Geo Hospice Care, Inc.

“Upon patient record review, 1 of 14 (Patient #4) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #4: This patient did not have evidence of an initial bereavement assessment in the record.”

“Upon patient record review, 6 of 14 (Patients #1, 2, 3, 4, 5, 6) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: The patient has related diagnosis of Diabetes type 2. There are no interventions or goals for Diabetes on POC. Patient #2: The POC for this patient states under Environment and safety that patient is to “place half rail up at all times. Place side rail up x2 at all times. The patient does not have a hospital bed or siderails in the home. The Respiratory POC does not include interventions or goals for nebulizer use, which is ordered under DME. Patient #4: The POC for this patient states under Environment and safety that patient is to “place half rail up at all times. The patient does not have a hospital bed or side rails in the home. The patient uses diabetic nutritional shakes. There is no interventions or goals for nutrition on the POC. Patient #5: The POC for this patient states under Environment and safety that patient is to “place half rail up at all times. The patient does not have a hospital bed or side rails in the home. The POC des not include interventions or goals for nebulizer or suction machine. Patients 2, 3, 4, and 6 the POC did not contain specific patient’s/family’s goals for pain management and their satisfaction with the current level of pain control”

“Upon patient record review, 1 of 14 (Patient #1) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1: The MS Frequency is written as “3 prn visits” with no scheduled frequency. PRN visits cannot stand alone.”

“Upon personnel record review, 1 of 13 (Personnel #10 ) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #10: During the initial aide competency, it is documented that the bed bath and bed pan/elimination was not observed directly with patient or pseudo patient, but verbally.”

“Upon patient record review, 4 of 14 (Patients #2, 3, 5, 6 ) did not have evidence in the patient record that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home. If the patient and/or family are not capable of safely administering drugs and biologicals in the home, the hospice must address this issue in the patient’s plan of care. Patient #2: There was no evidence that the nurse assessed if patient was capable of safely administering drugs and biologicals in the home. Patient #3: There was no evidence that the nurse assessed if patient was capable of safely administering drugs and biologicals in the home. Patient #5: There was no evidence that the nurse assessed if patient was capable of safely administering drugs and biologicals in the home. Patient #6: There was no evidence that the nurse assessed if patient was capable of safely administering drugs and biologicals in the home.”

“Observed in Record Review. In 9 of 14 patient records reviewed, the organization failed to assess and reassess its patients. 

During record review for RRHV#1, the Hospice Nurse Surveyor observed the RN had opened a SC and SW assessment but both were blank. There was no documentation on the part of the SW or SC to outreach the family for the assessments and under referrals in the nurses admission SW and SC are checked. 

For RRHV#2 and RRHV#3, the patients did not have documentation of a SW or SC assessment completed, only a minimal assessment by the nurse at SOC which did not include all components of the comprehensive assessment policy specifically emotional barriers to treatment, cognitive limitations, family relationships and involvement in religious groups. 

For RRNHV#1- RRNHV#4, the SW/ SC assessments were not completed. 

For RRNHV#5 and RRNHV#6, the Hospice Nurse Surveyor observed the SC assessment was not completed and there was no documentation as to why. 

This was discussed and reviewed with the Hospice Administrator.”

“Observed in Record Review. In 3 of 14 patient records reviewed, the organization failed to plan the patient’s care. During record review for RRNHV#2, RRBR#1, and RRBR#2, the care plan did not include all items needed for palliation and management of the terminal illness. For example, in RRNHV#2, the patient had nausea and Covid symptoms but interventions for those items were not included in the plan of care. In RRBR#1, the patient was on continuous care but this was not addressed on the plan of care. Also in RRBR#2, the patient was switched to continuous care but there were no orders for continuous care from the provider. This was discussed and reviewed with the Hospice Administrator.”

“Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to provide interdisciplinary, collaborative care, treatment, or services. During record review for all records, the Hospice Nurse Surveyor observed all core disciplines were not included in collaboration of care. There was no involvement of the Spiritual Care Clinician in any documented IDG meetings. Psycho-Social care was only intermittently involved in IDG meetings reflecting the last two meetings only. Upon discussion with the Hospice Administrator, the surveyor asked if there was a sign in sheet or documentation other than the clinical record of collaboration with the Interdisciplinary Care Team and the Hospice Administrator stated no. She also stated that they have had trouble keeping a spiritual care provider. 

This was discussed and reviewed with the Hospice Administrator. Observed in Tracer Activities. The organization did not include the medical director in the interdisciplinary group meeting as least every 15 days. During an interview with the Medical Director, he was asked by the surveyor about participation in the IDG meeting. He admitted that the hospice group does team meetings every 14 days but that he does not participate. Upon discussion with the Hospice Administrator she stated he does participate some but also the Medical Director Designee attends. The Medical Director Designee is not listed as attending in any record or on any sign in sheet, as the organization stated they do not maintain a record of who is at IDT. 

This was discussed and reviewed with the Hospice Administrator.”

“Observed in Tracer Activities. The organization leadership failed to provide a sufficient number and mix of individuals to support safe, quality care, treatment, or services. During tracer activities for leadership and record reviews, the Hospice Nurse Surveyor observed the organization was not able to perform many functions required due to staffing as evidenced by no bereavement assessments, no SW/ SC assessments, a large number of overdue comprehensive assessments and visits when there was a change in condition. Upon discussion with the Hospice Administrator, she informed the surveyor that they had multiple issues keeping SW and Chaplain but have just hired new and that one of their main RN’s had left, leaving a hole for many visits. 

This was discussed and reviewed with the Hospice Administrator. Observed in Tracer Activities. The organization failed to comply with law and regulation. During tracer activities for Leadership, the Hospice Nurse Surveyor observed there was no evidence the governing body and leadership had established processes to support patient care, treatment, and services through sustained compliance as evidenced by repeat findings related to provision of care, leadership, oxygen safety and patient rights. In addition, condition level deficiencies were identified at 418.54, 418.56, 418.58, 418.60, 418.104 and 418.100. This was discussed and reviewed with the Hospice Administrator.”

“Observed in Record Review. In 2 of 2 patient records reviewed, the organization failed to involve the patient in making decisions about their care, treatment, or services. During record review for RRDC#1 and RRDC#2, , the Hospice Nurse Surveyor observed 

In RRDC#1, the patient was discharged for extended prognosis but was not given a Notice of Non Coverage at least 48 hours prior to discharge. In RRDC#2, the patient was admitted to hospice and then discharged for cause due to a billing discrepancy but was not provided a Notice of Non Coverage or advanced notice. 

This was discussed and reviewed with the Hospice Administrator.”

“Observed in Record Review. In 1 of 1 patient records reviewed, patients with wound care, the organization failed to assess and reassess its patients. During record review for RRHV#1, the Hospice Nurse Surveyor observed the patient primary diagnosis was breast cancer and the patient had an active abscess related to the breast cancer on her left breast but there was no documentation of the wound measurements, description, stage, size, drainage, tunneling, . since SOC a year prior to survey. The organizational policy stated it would be completed at every visit. The only documentation was abscess is bigger and draining. 

This was discussed and reviewed with the Hospice Administrator.”

“Observed in Record Review. In 8 of 14 patient records reviewed, the organization failed to assess and reassess its patients. 

During record review for RRHV#1, the Hospice Surveyor observed the patient did not have a documented bereavement assessment for one year. 

For RRHV#2, the patient had no documentation of a bereavement assessment and had been on service for 5 months. 

For RRHV#3, the patient had no documentation of a bereavement assessment and had been on service for 8 months. 

For RRNHV#1, RRNHV#2, RRNHV#3 and RRNHV#4, there was no bereavement assessment completed. 

For RRNHV#6, the bereavement assessment was completed on day 13 with no documentation as to why. 

This was discussed and reviewed with the Hospice Administrator.”

“Observed in Record Review. In 5 of 14 patient records reviewed, the organization failed to reassess according to regulation. During record review for RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, and RRNHV#5, the Hospice Nurse Surveyor observed the comprehensive assessment was not completed at least every 15 days For example in RRNHV#1, the patient had a gap of 24 days. In RRNHV#2, the patient had a gap of 25 days. In RRNHV#3, the patient had a gap of 29 days and in RRNHV#4, the patient had a gap of 21 days. In RRNHV#5, there was a gap of 28 days.The LVN’s had been performing assessments in between but they were not the full comprehensive assessments as required by regulation and policy. 

This was discussed and reviewed with the Hospice Administrator. Observed in Record Review. In 2 of 14 patient records reviewed, the organization failed to reassess per organizational policy. During record review for RRNHV#4 and RRNHV#2, the Hospice Nurse Surveyor observed the patients had a change in condition and no comprehensive assessment was completed. For example in RRNHV$3, the patient went to the emergency room for passing out and the comprehensive assessment was not completed for 18 days with a missed RN visit in between. For RRNHV#2, the patient called the office with Covid symptoms. The office mailed a Covid test kit but no comprehensive assessment was made. 

This was discussed and reviewed with the Hospice Administrator.”

“Observed in Record Review. In 2 of 14 patient records reviewed, the organization failed to document in the medical record in a timely manner. During record review for RRHV#1 and RRNHV#7, the Hospice Nurse Surveyor observed documentation in the medical record was not done timely, according to policy. For example in RRHV#1, the documentation from 6 days prior to survey was not completed. The organization policy stated documentation would be completed in 48 hours. 

This was discussed and reviewed with the Hospice Administrator. Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to maintain a complete and accurate record. During record review for RRBR#1, the Hospice Nurse Surveyor observed the LVN providing continuous care documented that she gave Roxanol 0.5ml sub-lingual. The order was for Morphine Sulfate 0.5ml orally. 

This was discussed and reviewed with the Hospice Administrator.”

“Observed in Record Review. In 3 of 14 patient records reviewed, the organization failed to plan the patient’s care. During record review for RRNHV#3, RRNHV#5, and RRBR#2, the care plan did not include individualized and measurable goals. In RRNHV#3, the patient was recertified for hospice care with one of the worsening issues being edema, but there were no goals or interventions on the plan of care. In RRNHV#5, the patient had two recent falls but there were no goals to prevent fall on the plan of care. In RRBR#2, the patient did not have goals or interventions for continuous care or wound, which the patient had both. This was discussed with the Hospice Administrator.”

“Observed in Record Review. In 6 of 14 patient records reviewed, the organization failed to provide care, treatment, or services for each patient according to the Plan of Care. During record review for RRNHV#1, RRHV#2, RRNHV#2, RRNHV#6, and RRNHV#7, the Hospice Nurse Surveyor observed weeks where frequency on the Plan of Care was not followed. For example in RRNHV#6, the HHA was to be once a week and there were no visits the week of May 26. Also in RRNHV#6, the patient had nursing ordered on the Plan of Care 1x week but there were no nursing visits week of 5/26. There was a phone call by the afterhours nurse to check in, but no information as to why a visit was not made. In RRNHV#7, the patient did not get a visit the week of 5/26 as ordered by the Plan of Care. In RRBR#2, the patient had SOC 11/3 with nursing visits ordered 1-2 x week and home health aide scheduled 3x week. There were no nursing visits the week of 11/5 but there was communication that the aide continued to go. Communication also stated the nurse attempted x2 but did not collaborate to go along with home health aide. He was then made continuous care on 11/13 with only the start of care nursing visit. 

This was discussed and reviewed with the Hospice Administrator. Observed in Patient Home. In 1 of 2 home visits conducted, nursing visits with medication reconciliation, the organization failed to maintain a patient record that reflected the most current information. During home visit for RRHV#2, the Hospice Nurse Surveyor observed the patient was taking Norco 2x day scheduled for pain. The medical record reflected Norco every 6 hours PRN. The Hospice Administrator did some research and discovered the patient was taking an old prescription that was twice a day rather than the PRN order and the LVN from the organization continued to place the Norco in the medicine holder for twice a day, without confirming the appropriate order. 

This was discussed and reviewed with the Hospice Administrator.”

“Observed in Record Review. The organization failed to identify risks for acquiring and spreading infection related to the use of medical equipment. During tracer activities for Infection Control, the Hospice Nurse Surveyor observed the organization had been tracking all infections and compiling data but did not have goals for limiting spread of infections associated with the use of medical equipment, devises and supplies as evidenced by they were unable to produce documentation during survey. 

This was discussed and reviewed with the Hospice Administrator. Observed in Tracer Activities. The organization failed to identify risks for acquiring and spreading infection. During tracer activities for Infection Control, the Hospice Nurse Surveyor observed the organization had been tracking all infections and compiling data but did not have an infection risk analysis and therefore could not provide goals addressing the prioritized risks, as evidenced by they were unable to produce documentation during survey. 

This was discussed and reviewed with the Hospice Administrator. Observed in Tracer Activities. The organization failed to set goals to minimize the possibility of spreading infections. During tracer activities for Infection Control, the Hospice Nurse Surveyor observed the organization had been tracking all infections and compiling data but did not have an infection risk analysis and did not have goals to address the limiting spread of infections associated with procedures as evidenced by they were unable to produce documentation during survey. 

This was discussed and reviewed with the Hospice Administrator.”

“Observed in Record Review. In 1 of 3 home visits conducted, the organization failed to provide patient education and training based on each patient’s needs and abilities. During home visit for RRHV#3, the Hospice Nurse Surveyor observed the patient had a lit candle 5 feet from a portable cannister of oxygen. There was no education from the nurse to the patient regarding the safety and fire hazard. 

This was discussed and reviewed with the Hospice Administrator. 

 Observed in Patient Home. In 2 of 2 home visits conducted, in a single home, the organization failed to coordinate the patient’s care. During home visit for RRHV#2 and RRHV#3, the Hospice Nurse Surveyor observed the home patient did not have an individualized emergency management plan in the home. 

This was discussed and reviewed with the Hospice Administrator. Observed in Patient Home. In 1 of 3 patient records reviewed, the organization failed to provide patient education and training based on each patient’s needs and abilities. During home visit for RRHV#2, the Hospice Nurse Surveyor observed portable oxygen tanks being stored in the garage with 2/3 being stored outside of a stand. 

This was discussed and reviewed with the Hospice Administrator.”