Every finding on record at Wisteria Hospice, Inc.

Observed in Record Review. In 2 of 12 patient records reviewed, The organization did not conduct the patient’s initial assessment in accordance with written time frames it defines and law and regulation. Examples: HOSHV#1 the social work initial assessment following the SOC was not performed until two weeks later and the Bereavement Risk assessment not until the second benefit period. HOSNHV#2 the spiritual care assessment following the SOC was not performed for a week and a half. In both cases there was no documentation to justify the delay. This was reviewed with the CEO/Director of Nursing.

Observed in Record Review. In 3 of 12 patient records reviewed, The organization did not assesses and reassesses the patients wound status. Examples: The record review for HOSNHV#2 indicated that the patient had a Stage III pressure ulcer on the patient's back with wound initial measurements. The wound measurements were not re-assessed until two weeks after the wound was identified. The three subsequent nursing noted had no re-assessment of the wound condition. In HOSNHV#3 wound assessments and re-assessments were not documented during the period of time the patient had an active right buttock Stage III pressure ulcer. There was no documentation of the initial assessment indicating an issue or any subsequent wound assessments or measurements. . The three nursing notes in the following two weeks did not include any mention of the wound. HOSNHV#7 was also lacking right and left buttock wound assessments and reassessments. Reviewed with the CEO/ Director of Nursing.

Observed in Record Review. In 2 of 12 patient records reviewed, It was noted in record review HOSNHV#3 that wound care orders for a Right Buttock Stage III pressure ulcer were not obtained for a week and a half , three days before the order discontinuing the treatment as it had healed. The order called for Hydrogel for two weeks. Reviewed with the CEO/Director of Nursing.

Observed in Record Review. In 2 of 12 patient records reviewed, The organization planned care and treatment based on information from updates to the patient’s condition however did not obtain timely orders. Examples: In HOSNHV#2 a physician order for a right buttock Stage III pressure ulcer was not obtained. The only order was to discontinue the treatment on 5/30. In the same record, there was no order to treat a left ear Stage II wound. In HOSNH#7 nursing notes from 11/17 - 1/2/25 identify both a Left Buttock and Right buttock wounds however physician orders for treatment only reflect care for a Left Sacrum pressure ulcer within the same period of time. Reviewed with the CEO/Director of Nursing.

Observed in Patient Home. In 2 of 3 home visits conducted, The surveyor noted in two of three home visits (HOSRRHV#1and HOSRRHV#2) that the the most current medication profile from the clinical record not matching what was being administered. Examples: HV#1 MVI, Zinc Ointment and Vit C were still being given when an order was in place to discontinue. HV#2 Tylenol and Loperamide were still ordered but not being given. Reviewed with CEO/Clinical Director

Observed in Record Review. In 5 of 5 patient records reviewed, the organization did not ensure that the individualized plan of care reflected goals were individualized, specific, and measurable. For example: Throughout all records reviewed many of the goals were non-specific and not measurable such as comfort goal in RR#1, #2, #3, #4 and #5 stated optimal comfort of pain, patient comfort daily. Another goal In RR#5 the goals for safety state Will attain optimal pt/cg safety daily and will attain optimal family functioning daily. Similar findings can be noted throughout all clinical records. Each goal throughout the records reviewed had an end date that was at the end of the 2 week IDG period. These observations were reviewed with the DPCS.

Observed in Record Review. In 3 of 5 patient records reviewed, the organization failed to maintain complete and accurate patient records. For example: in review of the record for RR#2 and RR#4 both patients had falls with resulting wounds. The wound care was documented, however there was no documentation of fall plans. There was no goal, interventions or education related to falls documented in the records. Example 2: In review of RR#3 the patient had a foley catheter. The record did not include foley catheter in goals or interventions other than foley catheter care. This was confirmed with the DPCS present.

Observed in Record Review. In 5 of 5 patient records reviewed, there lacked documentation of progress toward outcomes and goals. For example: the organization utilized paper care plans and paper IDG documentation. These were to be updated at IDG meetings per discussion. The IDG meeting documentation did not address the patient's progress toward outcomes and goals, nor evidence that the interventions were implemented. Each care plan's goals and interventions were renewed each IDG with an adjusted outcome date for the next IDG meeting. This was noted throughout all clinical records. For example in RR#1 all 16 goals and their interventions remained the same from the time they were initiated to present. This observation was reviewed with the DPCS and Office Manager present.

Observed in Record Review. In 2 of 5 patient records reviewed, The organization failed to ensure that the visits were carried out according to the detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. For example, record review RR#1 the spiritual counselor was scheduled 1 time a month, however there was no documentation of visits in July or August. Example 2, record review RR#5 the Volunteer was scheduled 1 time a month, however there was no documentation of a visit in July. This was confirmed with the DPCS and Office Manager.

Observed in HR File Review. In 2 of 4 HR files reviewed, the organization failed to assess the skills and competence of all individuals furnishing care annually as required by organization policy. During review of the agencies HR Files, it was noted that the MSW and Bereavement Coordinator did not have current annual assessment of competency noted in the record. This observation was reviewed with the DPCS.

Observed in Record Review. In 3 of 5 patient records reviewed, the organization failed to ensure that the record contained information that reflected the patient's care, treatment, and services. For example: upon record review RR#3 the nurse's documentation indicated a change of foley catheter however there was no documentation of the patient's response to the treatment. In 1 of 5 records reviewed the organization failed to ensure that documentation was submitted within 10 days as required by organization policy. For example, RR#2 there were 2 aide visits that were not submitted to the record at the time of survey day. These visits were greater than 10 days prior to survey day. This was confirmed with the DPCS and Office Manager present.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to provide effective pain management and symptom control for the patient. For example: during HV#1 the patient complained that she was not receiving effective pain relief. She stated that she had complained of high pain levels to her face and left side to the nursing staff to include the Director of Nursing, yet her symptoms continued to not be relieved. Upon review of the record there was documentation of correspondence with the MD, DON and patient regarding reducing pain medications. Documentation in the nursing notes do not reflect any issues with pain control. This observation was reviewed with the Director of Nursing.

Observed in Record Review. In 3 of 11 patient records reviewed, the organization failed to document a comprehensive assessment as required by organization policy as related to wound care. For example: upon review of RR#4 the patient had extensive wounds. Per discussion with the Director of Nursing and the LVN it was noted that the wound assessment was pre-populated from visit to visit and therefore not assessed and documented weekly as per organization policy. In HV#1 the patient complained in the home observation of uncontrolled pain, upon review of the record the patient's comprehensive pain assessment had not been assessed per organization policy as the pain assessments were identical, with conflicting information in each visit and the SN acknowledged that the notes were pre-populated. In review of RR#7 the patient caregiver called on-call to request assistance stating the patient look like she is suffering, the on-call clinician gave the caregiver instruction to provide oxygen, positioning, and medications yet no visit to assess the patient status was made. The patient died during the night. These observations were reviewed with the CEO/Director of Nursing.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization did not ensure that the individualized plan of care reflected goals were individualized, specific, and measurable. For example: Throughout all records reviewed many of the goals were non-specific and not measurable such as pain goal in HV#1 stated optimal comfort of pain, patient comfort daily x 3 months, and Cg/Pt adequately informed on pain control measures x 3 months. Another goal for nutrition read will attain optimal hydration daily x 3 months and minimal anxiety regarding altered nutrition status daily x 3 months. In RR#5 the goals for safety state Will attain optimal pt/cg safety daily x 3 months and will attain optimal family functioning daily x 3 months. Similar findings can be noted throughout all clinical records. Each goal throughout the records reviewed had an end date that was at the end of the benefit period. These observations were reviewed with the CEO/Director of Nursing and the Quality Nurse.

Observed in Record Review. In 1 of 11 patient records reviewed, The organization failed to ensure that the visits were carried out according to the detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. For example: upon review of the record for RR#4 the MSW was scheduled 1 time a month, however there was no documentation of visits in January or February. This observation was reviewed with the Director of Nursing.

Observed in Record Review. In 7 of 11 patient records reviewed, throughout all clinical records reviewed that had been on service greater than 1 benefit period, there lacked documentation of progress toward outcomes and goals. For example: the organization utilized paper care plans and updated them at IDG meetings per discussion. The IDG meeting documentation did not address the patient's progress toward outcomes and goals, nor evidence that the interventions were implemented. Each care plan's goals and interventions were renewed each recertification with adjusted outcome date for the end of the next benefit period. This was noted throughout all clinical records. Example in RR#8 the fall risk goals and interventions remained the same for over a years time to include an intervention to instruct to remove boxes. This observation was reviewed with the CEO/Director of Nursing and Quality Nurse.

Observed in HR File Review. In 1 of 1 HR files reviewed, that provided aide services, the organization failed to complete Hospice Aide competency annually that included observing the aides performance of required tasks with a patient or pseudopatient. The aides annual competency utilized a Core Competency skill checklist that only included subjects such as concepts of death and dying, hospice philosophy, compliance with policy, and plan of care, yet did not address observing the aide's performance of safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination - Safe transfer techniques and ambulation - Normal range of motion and positioning. This observation was reviewed with the CEO/Director of Nursing.

Observed in Leadership Session. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: - §418.100, 418.56, 418.104, and 418.116.

Observed in Competency Session. In 3 of 7 HR files reviewed, the organization failed to assess the skills and competence of all individuals furnishing care annually as required by organization policy. During review of the agencies HR Files, it was noted that the volunteer coordinator, MSW, Chaplain, and Bereavement Coordinator did not have current annual assessment of competency noted in the record. This observation was reviewed with the CEO/Director of Nursing.

Observed in Record Review. In 4 of 11 patient records reviewed, the organization failed to maintain complete and accurate patient records. For example: in review of the record for HV#1, it was noted that there was conflicting documentation in the nurses notes. Over multiple notes the patient's pain in the pain assessment was noted as 3/10, the Edmonton pain assessment was noted at 4, and yet in another section it was noted that the patient denied pain. Further it appears that the nurses notes were pre-populated as many portions of documentation with the exception of vital signs are identical from one note to the next throughout all nursing notes in the 2nd benefit period. This pattern can also be noted in the 1st benefit period. In the nurses recertification note, there was documentation that the patient was taking Norco, however the medication profile specified Percocet. Example 2: In review of RR#4 the patient had extensive wounds, the LVN's notes contained the exact measurement over an extended period of time, and also noted that the wound care was performed by the caregiver. Upon discussion with the LVN the measurements and documentation was pre-populated and the wounds were not visualized during the visits. There was evidence throughout nursing notes that the assessment was pre-populated as documentation including narrative was nearly identical from note to note. In HV#3 there were similar findings that the documentation was identical from note to note over 8 visits in the current benefit period. Similar findings can be seen in RR#5. This observation was reviewed with the CEO/Director of Nursing, and the Quality RN.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to ensure that the record contained information that reflected the patient's care, treatment, and services. For example: upon interviewing the hospice aide for HV#1 the aide noted that the patient had significant pain that required him to be very careful with the patient's shower. He stated that the pain had been reported to the RN, however there was no indication in the clinical record that the patient's pain was reported by the aide to the RN. This observation was reviewed with the CEO/Director of Nursing. Observed in Record Review. In 4 of 11 patient records reviewed, the organization failed to ensure that documentation was submitted within 10 days as required by organization policy. For example: On review of RR#4 there were 9 skilled nursing visits in the current benefit period that were not submitted to the record at the time of survey day one. These visits were available in the record on survey day 2 but were submitted greater than 10 days as required by policy. In HV#1 the aide there were 11 visit pending submission that were greater that 10 days per policy on day one of survey. These were submitted and available for review on survey day 2. Example 2: on review of RR#8 the SN visit prior to the patient's revocation was noted to be blank with the exception of vital signs. Example 3: on review of RR#7 there was no documentation of attending the patient's death. Communication notes indicates the nurse, and spiritual counselor attended yet there was no documentation of the visits. These observations were reviewed with the Director of Nursing.

Observed in Tracer Activities. The organization failed to develop a process for providing the patient/caregiver with the Patient Notification of Hospice, Non-Covered Items, Services, and Drugs as required by CMS regulations. During review of the organizations admission packet there was no provision for the Patient Notification of Hospice, Non-Covered Items, Services, and Drugs. During discussion with the CEO/Director of Nursing and Office Manager it was acknowledged that there was no process to provide this information. Example 2: Upon review of RR#10, the patient was discharged for extended prognosis. There was no Notice of Medicare Non-Coverage noted on the record. After discussion with the CEO/Director of Nursing it was acknowledged that the organization had no process established to provide the Notice of Medicare Non-Coverage prior to discharge.