Every finding on record at Western Horizon Hospice and Palliative Care, Inc.

It is required that the hospice ensures the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG (interdisciplinary group) in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure hospice care and services provided to patients and families followed the individualized plan of care. Clinical Record 7: The patient elected the hospice benefit on 07/13/2023. The plan of care dated 07/13/2023 included an order for the bereavement coordinator one time per month. Clinical record review revealed no documented evidence of services provided by the bereavement coordinator and no documentation of why bereavement services were not provided. During a review of the record and interview on 11/29/2023, the Director of Patient Care Services /Administrator Designee confirmed bereavement services were not provided as ordered on the plan of care.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 6 of 14 (43%) clinical records reviewed, the organization did not ensure the individualized written plan of care (POC) included measurable outcomes anticipated from implementing and coordinating the POC. Clinical Record 2: The patient elected the hospice benefit on 06/21/2023. The POC dated 06/21/2023 included a bereavement goal that stated, "Be able to cope with changes." The goal did not include a description of who the goal was intended for the patient or the caregiver. The goal did not include how the achievement of "be able to cope" would be measured. Clinical Record 3: The patient elected the hospice benefit on 02/21/2023. The POC dated 02/21/2023 included a bereavement goal that stated, "Be able to cope with changes." The goal did not include a description of who the goal was intended for the patient or the caregiver. The goal did not include how the achievement of "be able to cope" would be measured. Clinical Record 7: The patient elected the hospice benefit on 07/13/2023. The POC dated 07/13/2023 included goals that stated, "ADL (activities of daily living) needs are met to an optimal level" and "Pt (patient) will maintain optimum peripheral circulation." The goals did not include a statement to describe how the goals would be measured for optimal level of ADLs and optimum peripheral circulation. Clinical Record 9: The patient elected the hospice benefit on 04/03/2023. The POC dated 04/03/2023 included a bereavement goal that stated, "Be able to cope with changes." The goal did not include a description of who the goal was intended for the patient or the caregiver. The goal did not include how the achievement of "be able to cope" would be measured. Clinical Record 12: The patient elected the hospice benefit on 11/21/2023. The POC dated 11/25/2023 included a bereavement goal that stated, "Be able to cope with changes." The goal did not include a description of who the goal was intended for the patient or the caregiver. The goal did not include how the achievement of "be able to cope" would be measured. Clinical Record 14: The patient elected the hospice benefit on 06/22/2023. The POC dated 06/23/2023 included a bereavement goal that stated, "Be able to cope with changes." The goal did not include a description of who the goal was intended for the patient or the caregiver. The goal did not include how the achievement of "be able to cope" would be measured. During a review of findings and interview on 11/29/2023, the Director of Patient Care Services /Administrator designee confirmed that the goals on the plans of care were non-measurable.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene, and use of gloves, mask, eye protection, or face shield depending on anticipated exposure. This standard was not met as evidenced by document review, observation, and interview. In 1 of 3 (33%) home visit observations, the agency did not ensure staff followed standard precautions as described in the agency's policy. Agency policy No. C:2-046.1 revised April 2016 stated in part, "Gloves are to be changed between tasks and procedures on the same patient...[and] after removing an old dressing." Home Visit 2: During the home visit observation with the Registered Nurse (staff 2), the nurse was observed to provide wound care with gloved hands. The nurse did not change gloves after removing the old dressing and continued to provide wound care. After providing the wound care, the same gloves remained on during a posterior skin assessment of the patient. During the daily wrap up and review on 11/29/2023, the Director of Patient Care Services /Administrator Designee, confirmed standard precautions were not followed per agency policy.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse (RN) who is a member of the Interdisciplinary Group (IDG). Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed with hospice aide services provided, the agency did not ensure the written patient care instructions prepared by the RN were individualized to the patient’s condition. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 09/01/2023. The initial comprehensive assessment dated 09/01/2023 included documentation that the patient had a Foley catheter. The hospice aide plan of care assignment dated 09/01/2023 did not include information related to the Foley catheter or how to care for it when the aide provided personal hygiene care to the patient. The patient was observed to have a Foley catheter during the home visit observation. Clinical Record 3/Home Visit 3: The patient elected the hospice benefit on 02/21/2023. A physician order dated 11/22/2023 ordered a Foley catheter for urinary retention. The hospice aide plan of care assignment dated 02/21/2023 was not updated to include information pertaining to the Foley catheter or how to care for it when the aide provided personal hygiene care to the patient. The patient was observed to have a Foley catheter during the home visit observation. During an interview with the Director of Patient Care Services /Administrator Designee on 11/29/2023, review of clinical records confirmed that the records were missing information/instructions in the aide plan of care related to the foley catheter.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by observation and interview. In 1 of 1 (100%) home visit observations with the hospice aide, the agency did not ensure the hospice aide provided services included in the plan of care. Home Visit 1: During home visit observation with the hospice aide (staff 1), it was observed that the patient had a Foley catheter. During an interview the aide confirmed that they provide catheter care and empty the drainage bag at each visit. The aide plan of care assignment did not assign the aide the tasks for catheter care. During an interview and review of findings on 11/29/2023, the Director of Patient Care Services /Administrator Designee confirmed the aide was providing services not included in the plan of care.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide, ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 5 of 12 (42%) clinical records reviewed with aide services provided, the agency did not ensure hospice aides were supervised by a Registered Nurse (RN) no less frequently than every 14 days. Clinical Record 2: The patient elected the hospice benefit on 06/21/2023. The plan of care (POC) included an order for hospice aide services. Clinical record review revealed no documented evidence of RN supervisory visits from 10/30/2023 through 11/29/2023 (30 days). Clinical Record 3: The patient elected the hospice benefit on 02/21/2023. The POC included an order for hospice aide services. Clinical record review revealed no documented evidence of RN supervisory visits from 10/02/2023 through 10/30/2023 (28 days) and from 10/30/2023 through 11/29/2023 (30 days). Clinical Record 7: The patient elected the hospice benefit on 07/13/2023. The POC included an order for hospice aide services. Clinical record review revealed no documented evidence of RN supervisory visits from 09/18/2023 through 10/16/2023 (28 days) and from 10/30/2023 through 11/14/2023 (15 days). Clinical Record 9: The patient elected the hospice benefit on 04/03/2023. The POC included an order for hospice aide services. Clinical record review revealed no documented evidence of RN supervisory visits from 11/01/2023 through 11/29/2023 (28 days). Clinical Record 10: The patient elected the hospice benefit on 02/02/2023. The POC included an order for hospice aide services. Clinical record review revealed no documented evidence of RN supervisory visits from 07/06/2023 through 08/03/2023 (28 days), from 09/14/2023 through 10/12/2023 (28 days) and from 10/26/2023 through 11/29/2023 (34 days). During review of findings and interview on 11/29/2023, the Director of Patient Care Services /Administrator Designee agreed the patients were receiving hospice aide services and the records did not include RN supervisory visit documentation.