Appalachian Hospice Care

“Observed in HR File Review. In 2 out of 2 personnel records reviewed, the organization failed to provide services in accordance with licensure requirements. During the personnel record review for HR#1-MSW and HR#2-MSW, it was noted that the personnel did not possess a valid permit or license as required by the state [201 KAR 23:160]. In addition, the individuals did not have a medical social work supervisor of record to oversee the care, treatment, and services they are providing. Both employees have continued to provide services without the required temporary permit or license. This was reviewed, discussed, and validated with the Administrator.”

“Observed in Record Review. In 3 out of 4 active records reviewed, the organization failed to plan the patient’s care. For example, during the record review for RRNHV#1, RRNHV#2, and RRNHV#3, the patient’s plan of care did not include goals with identified timeframes for achieving the stated goal. Examples include; Patient will be able to breathe comfortably as evidenced by respirations within 12-20, no s/s of distress, and O2 saturation to remain greater than 90%, Patient will have decreased edema, Patient/family will be prepared in the event of an emergency or natural disaster, and, Patient will demonstrate safe medication management by verbalizing understanding of medication dosage, schedule, side effects, and precautions. This was reviewed, discussed, and validated with the RN Assistant Clinical Manager and General Manager.”

“Observed in Document Review. The organization did not have defined criteria to screen, assess and reassess pain. For example, the organization had a general policy Admission Criteria which included general statements about a nursing assessment, however no defined criteria that identified when a specialized assessment might be required such as wound assessments or the required elements of a comprehensive pain assessment. The organization also provides care to pediatric patients when needed and there was no direction about what pain assessment tool was to be used in pediatric patients. This was discussed with the Clinical Manager”

“Observed in Record Review. In 4 of 16 patient records reviewed, the plan of care (POC) was not based on the patient’s goals. In the chart for HH#3, the POC was not updated with a goal related to safe use of oxygen when that treatment was implemented. In the chart for RRNHV#7, the POC safety goal time frame was not applicable to level of risk for this patient on oxygen who was also a smoker, Patient/family will have full understanding of how to safely use all equipment in the home correctly throughout the duration of care In the chart for RRNHV#8, there was no goal added to the POC re: understanding of safety with oxygen. In the chart for RRDC#2, there was no anticipated timeframe to meet the goal related to safe use of equipment (oxygen) on the POC for the patient who was an active smoker. This was discussed with the Clinical Manager and Nursing Supervisor.”

“Observed in Record Review. In 10 of 16 patient records reviewed, the plan of care (POC) did not include all drugs and treatments required for treatments necessary to meet the patient’s needs. In the chart for HV#2, the POC had not been individualized to the trach patient as it included orders for oxygen prn via nasal canula or face mask, yet the patient required continuous oxygen to his tracheostomy which was also on the POC. In the chart for HV#4, the patient has multiple medications, Docusate prn, Bisacodyl prn, Magnesium Citrate prn, Senokot prn all for no bowel movement without further clarity on what to administer when. The caregivers in collaboration with the hospice have implemented safety interventions such as increased caregiver hours, remote interactive cameras so the primary caregiver can monitor when she is on physically off-site; an APP and Aquaphor protectant cream as skin care interventions for pressure ulcer risk. None of these interventions had been added to the POC. In the chart for HV#3, oxygen was added to the patients care approximately one week after admission. The POC was not updated with any interventions related to teaching oxygen use and safety. In the chart for RRNHV#5, there was a note within the month prior to this survey indicating that a safety plan had been developed between the RN, MSW, APS worker and primary caregiver. The POC had not been updated with any interventions related to what the agreed upon actions were. In the chart for RRNHV#6, the patient had a Foley catheter. The RN staff had been instructing the caregiver about flushing the catheter. There was no order for this treatment on the POC. In the chart for RRNHV#8, the patient developed a skin tear approximately one week post admission. The POC was not updated with any orders for care which the RN documented she instructed the caregiver to perform. In the chart for RRNHV#13, the Humalog to scale order was missing the frequency of administration. Additionally, the POC did not include any interventions related to blood sugar monitoring. In the chart for RRNHV#14, the patient had orders for Humalog 100 units/mL sliding scale subcutaneous 2 times per day however was missing the scale and dosing. The patient is on tube feedings but the POC did not include the type, amount or frequency of feedings nor any free water. The patient has sliding scale insulin, but no orders for how often the blood sugars were to be checked. In the chart for RRDC#2, the POC did not include an intervention to teach the caregiver the wound care though it was ordered daily and the RN was not visiting daily. The POC order for the Mediport site did not include the detail of the sterile dressing change; the Heparin flush order was missing the concentration of what units/ML to administer. This was discussed with the Nursing Supervisor and Clinical Manager.”

“Observed in Record Review. In 5 of 19 patient records reviewed, the patient record did not include specific notes on care, treatment or services. In the chart for RRNHV#6, the primary caregiver had been noted by the RN to have made intimidating and disparaging remarks about a staff member approximately 5 months prior to the survey. The MSW then made a visit to the home to speak with the PCG about the requirement to be respectful of staff and the responsibility to provide a safe environment for care, with a conclusion by the MSW that the behavior would not be waning based on the reaction of the PCG. At the subsequent IDG’s, there was no documentation about the incident, nor discussion re: concerns about how to provide aide services, if the organization was going to discontinue service, how the patient’s needs would be met, etc. The patient was discharged from aide services approximately 2 months later, again with nothing documented in the IDG regarding the dismissal from aide services except for the discharge aide services order. In the chart for RRNHV#7, In IDT discussion during the survey, it was noted that the patient has history of substance abuse which is causing her reluctance to use her prescribed meds. There is no documentation of this in the record. In the chart for RRNHV#13, the initial assessment was not accurate as it included measurements and care for pressure ulcers, yet the HOPE question M1190 Does the patient have one or more skin conditions was answered no. In the chart for RRDC#1, the patient revoked the hospice benefit to pursue long-term care placement after a fall. There is no documentation in the record about how the organization found out the patient had a fall and was hospitalized. In the chart for RRDC#2, there was no indication in the record to indicate how the organization found out the patient had been admitted to the hospital prior to the discharge. This was discussed with the Clinical Manager.”

“Observed in Record Review. In 2 of 2 patient records reviewed, the hospice had not provided the receiving facility with a copy of the hospice discharge summary. In the chart for RRDC#1, the patient revoked the hospice benefit to pursue long term care placement after hospitalization for a fall at home. There was no documentation in the chart to support that a discharge summary had been provided to the hospital. In the chart for RRDC#2, the patient was discharged as pursing active treatment and the discharge order read due to inpatient admission to an ICU. There was no documentation that the discharge summary was provided to the receiving facility. This was discussed with the Clinical Manager.”

“Observed in Record Review. In 1 of 19 patient records reviewed, the organization had not provided patient education based on the patient’s condition and assessed needs. In the chart for RRDC#2, the patient was started on oxygen at the initial nursing visit and was assessed to be an active smoker and vaper. There was no documentation in the record that the patient was educated about safe use of oxygen until the 8th day of service. This was discussed with the Clinical Manager. Observed in Patient Home. In 1 of 4 home visits conducted, the organization had not provided patient education based on patient’s needs and abilities. During HV#1 there were 4 oxygen tanks in the home which were standing upright, not contained or restrained in any manner. No education was provided to the patient during the visit. This was discussed with the Clinical Manager.”