Franklin County Medical Center Hospice

“Based on review of patient medical records, policies, and staff interview, it was determined the agency failed to ensure the infection control program identified an infection for 1 of 1 current patients (Patient #1) with an infection and whose record was reviewed. This resulted in the infection control program not tracking the infection of Patient #1 with no actions or conclusions documented. Findings include: A hospice policy titled, “Infectious Disease Monitoring and Reporting Hospice” dated 3/03/22 included, “;The infection control nurse will extract all data from SPSS and record in an Infection Control log.” The policy defined a Skin and Soft Tissue Infection as an infection as, “;At least one of the following criteria: 1. Purulent drainage at wound, skin or soft tissue site OR 2. Four or more of the following six signs or symptoms with no other recognized cause: a. Fever Or worsening mental or functional status; b. Pain or tenderness at the affected site; c. Localized swelling at the affected site; Redness at the affected site. Heat at the affected site; f. Serous discharge at the affected site.” The policy was not followed. An example includes: Patient #1 was a 65 year old female admitted to hospice on 8/07/23 with terminal diagnosis of breast cancer. Patient #1 had secondary diagnosis of atrial fibrillation and received SN, MSW, and aide services. She lived in a skilled nursing facility. Her record for the certification period of 10/26/23 to 12/24/23 was reviewed. Patient #1s medical record included a nursing note dated 10/28/2023. It stated, “;Changes in the wound, wound bed has changed. It looks more yellow, increased in drainage. Patient requests that she try an oral ABX [antibiotics]. MD was notified and patient was started on Keflex.” The medical record included an order for Keflex, an antibiotic, on 10/28/23 signed by the Medical Director. Minutes from 11/21/23, “;Infection Control Committee Meeting” which included infections from the previous month, actions taken, and conclusion of actions stated, “;No infections met criteria” for Home Health and Hospice. The DCS was interviewed on 11/29/23 at 11:15AM and was asked, where would an infection be recorded for a Hospice patient. The DCS answered it should be recorded on Home Health and Hospice sections of Infection Control and included in the minutes of the committee meeting. She confirmed Patient #1s infection should have been included in the minutes. The hospice failed to identify and track Patient #1s infection through their infection control program.”

“Based on medical record review and staff interview, it was determined the hospice failed to ensure the clinical record contained current clinical notes for 3 of 14 Patients (Patients #1, #5, and #7) whose records were reviewed. This caused lack of current clinical information in the medical record. Findings include: 1. Patient #5 was a 98 year old female admitted to the agency on 9/08/23 with a primary diagnosis of pulmonary embolism. Additional diagnoses included hypoxia, UTI, and respiratory failure. She received SN, MSW, and aide services. Her record for the certification period 9/08/23 to 12/06/23 was reviewed. Patient #5s record included SN notes for the dates 10/26/23, 11/02/23, 11/09/23, 11/13/23, 11/20/23, and 11/27/23. Each of the 6 nursing notes included the same documentation regarding a foley catheter which stated, “;SN in to remove foley catheter as it has been in for >30 days. Family opted to place new foley. It was inserted using sterile technique with no problems. Inflated balloon with 10cc sterile h20 [10 milliliters sterile water].” The notes stated there was an order for the new foley catheter on 10/26/23. After 10/26/23, there was no current assessment of the foley catheter. The RN who completed the visit notes was interviewed with the Administrator and the DCS on 11/30/23 beginning at 9:00 AM. The RN stated the notes were not complete and would be changed. She confirmed the documentation was the same and not current for the 6 notes but stated they were short a nurse and she had not had time to complete the notes. The DCS stated her expectation for completion of clinical notes was within 48 hours after the visit. 2. Patient #7 was a 90 year old female admitted to the agency on 7/31/23 with a primary diagnosis of liver cirrhosis. She received SN, MSW, and PT services. Her record for the certification period 10/29/23 to 1/26/24 was reviewed. Patient #7s record included a POC which stated SW was to see her 1-3 times a month. As of 11/29/23, there was no MSW visit documented for the certification period beginning on 10/29/23. The DCS was interviewed on 11/30/23 beginning at 9:00 AM. The DCS stated her expectation for completion of clinical notes was within 48 hours after the visit. The Social Worker was interviewed on 11/29/23 beginning at 12:49 PM and Patient #7s record was reviewed with her. She stated she had done a visit the month of November however had not documented it. She confirmed the visit was not documented in a timely manner. 3. Patient #1 was a 66 year old female admitted to the agency on 12/30/22 with a primary diagnosis of breast cancer. Additional diagnoses included atrial fibrillation and venous thrombosis. She received SN, MSW, and aide services. Her record for the certification period 10/26/23 to 12/24/23 was reviewed. Patient #1s record included an MSW note dated 10/26/23 which for the assessment stated, “;see PCC documentation.” There was no current MSW visit with clinical data for the current certification period. Patient #1s record included a POC which stated MSW was to see her 1-3 times a month. As of 11/29/23, there was no MSW visit with current clinical information documented for the certification period beginning on 10/26/23. Patient #1s record included an SN note dated 11/04/23 which stated, “;Patient very quiet and answers in one-word answers. Appears to be tolerating life at this point.” The DCS was interviewed on 11/30/23 beginning at 9:00 AM. The DCS stated her expectation for completion of clinical notes was within 48 hours after the visit. The Social Worker was interviewed on 11/29/23 beginning at 12:49 PM and Patient #1s record was reviewed with her. She stated Patient #1 lived in the nursing home where the Social Worker was also employed, and she saw her every day there. She confirmed there was no MSW assessment in the hospice documentation with current clinical information for Patient #1. She stated she had done an additional visit the month of November however had not documented it. She confirmed the visit was not documented in a timely manner. The hospice failed to ensure patient records included current clinical notes.”

“Based on medical record review and staff interview, it was determined the agency failed to ensure entries into the clinical record were clear and complete for 3 of 14 patients (Patients #1, #5, and #14) whose records were reviewed. This caused information to be either incorrect or incomplete. Findings include: 1. Patient #1 was a 66 year old female admitted to the agency on 12/30/22 with a primary diagnosis of breast cancer. Additional diagnoses included atrial fibrillation and venous thrombosis. She received SN, MSW, and aide services. Her record for the certification period 10/26/23 to 12/24/23 was reviewed. Patient #1s record included an MSW note dated 10/26/23 which for the assessment stated, “;see PCC documentation.” The note did not include documentation of what happened during the visit, what the assessment was, or any clinical documentation. There was no other documentation of the visit in Patient #1s hospice medical record. It was unclear what “;PCC” documentation was. The Social Worker was interviewed on 11/29/23 beginning at 12:49 PM and Patient #1s record was reviewed with her. She confirmed there was no MSW assessment in the hospice documentation with current clinical information for Patient #1 for the 10/26/23 visit. 2. Patient #5 was a 98 year old female admitted to the agency on 9/08/23 with a primary diagnosis of pulmonary embolism. Additional diagnoses included hypoxia, UTI, and respiratory failure. She received SN, MSW, and aide services. Her record for the certification period 9/08/23 to 12/06/23 was reviewed. Patient #3s record included an MSW visit note dated 9/08/23. The note stated Patient #1 lived with “;friend/family” and her marital status was “;widowed.” Patient #3s record included an MSW visit note dated 10/13/23. The note stated Patient #1 lived “;with spouse/partner” and her marital status was “;married.” The documentation contradicted the documentation from the MSW visit on 9/08/23. The Social Worker was interviewed on 11/29/23 beginning at 12:49 PM and Patient #5s record was reviewed with her. She confirmed the information she documented about Patient #5s living situation and marital status on 9/08/23 was incorrect. 3. Patient #14 was an 85 year old female admitted to the agency on 4/02/23 and died on 4/13/23 with a primary diagnosis of neoplasm of the brain. She received SN, MSW, and aide services. Her record from start of care to her death, and her bereavement period after she died, were reviewed. Patient #14s bereaved person was her husband. An MSW bereavement visit from 8/01/23 stated, “;visit with [husband] today—see hospice for [husband] as we were there for a lengthy time setting him up with services and we discussed his wife as well.” The bereavement visit did not include assessment of the bereaved person. The Social Worker was interviewed on 11/29/23 beginning at 12:49 PM and Patient #14s record was reviewed with her. She confirmed Patient #14s record should have included the bereavement assessment of Patient #14s bereaved person rather than referring to a different medical record. The hospice failed to ensure medical records contained correct and complete information.”

“Based on review of patient medical records, policies, State Operations Manual Chapter 2, and staff interview it was determined the hospice failed to properly document a discharge for 1 of 3 patients (Patient #2) who were documented as a revocations or live discharges and whose records were reviewed. This caused a patient to be improperly documented as a revocation when they should have been discharged from hospice. Findings include: State Operation Manual Chapter 2 §2081 defined a revocation as, “;a voluntary action taken by the patient or representative. The election of the hospice benefit is the beneficiarys choice rather than the hospices choice, and the hospice cannot revoke the beneficiarys election.” State Operations Manual Chapter 2 §2082 states a discharge may occur when, “;the hospice determines that the patient is no longer terminally ill.” These guidelines were not followed. An undated hospice policy titled “;Hospice: Discharge Criteria,” stated, “;Patient will be discharged from services as follows ... Hospice determines patient is no longer terminally ill.” The policy did not include revocation processes. This policy was not followed. An example includes: Patient #2 was an 86-year-old male admitted to hospice on 3/09/23 with the terminal diagnosis of leukemia. Patient #2 had secondary diagnosis of atrial fibrillation and hypertension and received SN, MSW, and Chaplain services. His record for the certification period of 9/05/23 to 11/03/23 was reviewed. His medical record included an SN visit dated 10/27/23. The SN visit note stated, “;The SN then educated them [caregiver and patient] that yes in the beginning he [patient] was declining ... but now he is getting up on his own and walking without assistance ... Patient and cg [caregiver] agreed. Will revoke from hospice next Friday (11/3/23).” IDG meeting notes regarding Patient #2 from 10/31/23 stated, “;Patient has not had any decline for a few months and at the end of his cert period we will be revoking hospice d/t [due to] no decline.” Patient #2s medical chart attachments included scanned signed revocation from hospice dated 11/03/23. Patient #2s nurse was interviewed on 11/29/23 at 10:33AM and was asked if Patient #2 was discharged or revoked. The nurse reported she did not know until that morning there was a difference between discharge and revocation. The nurse confirmed Patient #2 should have been documented as a discharge and not revoked. The hospice failed to properly discharge Patient #2.”

“Based on personnel file review, policy review, and medical record review, it was determined the hospice failed to ensure all staff, including contracted staff, had a current background check. This caused failure of the hospice to provide a background check for the contracted medical director. Findings include: A policy provided titled, “;Criminal History and Background checks,” for the hospital which was over the hospice, reviewed May 2019 stated, “;All new employees will have finger print based criminal history and background check upon hiring,” and, “;A copy of criminal history background check report from the Idaho Criminal History Unit will be kept in each employees personnel file.” This policy was not followed. An example includes: The Medical Directors personnel file was reviewed. His personnel file did not include a background check. The Administrator and DCS were interviewed on 11/30/23 beginning at 9:00 AM. The Medical Directors personnel file was reviewed with and his background check was requested. The Administrator stated the Medical Director was contracted and was an employee of the affiliated medical center. They stated he worked for the medical center for over 30 years but did not have a current background check on file. They stated there was a background check started in 2018 but not completed. They confirmed there was no current background check for the Medical Director. The facility failed to ensure contracted staff had a current background check on file.”