Haga Hospice, Inc.

“Observed in Regulatory Review. In 5 of 5 patient records reviewed, During the record review, the surveyor noted that the organization did not have goals to all identified deficits, have measurable goals and have goal time frames that reflect the needs of the patient. For example, in NHVRR1, 2,3,4 and 5 the goals were all for the end of the certification period and not reflective of the needs of the patient. In those same records the goals were not measurable, for example optimum oxygen level; pain will be maintained at her comfort level’; optimum peripheral circulation; facilitate bowel elimination; ‘urinary elimination at acceptable level; :increase energy for functional activities; adequate food and fluids; decreased episode of SOB and comfortable during hospice care. In RRNHV2, the patient was on Metformin but there was no goal to address this. In RRNHV3, the patient was on Metformin and regular and sliding scale insulin but there was no goal to address this. This was validated in a discussion with and observation by the DCPS.”

“Observed in Data Session. It was noted in reviewing the QAPI meeting minutes for 2022-2023 (quarter 1, 2024 not recorded at this time) did not reflect the complexity of the organization. The minutes reflected review and data for pain, fall/safety, infection control, handwashing/hand hygiene, influenza and bag technique. It lacked data for family satisfaction/perception of care surveys, medication errors, adverse reactions to medications, other incidents, patient/family complaints, evaluation of contracted services, culture of safety reviews, volunteer program review, bereavement program review, and record review for all hospice services. This was discussed with the Administrator.”

“Observed in Document Review. In 6 of 14 patient records reviewed, It was noted the consent forms used by the organization lacked the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” section for the patient/representative to request or decline information of non-covered items, services and drugs. In addition during HV#2 record review, RR#3, RR#6 it was noted the election of benefit date on the consents was blank. During HV#1 record review, RR#1, RR#3, RR#6 and RR#7 it was noted the check boxes referencing Advance Directive information was blank. During HV#1, RR#3, RR#6 and RR#7, the acknowledgement of information provided prior to care was blank. This was discussed with the Administrator. Observed in Record Review. In 1 of 1 patient records reviewed, who were discharged, revoking the hospice benefit. It was noted live D/CRR#2 revoked the hospice benefit, the physician was notified but the medical record lacked a signed revocation form.”

“Observed in Record Review. In 3 of 14 patient records reviewed, It was noted in HV#1 record review lack of documentation of an RN visit every 15 days to conduct an assessment. The last documented RN assessment was the middle of February. It was noted in HV#3 record review lack of documentation of an RN visits every 15 days to conduct an assessment. There were 21 days between the end of December 2023 and the next RN visit the middle of January 2024. During RR#7 it was noted the last RN assessment documented in the medical record was the end of January 2024. This was discussed by the Administrator.
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“Observed in Record Review. In 8 of 14 patient records reviewed, It was noted in HV#1 record review lack of measurable goals. All the goals have the same target date of the end of the certification in April 2024. For example: Coping and acceptance of death by Family/PCG, Minimize complications due to impaired mobility, Patient will have adequate food and fluids as tolerated or desired, Patient will remain comfortable during care, Patient will have optimum level of oxygen. In addition there was an order for physical therapy (PT) 2x/week x 8 weeks with interventions documented in the physician order, plan of care (POC) summary but lacked PT goals of care. It was noted in HV#2 record review, all goals had the same target date, the end of the certification. For example: coping and acceptance of death by Family/PCG, Pt will remain free of injury. Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects, Pt/Family/PCG will have mortuary plan in place, Pt will verbalize and/or express decreased episodes of SOB at rest. Pt will verbalize and/or express decreased episodes of SOB during activities. Pt will have optimum level of oxygen. Pt/pcg will verbalize/express understanding of medication treatment orders and side effects. The chaplain had a frequency of visits of once a month however the POC lacked spiritual goals. It was noted in HV#3 record review lack of goals for the MSW. In addition there was lack of goals established for deficits identified during the RN assessments that included oxygen therapy and nutritional weight loss deficits. During RR#1 it was noted all goals had the same target date of the end of the certification. During RR#2 it was noted lack of goals related to deficits identified in the RN assessments that included oxygen safety, aspiration precautions, risk for skin breakdown due to incontinent of bowels and bladder. The mobility deficit identified included assessment of mobility however it lacked goals related to fall risk. During RR#3 it was noted the POC lacked goals related to deficits documented by the RN. They included goals for: nutrition related to poor appetite, aspiration risk due to poor dentition, weakness, fall risk score of 13, skin breakdown potential assessed on the Braden scale and oxygen therapy. During RR#4 it was noted 10/10 target date goals established by the IDG were to be accomplished at the end of the certification. During RR#5 it was noted goals related to nutrition, weakness, mental deficits, respiratory deficits and NIDDM were to be accomplished by the target date, the end of the certification period. During RR#6 it was noted the following goals that not individualized and not measurable:Pt will maintain optimum peripheral circulation, Facilitate bowel elimination and comfort, Pt/Family/PCG will verbalize having elimination needs met at an acceptable level, Increase strength/energy for functional activities, Pt needs will be met on a day to day basis as communicated, Pt will have adequate food and fluids to maintain comfort as exhibited by expressed verbal and non-verbal communication and Pt will have optimum level of oxygen. In addition it was noted that pain was identified during the RN assessment without goals documented on the POC. During RR#7 it was noted goals had target dates to be achieved the end of the 60 day certifications which remained the same for each certification since the SOC in September 2023. In addition there was lack of goals documented for deficits identified by the RN that included weight loss, poor appetite, fall risk and skin breakdown risk. This was discussed with the Administrator”

“Observed in Record Review. In 6 of 14 patient records reviewed, It was noted in HV#1 record review there were POC orders to assess pain, nutrition, neuro mental status, mobility and fall precautions however there was lack of interventions established by the RN on the identified deficits. It was noted in HV#2 record review lack of interventions added to the POC for deficits identified during the comprehensive assessments that included generalized pain and a decrease in appetite. In addition the chaplain had a frequency of once a month visits, however the POC lacked spiritual interventions. It was noted in HV#3 record review lack of interventions added to the POC for deficits identified during the comprehensive assessments that included oxygen safety (Pt on O2 at 3L continuous) and a nutritional issues related to weight loss. In addition the POC lacked interventions established by the MSW. During RR#1 it was noted lack of interventions for deficits identified on the RN assessment that included pain, anxiety, and weight loss. During RR#2 it was noted lack of interventions related to deficits identified in the RN assessments that included oxygen safety, aspiration precautions, risk for skin breakdown due to incontinent of bowels and bladder. Mobility deficit identified included assessment of mobility however it lacked interventions related to fall risk. During RR#3 it was noted the POC lacked interventions related to deficits documented by the RN. They included: nutrition related to poor appetite, aspiration risk due to poor dentition, weakness, fall risk score of 13, skin breakdown potential assessed on the Braden scale and oxygen therapy. During RR#5 it was noted that pain was identified on the RN assessment with an order for Norco to relieve the pain. Interventions related to pain were not included on the POC. During RR#6 it was noted pain was identified on the RN assessment with an order for Oxycodone and Morphine Sulfate solution to relieve the pain. Interventions related to pain control were not added to the POC. During RR#7 it was noted deficits assessed by the RN were not added to the interventions section of the POC. They included weight loss, poor appetite, fall risk, and skin breakdown risk. This was discussed with the Administrator.”

“Observed in Record Review. In 1 of 14 patient records reviewed, During RR#7 it was noted the most recent recertification period in March 2024 that the POC interventions and goals remained the same since the SOC in September 2023. The same goals were to be accomplished at the end of each certification period as each goal target date was advanced to the next 60 day recertification period. This was discussed with the Administrator. Observed in Record Review. In 4 of 14 patient records reviewed, It was noted in RR#2 lack of IDG meetings documented no less frequently than every 15 days. There was an IDG meeting the middle of February 2024 and the next IDG documented 21 days later. It was noted in RR#4 there was an IDG meeting the end of January 2024 and the next meeting was documented 21 days later. It was noted in RR#5 there was an IDG meeting the end of January 2024 and the next meeting was documented 21 days later. During RR#7 it was noted the last documented IDG was the third week in February with no further IDG meetings documented 22 days later to date. This was discussed with the Administrator.”

“Observed in Patient Home. In 3 of 3 home visits conducted, It was noted during HV#1 and #2, the SNs entered their clinical bag after removing gloves used for patient care without disinfecting their hands. The agency policy on hand hygiene and glove use stated hands must be disinfected after removing gloves. During HV#3 it was noted the aide disinfected her gloved hands multiple times. This was discussed with the Administrator. Observed in Patient Home. In 2 of 3 home visits conducted, It was noted during HV#1 the stethoscope, BP cuff, and pulse oximetry device were not cleaned per agency bag technique policy prior to returning to the clinical bag. It was noted during HV#2, the SN cleaned the equipment used during the visit that included a stethoscope, BP cuff, pulse oximetry and thermometer with alcohol prep pads and immediately placed them in the clinical bag. This was discussed with the Administrator.”

“Observed in Infection Control System Tracer. It was noted the organization infection control plan lacked a goal limiting the spread of infections associated with procedures. This was discussed with the Administrator. Observed in Infection Control System Tracer. It was noted the infection control plan lacked a goal limiting the spread of infections associated with the use of medical equipment, devices, and supplies. This was discussed with the Administrator. Observed in Infection Control System Tracer. It was noted the organization infection control plan lacked a goal limiting unprotected exposure to pathogens. This was discussed with the Administrator.”

“Observed in Document Review. In 7 of 9 contracts reviewed, It was noted the two pharmacy contracts lacked the inclusion of the manner in which contracted services will be coordinated, supervised, and evaluated by the hospice and a stipulation that the pharmacies will complete criminal background checks on employees or contracted staff who provide direct patient care or have access to patient records. It was noted the contract for ambulance services lacked a stipulation that the ambulance company will complete criminal background checks on employees or contracted staff who provide direct patient care or have access to patient records. It was noted two staffing contracts for RN, LVN and CHHA lacked the following: a stipulation that services may be provided only with the authorization of the hospice, a stipulation that services will be delivered in accordance with the patient’s plan of care, the manner in which contracted services will be coordinated, supervised, and evaluated by the hospice, the delineation of the role of the hospice and contractor in the admission process, patient/family assessment, and the interdisciplinary group conferences and the requirements for documenting that services are furnished in accordance with the agreement. It was noted one SNF contract lacked a stipulation that the facility will complete criminal background checks on employees and contracted employees who provide direct patient care or have access to patient records. It was noted the therapy contract for PT, OT and ST lacked a stipulation that the outside agency will complete criminal background checks on staff and contracted employees who provide direct patient care or have access to patient records. This was discussed with the Administrator.”