Christianacare Accentcare Hosp & Palliative Care

“Observed in Record Review. In 4 of 24 active patient records revviewed, the organization failed to conduct and document a patient-specific comprehensive assessment that identified the patient’s need for hospice care and services. In record RRNHV#5 the patient was admitted for osteomyelitis of the knee and the nurse wrote only in the note that there was purulent drainage. In records RRIP#3, RRNHV#2 a comprehensive spiritual assessment was not documented. In record RRNHV#10 both comprehensive spiritual and social work initial comprehensive assessments were not documented. This RFI was reviewed with and confirmed by the Senior Director of Clinical Operations. Observed in Record Review. In 1 of 24 patient records reviewed, the organization failed to conduct and document a patient-specific comprehensive assessment and reassessment that identified the patient’s need for hospice care and services. On review of RRHV#5 the patient had documentation of a laceration with significant bruising of the face and forehead that happened days prior to admission yet there was no wound assessment documented on initial comprehensive assessment nor subsequent nursing visits as required by organization policy. One nursing visit noted there was a wound but no description further. During conversation with the RN and patient husband on home observation the wound and bruising was present during time of admission. This observation was reviewed with the Director of Clinical Operations.”

“Observed in Record Review. In 5 of 24 activate patient records reviewed, the organization failed to ensure that the patient record was accurate. In record RRIP#1 the aide plan of care indicated that a bed bath was to be completed daily, but the visit frequency was twice a week. In record RRIP#2 the initial comprehensive nursing assessment documented that current hydration was regular liquids, however the patient was NPO. The medical social work assessment only included that the patient would return to the assisted livening facility which is an addiction treatment center. In record RRIP#3 a nurse wrote that the patient had an unstageable wound to the right buttock, however measurements were documented at 1x2x0.1 cm and 1x2.5x0.5 cm on two different days. In that same record an order was written for 14-16 French foley catheter. This RFI was reviewed with and confirmed by the Senior Director of Clinical Operations.”

“Observed in Record Review. In 17 of 24 active patient records reviewed, the organization failed to create plan of care goals that were individualized and measurable. Examples include: Patient/family/caregiver will have a patient defined good death by end of life AEB documented opportunities to verbalize final wishes, explore closure, and define a good death during visits by IDG members with a focus on SOC, sudden changes in condition and recertification visits. Patient’s nutritional needs will be managed within the context of their expected decline and expressed desires throughout hospice care. Patient/family/caregiver will report that patient’s urinary incontinence has been brought to/maintained at a level that the patient/family/caregiver expresses acceptable within the context of the disease process while on IPC AEB no urinary retention or incontinence present. Family will verbalize understanding of EOL education on symptoms of imminent death and POC to achieve a comfortable death by the end of the visit or call when imminent death is identified. Patient’s nutritional needs will be managed within the context of their expected decline and expressed desires throughout hospice care. This RFI was reviewed with and confirmed by the Senior Director of Clinical Operations.”

“Observed in Record Review. In 6 of 24 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRHV#1 the patient was diabetic with insulin administration that noted to hold with blood glucose <140. On conversation with the patient daughter she confirmed that they were monitoring the patient’s blood glucose daily however diabetes and blood glucose monitoring were not reflected in the plan of care. On admission the initial assessment documented the patient with a Pure Wick catheter yet the catheter was not reflected in the plan of care. In RRHV#3 the patient’s primary diagnosis was interstitial lung disease with continuous oxygen use but there was no care plan established for respiratory. On home observation the RN specified that constipation was an ongoing issue but was not reflected on the plan of care. In RRHV#4 pain was an ongoing issue where morphine was scheduled 3 times a day with morphine also being utilized for breakthrough pain yet there was no care plan for pain to guide the care. On review of RRHV#5 the patient had documentation of a laceration and significant bruising to the face/forehead yet there was no care plan or orders reflected on the plan of care to guide the care. The patient also had documented in the record, and per conversation at home observation, issues with agitation and sleep requiring medication changes yet the issues were not reflected on the care plans. In RRHV#6 the documentation noted the patient with a upper respiratory infection with use of antibiotics but no care plan for infection to guide the care. There was also documentation of significant weight loss and a diet of thickened liquids yet no nutritional care plan open. IN RRNHV#14 there was documentation of multiple medication changes to control the patient’s pain yet none of the changes were reflected in the plan of care. These observations were reviewed with the Director of Clinical Operations.”

“Observed in Record Review. In 1 of 24 patient records reviewed, the organization failed to ensure the plan of care contain all services needed for the palliation and management of the terminal illness and related conditions. On review of RRHV#2 the patient was receiving Oxycodone and Morphine as needed for pain however there were no specific instructions to guide the user as to when to use which medication. This observation was reviewed with the Director of Clinical Operations. Observed in Record Review. In 1 of 24 active patient records reviwed, 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. In the record of RRNHV#6 a nurse documented that the patent was using oxygen at 3 lpm per cannula, however there was no order for it. This RFI was reviewed with and confirmed by the Senior Director of Clinical Operations.”

“Observed in Record Review. the organization failed to ensure the plan of care was revised with progress toward goals based on the updated comprehensive assessment. In almost every active patient record reviewed the following goals were created. Care coordination services will be initiated within 5 days of request. Complete start of care physical assessment and initiate hospice plan of care by end of admission visit. None were identified as completed in the time frames stated. Complete start of care physical assessment and initiate hospice plan of care by end of admission visit. This RFI was reviewed with and confirmed by the Senior Director of Clinical Operations. Observed in Record Review. In 1 of 24 patient records reviewed, the organization failed to ensure the plan of care was revised with progress toward goals based on the updated comprehensive assessment. On review of RRHV#5 the current plan of care remained unchanged since admission in June through recertification. All goals remained current without documented progress to goals to include the goal: complete SOC physical assessment and initiate hospice plan of care by end of admission visit. This observation was reviewed with the Director of Clinical Operations.”

“Observed in Patient Home. In 3 of 6 home visits conducted, the organization failed to ensure accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions were followed per policy. On home observation for RRHV#2 the spiritual counselor was observed to place his bag, 2 phones and tablet on the patient’s room floor and did not sanitize the equipment when retrieved after the visit was concluded. In RRHV#4 and RRHV#5 the RN was observed to cleanse reusable equipment with Santi cloth wipe but did not allow a 2 minute contact time for disinfection as required by manufacturers guidelines as the nurses immediately placed back in the bag after wiping the equipment. These observation were reviewed with the Director of Clinical Operations Leadership Team.”

“Observed in Patient Home. In 3 of 24 patient records reviewed, with hospice aide services, the organization failed to ensure written patient care instructions for a hospice aide were prepared by a registered nurse. On review of RRHV#1 the patient was on oxygen continuously yet the Aide plan of care did not specify if the oxygen could be removed for providing care or should be left in place. Further, the patient had a wound dressing on the right forearm and great toe yet there were no specific instructions on how the aide was to handle the dressing while completing tasks. In RRHV#4 the patient was on 2 lts oxygen per nasal cannula yet there were no oxygen precautions or instructions on how to handle the oxygen on the aide plan of care. On review of RRHV#6 the patient was on oxygen yet there were no oxygen precautions noted on the aide plan of care. The patient also required assistance with transfers yet the aide plan of care did not provide instruction on the level of assistance for patient transfers. These observations were reviewed with the Director of Clinical Operations and Leadership team. Observed in Record Review. In 5 of 24 active patient records reviewed, with hospice aide services, the organization failed to ensure written patient care instructions for a hospice aide were prepared by a registered nurse. In records RRIP#2, RRIP#3 the patient was using oxygen continuously however the aide plan of care did not specify that it was to remain on during bathing. This RFI was reviewed with and confirmed by the Senior Director of Clinical Operations.”

“Observed in Patient Home. In 4 of 6 home visits conducted, the organization failed to ensure the patient record contain all information to reflect the patient’s care, treatment, and services. On home observation of the medication reconciliation for RRHV#3 there were discrepancies from the medication in the patient home to the orders per the plan of care. There was Tylenol 500mg tablets noted in use in the home but the medication orders showed Tylenol suppositories 650 mg. The daughter showed the surveyor ondansetron ODT bottle for nausea and vomiting but the medication was not found on the medication profile. Further, the med profile had gabapentin 300mg capsules but the daughter noted they had been giving the gabapentin liquid form and not capsules. In RRHV#4 on medication reconciliation with the facility medication list the Acetaminophen 650 mg was every 4 hours as needed in the facility but every 6 hours as needed on the hospice orders. Also, prochlorperazine maleate 10 mg tabs were noted on the hospice medication profile but was not included on the facility med profile. In RRHV#5 the patient was in a facility and on medication reconciliation there were several discrepancies as the Bisacodyl was being given as scheduled per the facility since June but the hospice orders were for as needed. The melatonin was 10 mg and Senna was daily on the hospice med profile but the melatonin was changed to 5 mg gummies and Senna moved to as needed per the facility back in Mid-August. The guaifenesin was noted as needed starting in July per the facility but scheduled per the hospice orders. Further, the facility medication profile had Seroquel that started 5 days prior to survey but was not reflected on the hospice medication profile. There were vitamins B-1, Vitamin C, and Atorvastatin that were on the hospice medication orders but were not on the facility orders. In RRHV#1 the patient daughter pointed out the patient’s medications on home observation and noted they were giving supplements Ocuvite and a Multivitamin, yet they were not included on hospice medication orders. These observations were reviewed with the Director of Clinical Operations and the Leadership Team.”

“Based on staff (EMP) interviews and document review, the Agency failed to ensure that orientation and training regarding hospice philosophy were performed for all staff providing care to the patients residing at 1 of 1 skilled nursing facilities (SNF1) sampled. Findings include: A review of the Agency document titled “Nursing Facility Service Agreement” between ChristianaCare-AccentCare Hospice & Palliative Care of Delaware and Nursing Facility #1 dated 11/1/2024 revealed, “...Hospice Care Training. Hospice shall provide orientation and ongoing hospice care training to Facility’s personnel as necessary to facilitate the provision of safe and effective care to Hospice Patients. Such orientation must include Hospice policies and procedures regarding methods of comfort, pain control and symptom management as well as principles about death and dying, individual responses to death, patient rights, appropriate forms and recordkeeping requirements...” During an interview on 12/20/24 at 9:10 AM, EMP1 revealed the Agency does not provide overall education to SNFs. EMP#11 meets with SNF1 staff 1:1 and with SNFEMP1 to review patient plans of care and emergency planning. During an interview on 12/20/24 between 10:40 and 10:50 AM, SNFEMP1 revealed he/she is not aware of in-services being provided by the Agency. He/She stated the hospice nurse educates the SNF nurse caring for the hospice patient and the Agency does let him/her know that education is available if requested. During an interview on 12/20/24 at 2:12 PM, EMP1 revealed the Agency has designated employees (Hospice Care Consultants) that regularly meet with staff of SNFs where patients reside that can include educational information. A review of the Agency document titled “Call Summary Report” dated 9/1/24 to 12/20/24 revealed that Hospice Care Consultants visited SNF#1 26 times, with notes documenting the visits included “...rounds to check on any hospice needs or concerns...” There is no evidence of hospice care education or orientation being provided to SNF staff during these visits. On 12/20/24 at 2:45 PM, EMP1 acknowledged that there is no evidence the Agency provided hospice orientation or philosophy education to SNF1 staff caring for their hospice patients. A review of the Agency document titled “Nursing Facility Service Agreement” between ChristianaCare-AccentCare Hospice & Palliative Care of Delaware and SNF1 (Skilled Nursing Facility) dated 11/1/2024 revealed, “...Hospice Care Training. Hospice shall provide orientation and ongoing hospice care training to Facility’s personnel as necessary to facilitate the provision of safe and effective care to Hospice Patients. Such orientation must include Hospice policies and procedures regarding methods of comfort, pain control and symptom management as well as principles about death and dying, individual responses to death, patient rights, appropriate forms and recordkeeping requirements...” During an interview on 12/20/24 at 9:10 AM, EMP1 revealed the Agency does not provide overall education to SNFs. EMP11 meets with SNF1 staff 1:1 (one to one) and with SNF1 EMP1 to review patient plans of care and emergency planning. During an interview on 12/20/24 between 10:40 and 10:50 AM, SNF1 EMP1 revealed he/she is not aware of in-services being provided by the Agency. He/She stated the hospice nurse educates the SNF nurse caring for the hospice patient and the Agency does let him/her know that education is available if requested. During an interview on 12/20/24 at 2:12 PM, EMP1 revealed the Agency has designated employees (Hospice Care Consultants) that regularly meet with staff of SNFs where patients reside that can include educational information. A review of the Agency document titled “Call Summary Report” dated 9/1/24 to 12/20/24 revealed that Hospice Care Consultants visited SNF1 twenty-six times during the time period, with notes documenting that the visits included “...rounds to check on any hospice needs or concerns...” There is no evidence of hospice care education or orientation being provided to SNF staff during these visits. On 12/20/24 at 2:45 PM, EMP1 acknowledged that there is no evidence the Agency provided hospice orientation or philosophy education to SNF1 staff caring for their hospice patients.”

“Based on medical record review, staff interview and policy and procedure review, it was determined that the Hospice agency failed to ensure that 1 out of 6 patients in the sample (Patient #1) were free from neglect and injury. Findings include: Agency policy titled “;In-Patient Services” revised 5/15/21, stated, “;...Provide 24-hour services including...Provision of care in accordance with the patients plan of care established by hospice for treatments...as prescribed...A focus on insuring that the patient is kept comfortable...and protected from accident, injury...” Agency policy titled “;IPC [inpatient care unit] Fall Prevention” revised 10/31/23, stated, “;...Assess patients risk of falling...on admission to IPC...High Fall Risk, Red, 4-10...Perform hourly safety rounds...every two hours during the night...Use a chair or bed alarm, if needed...” Review of the medical record for Patient #1 revealed: 1) Patient #1 was admitted to service on 7/19/2023. Review of document titled “;Hospice Certification and Plan of Care” revealed, “;Activities Permitted: Up as tolerated, walker...Mental Statuses: Forgetful, disoriented... Physician Narratives: This patient is a 91-year-old female admitted to hospice with late effects of cerebrovascular disease...the patient has fallen numerous times...The patient is also more confused, and confusion worsens at night. She seems to have increased levels of agitation and paranoia...” 2) Patient #1 was transferred to Wilmington Inpatient Unit on 9/3/2023 at 4:55 PM. Review of document titled, “;Provider Visit Note” dated 9/3/2023 revealed, “;Nurse sent out this morning to Straight Cath patient, as patient had not voided overnight. Patient confused, climbed on top of dining room table to use the bathroom. Taken to bathroom and unable to void. Confusion worse. Sustained a fall on Thursday 8/31/2023 with a quarter sized bump in the Right occipital region of skull. Will work up for a UTI [urinary tract infection] and brain bleed. Transferred to Bayhealth Sussex. UA [urinalysis] positive for UTI. CT [computerized tomography] of head was negative for a brain bleed.” 3) Review of document titled “;Hospice Plan of Care Report” revealed, “;... 9/5/2023 Initiated/Reinforced Fall Precautions to Minimize Incidence of Falls...” 4) Review of document titled “;Visit Note Report” dated 9/5/2023 at 4:26 PM revealed, “;...Pain Assessment...2 doses of Morphine in 24 hours...Which of the following factors contributing to fall risk are present? Mobility, Mentation, Elimination, History of Falls, regularly administered antipsychotic/antianxiety/or narcotic meds...Mentation findings: Periodic confusion, restlessness...Needs Assistance with Toileting...Fall Potential Score: 7...Indicate Fall Potential Interventions: Safety Checks on, Bed/Chair Alarm on...” 5) Review of document titled “;Hospice Daily Encounter Report” revealed the following: 9/6/2023 4:45 AM. Patient found in middle of room in an upright position. Patient assisted up and returned to bed. Cut above right eyebrow, Puffy with blood from orbital area. Bruising at eye area cleaned and covered. Bruise noted on underside of chin right side of face. Reclining chair had a pool of blood next to it. Patient reported having to go to the bathroom, no urine on the floor, sheets are dry. Patient complaint of pain when cleaning wound above eye. Denies pain anywhere else. Full range of motion in all extremities. 6) Review of document titled “;Client Occurrence Report” for Patient # 1 revealed, “;Patient got out of bed and fell. Patient hit her head on the chair resulting in a laceration and bruising around right eye. Alarm was not set on patients bed. She was found sitting on the floor near the recliner and doorway with obvious trauma. Patient was sent to ER [emergency room] for follow-up and X-ray showed a right orbital fracture and laceration requiring stitches...” Interview conducted with Employee #1 on 1/24/2024 between 12:40-12:50PM. Employee #1 confirmed that Patient #1s bed alarm was not on at the time of this fall. Patient sustained an injury, a laceration requiring stitches and a right orbital fracture.”

“Based on record review, policy review, and staff interview, it was determined that the hospice failed to update the comprehensive assessment as frequently as the condition of the patient required for 1 out of 2 patients in the sample who experienced a fall (Patient #5). Findings include: Record review revealed: A Clinical Occurrence Report dated 3/31/23 at 2:34 PM stated, “;Patients wife called to follow up on supply request and mentioned to this TD [Team Director] that patient rolled out of bed last night. No injuries.” Under the “;Follow-up Comments” section of the report “;Fall mats ordered through Medcare” is listed. A Coordination Note dated 4/1/23 5:19 PM stated, “;...Caller spouse [name & contact number] requesting a visit for swollen red right eye. No pain, itching, burning or drainage noted. Redness is around the eye not on the actual eye.” A Visit Note dated 4/1/23 at 7:40 PM completed by an RN revealed a fall risk assessment denying a history of falls within 3 months. The assessment narrative stated, “;Unscheduled visit for c/o [complaint of] per spouse of swelling and redness around (not in) right eye. Wife not with Pt [patient] at time of visit. Pt very confused, but denied SNAP [shortness of breath, nausea/vomiting, agitation/anxiety, and pain]. No s/sx [signs and symptoms of] distress noted. Pt refused VS [vital signs] and full assessment, but did allow quick check of eye with flashlight. No discharge noted, no c//o pain or burning. Suggested to nurse that they try warm compress. Phone call to update wife.” There is no evidence that the patients eye was assessed for possible injury. There is no evidence of a post fall assessment done for this patient. The finding above was confirmed by Employee #1 on 1/24/24 at 11:35 AM. Facility policy titled “;Fall Prevention 2017 Protocol” with an effective date of 12/15/2005 stated, “;...When the patient has fallen (refer to Protocol 2037 for visit guidelines when a fall has occurred)...” When Protocol 2037 was requested, facility policy titled “;Triage 2037 Protocol” with an effective date of 4/24/23 was provided to surveyors. This policy stated, “;...When a fall is reported by a family, patient, or facility/residence caregiver, it is considered a significant event and require a hospice nurse assessment visit including evaluation of patient status, any need for DME [durable medical equipment] equipment changes, any need for diagnostic x-rays, fall risk rating, evaluation of safety of environment, and determine any plan of care changes, including need for hospitalization, level of care, transfer, etc... If no reported injury, a Hospice Nurse visit will occur within 24 hours. The local team is aware through Coordination Note Report – Call Center Notes...” In an interview on 1/24/24 at 11:35 AM, Employee #1 confirmed that the agencys fall protocols were not initiated correctly. The patient should have been seen within 24 hours post fall by a nurse to conduct a post fall assessment, which was not done. The visit to evaluate the patients right eye on 4/1/23 did not include assessing if the symptoms were related to the fall.”

“Based on medical record review, document review, and staff interview, it was determined that the agency failed to track 1 out of 3 falls included in the sample (Patient #5) as part of their QAPI program. Findings include: Agency policy titled “;Quality Assurance and performance Improvement” revised 4/01/22, stated, “;...The Hospice agencys performance improvement activities shall.... Focus on...adverse patient events...Measures, analyzes, and tracks quality indicators to monitor program effectiveness, patient safety, and quality of care...Performance improvement results are tracked, trended, analyzed, and used by the hospice agency to address problem issues, improve the quality of care and patient safety, and shall be incorporated into program planning and process design...” A Clinical Occurrence Report for Patient #5 dated 3/31/23 at 2:34 PM stated, “;Patients wife called to follow up on supply request and mentioned to this TD [Team Director] that patient rolled out of bed last night. No injuries.” Under the section heading “;Nature of Occurrence”, “;Other” was listed. In an interview on 1/24/24 at 12:37 PM with Employee #1 indicated that on the Occurrence Report the information under “;Nature” is how falls are tracked and that an occurrence put in as “;other” would not have been tracked as a fall. Employee #1 confirmed that the fall reported for Patient #5 on 3/31/23 was not tracked as a fall.”

“Based on medical record review, Quality Assurance Performance Improvement [QAPI] document review, internal investigation reports review, staff interview, and policy and procedure review, the Hospice Agency failed to identify opportunities for improvement and failed to monitor quality-of-care related incidents that occurred for 2 out of 2 patients (Patient #1 and Patient #5) that experienced a fall. Findings include: Agency policy titled “;Quality Assurance and Performance Improvement” revised 4/01/22, stated, “;...The Hospice agencys performance improvement activities shall.... Focus on...adverse patient events...Measures, analyzes, and tracks quality indicators to monitor program effectiveness, patient safety, and quality of care...Performance improvement results are tracked, trended, analyzed, and used by the hospice agency to address problem issues, improve the quality of care and patient safety, and shall be incorporated into program planning and process design...” Agency policy titled “;Fall Prevention, 2017 Protocol” revised 10/31/2023, stated, “;...A Quality Incident (QI) will be documented in the EMR [electronic medical record] for each patient fall including the unwitnessed ones reported between nursing visits. An Adverse Event (AE) will be documented for each fall with injury. A patient falls report will be aggregated and presented at the QAPI meeting each quarter. Any trends will be discussed and analyzed for improved patient outcomes and fall prevention strategies.” Agency policy titled “;Incident and Adverse Event Reporting” revised 9/20/23, stated, “;Adverse event: Injury or unintended harm to a patient resulting from an act of commission or omission rather than by the underlying disease or condition of the patient...Adverse events include, but are not limited to...Falls, witnessed and un-witnessed...As Part of the agencys Quality Assurance Performance Improvement (QAPI) process, adverse patient events are analyzed to determine causes and preventive actions to be implemented that lead to an immediate correction of any identified problem that directly or potentially threatens the health and safety of any patient..” Review of document titled “;Client Occurrence Report” for Patient #1 revealed, “;Patient got out of bed and fell. Patient hit her head on the chair resulting in a laceration and bruising around right eye. Alarm was not set on patients bed. She was found sitting on the floor near the recliner and doorway with obvious trauma. Patient was sent to ER [emergency room] for follow-up and X-ray showed a right orbital fracture and laceration requiring stitches...” Review of document titled “;Client Occurrence Report” for Patient #5 dated 4/3/23 revealed, “;...Facility contacted office to inform patient found on floor in room c/o [complain of] right leg pain. BP [blood pressure] 70/50. 911 called and pt [patient] to be sent to...ED [emergency department] ...” Review of the agencys “;QAPI Quarterly Report and Professional Advisory Committee Meeting Minutes” dated 10/24/2023, revealed there was no documentation that the hospice agency had completed an analysis or review of processes of care that lead up to the adverse events for Patients #1 and # 5. Review of agencys internal investigation reports for Patients # 1 and # 5 revealed no documentation that the agency identified opportunities for improvement and failed to monitor the quality-of-care related incidents. These findings were confirmed by Employee #1 in an interview conducted on 1/24/2024 from 12:40PM –12:55 PM. In an interview on 1/24/24 at 1:49 PM with Employee #1, they stated that they were unable to provide data analysis for QAPI related to falls. The employee stated that the agency tracks the number of falls and compares month to month and quarter to quarter. The employee reports that no further analysis of falls was done as part of QAPI for 2023.”