St Catherine Hospice

“Observed in Data Session. The surveyor noted the HCO was not able to demonstrate the operation of its QAPI program as evidenced by the HCO was not able to produce the documentation of the program at the time of survey. This observation was reviewed with the Chief Nursing Officer. Observed in Data Session. The hospice surveyor noted the QAPI program did not include indicators that were related to improved palliative outcomes as evidenced by the organization was not able to produce this documentation at the time of survey This observation was reviewed with the Chief Nursing Officer. Observed in Data Session. The surveyor noted the HCO did not have an effective, ongoing, organization wide, data-driven QAPI program as evidenced by the HCO was not able to produce this documentation at the time of survey. This observation was reviewed with the Chief Nursing Officer.”

“Observed in Record Review. In 4 of 14 patient records reviewed, the organization failed to document a patient specific comprehensive assessment that identified the patient’s need for hospice services. On review of RRHV#1 the documentation noted the patient with a wound to the coccyx yet there was no wound assessment conducted as part of the comprehensive assessment or reassessment. On review of RRHV#3 during home observation there was discussion of a wound to the coccyx, and also documentation in the record of a wound that healed, yet there was no documentation of an assessment of the wound. In RRNHV#5 there was no documentation of vital signs in the initial comprehensive assessment and reassessment yet vital signs are required documentation per organization policy 14721832 for comprehensive assessment and reassessment. Further, the patient had documentation of weight loss and poor appetite yet no assessment of weight or mid arm circumference, and a history of diabetes and no assessment of the endocrine system on admission. In RRNHV#8 there were no vital signs documented on the initial comprehensive assessment as required. There was documentation of multiple skin tears but no documentation of a wound assessment. These observations were reviewed with the RN.”

“Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to ensure the plan of reflect the patient and family goals that were Individualized, specific, measurable, and time-bound. In review of the records almost all goals were noted to not be individualized to the patient’s needs as most of the goals were to noted at the end of the certification period or throughout the certification period. In RRHV#1 an example was an Oxygen safety goal that noted Patient/caregiver will understand ordered oxygen therapy including administration, safety, and care of equipment by return demonstration and reporting any increased needs t/o cert period and Patient/caregiver will demonstrate safe and appropriate use of bedside rails as well as understanding of instruction by return demonstration and report and concerns or needs t/o cert period. In RRHV#2 an example of a non-specific goal that was not measurable or time-bound was Patient/caregiver/family will demonstrate understanding of and ability to manage respiratory symptoms at end of life and Patient/caregiver will demonstrate home colostomy management as evidenced by ability to manage ostomy by end of cert period. In RRHV#3 an example of a goal was MSW will listen, support and be present for patient, caregivers and family. In RRHV#4 an example was Patient/caregiver/family: caregiver and family will verbalize understanding of diagnosis, prognosis, and the appropriate management of the symptoms of terminal diagnosis by asking appropriate questions t/o disease process. In RRNHV#5 a goal was Patient/caregiver/family: patient, caregiver and family will verbalize understanding of medication regimen by/within: by end of first cert period. Patient/caregiver will demonstrate understanding and effective home management of skin conditions: redness by keeping patient clean dry and frequent repositioning was a goal in RRNHV#10 that was not specific and time-bound. Goals that were not specific, measurable, and time-bound were noted throughout all records reviewed. These observations were reviewed with the RN.”

“Observed in Record Review. In 11 of 14 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRHV#1 there was documentation that a wound to the coccyx was covered with a Mepilex dressing yet there was no order for Mepilex nor was the dressing reflected in the plan of care. In RRHV#2 there was nursing documentation that the patient had increased pain that required an increased dosage of fentanyl and the social worker documented working on getting the patient Meals on Wheels. Neither of the issues noted in the record were reflected on the plan of care. In RRNHV#5 there was documentation of dysphagia and thickened liquids yet there were no orders for thickened liquids nor were the issues reflected on the plan of care. In RRNHV#6 the documentation noted oxygen use but no oxygen orders. There was also documentation of dysphagia and transitioning to end of life yet the issues were not reflected on the care plan. In RRNHV#7 the documentation noted a foley catheter but no orders for the catheter nor a urinary care plan to guide the care. In RRNHV#8 the documentation noted wound treatment of antibiotic cream with tegaderm but no physicians order for the treatment. In RRNHV#9 there was oxygen use but no oxygen orders. There was documentation of generalized edema that was not reflected on the care plan. In RRNHV#10 there was no order for oxygen but documentation of its use in the record. Further, there was documentation of wound care treatments yet no physicians order for the treatment provided. In RRNHV#12 the documentation noted increased fentanyl from one to two patches yet no physicians order noted in the record for the increase, nor was the increase in pain reflected in the plan of care. In RRNHV#13 the documentation noted a UTI with antibiotics orderd but no infection care plan to guide the care. In RRNHV#14 the patient was admitted at the end of life and documentation noted not swallowing yet the issue was not reflected in the plan of care. These observations were reviewed with the RN.”

“Observed in Record Review. In 3 of 14 patient records reviewed, the organization failed to ensure the plan of care revisions were based on information from updates to the patient’s comprehensive assessment and addressed the patient’s progress to goals and outcomes. On review of RRHV#2 and RRHV#3 there was no documentation on the patient’s progress toward goals and outcome noted in the record. The plan of care goals and interventions remained the same and unupdated from admission and continued IDT to IDT meeting. In RRNHV#5 all of the goals were noted to be completed by the end of the 1st certification period, yet the patient was in the 2nd benefit period. There was no progress toward goals and outcomes and the goals had not been updated based on the comprehensive assessment. These observations were reviewed with the RN.”

“Observed in Patient Home. In 1 of 1 home observations in a skilled nursing facility, the organization failed to provide all required information to the skilled nursing facility (SNF) to include the patient’s hospice election form and any advance directives, and the physician certification and recertification of the patient’s terminal illness. On review of RRHV#3 there was a binder provided to the SNF that contained the Plan of Care but lacked the patient hospice election, advance directives, and the certification/recertification of the patient’s terminal illness. This observation was reviewed with the Interim CNO.”