Avow Hospice Inc.

“Observed in Record Review. In 7 of 20 patient records reviewed, the organization failed to ensure that the written plan of care was developed in accordance with the patient’s identified goals with defined timeframes for achieving those goals. In all patient records reviewed some of the goals documented in the hospice plan of care were not measurable. For examples, HOSRRHV#4: Patient will remain free from UTI during this benefit period as evidenced by no UTI; Patient’s constipation will be controlled and/or relieved by end of this week. HOSRRHV#6 : Appropriate blood glucose level will be maintained by daughter to prevent a diabetic event each week as evidenced by daughter will check her blood sugar daily; Patient’s daughter will verbalize/demonstrate how to use oxygen safely and effectively within weekly visit as evidenced by patient will use oxygen as needed set at 10 LPM. Patient daughter verbalizes/demonstrates understanding of proper safety measures related to fire safety, oxygen safety, fall risk safety within visit as evidenced by no falls reported. HOSRRNHV#5: Ability to express understanding of diagnosis and signs and symptoms of disease progression. HOSRRNHV#6: Patient will have reduce anxiety. HOSRRNHV#8: Patient verbalizes/demonstrates decrease in associated discomfort and improved demeanor. HOSRRNHV#9: Patient’s need for assistance with personal care, hygiene, and ADLs will be met as needed. No timeframe, no measurable outcome, as needed is vague, no evaluation criteria. HOSRRNHV#11: Patient/caregiver will verbalize understanding of effects of terminal illness on nutrition and hydration including anorexia/dehydration , however, it did not include timeframe This finding was discussed and validated by the hospice leadership team.”

“Observed in Record Review. In 6 of 20 patient records reviewed, it was noted the organization failed to ensure that the hospice plan of care plan includes all services needed for the palliation and management of the terminal illness and related conditions, including treatments necessary to meet the patient’s. For example in record HOSRRNHV#1 reviewed, an order to “clean area with wound cleanser. Pat dry with gauze, apply skin prep around wound . Apply 4x4 foam bordered dressing. RN to assess and dress wound 1 x weekly and PRN for drainage greater than 75% or dislodgement. However, it did not indicate the wound location. Additionally, an order to remove and replace Foley catheter. However It did not indicate the size of the Foley catheter to be replaced and how often will it be changed. In HOSRRNHV#5: an order was received for skilled nursing to change indwelling catheter using sterile technique, however, it did not indicate the frequencies for the indwelling catheter change as well as the catheter size. Additionally, another order for hospice nurse to clean area with wound cleanser, pat dry with gauze, apply skin prep around wound, apply 5x5 foam bordered dressing once weekly and PRN for drainage greater than 75% or dislodgement, however, it did not indicate the wound location. HOSRRNHV#7: An order for hospice nurse to clean right hip with wound cleanser pat dry then use skin prep. Apply xeroform over wound then cover with Optifoam, however, It did not indicate the wound care frequency. On the other hand, hospice nurse was ordered to clean area with wound care cleanser pat dry apply non-stick foam bandage. Nurse to assess and do wound care weekly. Caregiver to do wound care if bandage becomes soiled or dislodged, however, the wound location was not indicated. HOSRRNHV#10 Order obtained to cleanse with wound cleanser, pat dry with gauze, cover with form dressing. It did not indicate the location and frequency of wound care. HOSRRNHV#12: An order obtained to cleanse wound with wound cleanser, pat dry, cover with non-stick dressing, secure with tape weekly and as needed if soiled or dislodged. It did not include the wound location. HOSRRNHV#14: SN to cleanse wound with wound cleanser, pat dry, cover with non-stick dressing, secure with tape, weekly and as needed if soiled or dislodged. Wound location was missing. This finding was discussed and validated by the hospice leadership team.ORDER INCOMPLETEit was noted the organization failed to ensure that the hospice plan of care plan includes all services needed for the palliation and management of the terminal illness and related conditions, including treatments necessary to meet the patient’s. For example in record HOSRRNHV#1 reviewed, an order to “clean area with wound cleanser. Pat dry with gauze, apply skin prep around wound . Apply 4x4 foam bordered dressing. RN to assess and dress wound 1 x weekly and PRN for drainage greater than 75% or dislodgement. However, it did not indicate the wound location. Additionally, an order to remove and replace Foley catheter. However It did not indicate the size of the Foley catheter to be replaced and how often will it be changed. In HOSRRNHV#5: an order was received for skilled nursing to change indwelling catheter using sterile technique, however, it did not indicate the frequencies for the indwelling catheter change as well as the catheter size. Additionally, another order for hospice nurse to clean area with wound cleanser, pat dry with gauze, apply skin prep around wound, apply 5x5 foam bordered dressing once weekly and PRN for drainage greater than 75% or dislodgement, however, it did not indicate the wound location. HOSRRNHV#7: An order for hospice nurse to clean right hip with wound cleanser pat dry then use skin prep. Apply xeroform over wound then cover with Optifoam, however, It did not indicate the wound care frequency. On the other hand, hospice nurse was ordered to clean area with wound care cleanser pat dry apply non-stick foam bandage. Nurse to assess and do wound care weekly. Caregiver to do wound care if bandage becomes soiled or dislodged, however, the wound location was not indicated. HOSRRNHV#10 Order obtained to cleanse with wound cleanser, pat dry with gauze, cover with form dressing. It did not indicate the location and frequency of wound care. HOSRRNHV#12: An order obtained to cleanse wound with wound cleanser, pat dry, cover with non-stick dressing, secure with tape weekly and as needed if soiled or dislodged. It did not include the wound location. HOSRRNHV#14: SN to cleanse wound with wound cleanser, pat dry, cover with non-stick dressing, secure with tape, weekly and as needed if soiled or dislodged. Wound location was missing. This finding was discussed and validated by the hospice leadership team.”

“Observed in Patient Home. In 1 of 6 home visits conducted, the organization failed to implement activities for the prevention and control of infections and communicable diseases as required by its policy. For example in HOSRRHV#2, the hospice nurse performed biliary tube insertion site care and a dressing change in accordance with the plan of care. However, the hospice nurse surveyor observed that the nurse failed to follow agency policy as evidenced by not changing gloves after removing the old dressing before applying clean, dry dressing to the insertion biliary tube site and before attaching a new clean bag. REFERENCE # 181 Hand Hygiene Process section 9(d) states change or remove gloves after touching a contaminated site and before touching a clean site or environment. This finding was discussed and confirmed by the hospice leadership team.”

“Based on medical record review and interview the Hospice Agency failed to ensure services were provided in accordance with the Hospice Certification and Plan of Care for 1(patient #2) of 3 patients sampled. Review of Patient #2 medical records revealed a Start of Care date of 1/25/23, with a Hospice Certification and Plan of Care, with a Certification Period 1/25/23 - 4/24/23. The Hospice Certification and Plan of Care listed a diagnosis of malignant neoplasm of the frontal lobe (cancerous tumor of the frontal lobe of the brain). Further review of the Plan of Care revealed, Orders of Discipline and Treatments: · Hospice nurse to evaluate patient and develop plan of care to be signed by physician. · Hospice nurse to instruct patient/caregiver on use of pain scale administration in side effects of pain medications. · Instruct caregivers on seizure precautions and the need to report seizure activity. · Patient may have general Hospice Comfort Care Kit, CCK. · MSW to evaluate patient and develop plan of care to be signed by physician. · Chaplain to evaluate patient and develop plan of care to be signed by physician. · Instruct caregiver on levels of consciousness and to report changes to Hospice nurse. · Change level of care to routine care. The physician signed the Certification Plan of Care on 1/26/23. The Plan of Care signed by the physician included in the orders of discipline and treatment, the “;Patient may have general hospice CCK (Comfort Care Kit)”. A Comfort Care Kit contains prescribed medications that are kept in a patients home to treat distressing symptoms during a medical crisis. The goals listed on the Plan of Care included for the general CCK to be provided to the patient within three days as evidenced by the CCK being ordered by the nurse and provided by the pharmacy. Review of the hospice Plan of Care Report for Patient #2 noted on 1/25/23 the nurse added the need for a Comfort Care Kit with a goal for the patient/caregiver to verbalize proper use of the Comfort Care Kit. On 6/5/24, the Senior Clinical Director provided a list of medications which she said were in the hospice general CCK which included: - Valium 10 tablets (used to treat anxiety, seizures, muscle spasms). - Hyoscyamine 10 tablets (used to reduce oral secretions). - Tylenol three Suppositories (used to treat pain and fever). - Two Bisacodyl (laxative). - 10 Lorazepam (used to treat anxiety). - Morphine15milliliters (used to reduce pain and ease shortness of breath). - Six Ondansetron (used to prevent nausea and vomiting). The medical records reviewed lacked documentation that the CCK was ordered and delivered to the patient’s home within three days as specified by the Plan of Care and physician’s orders dated 1/25/23 and signed by the physician on 1/26/23. On 1/26/23 the physician documented in a client coordination note report Patient #2 was seen in the Emergency Room on 12/23 with new onset seizure and was prescribed Levetiracetam (anti-seizure) and Dexamethasone (anti-inflammatory). On 1/31/23 at 3:41 p.m., the skilled nurse documented in a visit note report Patient #2s spouse stated the patient had vomited some coffee color emesis. She gave him some nausea medication he has in the home. He has not vomited since and had been resting comfortably. The nurse documented collaborating with the Advanced Practice Registered Nurse (APRN) on call. The APRN was updated on the patients status and issued an order for a comfort care kit. The order was called to the pharmacy to be delivered to the 5:00 p.m. run. The nurse documented while collaborating with the provider on call and the pharmacy the spouse and son took the patient to the restroom. Per the spouse the patient started shaking and appeared to be having a seizure. The patient was lowered to the ground. The medications included in the comfort care kit, including Valium, were not readily available to treat the patients distressing symptoms. On 6/5/24 at 1:30 p.m., in an interview the Senior Clinical Director said, “;No. The Comfort Care Kit was not ordered at the time of admission.” She said it was up to the discretion of the admission nurse in collaboration with the admitting physician as to when the CCK should be ordered. She said, “;This is not always done at the time of admission. The patients symptoms were being controlled by the medications he had in the home.” The medications in Patient #2s Plan of Care did not include the medications listed in the CCK such as the Ondansetron, Morphine, Lorazepam, Bisacodyl, Tylenol Suppositories, Hyoscyamine, or Valium. On 1/31/23 the patient started having symptoms which required the medications that are included in the general CCK. The medications were not available and had to be ordered. Not having the general CCK medications available created a delay in the patient receiving relief and treatment, from his symptoms. On 1/31/23 at 7:44 p.m., the skilled nurse documented in a visit note report upon arrival to the patients home the spouse reported Patient #2 had just passed away. The time of death was 7:05 p.m. Review of the pharmacy packing slips showed the Comfort Care Kit which included Diazepam (Valium) 20 milligram suppositories, and Ondansetron 4 milligrams tablets was delivered to the patients home on 1/31/23 at 8:05 p.m., one hour after Patient #2 expired.”