Accentcare Hospice & Palliative Care of Maryland

“Observed in Record Review. In 3 out of 24 records, reassessments related to the palliation and management of the terminal illness and related conditions were not documented. Examples: In RRNHV#9, RRNHV#10, and RRHV#19, reassessments related to the tube feeding formula, rate, and tolerance was not assessed and documented during routine nursing visits. This was confirmed by the Director of Operations. Observed in Individual Tracer. In 3 of 20 patient records reviewed, The surveyor noted (RRHV#4) that there was no evidence that the severity of the patient’s diabetes was assessed. The surveyor noted that the patient’s son indicated that he was monitoring her blood sugar and reported that her level was 300 on Sunday. He also noted that she had fainted that day. The patient was also prescribed two oral hypoglycemics. Also, ( in RRCR#24) there was no evidence that the severity of the patients ascites was assessed. The patient revoked the benefit to seek treatment for the ascites. Also, in (RRIPU#27), there was no assessment of the function or patency of the supra-pubic catheter documented on admission or since. This was confirmed with the leadership team.”

“Observed in Individual Tracer. In 4 of 24 patient records reviewed, The surveyor noted (RRHV#4) that the patient was admitted with a diagnosis of Diabetes managed with two oral hypoglycemics with Blood glucose levels recorded by the son above 200 since admission. The patient did not speak English and her primary language was Cantonese; however, this was not indicated on the care plan. Also, in (RRHV#5), the patient was admitted with COPD, dyspnea at rest on continuous oxygen an there was no respiratory care plan. In (RRIPU#26), there was no care plan for managing the midline central catheter. Also, in (RRIPU#27), there was no care plan for managing the patients supra-pubic catheter or urinary output and insertion site.”

“Observed in Record Review. In 24 out of 28 records, goals did not include outcome measures or timeframes for achievement. Examples: In RRHV#2, RRHV#3, RRNHV#7, RRNHV#8, RRNHV#9, RRNHV#11, RRNHV#13, RRNHV#16, RRNHV#17, RRNHV18, and RRNHV#20, there was a goal for pain to be managed at an acceptable level without identification of the target level. In RRHV#1, RRNHV#7, RRNHV#8, 10, RRNHV#12, RRNHV#14, RRNHV#15, RRNHV#17, and RRNHV#18, there was a goal stating that nutrition will be managed within the context of the expected decline and expressed desires. In RRHV#3, there was a goal stating patient/daughter will verbalize understanding of need for transmission based precautions within the scope of her disease process. In RRNHV#20, there was generic coordination of care goal that lacked definition of who (facility or agency) would be responsible for carrying out interventions within the plan of care. This was confirmed with the Director of Operations. Observed in Tracer Visit. In 8 out of 24 records, the written plan of care was not individualized to reflect the patient and family goals and interventions based on the problems identified in comprehensive assessments. For example: In RRNHV#9, patient had a diagnosis of Diabetes with routine insulin listed on the medication profile. However, there were no goals or interventions related to this diagnosis on the plan of care. In RRNHV#13, patient had a surgical wound with identified interventions on the plan of care. However, there were no were associated goals. Observed in Individual Tracer. In 7 of 24 patient records reviewed, The surveyor noted (RRHV#4) , that the goals did not include outcome measures or time frames for achievement. For example, the goal for pain was patient at an acceptable level. Also, in (RRHV#5) there were no outcome measures for managing pain. In (RRHV#6), the social work assessment indicated psychological needs to be monitored; however there was no outcome measure for managing the psychological needs. In (RRIPU#29) the goals: acceptable level for N/V, agitation and dyspnea were not measurable and did not include any time frames. In (RRDR#24) the goal for edema acceptable level of edema/ascites was not measurable and timed. This was confirmed with the director.”

“Observed in Record Review. The surveyor noted that (RRIPU#26) and (RRIPU#27) the medication orders were incomplete. The medication order template use by the physician did not specify the route for PO medications and indicated either oral/Macey catheter. Also, the orders for Morphine injection 2 mg/ml did not specify which route either IV or SQ. Also the oxygen orders did not include a frequency. The order only stated 5LNC. This was confirmed with the manager. Observed in Record Review. The surveyor noted (RRNHVIPU#26), that the plan of treatment did not include orders for care of the midline catheter in place on admission and utilized to administer medications daily. In (RRIPU#27), there were no interventions ordered to manage the patient’s Supra-pubic catheter. This was confirmed with the director.”

“Observed in Individual Tracer. In 1 of 6 home visits conducted, The surveyor noted (RRHV#6) that hand hygiene policies were not followed. The nurse used a large amount of hand sanitizer and instead of rubbing until dry, shook his hands to remove it. Also, he failed to sanitize his hands after two glove changes. This was confirmed with the team director. Observed in Tracer Visit. In 1 out of 3 home visits, the hospice did not follow accepted standards of practice to prevent the transmission of infections per their bag technique policy. Example in RRHV#3, the clinician was observed using sanitizer and shaking their hands to remove excess sanitizer prior to gloving. Also during RRHV#3, the total contact time as defined by the manufacturer of the product of 2 minutes for the disinfectant wipe was not followed as evidence by the clinician being observed wiping down and immediately placing equipment used during the visit back into their clinical bag. This was confirmed by the Director of Clinical Operations. Observed in Medication Management Tracer. In 1 of 2 medication tracers IPU, The surveyor noted (IPU Medication Tracer) that the nurse failed to sanitize the multi-use pill cutter after splitting a tablet of Dexamethasone. This was confirmed with the director. Observed in Building Tour. In 1 of 2 IPU tours, The surveyor noted (IPU#1) that several medical supplies had expired including three packages of glucometer strips, an aqua-cell dressing, hydrogel dressing, and five straight catheters all had expiration dates greater than 30 days ago. One of the catheters expired in 2023. This was confirmed with the IPU nurse.”

“Observed in Leadership Session. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by a condition level finding at 418.104 (Clinical Records) as significant issues were observed in the following areas: 1. The scribing of medication orders in the inpatient unit 2. The use of white out within the inpatient unit medical records. 3. Inaccurate medication profiles within the medical record 4. The absence of a discharge summary being sent to the primary care provider after revocation. These findings were confirmed with the Clinical Directors.”

“Observed in Tracer Visit. In 2 of 6 home visits, the medication profile within the medical record was inaccurate. Example: In RRHV#1, patient reported taking Tylenol every day. However, the medication profile within the medical record only indicated Acetaminophen prn via suppository. In RRHV#3, the medication profile was inaccurate. In the home, the daughter reported the patient also taking Tylenol prn, Dayquil prn, and routinely taking Vitamin D and B12. These medications were not new for the patient and had not been included in the medical record profile. These inaccuracies were confirmed by the Nurses being observed during the home visits .”