample with no indication if the items were organization specific and no date of use or location. Also there were 4 sections of the list that the prioritization was left blank. The organization's current patients were all located many miles inland of the office with a different geographical region. The organization moved 8/1/2023 and the plan was dated as last reviewed January 2023 and had not been reviewed following the move. This was discussed with the DPCS, Administrator and Administrator Designee present, they stated that they had not thought to update the Emergency Management related to the move about a month ago.

Observed in HR File Review. In 1 of 7 HR files reviewed, it was noted that the organization did not provide education and training to individuals providing services. For example, the Medical Director was an under arrangement/contracted hospice team member and the HR file did not contain any indication of emergency management education and training at least every two years. This was confirmed with the Administrator Designee present, who checked inservice attendance records for EM training and the Medical Director was not listed as attending.

Observed in Patient Home. In 3 of 3 home visits conducted, it was noted that the patient was not assessed per policy. For example, during RRHV#1, #2 and #3 the RN did not removed her stethoscope from the nurse bag and did not complete an assessment of breath sounds or bowel sounds. The organization's assessment policy stated in 2. F. that Breath sounds and in 2. H. Bowel sounds are part of the required assessment. This was confirmed and discussed with the DPCS and Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed, when the patient was transferred to the hospital/another Medicare/Medicaid certified facility the hospice did not provide the receiving facility a copy of the hospice discharge summary. For example, in record RDC#1 and #3 the patient revoked hospice to go to the hospital for aggressive treatment and there was no documentation of the discharge summary being provided to the hospitals. On discussion with the DPCS, Administrator and Administrator Designee they stated that they were unaware of the need to provide the discharge summary to the next Medicare/Medicaid-certified facility. Observed in Record Review. In 4 of 4 patient records reviewed, that included a patient discharged from hospice alive, the hospice did not document informing the attending physician of the availability of a discharge summary. For example, in records RRDC#1, #2, #3, and #4 the records included a completed discharge summary, however there was no notice to the attending physician of the availability of the discharge summary. This was discussed with the DPCS, Administrator and Administrator Designee who stated they had been unaware of the need to notify the physician.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to assess potential medication related problems, including adverse effects and drug reactions with drug therapy. During HV#2, the Hospice Nurse Surveyor observed the nurse asked many questions about the infusions the patient was receiving outpatient, but she did not have the name of the medications and she did not attempt to call the provider giving the care. This was discussed and reviewed with the Administrator, DPCS Designee and the Administrator Designee.

Observed in Record Review. In 1 of 4 patient records reviewed, the organization failed to perform an initial bereavement assessment, as required by regulation and organizational policy. During record review for RR#1, the Hospice Nurse Surveyor observed the initial MSW visit was declined and the RN did not perform the initial bereavement at SOC, so an initial bereavement assessment was not completed. This was discussed and reviewed with the Administrator, DPCS Designee and the Administrator Designee.

Observed in Record Review. In 6 of 6 patient records reviewed, the organization failed to plan the patient's care. During record review for all records, the Hospice Nurse Surveyor observed all records reviewed lacked progress towards goals. The patients had goals with timeframes placed at SOC but then closed at the first IDG. There was no documentation of progress towards goals. This was discussed and reviewed with the Administrator, DPCS Designee and the Administrator Designee.

Observed in Record Review. In 6 of 6 patient records reviewed, the organization failed to plan the patient's care. During record review for HV#1, HV#2, and HV#3, the Hospice Nurse Surveyor observed that some goals and timeframes were established at SOC but were listed as resolved and controlled at the first IDG. There were no active goals/ interventions/ timeframes on the POC. Also for HV#1, the patient had needs for medication education as evidenced by questions during survey visit, but the patient had no goals, interventions or timeframes listed. This was discussed and reviewed with the Administrator, DPCS Designee and the Administrator Designee.

Observed in Record Review. In 6 of 6 patient records reviewed, the organization failed to plan the patient's care. During record review for HV#1, HV#2, HV#3, the Home Care Nurse Surveyor observed the plan of care did not contain all services needed for the palliation and management of the terminal illness. In all records reviewed, all goals/ interventions/ timeframes were initiated at SOC but resolved and controlled at the first IDG. In HV#2, the patient mentioned multiple doctor appointments and nothing was addressed in the POC and in HV#3, code status was listed as undecided but it was not addressed on the POC. Also none of the records reviewed contained collaboration about scope/ frequency for the SW/ Chaplain visits. Also for HV#2, there was nothing on the POC for medication education related to infusions, collaboration with PACE providers or collaboration on the POC with the physical therapist she was seeing. This was discussed and reviewed with the Administrator, DPCS Designee and the Administrator Designee.

Observed in Record Review. In 1 of 3 home visits conducted, The organization failed to plan the patient's care. During record review for HV#1, the patient needed extensive medication education as noted during the visit with the RN and surveyor but it was not addressed on the POC. This was discussed and reviewed with the Administrator, DPCS Designee and the Administrator Designee.

Observed in Record Review. In 1 of 2 patient records reviewed, the organization failed to provide care, treatment, or services according to the Plan of Care. During record review for HV#2, the Hospice Nurse Surveyor observed the HHA had a missed visit for the week of May 14th but there was no documentation to the IDG for collaboration. This was discussed and reviewed with the Administrator, DPCS Designee and the Administrator Designee.

Observed in Patient Home. In 3 of 3 home visits conducted, The organization failed implement the infection prevention and control activities it had planned when related to hand hygiene. During home visits for HV#1, HV#2 and HV#3, the Hospice Nurse Surveyor observed the nurse fail to follow the organization's hand hygiene policy. For example in all three visits the nurse removed her gloves several times and reapplied gloves without completing hand hygiene. In HV#1, the nurse used the same paper towel to dry hands and turn off faucet- in violation of the organization's policy. And in HV#2 and HV#3 ( in the same Board and Care facility) , the nurse washed her hands in the shared bathroom, took a clean paper towel to turn off faucet but then used that paper towel to dry her clean hands. During all home visits, the Home Health Nurse Surveyor observed the nurse did not follow the organizational policy for bag technique. In all home visits, the nurse re-entered her nursing bag on numerous occasions without performing hand hygiene and she removed and replaced gloves on several occasions without performing hand hygiene. The organization did bring this staff in during survey to competency her. This was discussed and reviewed with the Administrator, DPCS Designee and the Administrator Designee. Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to reduce the risk of infections related to medical equipment. During HV#1, the Hospice Nurse Surveyor observed the nurse removed her equipment from her barrier, cleaned, and then returned to the same spot on the barrier where it was before cleaning. This was discussed and reviewed with the Administrator, DPCS Designee and the Administrator Designee.

Observed in HR File Review. In 1 of 11 HR files reviewed, the organization failed to document orientation to staff. During HR file review for HR#7, the Hospice Nurse Surveyor observed the MD designee file did not contain documentation of orientation to current hospice. This was discussed and reviewed with the Administrator, DPCS Designee and the Administrator Designee.

Observed in HR File Review. In 1 of 11 HR files reviewed, the organization failed to document initial competency. During HR file review for HR#9, the Hospice Nurse Surveyor observed the Chaplain/ BC/ VC staff member had documentation in his HR file of initial competency before he began employment with current organization. This was discussed with the Administrator Designee who stated it was probably done at another agency and they were unaware that this was non-compliant. This was discussed and reviewed with the Administrator, DPCS Designee and the Administrator Designee.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to maintain an accurate record. During home visit and record review for HV#2, the Hospice Nurse Surveyor observed the patient had been getting medication infusions from another provider but that information was not part of her hospice record. This was discussed and reviewed with the Administrator and the Administrator Designee.

Observed in Record Review. In 2 of 6 patient records reviewed, the organization failed to provide patient education and training based on each patient's needs and abilities. During record review for HV#1 and HV#2, the Hospice Nurse Surveyor observed lack of documented evaluation of the patient's understanding of the education and training provided related to medication. For example in HV#1, the nursing notes states medication education taught but the patient and CG had many questions and misunderstanding of his medications. For HV#2, the patient was taking several injections from a physician that the nurse had not coordinated with and she was unsure of what medications they were but she documented that education was provided on current medications. This was discussed and reviewed with the Administrator, DPCS Designee and the Administrator Designee.