Affinity Hospice

“Based on clinical record review, staff and family interview and review of policy “;Missed Visits,” it was determined that the hospice failed to ensure the care and services are provided in accordance with the plan of care for one patient (P) (P#2) of three patients reviewed. Findings include: Review of the policy titled” Missed Visits,” Policy No. 4-101.1 revised on November 2018, revealed that missed visits will be communicated to the Interdisciplinary Group (IDG) at the IDG meeting. A missed visit will be rescheduled the same week possible. Missed visits will be documented in the clinical record. Review of the complaint and on call logs failed to reveal that a complaint was made regarding missed visits. Review of order dated 5/5/2024 revealed HHA (Home Health Aide) services were ordered two times a week for nine weeks for certification period 5/20/2024 to 7/18/2024. Review of HHA Visit Notes revealed that there were missed visits during the weeks of 6/24/2024 to 6/29/2024, 7/1/2024 to 7/6/2024, 7/8/2024 to 7/12/2024. The agency failed to provide services in accordance with the plan of care. During a phone call interview with family member of P#2 on 11/13/2024 at 8:37 a.m., it was confirmed that P#2 had not received aide visits for several weeks. The family member stated that P#2 had not received aide visits for 5 weeks. The family member stated that because P#2 was not receiving aide visits is why they chose to go to another agency. During an interview with the Clinical Manager (CM) on 11/12/2024 at 11:15 a.m., she confirmed that there were missed visits as P#2 did not want different aide after his regular aide injured herself. The CM failed to present documentation of missed visits for the weeks of 6/24/24, 7/1/2024 and 7/8/2024.”

“Based on clinical records review, staff interview, and review of the policy titled, “;The Plan of Care,” it was determined the hospice failed to ensure that the Chaplain and Social Worker completed comprehensive assessments no later than five days after the election of hospice care for three patients (P) (P#9, P#14, P#19) of 19 sampled records. Findings include: Review of policy titled, “;The Plan of Care,” Policy No. 4-027.1, revised November 2018 reveals the following: 12. The written plan of care will contain, but will not be limited to, the following: E. Identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, educational, bereavement and counseling. R. Interdisciplinary group assessment of needs 1.Review of clinical records revealed P#9 was admitted to hospice on 5/16/2024. Review of the initial visit by hospice Social Worker (SW) was made on 5/29/2024, 14 days after the election of hospice care. Review of the Coordination Note by LPN dated 5/24/2024 (nine days from the start of care) reveals P#9 requested moving SW visit to 5/29/2024. Review of the initial visit by hospice Chaplain was dated 5/23/2024, eight days after the election of hospice care. Review of the Coordination Note by hospice Chaplain, dated 5/23/2024 reveals family member of requested a visit on 5/23/2024. Further clinical record review failed to reveal additional documentation regarding late assessments. 2. Review of the clinical records revealed P#14 was admitted to hospice on 8/9/2023. Review of the Initial Visit by hospice SW was made on 8/14/2023, six days after the election of hospice care. Review of the Coordination Note by SW, dated 8/14/2023, reveals “;This visit was sent late. LMSW is visiting today.” Initial visit by hospice Chaplain was made on 8/14/2023, eight days after the election of hospice care. Review of the Coordination Note by hospice Chaplain, dated 8/14/2023 reveals the visit for P#14 “;was put in late”. Further clinical record review failed to reveal additional documentation regarding late assessments. 3. Review of the clinical records revealed P#19 was admitted to hospice on 9/27/2023. Review of the Initial Visit by hospice Chaplain was made on 10/3/2023, seven days after the election of hospice care. Review of the Coordination Note by hospice Chaplain, dated 10/2/2023 (six days after the election of hospice care) reveals caregiver requested visit to be moved to 10/3/2024. Further review of the clinical record failed to reveal additional documentation regarding late assessments. On 6/12/2024 at approximately 10:00 a.m., an interview with the Area Vice President of Clinical Operations (AVPCO) revealed the agency now using a different scheduling program due to errors with the former program. The AVPCO confirmed the clinical records lacked additional documentation explaining the late assessments on P#9, P#14, or P#19.”

“Based on record reviews, review of the facility policy titled “;”Missed Visits,” and staff interview, it was determined the agency failed to ensure the Certified Nursing Assistant (CNA) and nursing services were provided as ordered in the plan of care (POC) for five patients (P) (P#10, P#14, P#15, P#16, P#19) of 19 sampled patients. Findings include: Review of the policy titled “Missed Visits,” dated November 2018, revealed the following: 2. If a visit is missed and not rescheduled the clinician will: A. Notify the interdisciplinary group (IDG) and clinical supervisor of the missed visit and reason for missed visit B. Document in the patient’s record the following information: 1. Patient’s Name 2. Date and type of visit that was missed 3. Reason for the missed visit 4. Description of any unmet needs 1. Review of the clinical record for P#10 revealed that the patient was admitted to hospice services on 4/28/2023 with start of episode 4/22/2024. Review of the “;Hospice Physician Order” dated 4/22/2024 reveals The skilled nurse Registered Nurse (RN) was scheduled to visit the patient three times a week. The clinical record revealed the RN visited the patient two times the week of 5/19/2024 and two times the week of 5/26/2024. The clinical record failed to reveal RN missed visit notes for the weeks of 5/19/2024 and 5/26/2024 to indicate the physician was notified of the missed visits thus resulting in unauthorized missed visits. 2. Review of the clinical record for P#14 revealed P#14 was admitted to hospice services on 8/9/2023. Review of the “;Hospice Certification and Plan of Care,” with start of care 8/9/2023, reveals the hospice certified nursing assistant (CNA) was scheduled to visit the patient three times a week for twelve weeks then one time a week for one week. Review of the clinical records for P#14 reveals the CNA visited the patient two times each week from 8/13 - 9/3/2023. The clinical record failed to reveal CNA missed visit notes for the weeks of 8/13 - 9/3/2023 to indicate the physician was notified of the missed visits thus resulting in unauthorized missed visits. 3. Review of the clinical record for P#15 revealed that the patient was admitted to hospice services on 6/14/2021. Review of the “;Hospice Physician Order,” dated 5/31/2024 reveals the CNA was scheduled to visit the patient five times a week for eight weeks then two times a week for one week. The clinical record revealed the CNA visited the patient two times the week of 5/19/2024 and one time the week of 5/26/24. The clinical record failed to reveal CNA missed visit notes for the weeks of 5/19/2024 and 5/26/24 to indicate the physician was notified of the missed visits thus resulting in unauthorized missed visits. 4. Review of the clinical record for P#16 revealed P#16 was admitted to hospice services on 3/7/2024. Review of the “;Hospice Certification and Plan of Care” reveals, the CNA was scheduled to visit the patient three times a week for 12 weeks then one time a week for one week. The clinical record revealed the CNA visited the patient two times a week from 3/17/2024 to 3/31/2024. The clinical record failed to reveal CNA missed visit notes for the weeks of 3/17 - 3/31/2024 to indicate the physician was notified of the missed visits thus resulting in unauthorized missed visits. 5. Review of the clinical record for P#19 revealed that P#19 was admitted to hospice services on 9/27/2023. Review of the “;Hospice Certification and Plan of Care,” reveals the CNA was scheduled to visit the patient one time a week for one week then two times a week for 12 weeks. The clinical record revealed the CNA failed to visit the patient the week of 9/7/2023 and visited the patient one time the week of 10/1/2023. The clinical record failed to reveal CNA missed visit notes for the weeks of 9/7/2023 and 10/1/2023 to indicate the physician was notified of the missed visits thus resulting in unauthorized missed visits. During an office interview on 6/12/2024 at 10:00 a.m., the Executive Director did not provide any documentation of the missed visits or physician notification of missed visits.”

“Based on clinical record review, review of facility policies titled “;The Plan of Care”, “Missed Visits,” and staff interviews, it was determined that the facility failed to ensure the management of all hospice operations as evidenced by failures to ensure: · Initial comprehensive assessments were completed by the Chaplain and Social Worker no later than five days after the election of hospice care for three patients (P) (P#9, P#14, P#19) of 19 sampled records · Certified Nursing Assistant (CNA) and nursing services were provided as ordered in the plan of care (POC) for five patients for five patients (P) (P#10, P#14, P#15, P#16, P#19) of 19 sampled patients · Develop a plan of care that included all services and orders necessary for the palliation and management of the terminal illness and related conditions for one patient (P) (P#7) of 19 sampled patients. Findings include: 1. On 6/12/2024 at approximately 10:00 a.m., an interview with the Area Vice President of Clinical Operations (AVPCO) revealed that the agency is now using a different scheduling program due to errors with the former program. The AVPCO confirmed the clinical records lacked additional documentation explaining the late assessments on P#9, P#14, or P#19. Review of policy titled, “;The Plan of Care”, Policy No. 4-027.1, revised November 2018 reveals the following: 12. The written plan of care will contain, but will not be limited to, the following: E. Identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, educational, bereavement and counseling. R. Interdisciplinary group assessment of needs Refer to L0523 with additional findings related to initial comprehensive assessments 2. Review of the policy dated November 2018 titled “Missed Visits” revealed: 2. If a visit is missed and not rescheduled the clinician will: A. Notify the interdisciplinary group (IDG) and clinical supervisor of the missed visit and reason for missed visit B. Document in the patient’s record the following information: 1. Patient’s Name 2. Date and type of visit that was missed 3. Reason for the missed visit 4. Description of any unmet needs Review of the clinical record for P#10 lacked documentation of skilled nurse missed visit notes for the weeks of 5/19/24 and 5/26/24. Review of the clinical record for P#14 lacked documentation of CNA missed visit notes for the weeks of 8/13 - 9/3/23. Review of the clinical record for P#15 lacked documentation of CNA missed visit notes for the weeks of 5/19 and 5/26/24. Review of the clinical record for P#16 lacked documentation of CNA missed visit notes for the weeks of 3/17 - 3/31/24. Review of the clinical record for P#19 lacked documentation of CNA missed visit notes for the weeks of 9/7/23 and 10/1/23. Refer to L0555 for additional information relating to coordination of services. 3. Review of the facility’s undated document titled “Wound Care Protocol” revealed: 1. Nursing staff will provide wound care per physician orders Review the clinical record for P#7 revealed the nurse visited the patient on 2/17/24 and documented the patient has a right chest central venous catheter (CVC) (a thin tube inserted into a vein to give fluids, blood transfusions and medication). During the visit, the nurse documented the CVC has good blood return and flushes easily. Review of the clinical revealed the record lacked an order for the CVC to be accessed and flushed. Additionally, the nurse visited the patient on 5/10 and 5/15/24 and documented P#7 has a wound to the coccyx area. Review of the clinical revealed the record lacked a physicians order for the wound care provided. During an office interview on 6/12/24 at 10:00 a.m., the Executive Director did not provide an order for the wound care completed on 5/10 and 5/15/24. It was also confirmed that the clinical record lacked orders for the CVC to be accessed and flushed. Additionally, it was confirmed the nurse failed to identify the location of the wounds on the verbal orders taken on 5/17/24 and 5/22/24. Refer to L0678 for additional findings relating to content.”

“Based on record reviews, staff interview, and review of policy facility documents, it was determined the hospice failed to develop a plan of care that included all services and orders necessary for the palliation and management of the terminal illness and related conditions for one patient (P) (P#7) of 19 sampled patients. Findings include: Review of the facility’s undated document titled “Wound Care Protocol” revealed: 1. Nursing staff will provide wound care per physician orders Review the clinical record for P#7 revealed the nurse visited the patient on 2/17/2024 and documented the patient has a right chest central venous catheter (CVC) (a thin tube inserted into a vein to give fluids, blood transfusions and medication). During the visit, the nurse documented the CVC has good blood return and flushes easily. Review of the clinical revealed the record failed to reveal an order for the CVC to be accessed and flushed. Additionally, the nurse visited the patient on 5/10 and 5/15/2024 and documented P#7 has a wound to the coccyx area. Review of the skilled nurse visit notes dated 5/10 and 5/17/2024 revealed the skilled nurse provided wound care as follows: area cleansed and dried, silver wound gel (used for wound healing) applied, Dakins (wound wash) soaked gauze packed into wound. Hydrofoam (absorbent foam dressing) placed and Meplex (highly absorbent wound dressing) to secure dressing. Review of the clinical revealed the record failed to reveal an order for the wound care provided. The clinical record revealed two physician’s orders dated 5/17/2024 and 5/22/2024 for wound care however, the orders failed to identify the location of the wounds to be treated. During an office interview on 6/12/2024 at 10:00 a.m., the Executive Director did not provide an order for the wound care completed on 5/10 and 5/15/2024, confirmed the clinical record lacked orders for the CVC to be accessed and flushed, and that the nurse failed to identify the location of the wounds on the verbal orders taken on 5/17/2024 and 5/22/2024.”

“Based on record reviews, staff and family interviews, it was determined the agency failed to follow the written plan of care (POC) established by the agency Interdisciplinary group (IDG) in collaboration with the attending physician for one patient (P) (P#1) of three patient records reviewed. Findings include: Record review of P#1 (certification period 7/1/23 through 8/29/23), revealed skilled nursing (SN) visit frequency was ordered as three times a week for eight weeks and then one time a week for one week beginning on 7/2/23. Record review for week of 7/23/23 through 7/29/23, revealed patient was visited by the SN on 7/24/23 and 7/26/23. SN failed to follow the patients POC to complete a third visit for the week of 7/23/23 through 7/29/23. On 7/28/23 at 10:30 a.m., during a phone interview with family member of P#1, revealed family member stated, “;we really did not have a problem with the agency until the end of July and in one week it was like everyone just disappeared. A nurse came out on Wednesday of one week and we did not see a nurse again until the next Wednesday. I spoke to the social worker (SW) about the nurse not showing up or calling us to explain why she was not coming, but I never heard anything from the agency about it.” The family member additionally stated she did not remember SN missed visits before the week of 7/23/23 through 7/29/23 in July and she said that after that time she does not recall any missed visits. The family member stated she transferred P#1 to another hospice in August. On 2/28/24 at 12:45 p.m., during an interview with the agencys Administrator, he admitted the agency had terminated many nurses and nursing assistants during the month of July 2023. He states, “;during that time the agency came in and fired a lot of our nurses and nursing assistants and hired all new staff. I have only been in my position since the end of July”. On 2/28/24 at 1:00 p.m., during an interview with the Vice President of Operations, he stated, “;I can understand how this happened that the SN visit was missed since the company was going through so many changes during that time. But I also understand the patient comes first and this missed visit should have never happened.””