Good Samaritan Society Hospice

“Based on observation, interview and document review, the agency failed to ensure all prescribed medications were part of the plan of care (POC) for 1 of 3 patients (P2) whose medications were reviewed during a home visit. P2’s plan of care (POC) dated 1/3/25 to 3/3/25, identified start of care on 1/9/24. Diagnoses included chronic congestive heart failure (CHF), diabetes, and hypertension. Skilled nurse visits were ordered one time weekly and five as needed for symptom management, various assessments and teaching, including assessment and instruction on medication regimen and potential side effects. The POC included a clinical update progress note dated 12/17/24,which identified P2 experienced two CHF exacerbations over the past eight weeks with increased edema (swelling) to his legs and hand. P2’s Lasix (for fluid retention) was increased. Prescribed and patient reported medications were listed including hydrochlorothiazide (for fluid retention) 25 milligrams (mg) every day, omeprazole 40 mg every day, and trazodone 50 mg two tablets at bedtime. During a home visit on 1/7/25, at 12:00 p.m. family member (FM)-A reviewed the medications P2 was currently taking. FM-A identified P2 was no longer taking hydrochlorothiazide, omeprazole or trazadone and had not been taking the medications for several months. When interviewed on 1/7/25, at 12:20 p.m. registered nurse (RN)-A stated she had not removed the medications from P2’s active medication list so that they could use them if symptoms popped up. RN-A stated if a patient was no longer taking a medication, the medication should be removed from the active medication list or changed to as needed. When P2’s recertification was done, RN-A should have updated the medication list on the POC to reflect what the patient was actually taking. It was important to have the medication list accurate in case another nurse made a home visit, she would wonder where the hydrochlorothiazide or trazodone was. During joint interview with administrator and director of nursing (DON) on 1/8/25, at 2:30 p.m. the DON stated nurses were to review medications every visit and her expectation was for the medication list to accurately identify the medications a patient was taking. The agency policy Medication Management Hospice dated 12/28/23, identified a comprehensive assessment of medication would include a review of all prescribed medications, herbal remedies, and over the counter medications the patient was currently using. Staff would ensure the patient’s medication list would be current at each medication reconciliation. Once staff became aware of a new or change in medication, documentation in the medical record would include medication changes, observation and teaching.”

“Based on interview and document review, the agency failed to ensure scheduled visits were provided in accordance with the plan of care (POC) for 4 of 10 patients (P1, P5, P6, P7) reviewed for services planned. P1’s plan of care (POC) for the certification date of 10/4/24, identified a start of care date 10/4/24. Diagnoses included cerebral infarction, vascular dementia, hemiplegia and depression. P2’s planned visits as of 10/4/24, included volunteer visits one to two times per month for three months. P1’s medical record reviewed 11/1/24 through 1/8/25, identified no volunteer visits were conducted throughout November or December. P1’s medical record lacked volunteer visit documentation, the reason for lack of volunteer visits or notification to the provider of the missed visits. P5’s POC for certification date of 11/17/24 identified a SOC date of 9/18/24. Diagnoses included senile degeneration of the brain, dysphagia, pneumonia, and malnutrition. P5’s planned visits as of 11/17/24, included volunteer visits one to two times per month for two months. P5’s medical record reviewed 11/1/24 through 1/8/25, identified no volunteer visits were completed throughout November or December. P5’s medical record lacked volunteer visit documentation, the reason for the lack of volunteer visits or notification to the provider of the missed visits. P6’s POC for the certification date of 11/11/24 identified a SOC date of 11/11/24. Diagnoses included lymphoma, kidney disease, diabetes, and malignant neoplasm of the breast. P6’s planned visits as of 11/11/24, included chaplain visits two to four times per month plus ten visits as needed for three months. The Interdisciplinary Group note dated 12/5/24, identified visit frequency to continue for chaplain visits two to four times per month with no missed visits. P6’s medical record reviewed 11/11/24 through 1/8/25, identified only one chaplain visit completed on 11/11/24, in which the patient declined any further visits. P6’s medical record lacked notification to the provider of the refused services and discontinuation of the current orders for chaplain visits two to four times per month. P7’s POC for certification date 10/18/24 identified a SOC 6/26/23. Diagnoses included malignant neoplasm of bilateral ovaries, heart disease, and Alzheimer’s disease. P7’s planned visits included volunteer visits one to two times per month for nine weeks P7’s medical record reviewed from 11/1/24 through 1/8/25, identified no volunteer visits were completed in December. P7’s medical record lacked volunteer visit documentation, the reason for the lack of volunteer visits or notification to the provider of the missed visits. A joint interview with the administrator and director of nursing (DON) was conducted on 1/9/25, at 1:30 p.m. The DON stated when a patient’s services changed the staff were expected to obtain a verbal order to reflect the changes. The nurse should have written orders to either discontinue or change to as needed when the patient was no longer receiving visits as ordered from the chaplain or volunteers and update the POC. The POC should be reviewed and changes addressed at the patient’s IDG meetings conducted every two weeks. When the POC was updated with changed services, the system automatically generated a verbal order for the provider. A policy on missed visits was requested, however none were received.”

“Based on interview and document review, the agency failed to ensure there was an agency-wide infection control program that tracked and trended patient infections to prevent potential outbreaks and use bring the information collected to the quality assessment and performance improvement (QAPI) program. This had the potential to affect all current hospice patients. The agency’s Adverse Events report for 10/8/24, through 1/8/25, identified the patient, location, date, and event type. One patient was identified with an eye infection, two patients had respiratory infections, four patients had skin or wound infections, seven patients had a urinary infection, and seven patients with other infections. The report failed to identify if the infection was community acquired, catheter associated, if an organism was identified, if the infection was treated and/or type of treatment or if the infection had resolved. The agency QAPI minutes June 2024 to January 2025, identified the following: QAPI Meeting 6/18/24, agenda item infection control discussion identified all staff completed yearly hand washing test out and N-95 testing. No current restrictions were noted at facilities. Actions/Outcomes were listed to continue per policy and annual hand washing at all staff on 7/2024, and a follow-up of 9/19/24. Meeting notes lacked information if any hospice patients or employee infections had occurred during this time frame as part of the QAPI process. QAPI Meeting 12/11/24, agenda item infection control identified discussion were completed and flu season protocols and procedures were reviewed as well as annual N95 and handwashing clinic. Actions/Outcomes were listed yearly review and competence with a follow update on 12/30/24. Meeting notes lacked information if any hospice patients or employee infections had occurred during this time frame as part of the QAPI process. During interview on 1/9/25, at 1:30 p.m. the director of nursing (DON) stated she recorded all employee illnesses in the logbook but did not formally track or trend their illnesses. When a patient was ill or required an antibiotic, the nurses recorded it under the adverse events tab in the patient’s medical record. The DON printed the Adverse Events Detail Report quarterly to discuss at QAPI and individual patient illness was discussed every two weeks at their Interdisciplinary Group meetings (IDG). Infection control was a part of QAPI but had not been doing any formal surveillance with patients other than the quarterly report. The agency was now working on the plan for the 2025 QAPI agenda. The agency policy Quality Assurance and Performance Improvement QAPI dated 10/9/23, identified the QAPI program was ongoing, comprehensive and data-driven and addressed the complexity and uniqueness of the care and services provided. The QAPI program would identify and prioritize problems and opportunities that reflect the organizational processes, functions, and services provided on performance indicator data, safety of the served, input from stakeholders and other information. The QAPI program used data to monitor the effectiveness and safety of the services and quality of care, identify and prioritize problems and process improvement opportunities and would take action to address areas that needed improvement. The agency policy Identification and Reporting of Suspected Infections dated 1/16/24, identified staff were to document the time of symptoms onset, any cultures obtained, any treatment initiated, any outcome, precautions initiated and the suspected infection in the electronic medical record, along with provider notification. Staff were to collect infection surveillance data including, symptoms, date of onset, location, etc. If infection was suspected, infections would be logged for trending and infections and outbreaks would be reported at QAPI committee for review and action planning, when needed.”

“Based on interview and document review, the agency failed to ensure a registered nurse (RN) provided a supervisory visit of home health aide services at least every 14 days for 4 of 9 patients (P1, P2, P7, P9) reviewed with hospice aide services. P1’s plan of care (POC) for certification date 10/4/24, identified a start of care (SOC) of 10/4/24. Diagnoses included cerebral infarction, vascular dementia, hemiplegia, and depression. P1’s orders identified P1 received skilled nurse visits (SNV) one time per week for 13 weeks and home health aide visits (HHA) one time per week for 13 weeks. P1’s plan of care (POC) for certification date 1/2/25, P1’s orders identified P1 received skilled nurse visits one time per week for 13 weeks and home health aide visits one time per week for 13 weeks. P1’s medical record identified P1 received hospice aide services weekly throughout November and December with no missed visits recorded. The registered nurse (RN) completed home health aide supervision visit with the scheduled visit on 12/17/24, however, there was no evidence supervisory visits were conducted from 12/18/24 to 1/8/25. P2’s POC for certification date 9/4/24, identified a SOC 1/9/24. Diagnoses included chronic congestive heart failure (CHF), diabetes, and hypertension. SNV were ordered one time weekly for nine weeks and HHA visits three times per week for eight weeks. P2’s POC for certification date 1/3/25 , included orders for SNV one time weekly for nine weeks and HHA visits three times per week for eight weeks. P2’s medical record identified P2 received HHA visits three times weekly throughout November and December with no missed visits recorded. The RN completed HHA supervisory visit on 11/5/24 and then again 11/22/24, 17 days after the 11/5/24 supervisory visit. P7’s POC for certification date 10/18/24, identified a SOC 6/26/23. Diagnoses included malignant neoplasm of bilateral ovaries, heart disease and Alzheimer’s disease. SNV were ordered one time per week for nine weeks and HHA visits two times per week for nine weeks. P7’s POC for certification date 12/17/24, included orders for SNV one time per week for nine weeks and HHA visits two times per week for nine weeks. P7’s medical record identified P7 had received HHA visits two times weekly throughout November and December with no missed visits recorded. The RN completed HHA supervisory visit on 12/12/24. There was no evidence any other HHA supervisory visits were documented throughout November or December. P9’s POC for certification date 11/25/24, identified a SOC 8/27/24. Diagnoses included senile degeneration of brain, dementia and depression. SNV were ordered one time per week for 13 weeks and HHA visits two times per week for thirteen weeks. P9’s medical record identified P9 received HHA visits two times weekly throughout November and December with no missed visits recorded. The RN completed HHA supervisory visit on 12/5/24 and 12/10/24. No other HHA supervisory visits were documented in December. A joint interview was conducted with the administrator and director of nursing (DON) on 1/9/25, at 1:30 p.m. The administrator stated the agency nurses were expected to complete a HHA supervisory visit every two weeks. The DON stated it was important to have the supervisory visits completed as the aides were not licensed employees and needed to be supervised to ensure they were following the patient’s POC and supervisory visits were required every 14 days. The agency policy Home Health Aide Supervision and Delegation of Duties dated 6/14/24, identified when a home health aide provided services to the skilled patient, a supervisory visit to a patient’s home must be completed by skilled personnel at least every 14 days.”

“Based on interview and document review the agency failed to ensure volunteers provide administrative or direct patient care services to patients to equal a minimum of 5 percent of the total patent care hours of all paid hospice employees and contract staff, which had the potential to affect all hospice patients. Findings include: The agency Home Health and Hospice Contact list updated 1/6/25, identified 9 volunteers. The Hospice Volunteer Hours Report from January 2024 through December 2024, identified a cost savings of 4.29% for the year. The monthly data identified the following cost savings per month: January 2024 = 5.18% February 2024 = 3.39% March 2024= 4.59% April 2024 = 3.11% May 2024 =4.34% June 2024 =3.43% July 2024 =2.39% August 2024= 3.55% September 2024= 6.88% October 2024 =5.83% November 2024= 3.85% December 2024 =6.36% When interviewed on 1/8/25 at 2:20 p.m. the volunteer coordinator (VC) stated they had volunteers do patient and family visits and assist with some administrative duties. She was aware they had not met the 5 percent cost savings. VC recently took over the volunteer coordinator position in September. VC was working on improving the volunteer hours since she took over the position in September and getting the hours within the required 5%. VC knew the low hours in November were related to having two of the agency full time volunteers on vacation. She did not know why the hours were not in the required 5% prior to taking over the position. A policy for volunteer hours was requested, however, none were received.”

“Based on interview and document review, the agency failed to ensure advanced directives were accurately documented in patient medical records for 1 of 10 patients (P3) whose advanced directives were reviewed. P3’s plan of care (POC) for certification period dated 1/6/25, identified a start of care (SOC) date 1/12/24. Diagnoses included diabetes, kidney disease, and heart failure. Directives included informed consent signed and do not resuscitate. P3’s Clinical Admission Summary note dated 1/12/24, identified P3 was appropriate for hospice with chronic kidney disease and co-morbidities of heart failure and diabetes. P3 was do not resuscitate (DNR), comfort measures only. P3’s Provider Orders for Life-Sustaining Treatment (POLST) signed by P3 and dated 1/12/24, identified attempt resuscitation/CPR was selected for option A. During telephone interview on 1/8/25, at 3:00 p.m. registered nurse (RN)-B stated she had not completed the start of care assessment for P3 but was very familiar with P3 and was her current case manager. RN-B was sure P3 would have never chosen a full code and would wish to have DNR on her records. RN-B was sure the POLST had been documented incorrectly, as the admitting nurse was not familiar with the admission process and forms. RN-B knew P3 would never want to be CPR and she planned to go out to the home and complete a new POLST form with P3 as soon as possible to correct the error. RN-B never specifically talked about P3’s code status with her because she had always thought P3 was a DNR and her POC indicated a DNR. P3 was always comfortable talking about her death and the dying process during their visits. RN-B would look at the POC for direction on code status. During telephone interview on 1/8/25, at 3:40 p.m. P3 stated her wishes were for DNR and she had that on all of her medical records. There was no way she would have asked to have full code and CPR. P3 had been DNR for a long time and all of her records reflected that. When interviewed on 1/9/25, at 1:30 p.m. the director of nursing (DON) stated the medical record should have code status match the patient’s POLST or advanced directives. It was important for the agency to comply with the patient wishes. She knew P3 and felt P3’s POLST was filled out in error as the admission note and all other documents indicated the P3 did not wish to be resusictated. She asked P3’s case manager to go out to the home and clarify P3’s wishes and fill out a new POLST document. An advanced directive policy was requested, however, none were received.”