Acts Signature Hospice Delaware

“Based on observations, medical record review, document review, and staff interview it was determined that the hospice failed to update the comprehensive assessment for 2 out of 14 patients in the sample (Patient #’s 9 and 10). Findings include: Facility policy titled “;Ongoing Comprehensive Assessments” with an effective date of 1/2017 stated, “;... During each home visit, the Case Manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment...The nurse will assess each patient on each visit, for: ...Pain, including the origin, location, duration, severity, and relief measures...Secondary symptoms related to the terminal illness such as, nausea, vomiting, and respiratory distress, and patients response to medications and other interventions... Current treatment related to the identified symptoms and the patients response... Breath sounds... Skin integrity... Progress toward hospice goals and patient needs and problems...” Medical record review for Patient #10 revealed: Team Care Plan with a start date of 10/20/22 listed goals including “Patient experiences peaceful death with dignity and symptoms managed within limits of disease process” with an associated intervention of “Assess/instruct patient/caregiver on disease process/progression and management of symptoms” and “Patient maintains adequate airway and respiratory function within limits of disease process” with an associated intervention of “Pt [patient] will have parkinsons related dyspnea effectively palliated”. Nursing assessment on 10/11/23 indicated the following for the patient’s respiratory status: periods of apnea, diminished breath sounds, irregular respiratory pattern, shallow respirations, and absence of dyspnea (labored breathing). The Interdisciplinary Group Plan of Care Update for 10/12/23 showed that respiratory function had changed and “...respirations are very shallow with weakening respiratory effort and hoarse voice...” Nursing assessments on 10/25/23, 11/1/23, and 11/7/23 did not show evidence of a complete respiratory assessment including assessing for dyspnea. The above finding was confirmed with Employee #2 on 11/16/23 at 12:03 PM II. Medical record review for Patient #9 revealed: “Physician’s Orders/Plan of Care from 8-18-23 to 11-14-23” documents patient’s primary diagnosis of End Stage Heart Failure with a treatment plan that includes “...Assess/instruct patient/caregiver on disease process/progression...” “Routine visit” dated 10/20/23 with no evidence patient’s cardiac and respiratory status was assessed. The finding that Patient #9’s cardiac and respiratory status was assessed on 10/20/23 was confirmed with Employee #2 on 11/16/23 at 12:55 PM.”

“Based on medical record review, Agency policy and document review, and staff interviews, it was determined that the Agency failed to ensure all services necessary for management for palliation and management of the terminal illness and related conditions were provided for 1 of 14 patients (Patient #6) sampled. Findings include: Agency policy titled “Hospice Nursing Care” with effective date 1/2017 stated, “Nursing services will be provided in accordant with accepted standard of practice...The hospice nurse will play a key role in managing physical...symptoms and initiating communication with the interdisciplinary group to establish the plan of care...The hospice nurse will: Manage...provide symptom relief per MD [medical doctor] orders...” Agency policy titled “Monitoring Patient’s Response/Reporting to Physician” with effective date 1/2017 stated, “...the clinician will monitor the patient’s response to care...including...Care interventions...and symptom management...” Agency policy titled “Plan of Care/Interdisciplinary Group of Care” with effective date 1/2017 stated, “...Each patient will be monitored for his/her response to care... Review of Patient #6’s medical record review. A. “Routine visit” dated: -11/10/23 documents, “...stops & takes extra breaths every 4-6 words...resistant to using O2 during the day...Dyspnea at rest, Dyspnea when walking (# steps): 15, Dyspnea when speaking (# words): 5...” -11/15/23 documents, “...Breathing - labored with Oxygen [sic] support...Denies SOB...states she does use O2...during day at times...Dyspnea at rest, Dyspnea when walking (# steps): 10-15, Dyspnea when speaking (# words): 2-5...” B. “Interdisciplinary Group Plan of Care Update” dated: -8/31/23 RN [registered nurse] documents, “Resident...taking twice as long to completed ADLs [activities of daily living]...increased use of O2 [oxygen] during the day...” Social Work documents, “...resident appeared less conversational, and increasingly SOB [short of breath] while speaking...” -9/14/23 RN documents, “...O2 at HS [nighttime] & [and] using more frequently during the day for recovery needed after exertion...breaths noted every 4-5 words when speaking...” Social Work documents, “...resident was becoming increasingly SOB when speaking for only short periods of time of every 2-3 words...” -9/28/23 RN documents, “...able to carry on a conversation but stops for breaths...to 2-3 words after a few minutes...Over the past few weeks she...is using the PRN [as needed] O2 during the day as she is increasingly SOB performing tasks...maintains the HOB [head of bed] @ 30-35 degrees...” Social Work documents, “...Resident appeared increasingly SOB and needing to take larger and deeper breaths between words while speaking...” -10/26/23 Social Work documents, “...resident appeared increasing SOB while speaking, needing to take frequent breaks mid conversation to...catch her breath...” Spiritual Care documents, “...[resident] not as interactive or conversational, stating [he/she] was very fatigued...only able to speak 3-5 words without becoming needing [sic] to take longer pauses then upon [his/her] hospice admission...” - No evidence that care plan was updated for patient’s documented increased dyspnea. The finding that Patient #6’s care plan was not updated despite ongoing documentation of increased dyspnea was confirmed with Employee #2 on 11/16/23 at 12:55 PM. ...”

“Based on medical record review, document review, and staff interview it was determined that the hospice failed to include drugs necessary to meet the needs of the patient (comfort medications) in the plan of care for 4 out of 14 patients sampled (Patient #’s 1, 8, 9, and 10). Findings include: IV. Review of Patient #9’s medical record revealed: “Medication List” as of 11/16/23 shows no evidence patient ordered to receive comfort medications for anxiety as needed. The finding of no evidence of physician orders for comfort medication was confirmed with Employee #2 on 11/16/23 at 3:35 PM. Facility policy titled “;Patient Bill of Rights” with an effective date of 6/2017, stated, “...The patient has a right to the following: Receive effective pain management and symptom control from the hospice for conditions related to the terminal illness...” There was no evidence of comfort medications ordered for Patient #1 in the medical record. In an interview with Employee #2 on 11/15/23 at 3:18 PM the above finding was confirmed and the employee indicated that the expectation is that orders would be in place for comfort medications. There was no evidence of comfort medications ordered for Patient #8 in the medical record. In an interview with Employee #2 on 11/16/23 at 10:37 AM the above finding was confirmed. The employee went on to say the process for patient’s in the SNF is for comfort medication to not be ordered until the patient is declining, at which time comfort medication orders would be placed. Employee #2 stated that in the case of an emergent need for these medications the on-call provider could be called for verbal orders. Once verbal orders were obtained, the nurse would then have to call omnicell to get a pass code to the “E-box” (a secure storage for comfort medications in case of emergency). When asked how long a patient experiencing symptoms might have to wait for comfort medications, the employee indicated uncertainty and said it might take an hour if the nurse were able to get ahold of the on-call provider right away. There was no evidence of comfort medications ordered for Patient #10 in the medical record. In an interview with Employee #2 on 11/16/23 at 12:03 PM the above finding was confirmed”

“Based on Agency policy and document review and staff interviews, it was determined the Agency failed to analyze and identify preventive measures for 52 patient falls between 11/14/22 to 11/14/23. A. Adverse Events - Falls Review of the Agency document titled “Adverse Event. Detail” revealed there were 52 documented falls between 11/14/22 and 11/14/23. Review of the Agency’s investigation of the 1/20/23 fall of Patient #4 revealed no evidence of a root cause analysis for the fall. During an interview on 11/14/23 at 1:07 PM, Employee #2 confirmed the Agency’s investigations of falls do not include a cause analysis of the event or identification of preventive actions. Agency policy titled “Adverse Event Policy” with an effective date of 1/2017 stated, “...It is the policy of Acts Signature Hospice Delaware to adhere to an established procedure for monitoring and reporting information involving adverse events that have the potential to endanger the health/safety of patients and employees...An incident report must be completed for all adverse events/incidents involving patients and employees...All adverse events or incidents/occurrences are reviewed by the PI/QA [Performance Improvement/ Quality Assurance] Committee for appropriate and timely response and trends. All adverse event occurrence data shall be tracked, analyzed and trended as part of risk management. Corrective actions are implemented and evaluated as indicated and necessary... Documentation of adverse events: Will include collection of information on adverse experiences by means of a patient interview. Log: All adverse events must be recorded on Adverse Event Log as well as a report written...””

“Based on Agency document review and staff interview, it was determined the Agency failed to track staff performance to ensure that quality improvements are sustained. Agency document titled “Performance Improvement/Quality Assurance Process” with a revised date of 7/2016 stated, “...Performance Improvement (PI) is a method for analyzing performance problems/issues...Step 6: Document progress towards identified goal...Step 8: Review the progress and make process changes if indicated.” Review of the Agency’s 2022 Performance Improvement Project investigation document titled “Bereavement Support Calls Noting QAPI” revealed: -No evidence the project investigation included a review of the progress and if process changes were needed. -No evidence the Agency tracked staff performance to ensure quality improvements were sustained. During an interview on 11/14/23 at 12:45 PM, Employee #s 1 and 2 confirmed the “Bereavement Support Calls Noting QAPI” project did not include a review of progress and tracking of staff performance to ensure quality improvements were sustained. Agency policy titled “PI/QA Program” with a revised date of 7/2016 stated, “...PI/QA step by step process: Document progress towards identified goal. Document your attempts to reach the goals...Establish a Timeline for improvement...Review the progress and make process changes if indicated...””

“Based on Agency document review and staff interviews, it was determined the Agency failed to conduct at least one performance improvement project for the year 2023. Findings include: Agency policy titled “Performance Improvement Program” with an effective date of 1/2017 stated, “...Specific outcome targets are set each year for improvement or replication of outcome. These outcomes are benchmarked by utilizing internal standards (PI Committee tasks), processes and protocols (PI program policies), practice or service guidelines, industry research and/or best practices. PI data is collected quarterly and has a structured framework for the investigation of the targeted outcome. Agency continually evaluates progress toward outcomes and identifies new areas to improve or replicate as indicated by results of data analysis. Maintain achieved improvements. The Administrator sets expectations, develops plans, and mandates the processes to achieve outcomes....” Agency policy titled “PI/QA Program” with a revised date of 7/2016 stated, “...The Agency will ongoing, investigate at least one (1) quality indicator as part of the overall Agency QA program...” Agency was unable to provide documentation of a 2023 performance improvement project when requested by surveyors on 11/14/2023. During an interview on 11/14/23 at 12:45 PM, Employee #s 1 and 2 confirmed the Agency has not completed a performance improvement project in 2023.”

“Based on observation, policy review, and medical record review, it was determined that the Agency failed to ensure the nursing needs of 1 of 3 patients observed (Patient #6) were met. Findings include: Agency policy titled “Hospice Nursing Care” with effective date 1/2017 stated, “Nursing services will be provided in accordance with standards of practice by...a registered nurse...” During an observation of a routine visit by Employee #8, RN, for Patient #6 on 11/15/23 between 10:00 and 10:30 AM, the following was observed: -Vital signs obtained and recorded. -RN asked patient if he/she was having any problems with his/her colostomy. -RN auscultated bowel sounds without moving patient’s blouse. -RN did not remove TED (thromboembolism-deterrent) stockings during observed assessment. Review of Agency medical record titled “Routine visit - on 11-15-2023” for Patient #6 stated, “...TED’s [sic] in place...Ostomy type: Colostomy...Location: LLQ (left lower quadrant of abdomen)...Color: Pink...Shape: Round...Peristomal Skin: Intact...Skin Integrity: Intact...Skin Color and Warmth - Extremities...Lower - Ruddy...Comments: bilateral feet cool to touch and ruddy in color. Resident wearing TEDs and non skid slippers...” During an interview on 11/16/23 at 12:55 PM, the finding that Employee #8 was not observed completing skin assessment of abdomen or lower extremities for patient #6 during the 11/15/23 routine visit was confirmed with Employee #2. ...”

“Based on document review, policy review, and staff interview it was determined that the hospice failed to provide hospice training to 88 out of 97 skilled nursing facility staff members. Findings include: Facility policy titled “;Coordination of Care with Contracts/Agreements” with an effective date of 1/2017 stated, “;...Hospice will provide education and training regarding hospice care to inpatient personnel at contracted facilities at least once annually...” Facility policy titled “;Provision of Care to Residents of SNF/NF or ICF/MR” with an effective date of 1/2017 stated, “;...The organization must assure orientation of SNF/NF or ICF/MR staff furnishing care to hospice patients in the following: Hospice philosophy...Hospice policies and procedures regarding methods of comfort, pain control, symptom management...Principles about death and dying and individual responses to death...” There was no evidence of Hospice training for 88 out of 97 SNF staff. The above finding was confirmed on 11/16/23 at 9:45 AM.”