Every finding on record at Wkm Hospice LLC

Observed in Individual Tracer. In 1 of 3 patient records reviewed, the hospice care plan did not reflect interventions based on patient's assessed needs. Based on a review of assessment for RR#1 the patient had a stage two sacral decubiti. A review of the plan of care and updates to the plan of care did not reflect any interventions and or goals for this assessed problem. This observation was discussed with the director.

Observed in Individual Tracer. In 1 of 3 patient records reviewed, the Hospice did not provide services as ordered. RR#3 had orders for monthly social work visits for depression. The last social work visit occurred two months ago and there was no notification of the IDG or change in the most recent plan of care. This observation was discussed with the administrator.

Observed in Infection Control System Tracer. Based on a review of the infection control plan, there was no goal that specifically addressed hand hygiene compliance or the measurement of compliance. This observation was discussed with the administrator.

Observed in Record Review. In 3 of 3 patient records reviewed, it was noted that the organization had not ensured the plan of care included goals to reflect the patient and family goals based on the update to the comprehensive assessments. For example: review of RR# 1’s current plan of care revealed MSW and Chaplain visit frequency of one visit a month. However, review of the plan of care revealed no MSW or Chaplain goals. Review of RR# 2’s patient record revealed a RN recertification comprehensive assessment with RR# 2 assessed as a high fall risk. Review of RR# 2’s plan of care revealed no goals related to fall prevention. In addition, RR# 2’s plan of care revealed MSW visit frequency of one visit a month. However, review of the plan of care revealed no MSW goals. Review of RR# 3’s plan of care revealed MSW visit frequency of one visit a month. However, review of the plan of care revealed no MSW goals. This was reviewed and discussed with the Administrator and Compliance Officer.

Observed in Record Review. In 3 of 3 patient records reviewed, the organization had not ensured the plan of care included interventions to manage pain and symptoms. For example: review of RR# 2’s patient record revealed a RN recertification comprehensive assessment with documentation RR# 2 was a high risk for falls. Further review of the plan of care revealed no fall prevention interventions. In addition, review of the plan of care revealed MSW visit frequency of one visit a month and no MSW interventions. Review of RR# 1’s plan of care revealed MSW and Chaplain visit frequency of one visit a month with no MSW or Chaplain interventions. Review of RR# 3’s patient record revealed MSW frequency visit of one visit a month with no MSW interventions. This was reviewed, discussed, and validated with the Administrator and Compliance Officer.

Observed in Document Review. The organization's written infection control plan did not include all required elements. For example, the written infection control plan did not include a description of prioritized risk areas, and infection prevention and control goals. Since the written infection control plan did not include all required elements an effective infection control program was not documented to protect patients, families, visitors, and hospice personnel. This information was discussed and reviewed with the Administrator and Compliance Officer.

Observed in Document Review. The organization did not have written infection prevention and control goals that included limiting the unprotected exposure to pathogens. This was discussed and reviewed with the Administrator and Compliance Officer. Observed in Document Review. Since the organization did not identify infection risks for acquiring and spreading infections; the organization did not have written infection prevention and control goals that addressed its prioritized risks. This was discussed and reviewed with the Administrator and Compliance Officer. Observed in Document Review. The organization did not have written infection prevention and control goals that included limiting the spread of infections associated with procedures. This was discussed and reviewed with the Administrator and Compliance Officer. Observed in Document Review. The organization did not have written infection prevention and control goals that included improving compliance with hand hygiene guidelines. This was discussed and reviewed with the Administrator and Compliance Officer. Observed in Document Review. The organization did not have written infection prevention and control goals that included limiting the spread of infections associated with the use of medical equipment, devices, and supplies. This was discussed and reviewed with the Administrator and Compliance Officer.

Observed in Document Review. 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 and §418.60.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization did not ensure that the comprehensive assessment included all required information. For example, a review of the medical record for RR#8, revealed that the comprehensive assessment did not include an initial nursing assessment to identify the patient's physical needs, and areas related to palliation and management of terminal illness and related conditions. This observation was reviewed with the Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization did not ensure that a plan of care that specified the hospice care and services necessary to meet the patient and family-specific needs was completed. For example, a review of the medical record for RR#8, revealed that a plan of care that included all services needed for the palliation and management of the terminal illness and related conditions, interventions to manage pain and symptoms, a statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs; and measurable outcomes anticipated from implementing and coordinating the plan of care, medications and treatment necessary to meet the patient’s needs, and medical supplies and appliances necessary to meet the patient’s needs was completed. This observation was reviewed with the Administrator.

Observed in Record Review. In 6 of 11 patient records reviewed, it was noted that the organization did not ensure that goals for care were patient specific and measurable. For example, a review of the medical record for HV#1, included the following information: The patient's fall risk assessment was scored as high fall risk, the patient ambulated with a rolling walker. The goal related to fall risk was Promote optimal patient safety and prevention of injury. The timeframe for goal achievement was by time of death/discharge. This patient experienced a fall during week 2 of services and the goal was not revised, and the goal achievement timeframe was not adjusted. Example #2: A review of the medical record for HV#2, revealed the following information: The initial pain assessment: pain intensity was equal to 4, pain relief measures included hydrocodone 10/325, number of breakthrough medications in last 24 hours was equal to 6. The goal for pain management was Patient will achieve and maintain optimal physical comfort, and the timeframe for goal achievement was by time of death/discharge. This goal was not patient specific and measurable. Example #3: A review of the medical record for RR#3, included the following information: The patient's fall risk assessment was scored as high fall risk, the patient ambulated with a cane or walker. The goal related to fall risk was Promote optimal patient safety and prevention of injury. The timeframe for goal achievement was by time of death/discharge. This goal was not patient specific and measurable. Example #4: A review of the medical record for RR#7, included the following information: The patient was ambulatory with assistance, the patient’s fall risk assessment was scored as high fall risk. The plan of care did not include a goal statement to evaluate the effectiveness of fall prevention interventions. Example #5: A review of the medical record for RR#4, and RR#6, revealed the goal related to fall risk was Promote optimal patient safety and prevention of injury. The timeframe for goal achievement was by time of death/discharge. This goal was not patient specific and measurable. This observation was reviewed with the Administrator.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization did not ensure the plan of care included all required information. For example, a review of the medical record for HV#1, revealed that the patient experienced a fall during week 2 of services. The plan of care was not updated with interventions to maintain patient safety, strategies to prevent injury and a goal statement to evaluate the effectiveness of fall prevention interventions. Example #2: A review of the medical record for RR#7, included the following information. The patient was ambulatory with assistance, the patient’s fall risk assessment was scored as high fall risk. The plan of care did not include interventions to maintain patient safety, or strategies to prevent injury.

Observed in Record Review. A review of 7 of 11 patient records revealed that the organization did not ensure that plan of care revisions included all required elements. For example, during a review of the medical record for HV#1, was noted that the interdisciplinary team meeting documentation did not include information from updates to the comprehensive assessment; and progress toward outcomes and goals specified in the plan of care. Example #2: A review of the medical record for HV#2, revealed that during week 10 and 12 of the 1st benefit period; and during week 1 and 3 of the 2nd benefit period, the interdisciplinary team meeting documentation did not include information from updates to the comprehensive assessment; and progress toward outcomes and goals specified in the plan of care. Example #3: A review of the medical record for HV#3, revealed that during week 4 and 6 of the 1st benefit period, the interdisciplinary team meeting documentation did not include information from updates to the comprehensive assessment; and progress toward outcomes and goals specified in the plan of care. Example #4: A review of the medical records for RR#4, RR#6, RR#7, and RR#8 revealed that the interdisciplinary team meeting documentation did not include information from updates to the comprehensive assessment; and progress toward outcomes and goals specified in the plan of care. This observation was reviewed with the Administrator

Observed in Data Session. The organization leaders did not ensure that it's policy titled Quality Assessment Performance Improvement Program was implemented. For example, a quality assessment and performance improvement program was not developed that: a) reflects the complexity of the organization and its services; b) involves all hospice services, including those provided under contract and/or arrangement; and c) focuses on indicators that are related to improved palliative outcomes, processes of care, hospice services, and non-clinical operations, (d) and takes actions to demonstrate improvement in hospice performance. The organization did not maintain documentation of its quality assessment and performance improvement program in an effort to demonstrate improvement in its operation. This observation was reviewed with the Administrator. Observed in Data Session. The organization leaders did not ensure that a quality assessment and performance improvement program was developed that: a) reflects the complexity of the organization and its services; b) involves all hospice services, including those provided under contract and/or arrangement; and c) focuses on indicators that are related to improved palliative outcomes, and (d) takes actions to demonstrate improvement in hospice performance. There was no documented evidence that the organization leaders evaluated the quality assessment and performance improvement program annually. This observation was reviewed with the Administrator.

Observed in Data Session. The organization's written infection control plan did not include all required elements. For example, the written infection control plan did not include a description of prioritized risk areas, and infection prevention and control goals. Since the written infection control plan did not include all required elements an effective infection control program was not documented to protect patients, families, visitors, and hospice personnel. This information was reviewed with the Administrator.

Observed in Data Session. The organization did not have written infection prevention and control goals that included improving compliance with hand hygiene guidelines. This observation was reviewed with the Administrator. Observed in Data Session. Since the organization did not identify infection risks for acquiring and spreading infections; the organization did not have written infection prevention and control goals that addressed its prioritized risks. This observation was reviewed with the Administrator. Observed in Data Session. The organization did not have written infection prevention and control goals that included limiting the spread of infections associated with the use of medical equipment, devices, and supplies. This observation was reviewed with the Administrator. Observed in Data Session. The organization did not have written infection prevention and control goals that included limiting the unprotected exposure to pathogens. This observation was reviewed with the Administrator. Observed in Data Session. The organization did not have written infection prevention and control goals that included limiting the spread of infections associated with procedures. This observation was reviewed with the Administrator.

Observed in Competency Session. In 1 of 7 Human Resource files reviewed, it was noted that the organization did not ensure competence was assessed as a part of orientation. For example, a review of the human resource file for Hospice Aide #1, revealed no documented evidence that a competence assessment was completed as a part of orientation. This observation was reviewed with the Administrator.

Observed in Record Review. In 3 of 3 patient records reviewed, for patient's receiving Hospice Aide services, it was noted that a Hospice Aide supervisory visit was not documented every 14 days. For example, a review of the medical record(s) for HV#1, and HV#3, revealed that a Hospice Aide supervisory visit was not documented during week 6 of services. Example #2: A review of the medical record for RR#3 revealed that a Hospice Aide supervision note was documented during week 1 of the 1st benefit period and the next supervision visit was documented during week 2 of the 2nd benefit period. This observation was reviewed with the Administrator.

Observed in Data Session. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: -§418.56, §418.58, §418.76 and §418.60.

Observed in Record Review. A review of 2 of 11 patient records revealed that the organization did not ensure that a written certification of the patient’s life expectancy was accomplished. For example, a review of RR#6, and RR#8, revealed no documented evidence that an initial certification of terminal illness statement was completed.