Hospice of Lake Cumberland

“Based on interview, record review, documentation review, and review of facility policy, the facility failed to ensure patient Plans of Care (POC) included measurable goals to assess if progress toward expected outcomes were being met for 16 of 16 sampled patients (Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15, and P16). This failure had the potential for staff to be unable to assess if progress toward expected outcomes were being met related to patients health status. The findings include: Review of the patient “Care Plans” for 16 of 16 patients revealed there was no documentation to indicate goals included on their “Care Plans” were measurable. (Refer to L548)”

“Based on interview, and record review, the facility failed to perform an initial bereavement risk assessment for three (3) of 16 sampled patients, (Patient (P)1, P2, and P4). Failure to perform an initial bereavement risk assessment had the potential for a patient or caregiver requiring assistance in the grieving process, not to be identified. The findings include: 1. Review of P1’s “General Patient Details” provided by the facility, revealed P1 was admitted to hospice services on 02/23/2024. Review of P1’s Social Worker’s initial “Assessment”, dated 02/25/2024, provided by the facility, revealed no documented evidence of an initial bereavement assessment. During an interview on 08/19/2024 at 1:10 PM, Registered Nurse (RN)3 confirmed there was no documentation of an initial bereavement assessment. 2. Review of P2’s “General Patient Details” provided by the facility, revealed P2 was admitted to hospice services on 06/28/2024. Review of P2’s Social Worker’s initial “Assessment”, dated 06/29/2024, provided by the facility, revealed no documented evidence of an initial bereavement assessment. During an interview on 08/19/2024 at 3:00 PM, RN3 confirmed there was no documentation of an initial bereavement assessment. 3. Review of P4’s “General Patient Details” provided by the facility, revealed P4 was admitted to hospice services on 08/08/2024. Review of P4’s Social Worker’s initial “Assessment”, dated 08/08/2024, provided by the facility, revealed no documented evidence of an initial bereavement assessment. During an interview on 08/20/2024 at 3:12 PM, RN3 confirmed there was no documentation of an initial bereavement assessment. During an interview on 08/22/2024 at 9:30 AM, Social Worker (SW)1 confirmed an initial bereavement assessment should be completed on the Social Worker’s initial assessment with each patient admitted to Hospice services. During an interview on 08/22/2024 at 2:15 PM, the Director of Clinical Services/Registered Nurse (RN)1 stated, “I expect the Social Worker to assess for the bereavement risk assessment each time an initial assessment is done.””

“Based on interview, record review, and review of facility policy, the facility failed to ensure patient plans of care (POCs) included measurable goals to assess if progress toward expected outcomes were being met for 16 of 16 sampled patients, (Patient (P) 1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15, and P16) reviewed for care plan development. This deficient practice had the potential to affect all patients receiving services from the facility. The findings include: Review of the facility policy titled, “Plan of Care”, dated 01/2009, revealed the “Plan of Care includes, but is not limited to ... measurable outcomes anticipated from implementing and coordination of the plan of care...and revisions to the plan of care are based on information from the patient’s updated comprehensive assessment and the patient’s progress toward outcomes specified in the plan...” Review of the facility policy titled, “Plan of Care: Content,” undated, revealed “The plan of care includes, but is not limited to: ...measurable outcomes anticipated from implementing and coordinating the plan of care...” 1. Review of P1’s hospice “POC” provided by the facility, revealed the Registered Nurse (RN), Social Worker (SW) and Chaplin, started P1’s “POC” on 03/24/2024 with problems which included: desire to remain in the home, affirmation of present spiritual comfort and acceptance of death, and risk of injury related to falls. However, the “POC” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 2. Review of P2’s hospice “POC” provided by the facility, revealed the RN and SW started P2’s “POC” on 06/29/2024 with problems including: risk for injury related to falls, and deficit related to the normal grief process. However, the “POC” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 3. Review of P3’s hospice “POC” provided by the facility, revealed the RN, SW, and Chaplain, started a “POC” on 07/19/2024 with problems which included: desire to remain in home, affirmation of present spiritual comfort and acceptance of death, deficit for potential falls, and physical comfort alteration. However, the “POC” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 4. Review of P4’s hospice “POC” provided by the facility, revealed the RN, SW, and Chaplain started a “POC” on 08/08/2024 with problems including: deficit related to increased needs as death nears, risk for injury related to falls, affirmation of present spiritual comfort and acceptance of death. However, the “POC” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 5. Review of P5’s hospice “POC” provided by the facility, revealed the RN, SW, and Chaplain started a “POC” on 07/13/2024 with problems including: patient is exhibiting signs of anxiety and restlessness, deficit related to normal grief process, affirmation of present spiritual comfort and acceptance of death, and risk for injury related to falls. However, the “POC” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 6. Review of P6’s hospice “POC” provided by the facility, revealed the RN started a “POC” on 04/10/2024 with problems including: patient has a high potential for aspiration, deficit related to skin/membrane integrity, and physical activity/mobility impaired with potential for injury. However, the “POC” did not include measurable data elements to monitor progress toward the expected outcomes and goals. 7. Review of P7’s hospice “POC” provided by the facility revealed the RN started a “POC” on 07/25/2024 with problems including: deficit related to risk for injury related to falls. However, the “POC” did not include measurable data elements to monitor progress toward the expected outcomes and goals. An interview with RN3, on 08/19/2024 at 1:10 PM, confirmed the “POCs” did not include measurable goals for P1, P2, P3, P4, P5, P6, and P7. 8. Review of P8’s “Care Plan Problem Details,” located in P8’s Electronic Medical Record (EMR) under the “Care Plan” tab, revealed “Care Plan Problems” included the following problems and associated goals: 08/04/2024: Deficit related to risk for injury related to falls with a goal stating Promote optimal safety and prevention of injury. 08/05/2024: Deficit related to normal grief process with a goal stating facilitate normal grief process. 08/06/2024: Physical comfort alteration due to back pain with a goal stating patient will achieve and maintain optimal physical comfort; and Deficit related to affirmation of present spiritual comfort to the unresponsive patient with a goal stating provide spiritual support. However, the “POC” did not include measurable goals to monitor P8’s progress. During interview with RN2 on 08/19/2024, 08/20/2024, and 08/21/2024, throughout the day while assisting the Surveyor with the computer software, RN2 confirmed the goals for P1 through P8 were not measurable. 9. Review of P9’s “Care Plan Problem Details,” located the EMR under the “Care Plan” tab, revealed P9’s “Care Plan Problems” included the following problems and associated goals: 06/19/2024: Deficit related to risk for injury related to falls with a goal to Promote optimal patient safety and prevention of injury. However, the “POC” did not include measurable goals to monitor P9’s progress. 10. Review of P10’s “POC” located in the EMR under the “Care Plan” tab, revealed P10’s “Care Plan Problems” included the following problems and associated goals: 10/17/2023: Deficit related to sleep patterns with a goal stating Patient and PCG (primary care giver) will achieve optimal sleep/rest pattern. 05/28/2024: Physical comfort alteration due to edema with a goal stating Patient will achieve and maintain optimal physical comfort.” However, the “POC” did not include measurable goals to monitor P10’s progress. 11. Review of P11’s “Care Plan Problem Details,” located in the EMR under the “Care Plan” tab, revealed P11’s “Care Plan Problems” included the following problems and associated goals: 04/28/2024: Deficit related to risk for injury related to falls, with a goal to Promote optimal patient safety and prevention of injury. 05/06/2024: Deficit related to bowel elimination with a goal stating Patient will achieve and maintain regular bowel elimination and skin integrity. However, the “POC” did not include measurable goals to monitor P11’s progress. 12. Review of P12’s “Care Plan Problem Details,” located in the EMR under the “Care Plan” tab, revealed P12’s “Care Plan Problems” included the following problems and associated goals: 05/10/2024: Deficit related to affirmation of present spiritual comfort, acceptance of death, and utilization of spiritual resources with a goal to provide spiritual support to patient and family. 05/15/2024: Patient is exhibiting signs of anxiety and restlessness with a goal stating Patient will have managed symptoms of anxiety and restlessness; and Physical comfort alteration due to (specify) (there was no cause documented for the alteration in comfort) with a goal stating Patient will achieve and maintain optimal physical comfort. However, the “POC” did not include measurable goals to monitor P12’s progress. 13. Review of P13’s “Care Plan Problem Details,” located in the EMR under the “Care Plan” tab, revealed P13’s “Care Plan Problems” included the following problems and associated goals: 08/08/2024: Deficit related to risk for injury related to falls with a goal to Promote optimal patient safety and prevention of injury; and Deficit related to affirmation of present spiritual comfort, acceptance of death, and utilization of spiritual resources with a goal to provide spiritual support to patient pt and family. 08/09/2024: Deficit related to normal grief process with a goal to facilitate normal grief process. 08/19/2024: Deficit related to nutrition/hydration with a goal stating Patient will maintain optimal nutrition and hydration; and Physical comfort alteration due to Peripheral Vascular Disease (PVD), unstageable to right heel with a goal stating Patient will achieve and maintain optimal physical comfort. However, the “POC” did not include measurable goals to monitor P13’s progress. 14. Review of P14’s “Care Plan Problem Details,” found in the EMR under the “Care Plan” tab, revealed P14’s “Care Plan Problems” included the following problems and associated goals: 08/12/2024: Deficit related to airway and breathing patterns with a goal stating Patient will achieve optimal breathing patterns, airway patency, and comfort. However, the “POC” did not include measurable goals to monitor 14’s progress. 15. Review of P15’s “Care Plan Problem Details,” located in the EMR under the “Care Plan” tab, revealed P15’s “Care Plan Problems” included the following problems and associated goals: 08/19/2024: “Initial Plan of Care prior to Service provision” with a goal to “Facilitate compliance with CMS regulations regarding new admissions to Hospice services.” However, the “POC” did not include measurable goals to monitor P15’s progress. 16. Review of P16’s “Care Plan Problem Details,” located in the EMR under the “Care Plan” tab, revealed P16’s “Care Plan Problems” included the following problems and associated goals: 07/02/2024: Deficit related to desire to remain in home with a goal to assist patient/family in maintaining their desired living arrangement. 07/22/2024: Cardiac/circulatory function and fluid volume alteration with a goal stating Patient will maintain adequate fluid volume as disease will allow while in hospice care. However, the “POC” did not include measurable goals to monitor P16’s progress. During an interview, on 08/22/2024 at 2:15 PM, the Director of Clinical Services/Registered Nurse (RN)1 stated the “POCs” should have goals with timeframes or measurements in order to determine if the goal was met.”

“Based on interview, record review and review of facility policies, the facility failed to have a complete and accurate record regarding the documentation of the disposal of a Fentanyl patch used for pain for one (1) of 16 sampled patients (Patient (P)1). This failure had the potential to expose others to the medication in the Fentanyl patch when disposed of inappropriately. The findings include: Review of the undated facility policy, titled “Medication Management and Disposal” revealed “...Disposal instructions and activities are documented in your medical record...” Review of the undated facility policy, titled “Tracking and Disposal of Controlled Substances”, revealed “...Controlled drugs no longer needed by the patient are disposed of in compliance with State and Federal regulations... Review of P1’s “General Patient Details” provided by the facility, revealed P1 was admitted to hospice services on 02/23/2024 with the diagnosis of malignant neoplasm of the pancreas, liver, and intrahepatic bile duct. Review of P1’s “;Physician Orders” provided by the facility, revealed an order for Fentanyl 12 MCG/HR (micrograms per hour) patch to be applied every 72 hours transdermal. Review of the “RN [Registered Nurse] Comprehensive Assessment”, dated 02/24/2024, revealed no documented evidence of patient education on the proper way to dispose of the Fentanyl patch P1 removed every 72 hours. Additionally, review of the “;Weekly Nurses Notes” revealed no documented evidence of patient education on the proper way to dispose of the Fentanyl patch P1 removed every 72 hours for the months of February 2024 through 08/21/2024. During an interview, on 08/19/2024 at 1:10 PM, RN3 confirmed there was no documentation to reflect P1 received education on the proper disposal of the Fentanyl patch when removed by the patient. During an interview, on 08/22/2024 at 2:15 PM, the Director of Clinical Services/Registered Nurse (RN)1 stated, “The nurses should have documented that the patient had been on this patch previously and educated her on the process of the correct disposal of the patches.” n disposed of inappropriately.”

“Based on interview, and record review, the facility failed to ensure the Medical Director signed the “Hospice Certification of Terminal Illness” in a timely manner for one (1) of 16 patients reviewed for accepted standards of practice, Patient (P)16. The findings include: An interview with the Director of Clinical Services/Registered Nurse (RN)1, on 08/22/2024 at 2:15 PM, revealed the facility did not have a policy related to the signing of the “Certification of Terminal Illness.” Review of P16’s “Hospice Certification of Terminal Illness” located in the electronic medical record (EMR) under the “Hospice Certification of Terminal Illness” tab, revealed the patient was admitted to Hospice care on 07/01/2024 and the family elected Hospice for end-of-life care. However, there was no signature from the Medical Director or the Attending Physician on P16’s form. The form only had the electronic signature of the nurse taking the verbal order. During an interview, on 08/22/2024 at 12:02 PM, via telephone, the Medical Director stated, “I try to get into the office a couple days per week.” The Medical Director further stated he had to be reminded to sign the certifications. An interview with the Director of Clinical Services/Registered Nurse (RN)1, on 08/22/2024 at 2:15 PM, revealed the facility allowed the Medical Director 30 days to sign the “Certification of Terminal Illnesses.” The Director of Clinical Services/RN1 confirmed P16’s “Hospice Certification of Terminal Illness” was completed more than 30 days ago.”

“Based on interview and review of the facility’s Hospice contracts, the facility failed to ensure four (4) of nine (9) contracts/written agreements reviewed between the Hospice and SNF/NF and/or ICF/IID facilities providing various levels of care to hospice patients included provisions to indicate Hospice would report allegations of any type of abuse, neglect, mistreatment or misappropriation by anyone unrelated to the Hospice to the facility Administrator within 24 hours of becoming aware of the alleged violation. Failure to include this provision in the contract/written agreement had the potential to affect the quality of life and safety for all patients receiving hospice services. The findings include: Review of the Hospice’s contracts/written agreements indicated the Hospice maintained contracts/written agreements with nine (9) facilities including SNF/NF (Skilled Nursing Facility/Nursing Facility) and/or ICF/IID (Intermediate Care Facilities for Individuals with Intellectual Disabilities) providing various levels of care to hospice patients. The levels of care included general inpatient, routine (inpatient), and respite care. Four (4) of the nine (9) contracts/written agreements reviewed did not contain a provision indicating the responsibility of the Hospice to report allegations of abuse, neglect, mistreatment, or misappropriation by anyone unrelated to the Hospice to the Administrator of the facility in which the specific patient resided, within 24 hours of learning of the allegation. During an interview with the Chief Executive Officer (CEO), on 08/21/2024 at 4:00 PM, the CEO stated she reviewed the four (4) contracts in question and confirmed those contracts were missing the required verbiage.”

“Based on interview, record review, review of the Hospice contract, and review of facility policy, the facility failed to provide a signed “Hospice Election of Benefits form” to a Skilled Nursing Facility (SNF) for one (1) of one (1) sampled patients residing in a SNF, (Patient (P)8). Failure to provide this information had the potential to affect the care received by any patient receiving Hospice care within a SNF. Findings include: Review of the facility policy titled, “Hospice Care for Nursing Facility Residents”, dated 01/2009, revealed “... Facilitating coordination of care, the following information is provided to the facility... Hospice election form ...” Review of the contract between the Hospice and the SNF revealed Hospice would provide the SNF with a signed “Election of Benefits” form. Review of P8’s electronic medical record (EMR) at the SNF revealed there was no signed “Hospice Election of Benefits form” maintained by the SNF. During an interview with the Director of Nursing (DON) of the SNF on 08/20/2024 at 12:30 PM, it was confirmed the “Election of Benefits” form was not present in their EMR.”