Harbor Grace Hospice, Inc.

“Based on review of records, review of policy “;Interdisciplinary Team Plan of Care,” and staff interview, it was determined the agency failed to ensure the requirements for the Interdisciplinary Group (IDG), care planning and coordination of services were met for four patients (P) (P#1, P#2, P#3 and P#4) of four sampled patients. · Findings include: Review of policy titled “Interdisciplinary Team Plan of Care” effective 3/2004 revealed the following: Policy: Data gathered from discipline-specific assessments (nursing, social work, chaplaincy, etc.) will be integrated into the IDT plan of care. 1. Review of the IDG assessment for P#1 dated 12/17/24 failed to reveal coordination of care between all disciplines. The IDG Assessment Details revealed a SN visit note narrative. The IDG failed to reveal assessments or updates from other disciplines. 2. Review of the IDG assessment for P#2 dated 12/17/24 and 12/31/24 failed to reveal coordination of care between all disciplines. The IDG Assessment Details revealed a SN visit note narrative. The IDG failed to contain assessments or updates from other disciplines. 3. Review of the IDG assessment for P#3 dated 12/17/24 and 12/31/24 failed to reveal coordination of care between all disciplines. The IDG Assessment Details revealed a SN visit note narrative. The IDG failed to contain any assessments or updates from other disciplines. 4. Review of the IDG assessment for P#4 dated 12/3/24 and 12/17/24 failed to reveal coordination of care between all disciplines. The IDG Assessment Details revealed a SN visit note narrative. The IDG failed to contain any assessments or updates from other disciplines. During an office interview on at 1/15/25 11:00 a.m. with the Director of Homecare and the Administrator it was confirmed that the IDG notes lacked documentation of coordination of patient care with all disciplines and all disciplines are responsible for participating in IDG meetings.”

“Based on record reviews, review of policy “Ongoing Procedures of Active Patient Care,” and staff interview, it was determined the hospice agency failed to ensure the clinical record contained complete, clear and timely documentation for services provided for three patients (P) (P#1, P#3, and P#4) of four patient records reviewed. Findings include: Review of policy titled “Ongoing Procedures of Active Patient Care,” effective 3/2004 revealed: • Document all visits and phone calls on progress notes. Sign and date all entries. 1. Review of the POC for P#1 revealed the skilled nurse (SN) was required to visit the patient one time a week starting 7/27/24. The SN failed to visit the patient the weeks of 12/22/24 and 12/29/24. The clinical record failed to reveal documentation of a missed visit note with physician notification of the missed visits. Review of the clinical record revealed a wound care order which reads as follows: tumor wound care: cleanse with normal saline and apply 4X4’s, wet to dry bandage and cover with abdominal (ABD) pad (absorbent padding), secure with paper or silk tape. The wound care order failed to reveal a frequency for wound care to be provided. The SN failed to obtain a complete physician’s order for wound care. 2. Review of the POC for P#3 revealed SN services were ordered two times a week starting 11/16/24. The SN failed to visit the patient the week of 12/22/24. The clinical record failed to reveal documentation of a missed visit note with physician notification of the missed visits. Review of the clinical record revealed a wound care order as follows: sacrum: cleanse with soap and water. Pat dry and apply the Mepilex Border (flexible and highly absorbent foam dressing) pad. The wound care order failed to reveal a frequency for wound care to be provided. The SN failed to obtain a complete physician’s order for wound care. 3. Review of the POC for P#4 revealed a wound care order dated 11/18/24 which reads as follows: cleanse bilateral hip wounds with saline or wound cleanser, pat dry, apply border gauze every 3 days and as needed for soiled dressing or if dressing falls off. The SN visited the patient weekly from 12/2-12/23/24. The SN documents the wound care was provided however, failed to identify the steps or supplies used to perform the wound care. The clinical record failed to reveal SN visit notes for the month of December. Review of the clinical record contained SN visit notes dated 12/2, 12/11, 12/17and 12/23/24. The clinical notes indicate the SN completed and signed these notes on 1/14/25 (greater than 30 days after the initial visit). During an in-office interview with the Director of Homecare and the Administrator on 1/14/25 at approximately 1:30 p.m., the Director confirmed the clinical record lacked SN visit notes or missed visits for the month of December. The Administrator explained if a visit is missed the clinician is responsible for putting documentation in the record of the missed visit and the reason why the visit was missed. The Director of Homecare confirmed the wound care orders were incomplete in that they lacked a frequency for wound care to be provided. The Administrator and Director of Homecare reported that clinical staff are expected to document care and services on the day services are provided. It was confirmed the SN failed to document home visits on the day of service as required.”

“Based on review of records, staff interviews, and review of policy “;Plan of Care,” it was determined the agency failed to ensure the requirements for the interdisciplinary group, care planning and coordination of services were met. Specifically, the agency failed to follow the plan of care (POC) to ensure that visit frequencies were met, and wound care was provided as ordered for three patients (P) (P#1, P#2 and P#3) of four sampled patients. Findings include: Review of the policy titled “;Plan of Care,” effective date 3/2004 revealed the following:Purpose:The Administrator is responsible for ensuring interventions by hospice employees are consistent with the initial and integrated plans of care. 1. Review of the POC for P#1 revealed the skilled nurse (SN) was required to visit the patient one time a week starting 10/22/24 and provide wound care to the right forearm as follows: cleanse right lower forearm with normal saline, apply wet to moist normal saline soaked dressing, cover with kerlix (made of prewashed, fluff-dried 100% woven gauze with unique crinkle-weave pattern for loft and bulk to cushion and protect wound) every 12 hours and as needed. The SN visited the patient on 10/23/24 and documented wound care to lower anterior forearm as follows: cleansed with saline, cover with Vaseline gauze, wet saline on top, and cover with kerlix. The SN failed to complete wound care as ordered. 2. Review of the POC for P#2 revealed SN services were ordered two times a week starting 7/4/24. It was determined the SN failed to visit the patient the week of 10/27/24. The clinical record lacked documentation of a missed visit note with physician notification of the missed visits. 3. Review of the POC for P#3 revealed SN services were ordered two times a week starting 5/2/24. It was determined the SN failed to visit two times the week of 10/20/24, failed to visit the patient the week of 10/27/24, and failed to visit two times the week of 11/3/24. The clinical record failed to reveal documentation of a missed visit note with physician notification of the missed visits. The clinical record failed to reveal coordination of care with the interdisciplinary team to ensure the missed visits could be rescheduled to provide consistent care and services. During an in-office interview with the Administrator and Director of Homecare on 11/25/2024 at approximately 1:30 p.m., both were unable to locate SN visit notes or missed visits for the weeks requested. The Administrator explained if a visit is missed the clinician is responsible for putting documentation in the record of the missed visit and the reason why the visit was missed. The Administrator confirmed the clinicians are required to follow the ordered plan of care to include following all physician’s orders. The Director of Homecare was unable to provide documentation of missed visit notes for the visits missed and confirmed the SN performed the incorrect wound care protocol on 10/23/24.”

“Based on record reviews, policy review, and staff interviews, it was determined that the agency Interdisciplinary Team (IDT) failed to ensure that skilled nurse visits were provided as ordered and wound care was provided as ordered in the plan of care (POC) for three patients (P) (P#1, P#2, P#3) of four sampled records reviewed. The findings include: Review of the policy titled “;Wound Care Protocols,” approved 12-5-11, revealed the following:Always follow the doctor’s order when providing wound care. 1. Review of the POC for P#1 revealed the skilled nurse (SN) was required to visit the patient one time a week starting 10/22/24 and provide wound care to the right forearm as follows: cleanse right lower forearm with normal saline, apply wet to moist normal saline soaked dressing, cover with kerlix (made of prewashed, fluff-dried 100% woven gauze with unique crinkle-weave pattern for loft and bulk to cushion and protect wound) every 12 hours and as needed. The SN visited the patient on 10/23/24 and documented wound care to lower anterior forearm as follows: cleansed with saline, cover with Vaseline gauze, wet saline on top, and cover with kerlix. The SN failed to complete wound care as ordered. 2. Review of the POC for P#2 revealed SN services were ordered two times a week starting 7/4/24. It was determined the SN failed to visit the patient the week of 10/27/24. The clinical record failed to reveal documentation of a missed visit note with physician notification of the missed visits. 3. Review of the POC for P#3 revealed SN services were ordered two times a week starting 5/2/24. It was determined the SN failed to visit two times the week of 10/20/24, failed to visit the patient the week of 10/27/24, and failed to visit two times the week of 11/3/24. The clinical record failed to reveal documentation of a missed visit note with physician notification of the missed visits. The clinical record failed to reveal coordination of care with the interdisciplinary team to ensure the missed visits could be rescheduled to provide consistent care and services. During an in-office interview with the Administrator and Director of Homecare on 11/25/2024 at approximately 1:30 p.m., both were unable to locate SN visit notes or missed visits for the weeks requested. The Administrator explained if a visit is missed the clinician is responsible for putting documentation in the record of the missed visit and the reason why the visit was missed. The Administrator confirmed the clinicians are required to follow the ordered plan of care to include following all physician’s orders. The Director of Homecare was unable to provide documentation of missed visit notes for the visits missed and confirmed the SN performed the incorrect wound care protocol on 10/23/24. During a telephone interview on 11/26/2024 at approximately 10:00 a.m., with RN CC, RN CC confirmed that she had not documented any skilled nurse visits for the months of October and November 2024. RN CC offered to document the skilled nurse visit notes on 11/26/24 (2 months later) from when the skilled nurse visits were initially made.”

“Based on record reviews, personnel file reviews, agency document, and staff interviews, it was determined the hospice governing body and Administrator failed to ensure hospice staff followed the plan of care to ensure visit frequencies were met and wound care was provided as ordered for the palliation and management of the terminal illness for three patients (P) (P#1, P#2, and P#3) of four sampled patients and to ensure competency assessments were completed for staff prior to performing independent patient care for two of two sampled personnel files. Findings include: A review of document titled “;267 Plan of Care” effective date 3/2004 revealed the Administrator is responsible for ensuring interventions by hospice employees are consistent with the initial and integrated plans of care. 1. Review of Registered Nurse (RN) AA and RN BB personnel file was reviewed and the document titled “Nursing Competency Evaluation” was found to be blank failed to indicate RN AA and RN BB had been deemed competent to perform independent care in the field. 2. Record review reveals P#1 was admitted to hospice on 10/22/24. Physician order dated 10/22/24 revealed wound care to the right forearm as follows: cleanse right lower forearm with normal saline, apply wet to moist normal saline soaked dressing, cover with kerlix (made of 100% cotton gauze with crinkle-weave pattern for wound protection and cushioning) every 12 hours and as needed. The skilled nurse (SN) visited the patient on 10/23/24 and documented wound care to lower anterior forearm as follows: cleansed with saline, cover with Vaseline gauze, wet saline on top, and cover with kerlix. The SN failed to complete wound care as ordered. Record review revealed P#2 was admitted 7/4/24. Review of the plan of care (POC) for P#2 revealed SN services were ordered two times a week starting 7/4/24. The SN failed to visit the patient the week of 10/27/24, and the clinical record failed to reveal documentation of a missed visit note with physician notification of the missed visit. Record review revealed P#3 was admitted on 5/2/24. Review of the POC for P#3 revealed SN services were ordered two times a week starting 5/2/24. The SN only visited the patient one time the week of 10/20/24, failed to visit the patient the week of 10/27/24, and only visited one time the week of 11/3/24. The clinical record lacked documentation of a missed visit notes with physician notification of the missed visits. The clinical record failed to reveal documentation of any coordination with the physician regarding the missed visits or incorrect wound care provided. During an in-office interview with the Administrator and Director of Homecare on 11/25/2024 at approximately 1:30 p.m., both were unable to locate SN visit notes or missed visits for the weeks requested. The Administrator further revealed if a visit is missed the clinician is responsible for putting documentation in the record of the missed visit and the reason why the visit was missed. The Director of Homecare did review the record and was unable to provide documentation of missed visit notes for the visits missed. It was also confirmed the SN performed the incorrect wound care protocol on 10/23/24. During an in-office interview on 11/26/24 at 11:00 a.m., the Administrator verbalized not being aware that the nursing competency evaluation was not completed for RN AA and RN BB and acknowledged that all clinicians are required to complete competency assessments prior to providing independent care in the field.”

“Based on personnel file reviews and staff interviews, it was determined that the agency failed to ensure staff competency assessments were completed prior to performing independent care in the field for two employees, Registered Nurse (RN) AA and RN BB of two sampled employees. Findings include: RN AA and RN BB personnel files were reviewed and revealed a hire date of 9/10/24. The document titled “Nursing Competency Evaluation” was found in each file blank and failed to indicate RN AA and RN BB had been deemed competent to perform independent care in the field however, both clinicians have been performing skilled nurse visits in the field independently. During an in-office interview on 11/26/2024 at 11:00 a.m., with the Administrator and the Director of Homecare, the Administrator verbalized not being aware that the nursing competency evaluation was not completed for RN AA and RN BB and acknowledged that all clinicians are required to complete competency assessments prior to providing independent care in the field. The Director of Homecare stated the clinicians did have a preceptor during orientation but did and confirmed the personnel files lacked documentation to show the nurses were competent to perform independent care in the field.”

“Based on record review, review of policy “;Quality Management,” and staff interview, the agency failed to measure, analyze and track quality indicators, including adverse patient events and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations. Findings include: Review of policy titled “;Quality Management,” dated March 2004, revealed that hospice shall appoint a multidisciplinary quality management committee that reflects the hospice scope of services, The committee shall develop and implement a comprehensive and ongoing quality management, utilization, ad peer review program that evaluate the quality and appropriateness of patient care provided, including the appropriateness of level of service received by patient, and submits required patient incident reports to the Department. Procedure: The quality management, utilization, and peer review program shall establish and use written criteria as the basis to evaluate the provision of patient care. The written criteria shall be based on accepted standards of care and shall include at a minimum, systematic reviews of: o Appropriateness of admissions, continued stay, and discharge o Appropriateness of professional services and level of care provided o Effectiveness of pain control and symptom relief o Patient injuries, such as those related to falls, accidents, and restraint use o Errors in medication, administration, procedures, or practices that compromise patient safety o Infection control practices and surveillance data o Patient and family complaints and on-call logs o Inpatient hospitalizations o Staff adherence to the patients plan of care o Appropriateness of treatment o Findings of the quality management utilization, and peer review program shall be utilized to correct identified problems, revise hospice policies, and improve the care of patients. o There shall be an ongoing evaluation of the quality management, utilization, and peer review committee to determine its effectiveness, which shall be presented at least annually for review and appropriate action to the medical staff and the governing body. The agency failed to reveal quantitative data that they could improve quality as measured by their own indicators. Requested infection control tracking data and the data was not received by survey exit date. An interview with the Administrator in the agency’s office on 10/9/2024 at approximately 10:40 am confirmed that the agency had not met the specific requirement to track adverse events as defined in hospice policy.”

“Based on record review, and staff interview, it was determined that governing body failed to ensure the Quality Assessment and Performance Improvement (QUAPI) program was created and is working to address any problem areas in patient care and hospice operations, and to improve performance in these areas. Governing body failed to ensure that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained, and is evaluated on quarterly basis. Findings include: The agency QUAPI program and meeting minutes was requested. After review of the QUAPI binder, it was revealed that the agency failed to have a QUAPI meeting since 2021. On 10/9/24 at approximately 11:20 am, an interview with the Administrator acknowledged that the agency has not had a QUAPI program and meetings since 2021.”