Hospice East

“Based on interview, review of Quality Assessment and Performance Improvement (QAPI) records, and review of the agency’s policy, the agency failed to maintain documentation of assessment of the hospices performance in the areas of palliative outcomes, such as pain and other symptoms. Failure to assess performance with pain and symptom management has the potential to allow lack of effectiveness in this area to remain unidentified and does not enable the hospice to reflect improved outcomes. This deficient practice had the potential to affect the 53 patients who were currently receiving hospice services and all future hospice patients. The findings include: Review of the agency’s policy titled, “;Quality Assessment and Performance Improvement Project,” undated, revealed “The QAPI program includes processes for measuring, analyzing, and tracking quality indicators, and other aspects of performance that enable the hospice to assess processes of care, services, and operations.” Review of QAPI documents revealed there was no documentation of an assessment of how the agency performed in the areas of palliative outcomes such as controlling pain, shortness of breath, or other patient symptoms after admission, and the implementation of hospice interventions. During an interview on 09/13/2024 at 2:30 PM with the Clinical Director, who was responsible for the QAPI program, she acknowledged the finding and stated, “We dont really look at how well we do with relieving pain or other symptoms until the end of care when we do our patient satisfaction surveys. I agree that documenting that would be helpful.””

“Based on observation, interview, record review, and review of the agencys policy, the agency failed to conduct physical assessments and/or bathing in a manner to prevent cross contamination for two of four patients observed receiving care, Patient (P) 3 and P4. This had the potential to increase the risk of infection for the patients. The findings include: Review of the agency’s policy titled, “Infection Control – Bag Technique,” undated, revealed “;. . . Hand washing supplies are retrieved from the bag if needed and hands are washed before removing other items from the bag . . .” Review of the agency’s policy titled, “Guidelines for Reducing the Risk of Infection,” undated, revealed, “. . . Gloves . . . should be used to prevent all direct contact with blood and body fluid, regardless of the patient’s diagnosis . . . Hands often become contaminated with bacteria and viruses acquired from infected patients and other sources . . . In the absence of a true emergency, personnel should always wash their hands . . . after situation during which microbial contamination is likely to occur, especially those involving contact with mucous membranes, blood or body fluids, secretions, or excretions . . .” 1. Review of P3’s “Start of Care,” revealed P3 was admitted to hospice services on 06/06/2024 with diagnoses that included unspecified sequelae of cerebral infarction. During an observation on 09/12/2024 at 11:30 AM, State Registered Nurse Aide (SRNA) 4 provided a bed bath to P3. SRNA4 donned (put on) gloves and washed P3’s back and buttocks. Without doffing or changing her gloves, SRNA4 left the bedside, opened P3’s closet, obtained an incontinence brief, returned to P3’s bedside, and placed the incontinence brief on P3. SRNA4 then doffed (took off) her gloves, obtained clean bathing water, donned new gloves, and returned to the bedside. SRNA4 then washed P3’s peri-anal area, and without doffing her gloves, left the bedside, opened P3’s closet and obtained two clothing items. SRNA4 placed one of the clothing items on P3’s bed, opened P3’s bedside table drawer, obtained body lotion, and applied lotion to P3’s arms, abdomen, and legs. SRNA4 then removed her gloves, dressed P3, and left the room to obtain help with repositioning P3. SRNA4 did not perform hand hygiene. During an interview on 09/12/2024 at 12:32 PM, SRNA4 confirmed she was wearing soiled gloves when she opened P3’s closet and bedside table drawer. SRNA4 stated she should doff their gloves and perform hand hygiene before touching items in the patient’s environment. During an interview on 09/12/2024 at 4:58 PM, the Clinical Director (CD) stated it was the agency’s expectation and a standard of practice to remove gloves and perform hand hygiene before touching surfaces in a patient’s environment while completing care such as a bed bath. 2. Review of P4’s “Start of Care,” revealed P4 was admitted to hospice services on 08/15/2024 with diagnoses that included other sequelae of cerebral infarction. During an observation on 09/12/2024 at 11:00 AM, Registered Nurse (RN) 3 completed a physician assessment for P4. RN3 washed her hands, donned gloves, placed a barrier on P4’s overbed table, and obtained a computer from her bag. RN3 assisted P4 in repositioning the patient’s oxygen nasal cannula. RN3 then obtained her stethoscope and blood pressure cuff from her bag and started taking P4’s blood pressure. RN3’s cellular phone rang, and wearing the same gloves, RN3 took the phone from the side of her bag, silenced the phone, and placed it back into a pocket of the bag. RN3 then listened to P4’s lung, heart, and abdominal sounds, and assessed P4’s lower extremities. RN3’s cellular phone rang again, RN3 obtained the phone and silenced it, and placed the phone back into her bag. RN3 completed the physical assessment, helped P4 reposition in bed, and wearing the same gloves, obtained disinfecting wipes from her bag, and wiped her stethoscope and blood pressure cuff and placed them back into her bag. RN3 then doffed her gloves and performed hand hygiene. During an interview on 09/12/2024 at 11:30 AM, RN3 confirmed she wore the same gloves throughout the assessment, including when adjusting P4’s oxygen nasal cannula, obtaining items from the bag, helping the patient to reposition, and while wiping the stethoscope and blood pressure cuff. RN3 confirmed she should have changed gloves and performed hand hygiene prior to obtaining items from her bag, touching the cellular phone, and prior to wiping the stethoscope and blood pressure cuff with the disinfecting wipe. During an interview on 09/12/2024 at 4:58 PM, the CD stated it was the agency’s expectation and a standard of practice to perform hand hygiene prior to obtaining items from the nurse’s bag and before disinfecting any equipment.”

“Based on interview, review of personnel files, and review of the agencys policy, the agency failed to offer Hepatitis B vaccines to four of seven professional staff (State Registered Nurse Aide (SRNA)2, SRNA 3, SRNA 4, and Clinical Social Worker (CSW) 1), and two of three hospice volunteers (Volunteer (Vol) 2 and Vol3). This had the potential for the transmission of potential Hepatitis B to patients and other staff employed by the agency. The findings include: Review of the agencys policy titled, “Bloodborne Pathogen Exposure Control Plan,” revised March 2008, revealed “Hepatitis B Control... Each clinical employee will be given the opportunity to receive the Hep B series {of vaccine}. If the employee consents to be vaccinated, he/she will be referred to an Occupational Medical Clinic... Medical Records of vaccination will be maintained in employee health file.” 1. Review of SRNA2’s personnel file revealed a hire date of 02/19/2024. There was no evidence that the hepatitis vaccine had been offered, accepted, or declined by the employee since the date of hire. 2. Review of SRNA3’s personnel file revealed a hire date of 03/21/2024. There was no evidence that the hepatitis vaccine had been offered, accepted, or declined by the employee since the date of hire. 3. Review of SRNA4’s personnel file revealed a hire date of 12/19/2023. There was no evidence that the hepatitis vaccine had been offered, accepted, or declined by the employee since the date of hire. 4. Review of CSW1’s personnel file revealed a hire date of 12/11/2023. There was no evidence that the hepatitis vaccine had been offered, accepted, or declined by this employee since the date of hire. 5. Review of Vol2’s personnel file revealed a hire date of 11/22/2013. There was no evidence that the hepatitis vaccine had been offered, accepted, or declined by this employee since the date of hire. 6. Review of Vol3’s personnel file revealed a hire date of 12/18/2023. There was no evidence that the hepatitis vaccine had been offered, accepted, or declined by this employee since the date of hire. During an interview with the Volunteer Coordinator (VC) on 09/11/2024 at 3:00 PM, the VC was queried about whether each volunteer is offered the Hepatitis B vaccine upon hire. The VC stated “Yes, we should do that.” During an interview on 09/13/2024 at 8:00 AM, the Clinical Director (CD) verified the findings and acknowledged that there was no evidence the Hepatitis B vaccine had been offered to the referenced employees at the time of hire. The CD stated, “;we didnt know that we had to have employees sign a waiver if they didnt want the vaccine, but it makes sense, thats the only way you could document that they were offered the chance to receive it.””

“Based on interview, record review, and review of the agencys job descriptions, the facility failed to provide medically related social services to meet the needs of the patients for 3 of 14 patients (Patient (P) 13, P1, and P9) reviewed for social service needs out of a total sample of 19. This increased the risk of patient and family needs going unmet. The findings include: 1. Review of P13’s “Face Sheet,” revealed P13 was admitted to hospice services on 08/07/2024 with diagnoses that included malignant neoplasm of the oropharynx. Review of P13’s “Initial Assessment,” dated 08/07/2024 at 3:00 PM and written by the facility’s Social Worker (CSW) 1, revealed “. . . [P13] uses a direct express card and the company has locked her card and she has not been able to access her money . . . has been diagnosed with throat cancer with a prognosis of six months or less . . . currently lives alone in her apartment with her cat but has a neighbor down the hall who is her PCG [patient caregiver] . . . is currently having some financial trouble with her direct express account and it is locked and SW will be coming back to the home earlier in the day to help address this issue. There is no family involvement . . .” Review of P13’s “General Visit Note Information,” dated 8/12/2024 at 12:30 PM, revealed “. . . SW made a PRN [as needed] visit to assist [P13] with her direct express card. Her card has not been working for about 2 months and she has not been able to get a hold of customer service. SW tried to solve issue by creating an account online but get [sic] the error message of ‘Card not showing service, please call.’ When attempting to call there was a 90 minute estimated wait and so SW took information down and will attempt to call at a later time when the wait is not so long . . .” Review of P13’s “General Visit Note Information,” dated 08/13/24 at 11:00 AM, revealed “. . . SW called and waited on the line for direct express for a [sic] hour. When speaking to a representative, they told SW that they needed to send a text to [P13]’s phone for verification or an email of her picture ID could be sent. [P13] does not have an ID and cannot send an email, she also does not have an email and was not sure what email the company would have on file for her. SW told [P13] she would need to call and have them send the text to her phone and then they should be able to help her unlock her card from there . . .” Review of P13’s “IDG (Interdisciplinary Group) Comprehensive Assessment Details,” dated 08/14/2024 revealed, “. . . SW is assisting pt with getting money from ‘Direct Express’ as it has ‘been locked up’ for 2 months . . .” There was no documentation in the Electronic Medical Record (EMR) from 08/15/2024 through 08/26/2024 regarding P13’s money card. Review of P13’s “General Visit Note Information,” dated 08/27/2024 at 1:00 PM, revealed “. . . SW made a PRN [as needed] visit due to a phone call from [P13’s caregiver] saying that [P13] still has not been able to get her money from direct express and they were unsure why SW was not taking care of this situation. SW came over and explained again that the company would not let me speak to them on her behalf and SW was instructed to tell [P13] she needed to call from her phone in which they would send a verification code to the phone and when she gave them that verification code, they would be able to speak to her about the locked card. [P13’s caregiver] said they tried this and was told they still needed to send a photo ID and call back again after this was done. SW said this was the 2nd option that was given when SW called but the verification method should be just able to be done with a text message. SW wrote down instructions on how this process should occur and asked for them to try again and ask to speak to a supervisor if they would not work with them about this . . .” Review of P13’s “IDG Comprehensive Assessment Details,” dated 08/28/2024, revealed “. . . Hospice SW [Social Worker] is working with [P13] on getting money back from direct express [sic] with SW educating [P13] on steps she needs to do . . .” Review of P13’s “IDG Comprehensive Assessment Details,” dated 09/11/2024, revealed no documentation related to whether the issue had been resolved with P13’s money card. Review of P13’s EMR revealed P13 passed away on 09/12/2024. During an interview on 09/13/2024 at 11:58 AM, CSW1 stated she had called Direct Express and waited for over an hour to talk to someone and had been instructed to have P13 call from her phone to get a verification code or for P13 to send in a photo ID in order to speak with someone. CSW1 stated she had informed P13 and the PCG of this but P13 did not have any minutes on her phone and that P13 did not have a photo ID. CSW1 stated the PCG or another friend had put minutes on P13’s phone, but during their conversation with Direct Express, the phone had cut off again. CSW1 stated she had gone to another CSW with the agency and to the Team Coordinator (TC), and they instructed her that P13 needed to handle the problem on her own. CSW1 stated that was when she had written down step by step what P13 needed to do. CSW1 stated she did not have enough time to wait on the phone to speak with Direct Express. CSW1 stated she had brought the concern up during P13’s IDG meetings. CSW1 stated she had learned that P13 was behind on her rent payments but not in immediate danger of eviction from her apartment and that P13 had funds available on her Food Stamps card. CSW1 confirmed P13 had passed away and that her money was still on the Direct Express card. CSW1 stated she did not know what would or should happen with the funds at this point. CSW1 was asked what resources she had utilized to assist P13 in obtaining her money. CSW1 made no comment. During an interview on 09/13/2024 at 1:22 PM, the TC was asked if CSW1 had talked with her about P13’s Direct Express card. The TC stated, “Yes.” The TC stated she had told CSW1 that she did not know what to do but she should do an internet search for assistance. During an interview on 09/13/2024 at 1:57 PM, the Clinical Director (CD) stated it was the agency’s expectation for staff to investigate and use all resources available to help meet the patients’ needs. The CD stated the agency had resources that could have been used to purchase minutes for P13’s phone and that the Executive Director, who was a Social Worker, could have been asked for guidance. The CD stated that all time needed to meet the needs of the patients would be provided. 2. Review of the facility’s job description for Social Workers, dated January 2024, revealed, “. . . Responsible for direct case work and counseling services to the patient/family unit wherever they may be within the hospice program of care . . .” Review of P1’s EMR revealed P1 was admitted to hospice services on 04/10/2024 with diagnoses that included acute and chronic respiratory failure. Review of P1’s “Patient Information for Volunteer,” revealed P1’s PCG declined the services of a volunteer when P1 was admitted to services. Review of P1’s “General Visit Note,” dated 08/26/2024 and written by CSW1, revealed, “. . . [PCG] also asked for a sitter list today in case he is in need of additional help when his [family member] is not available. SW provided list and explained what to ask when he called for additional help . . .” There was no documentation the PCG was offered volunteer services. During an interview on 09/11/2024 at 1:00 PM, P1’s PCG was asked if volunteer services had been offered for P1. He/she stated they did not know anything about volunteers. He/she then asked how much volunteer services cost and what a volunteer could do. The surveyor explained volunteer services to the PCG, and he/she stated that was something they were very much interested in. During an interview on 09/12/2024 at 4:58 PM, the CD confirmed that when P1’s PCG inquired about sitters, the social worker should have offered volunteer services. The CD stated she expected staff to monitor patient and family needs and offer any available services as the need became apparent. During an interview on 09/13/24 at 11:58 AM, CSW1 was asked if she had offered volunteer services when P1’s PCG had requested a list of sitters. CSW1 stated she did not because the PCG had requested information about a sitter. CSW1 was asked if volunteer services were ever offered after the initial admission. CSW1 stated during the admission process, patients and caregivers were instructed to notify the agency if they changed their minds and wanted additional services. CSW1 stated she had visited with P1’s PCG this morning, volunteer services had been offered, and the PCG had accepted the services. 3. Review of P9’s record revealed an admission date of 08/29/2024 with a diagnosis of metastatic pancreatic cancer. P9 resided at home with their elderly spouse, was bed bound, and required total care. Review of the physician’s order located on the “Plan of Care (POC), dated 08/29/2024, specified “Social Worker 1 visit monthly, 1 [one] prn (as needed) visit monthly. Review of the CSW1s initial assessment, dated 08/30/2024, revealed “;There is a daughter in town who comes by to help, but there is a caregiver option being worked on and the family would like to hire soon.” Review of the Nurses “Admission Assessment Note,” dated 08/30/2024, revealed “;patient is bedbound and requires total care with all Activities of Daily living (ADLs). Her family wants to hire c/gs (caregivers). SW (social worker) is present and provided with sitters list and list of agencies.” No further documentation of follow up by CSW 1 was evident in the clinical record until the IDT (Interdisciplinary Team) update to the Plan of Care, dated 09/11/2024, documented “;Hospice SW reports no social concerns.” There was no documentation to indicate that CSW1 contacted the family by phone or with a “;prn” visit to determine if they were successful in obtaining the assistance they needed and requested at the start of care. There was no evidence CSW1 provided the support and direction needed to facilitate the patients care and treatment. During an interview on 09/13/2024 at 12:30 PM, CSW 1 verified the findings and acknowledged that follow up for the patient about securing caregiver assistance was very important but had not been completed. CSW1 stated “;I should have gotten back with the family to see if they were able to find a caregiver. I just thought they could figure it out on their own.””

“Based on review of personnel files, interview, and review of agency policy, the agency failed to maintain documentation that a criminal background check had been completed for one of three volunteers, Volunteer (Vol) 3. This had the potential to negatively affect the employees and the 53 patients who were currently receiving hospice services and all future hospice patients/patient family units. The findings include: Review of the agencys policy titled, “;Volunteers – Records,” undated, revealed “;The Volunteer Coordinator is responsible for the maintenance of volunteer files. Each volunteer file should contain... criminal background check information.” Review of the personnel file for Vol3 revealed a hire date of 12/18/2023. There was no documentation that a criminal background check had been obtained for this volunteer, who was responsible for patient visits in patient’s homes. During an interview on 09/11/2024 at 3:00 PM, the Volunteer Coordinator (VC) stated hospice policy required background checks on all employees to be done at hire and would attempt to locate the missing background check. During an interview on 09/13/2024 at 8:00 AM, the Clinical Director (CD) stated there was no documentation to show that a criminal background check was completed for Vol3. The CD confirmed that the agency’s policy required background checks on all employees to be done at hire and said it must have been missed.”