T M C Hospice Aka Peppi’s House

“Observed in Tracer Activities. In 1 of 5 bereavement records reviewed, the organization had not completed bereavement assessments according to policy. The patient admitted to hospice 3/16/2024 and the patient’s date of death was 4/21/2024. The first documented bereavement assessment was done 5/2/2024. There was no documented bereavement assessment completed at the time of admission. The first bereavement assessment was completed 5 weeks post death. The organization’s policy states that an initial bereavement assessment will be completed at the time of admission and that it will be updated after the patient’s death.”

“Observed in Record Review. In 1 of 6 home visits conducted, the organization failed to ensure the patient record was promptly and accurately documented. On review of RRHV#1 the documentation for the home observation visit reviewed noted documentation of a wound assessment to include measurements, and color of the wound and dressing change completed. On home observation the RN was not observed to assess the wound. On discussion with the RN he noted that he got the information from the patient caregiver as he gestured to him an approximate size with his hands and the RN used that information estimate measurements. There was no documentation in the record to indicate the documentation was based on the caregiver’s description and not an actual assessment by the RN. This observation was reviewed with the Manager of Patient Care Services.”

“Observed in Record Review. In 4 of 20 patient records reviewed, the organization failed to ensure thee individualized written plan of care is based on the patient’s goals that are specific, measurable, and time-bound. For example: on review of RRHV#1 there were goals that were no specific, measurable and time-bound such as: Patients wound will heal without s/s of infection – no achieve by date and Patient will maintain normal bowel patterns and control within the limits of disease progression.
example in RRHV#3 was Pt will remain as independent as possible, within limits of his/her disease, and will remain in a safe environment for the duration of hospice course. Many of the goals had time periods for until death or throughout hospice even when they were noted to be short term goals. In RRHV#4 an example was Patient will have no evidence of skin breakdown related to incontinence throughout hospice stay, however the goal was not individualized as the patient had an extensive sacral wound. In RRHV#6 examples of goals were Pt ecchymosis will heal thoroughly and Pt will have decreased nausea and vomiting. These observations were reviewed with the Manager of Patient Care Services.”

“Observed in Record Review. In 4 of 20 patient records reviewed, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#4 during home observation with the patient and MSW one of the focuses of the visit was to ensure a smooth transition as the patient had recently been moved form one group home to another, however the transition was not reflected in the plan of care. In RRHV#1 documentation noted multiple changes in the patient’s wound as it was described to open and close frequently with differing treatments documented yet the changes were not reflected in the care plan as the goals and interventions had been established and remained unchanged since 2022. In RRHV#4 the patient had 2 episodes on GIP yet the GIP status was not reflected on the plan of care. Further, there was documentation that the suprapubic catheter was not patient and ordered to be replaced yet the changes were not reflected on the plan of care. In RRHV#5 the patient had neurogenic bladder requiring straight catheter multiple times daily yet was not reflected in the care plan. In RRHV#6 there was lower extremity edema and a fall documented yet the issues were not reflected in the care plans. These observation were reviewed with the Manager of Patient Care Services.”

“Observed in Patient Home. In 3 of 6 home visits conducted, the organization failed to ensure the plan of care includes all services needed for the palliation and management of the terminal illness and related conditions. For example: on RRHV#1 home observation the RN and patient caregiver discussed the patient’s wound and dressings the caregiver was utilizing such as mepilex and a silver dressing yet there were no physicians orders noted on the record for the dressings being utilized. Further, the order for wound care on the care plan was noted to be incomplete as it simply stated twice weekly dressings and PRN/zinc oxide. There was no indications such as location, how to cleanse, of what type of dressing, who was to perform, and what situation to change as needed. In RRHV#2 the patient had multiple medications on the medication profile such as , Acetaminophen, Morphine, Tramadol, and Oxycodone listed for PRN use yet there were no specific instructions to guide the user as to which medication to use for what situation or type/severity of pain. In RRHV#4 there were three pain meds Acetaminophen, Morphine IR and Morphine liquid yet there were no instructions on which to use for what situation. These observations were reviewed with the Manager of Patient Care Services. Observed in Record Review. In 2 of 20 HOS patient records reviewed and confirmed by the Patient Care Manager. The patient plan of care had not been reflective of the assessed need. Example: During review of HOSrr# 5 the RN assessment had identified 4 plus edema with weeping, however the plan of care had not identified interventions to address the edema. HOSrr#4 the patient initial assessment had identified nausea and a G tube, however the plan of care had not identified interventions to be provided .”

“Observed in Record Review. In 1 of 19 HOS patient record reviewed and confirmed by the Patient Care Manager. The Plan of care had not been updated. Example: During review of HOSrr#4 had not been updated to show progress to goals. The initial plan had stated that an advanced directive would be in the patient chart in 5 days. The updated POC had not identified the progress to goal or goal met. Observed in Record Review. In 5 of 20 patient records reviewed, the organization failed to ensure plan of care revisions are based on information from updates to the patient’s comprehensive assessment and address progress toward goals. For example: on review of RRHV#1 there was noted goals that were established on admission in 2021 and remain unchanged throughout care IDG to IDG. An example noted Family/caregiver will verbalize understanding of how vital signs will change during the death/dying process within 5 days the goal was established in 2021. In RRHV#3 an example of a goal established on admission in 2022 and remained unchanged was Pt/family/caregiver will verbalize receiving emotional support during the next 2 weeks. There were many goals that had noted goal met week after week yet the goal remained in place without update to reflect changes. Further examples can be seen in RRHV#4, RRHV#5, and RRHV#6. These observations were reviewed with the Manager of Patient Care Services.”

“Observed in Patient Home. In 1 of 6 home visits conducted, the organization failed to ensure the patient care, treatment, and services were provided according to the patient’s individualized plan of care. For example: on review of RRHV#1 during the home observation the RN failed to assess and provide treatment for the patient wound as specified in the plan of care which stated to assess the skin integrity each visit. This observation was reviewed with the Manager of Patient Care Services, and the Director of Patient Care Services. Observed in Patient Home. In 1 of 6 home visits conducted, the organization failed to conduct and document a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services for severity of symptoms. On RRHV#1 during home observation the RN discussed the patient’s wound with the caregiver yet did not perform an assessment of the wound even though the caregiver noted the wound had changed as he noted it was previously open but now the skin was intact. The care plan noted the wound would be assessed twice weekly. This observation was reviewed with the Director of Patient Care Services, and the Manager of Patient care services.”

“Observed in Patient Home. In 3 of 6 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned. For example: on home observation for RRHV#1 it was noted that the RN gathered all trash used during the visit and removed form the home and place the trash in the back of the clinician’s car. The organizations bag technique policy HO-01067 states when visit is complete, dispose of non-permeable barrier and waste generated during visit in the patient’s household trash. The process of removing trash generated during visit and remove from the home by the clinician was also seen in RRHV#4, and RRHV#5. These observations were reviewed with the Manager and Director of Patient Care Services. Observed in Patient Home. In 1 of 6 home visits conducted, the organization failed to ensure they implemented the infection prevention and control activities had planned. For example: on home observation at RRHV#1 the RN failed to perform hand hygiene as specified in policy IC-01-152 and it was noted throughout care the clinician had multiple missed opportunities for hand hygiene such as after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. The RN was observed to no perform hand hygiene after reaching for medication bottles, and later after removing trash form the patient home. Further, multiple time throughout the providing patient care the clinician reached for his phone, and used pen and returned to pocket. These observations were reviewed with the Manager and Director of Patient Care Services. 





 Observed in Individual Tracer. In 1 of 3 HOS IPU patients and confirmed by the Patient Care Manager. Staff had not followed its infection control protocol for hand hygiene based on organization policy and CDC guidelines. Example: During observation of a Patient Care Tech providing a bed bath to a patient in the IPU . The Patient Care Tech frequently changed gloves during patient care, but hand not cleansed his hands between glove changes . Observed in Patient Home. In 1 of 6 home visits conducted, the organization failed to implement infection prevention and control activities when cleaning and performing disinfection of medical supplies and devices. On home observation for RRHV#2 it was noted that the RN cleansed the laptop used during the visit but failed to allow for contact/dry of the manufacturer’s guidelines as specified in the organization policy HO-01-67. This observation was reviewed with the Manager, and Director of Patient Care Services.”

“Observed in Tracer Activities. In 1 of 5 bereavement records reviewed, the organization had not developed a bereavement plan of care that specified the type of services to be offered or the frequency of the services. The organization had completed initial and post mortem bereavement assessments, but failed to develop a plan of care for the bereaved. The post mortem assessment was completed September 14, 2023, as of June 2024, no bereavement services were documented. The finding was reviewed with the lead social worker at the time of the record review.”

“Observed in Record Review. In 1 of 20 patient records reviewed, the organization failed to ensure the RN provide written patient care instruction for the hospice aide. On Review of RRHV#4 the hospice aide plan of care did not cover any tasks related to the aides visit yet included wound care orders, to which the Manager of Patient Care Services noted the aide was not providing wound care. The aide’s documented assisted with a bed bath. The patient had extensive wounds, suprapubic catheter, and colostomy yet there were no instructions of how to handle these while providing care. This observation was reviewed with the Manager of Patient Care Services. Observed in Record Review. During review of 3 of 20 Hospice active records and confirmed by the Patient Care Coordinator. The Home Health Aide plan of care had not been complete to include specific bathing to be provided. Example: HOSrr#10, HOSrr#11 and HOSrr#12 had documented for the HHA to provide personal care per RN direction . Bathing had not specified what type of bath to be provided.”

“Observed in Patient Home. In 1 of 6 home visits conducted, the organization failed to ensure the patient record contain all information that reflects the patient’s care, treatment and services. On home observation of RRHV#1 on review of the medication profile the it was noted that there was no oxygen in the home and caregiver stated it had been discontinued and removed form the home yet the order for oxygen remained on the medication profile. The caregiver also stated that the diazepam and mirtazapine that were on the medication profile had not been given in some time and were no longer in the home. Further, on discussion with the caregiver he directed us to a box full of ointments and bottles and stated that many were probably not on the medication profile but he uses them as needed. These observations were reviewed with the Manager and Director of Patient Care services.”