VNA Health at Home 1

“Based on interview and policy review, the Hospice Agency failed to provide Emergency Preparedness training every two years to all 13 staff members of the agency. This deficient practice had the potential to affect all 20 patients receiving services from the Hospice Agency. During an interview on 09/04/2024 at 2:20 PM, the Director of Clinical Services (DCS) confirmed that Emergency Preparedness training was not performed for any of the 13 staff employed by the agency for the past two years. Review of the agency’s policy titled “Emergency Operations Plan,” revised 06/26/23, revealed “ 24. At orientation and annually thereafter, employees will be educated on their role in the preparedness activities in the EOP including the importance of having a home or family emergency management plan...””

“Based on record review, interview, and policy review, the Hospice Agency failed to ensure that patient care plans incorporated measurable data elements to assess if progress toward expected outcomes of care plan goals were being met for 10 of 14 sampled patients (Patient (P) 1, P2, P3, P4, P5, P6, P7, P8, P9, and P10) reviewed for care plan development. This deficient practice had the potential to affect all 20 patients receiving services from the Hospice Agency. 1. Review of P1’s “Hospice POC (Plan of Care) Report,” found in P1’s Electronic Medical Record (EMR) under the “Care Plan” tab, indicated the Registered Nurse (RN) started P1’s “POC” on 06/16/2024 that included altered comfort, altered home safety, altered genitourinary system, altered gastrointestinal status, altered endocrine system, altered nutrition/hydration, and altered skin integrity. The Social Worker started P1’s “POC” on 06/03/2024 that included declining status/imminent death. The “POCs” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 2. Review of P2’s “Hospice POC Report,” found in P2s EMR, indicated the RN started P2’s “POC” on 08/06/2024 that included altered comfort, altered cardiopulmonary status, altered genitourinary status, altered gastrointestinal status, altered endocrine system, altered nutrition/hydration, altered neurological status, and altered skin integrity. The MSW started P2’s “POC” on 08/15/2024 that included declining status/imminent death. The “POCs” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 3. Review of P3’s “Hospice POC Report,” found in P3’s EMR, indicated the RN started P3’s “POC” on 08/09/2024 that included altered comfort, altered cardiac/circulatory system, altered cardiopulmonary status, altered genitourinary status, altered gastrointestinal status, altered nutrition/hydration, altered neurological status, and altered skin integrity. The Social Worker started P3’s “POC” on 08/12/2024 that included declining status/imminent death. The “POCs” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 4. Review of P4’s “Hospice POC Report,” found in P4’s EMR, indicated the RN started P4’s “POC” on 07/19/2024 that included altered comfort, altered home safety, altered genitourinary status, altered gastrointestinal status, altered endocrine system, altered nutrition/hydration, potential for bleeding/hemorrhage, and altered skin integrity. The “POC” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 5. Review of P5’s “Hospice POC Report,” found in P5’s EMR, indicated the RN started P5’s “POC” on 08/13/2024 that included altered nutrition/hydration, altered neurological status, and altered skin integrity. The MSW started P5’s “POC” on 08/15/2024 that included declining status/imminent death. The “POCs” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 6. Review of P8’s “Hospice POC Report,” found in P8’s EMR, indicated the RN started P8’s “POC” on 04/05/2023 that included altered comfort, altered gastrointestinal status, and altered nutrition/hydration. The MSW started P8’s “POC” on 04/06/2023 that included declining status/imminent death. The “POCs” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 7. Review of P6’s “Hospice POC (Plan of Care) Report,” facility provided, indicated the RN started P6s “POC” on 06/19/1994 that included altered home safety, altered genitourinary status, altered endocrine system, altered nutrition/hydration, altered neurological status, altered skin integrity, altered cardiopulmonary status, and altered gastrointestinal status. The “POCs” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 8. Review of P7’s “Hospice POC Report,” facility provided, indicated the RN started P7s “POC” on 07/21/2023 that included altered home safety, altered genitourinary status, altered nutrition/hydration, altered neurological status, altered skin integrity, and altered gastrointestinal status. The “POCs” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 9. Review of 9’s “Hospice POC Report,” facility provided, indicated the RN started P9s “POC” on 02/29/2024 that included altered home safety, altered cardiopulmonary status, altered nutrition/hydration, altered neurological status, altered skin integrity, and altered gastrointestinal status. The “POCs” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 10. Review of 10’s “Hospice POC Report,” facility provided, indicated the RN started P9s “POC” on 07/22/2024 that included altered comfort, altered cardiopulmonary status, altered gastrointestinal status, altered nutrition/hydration, altered neurological status, and altered skin integrity. The “POCs” did not include measurable data elements to monitor progress toward the expected outcomes and goals. During an interview on 09/05/2024 at 2:00 PM, the Director of Clinical Services (DCS) confirmed that the agency staff including the RNs and Social Workers were not creating “POCs” that were measurable and included data elements to monitor progress toward the expected outcomes and goals. Review of the agency’s policy dated 06/12/2023 titled “Home Care and Hospice – Individualized Plan of Care” indicated “The plan of care must include specific interventions and measurable treatment goals which pertains directly to the patient’s illness of injury.””

“Based on record review, interview, and policy review, the Hospice Agency failed to reassess one of 14 (Patient (P) 8) sampled patients on symptoms including chest pain, abnormal lung sounds, increased fatigue and after breathing treatments and antibiotic therapy was ordered by the physician. This deficient practice had the potential for the patient to have unmet healthcare needs. Review of P8’s “Client Coordination Note Report” dated 08/12/2024, found in P8’s Electronic Medical Record (EMR) under the “Client Coordination” tab indicated that during the Registered Nurse’s (RNs) homecare visit P8’s lungs were diminished in all lobes and was on two liters of supplemental oxygen. The patient had crackles (may indicate fluid inside the lungs) in upper left lobe, was coughing up brown, yellow sputum, reported sharp pain with deep breaths, had a tachycardic (fast beating) heart rate, and complained of fatigue with any exertion requiring longer rest periods. The RN received orders from the physician for the patient to start ipratropium-albuterol nebulization solution (a breathing treatment), amoxicillin (an antibiotic), and azithromycin (an antibiotic). There was no documentation indicating that a follow-up visit was made by the RN until 08/19/2024. During an interview on 09/05/2024 at 2:00 PM, the Director of Clinical Services (DCS) confirmed that the RN should not have waited a week before following-up on P8’s respiratory symptoms and the effectiveness of the new medications started. Review of the agency’s policy dated 12/07/2021 titled “Pain Assessment, Reassessment and Management” indicated “ ... 1. Hospice employees are responsible for the assessment and reassessment of the patient for pain and relief from pain including the intensity and quality; that is character, frequency, location, and duration of pain. 2. Hospice employees are also responsible for assessing and reassessing the responses to treatment with each patient contact. ...””

“Based on record review, interview, and policy review, the Hospice Agency failed to correctly transcribe verbal medication orders received from the physician for two out of 14 (Patient (P) 4 and P5) sampled patients. This deficient practice had the potential to affect the accuracy of medications ordered for both patients. 1. Review of P4’s “Order Description” dated 07/25/2024, found in P4’s EMR under the “orders” tab revealed the RN documented “Verbal order obtained from [doctor’s name] to update medication profile.” The verbal order did not contain the medications’ names, doses, frequencies, and routes of the medications to be updated in the medication profile. Review of P4’s “Order Description” dated 08/19/2024, found in P4’s Electronic Medical Record (EMR) under the “orders” tab revealed the Registered Nurse (RN) documented “Verbal order obtained from [doctor’s name] to discontinue medication.” The verbal order did not contain the name, dose, frequency, and route of the medication to discontinue. 2. Review of P5’s “Order Description” dated 08/29/2024, found in P5’s EMR under the “orders” tab, revealed the RN documented “VO (verbal order) [doctor’s name] add medication for loose diarrhea.” The verbal order did not contain the medication name, dose, frequency, and route of the medication. During an interview on 09/04/2024 at 4:00 PM, the Director of Clinical Services (DCS) confirmed that the verbal orders were missing pertinent medication information and were not documented properly by the RNs. Review of the agency policy dated 02/17/2022 titled “Verbal and Written Orders” indicated “ ... All orders for medications will include: The date and time of the order, the name of the drug, the dosage, the route, frequency of administration, and the name of the prescriber. ...””