Hunterdon Hospice Inc.

“Observed in Record Review. In 2 of 16 patient records reviewed, did not comprehensively advise patients of their rights upon admission. RR#1 had a consent form that was signed by the patient however the following sections on the consent were not completed/checked; payment source, advance directives, and the release of information. Similarly, the consent form was signed for RR#6 NHV, however the sections on the consent form pertaining to the notification of uncovered services, election of benefits, and release of information were not completed. This information was discussed with the director.”

“Observed in Record Review. In 2 of 16 patient records reviewed, did not have care plans that comprehensively reflected the interventions needed to address symptoms. RR#2 had a Foley and the care plan did not reflect the balloon size and the frequency of Foley change was written as- prn- without further qualification. RR#7 NHV was placed on continuous care for two days and there was no documentation in the record that the medical director was notified and or an order received to change the patient’s level of care. This observation was discussed with the director.”

“Observed in Individual Tracer. In 3 of 4 patient records reviewed, that had aide service, did not have accurate and or comprehensive written instruction provided by the RN. RR#1 hospice aide care plan reflected that the patient was on oxygen which she was not on and neglected to include wound precautions. This patient had a sacral decubitus requiring dressing. The hospice aide care plan of RR#2 reflected that the patient had a condom catheter, and the patient actually had a Foley catheter. Additionally, this patient had issues with dysphagia and the care plan did not reflect aspiration precautions. RR#6 had a wound and the aide care plan did not reflect wound precautions. This observation was discussed with the director.”

“Observed in Individual Tracer. In 1 of 4 patient records reviewed, that had hospice aides, did not have activity sheets in the record that reflected the care that was delivered. RR HV#3 aide applied two ointments to the patient’s rash after bathing for over a week. A review the activity sheets completed this week by the aide did not reflect this activity. This observation was discussed with the director. Observed in Patient Home. In 2 of 4 home visits conducted, the hospice medication profile did not accurately reflect the medications that the patients were taking. Per the primary caregiver of RR#1, the patient has not been taking oral medications for the last two weeks. The hospice medication profile reflected that the patient was taking in excess of 13 medications that included multiple vitamins, Flomax, Vit D, Vit B12,Carvedilol, and Biotin. Similarly, per the primary caregiver of RR#2 reported that the patient had not been taking Klonopin for months. This medication appeared on the hospice medication profile. Both patients were being seen by the RN at least weekly. The medication record of RR#3 HV who resided in a nursing home, did not include the following medications; Pantoprazole, Reglan Buspirone, Hyoscyamine, zinc tablets, Compazine, zinc oxide and Alcort. This observation was discussed with the director.”

“Based on medical record review, staff interviews, and review of facility documents, it was determined the facility failed to ensure that the plan of care contained a detailed statement of the frequencies of services necessary to meet the patients needs for chaplain and social worker services in three of ten medical records reviewed (Patients (P)1, P7, and P9). Findings include: Facility policy titled “;Scope of Services”, last reviewed 9/2024, states, “;....4. The scope and frequency of services provided by the hospice are in accordance with each patients needs as identified in his/her plan of care.”. On 11/14/2024 at 11:30 AM a review of patient (P) 7s medical record was conducted. A review of P7s certification period starting 10/26/24 revealed the following: P7 received visits by social work on 10/30/24 and 11/7/24. P7s “;Team Care Plan” had a visit frequency for skilled nursing visits starting 10/26/24. The facility was unable to provide evidence of documentation of a visit frequency for social worker visits. On 11/15/2024 at 10:00 AM a review of P9s medical record was conducted. A review of P9s certification period starting 9/21/24 revealed the following: P9 received a visit by social work on 10/9/24. P9s “;Team Care Plan” had a visit frequency for skilled nursing and home health aide visits starting 9/21/24. The facility was unable to provide evidence of documentation of a visit frequency for social work visits. On 11/14/2024 at 11:35 AM, an interview was conducted with staff (S) 13, Case Manager/Registered Nurse (RN). When questioned about frequency orders for social work, S13 stated, “;yes, there should be frequency orders for social services”. 11/15/2024 at 2:05 PM, an interview was conducted with S3, Director of Hospice. S3 confirmed there were no visit frequency orders for social worker in P7 and P9’s plan of care. S3 explained social services and nursing enter their own orders and there should be frequency orders in plan of care. Findings include: Facility policy titled, “Scope of Services”, last revised 9/2024, states, “...The scope and frequency of services provided by the hospice are in accordance with each patient’s needs as identified in his/her plan of care...” On 11/15/24 at 10:09 AM, a medical record review for Patient (P)1 was conducted. A review of P1’s certification period starting 9/16/24 revealed the following: P1 received chaplain visits on 9/23/24, 10/15/24, and 11/7/24. P1’s “Team Care Plan” had a visit frequency for skilled nursing, social worker, and home health aide visits starting 9/16/2024. The facility was unable to provide evidence of documentation of a visit frequency for chaplain visits. On 11/15/24 at 10:09 AM, an interview was conducted with Staff (S)13, Nurse Manager, to discuss how discipline frequencies are added to the patient’s plan of care. S13 stated, “the chaplain puts in [his/her] own frequency.” S13 added that the facility’s chaplain was new and adding order frequencies for his/her services “is an area we can improve on.” N.J.A.C.8:42C-6.3(a)(6) Findings include: Facility policy titled, “;Scope of Services” last reviewed 9/2024, states, “;....4. The scope and frequency of services provided by the hospice are in accordance with each patients needs as identified in his/her plan of care.” On 11/14/2024 at 11:30 AM, a review of P7s medical record for the certification period starting 10/26/24 revealed the following: P7 received visits from social work on 10/30/24 and 11/7/24. P7s “;Team Care Plan” had a visit frequency for skilled nursing visits starting 10/26/24, however, there were no orders for the frequency of visits for social work. Upon request, S3 was unable to provide evidence of documentation of a visit frequency for social worker visits. On 11/15/2024 at 10:00 AM, a review of P9s medical record for the certification period starting 9/21/24 revealed the following: P9 received a visit from social work on 10/9/24. P9s “;Team Care Plan” had a visit frequency for skilled nursing and home health aide visits starting 9/21/24. The facility was unable to provide evidence of documentation of a visit frequency for social work visits. On 11/15/24 at 10:09 AM, a medical record review for P1 was conducted. A review of P1’s certification period starting 9/16/24 revealed the following: P1 received chaplain visits on 9/23/24, 10/15/24, and 11/7/24. [During the review, did you identify any issues the patient might have related to chaplain services?] P1’s “Team Care Plan” had a visit frequency for skilled nursing, social worker, and home health aide visits starting 9/16/2024. The facility was unable to provide evidence of documentation of a visit frequency for chaplain visits. On 11/14/2024 at 11:35 AM, an interview was conducted with Staff (S)13, Case Manager/Registered Nurse (RN). When questioned about the frequency orders for social work, S13 stated, “;yes, there should be frequency orders for social services.” On 11/15/24 at 10:09 AM, an interview was conducted with S13, to discuss how visit frequencies are added to a patient’s plan of care. S13 stated, “The chaplain puts in [his/her] own frequency.” S13 added that the facility’s chaplain was new and adding visit frequencies for his/her services “is an area we can improve on.” 11/15/2024 at 2:05 PM, on an interview, S3 confirmed the findings for P1, P7, and P9.”

“Based on medical record review, review of facility documents, and staff interviews, it was determined the facility failed to ensure that home health aide visits are in alignment with the patient’s plan of care in five of 15 medical records reviewed (Patient (P) 1, P4, P11, P13, and P14). On 11/15/24 P11s “;Team Care Plan” for the certification period beginning 9/25/2024 revealed the following: The section labeled Visit Frequency stated “;...AID [Home Health Aide] 09-25-2024 6 PRN [as needed]: A week, for patient care. 09-25-2024 2-3 x week x 1 week [2-3 times a week for one week]. 09-29-2024 4-5 x week x 9 weeks [ 4-5 times a week for 9 weeks].” During the week of 10/14/24, there were no Home Health Aide visits provided. These findings were confirmed with S3 (Director of Hospice) on 11/15/24. N.J.A.C. 8:42C-6.3(a)(6) Findings include: Facility policy, titled, “Plan of Care”, last revised 1/1/23, states, “The care and services provided to patients and their families are in accordance with an individualized, written plan of care...” Facility policy, titled, “Scope of Services”, last revised September 2024, states, “...The scope and frequency of services provided by the hospice are in accordance with each patient’s needs as identified in his/her plan of care...” On 11/15/24 at 9:58 AM, Patient (P)1’s medical record was reviewed. P1’s “;Team Care Plan” for the certification period beginning 9/16/24 revealed the following: The section labeled Visit Frequency stated “;...AID [Home Health Aide] 09-16-2024 2-3 x week x 9 weeks [2-3 times a week for 9 weeks].” P1’s medical record revealed a missed aide visit the week of 11/3/24 and two missed aide visits the week of 11/10/24. On 11/15/24 at 11:06 AM, Staff (S)13, Nurse Manager, confirmed the finding. On 11/15/24 at 1:18 PM, P13’s medical record was reviewed. P13’s “;Team Care Plan” for the certification period beginning 9/1/24 revealed the following: The section labeled Visit Frequency stated “;...AID [Home Health Aide] 09-16-2024 2-4 x week x 9 weeks [2-4 times a week for 9 weeks].” P13’s medical record revealed two missed aide visits the week of 9/1/24, two missed aide visits the week of 9/8/24, and one missed aide visit the week of 9/15/24. On 11/15/24 at 1:23 PM, S13 confirmed the finding. On 11/15/24 at 1:24 PM an interview was conducted with S13 to discuss the process when aide visits are missed. S13 explained the scheduler makes an effort to send the patient a different aide when available. If there is no availability, the patient may receive additional nursing visits. The facility failed to provide evidence of documentation for additional nursing visits for P1 and P13. On 11/14/24 at 10:30 AM, a medical records review of Patient (P) 4s medical record was conducted. P4’s “Team Care Plan” for the certification period beginning 10/11/2024 revealed the following: The section labeled Visit Frequency stated “...AID [Home Health Aide] 10/13/24 2-3 x week x 8 weeks [2-3 times a week for 8 weeks]. P4’s medical record revealed that the week of 10/27/24-11/2/24 the aide conducted no visits (three missed visits). On 11/14/2024 at 12:00 PM, a medical record review of P14s conducted. P14s “;Team Care Plan” for the certification period beginning 10/21/24 revealed the following: The section labeled Visit Frequency stated “;...AID 2-3 x week x 9 weeks [2-3 times a week, for 9 weeks]. P14s medical record revealed that the week of 10/27/24 – 11/2/24 the aide conducted no visits (three missed visits). On 11/15/2024 at 10:00 AM, a review of P9s medical record was conducted. P9s “;Team Care Plan” for the certification period beginning 9/21/24 revealed the following: The section labeled Visit Frequency stated “;...AID 3-4 x week x 9 weeks [3-4 times a week for 9 weeks]. P9s medical record revealed that on the week of 10/6/24 – 10/12/24 the aide conducted two visits (one missed visit), the week of 10/13/24-10/19/24 the aide conducted two visits (one missed visit), the week of 10/27/24-11/2/24 the aide conducted two visits (one missed visit), the week of 11/3/24-11/9/24 the aide conducted two visits (one missed visit), and the week of 11/10/24-11/16/24 the aide conducted two visits (one missed visit). On 11/15/24 at 2:00 PM, Staff (S)3 confirmed the above findings.”

“Based on medical record review, staff interviews, and review of facility documents, it was determined the facility failed to ensure the ongoing sharing of information between disciplines providing care and services concerning missed visits in five of ten medical records reviewed (Patient (P)1, P4, P11, P13, and P14). On 11/15/24 Patient (P) 11s “;Team Care Plan” for the certification period beginning 9/25/2024 revealed the following: The section labeled Visit Frequency stated “;...AID [Home Health Aide] 09-25-2024 6 PRN [as needed]: A week, for patient care. 09-25-2024 2-3 x week x 1 week [2-3 times a week for one week]. 09-29-2024 4-5 x week x 9 weeks [ 4-5 times a week for 9 weeks].” During the week of 10/14/24, there were no Home Health Aide visits provided. There was a Clinical Note dated 10/14/24, 10/15/24 and 10/18/24 indicating the Hospice IDT, Hospice MD, PCP/Attending Physician, as well as patient/family were aware of the change in plan. P11s medical record lacked evidence of a clinical note/missed visit note documented on 10/16/24 or 10/17/24. These findings were confirmed with S3 (Director of Hospice) on 11/15/24. Findings include: Facility policy titled “;Missed Visit Policy & Procedure” last reviewed on 7/9/2022, states, “;Procedure: 1. Enter a CLINICAL NOTE (each discipline is accountable for its own visit activities) when a frequency order CANNOT be met.” Facility policy titled “Coordination of Services” [No review date noted on policy], states, “Policy: The IDG ensures that there is a coordinated and effective ongoing sharing of information amongst and between all disciplines, with all contracted service providers and in all settings.” On 11/14/24 at 10:30 AM, a medical records review of patient (P) 4s medical record was conducted. P4’s “Team Care Plan” for the certification period beginning 10/11/2024 revealed the following: The section labeled Visit Frequency stated “...AID [Home Health Aide] 10/13/24 2-3 x week x 8 weeks [2-3 times a week for 8 weeks]. P4’s medical record revealed that the week of 10/27/24-11/2/24 the aide conducted no visits (three missed visits). There was no evidence of documentation of the missed visits in the clinical record or interdisciplinary team (IDT) notes. On 11/14/2024 at 12:00 PM, a medical record review of P14s conducted. P14s “;Team Care Plan” for the certification period beginning 10/21/24 revealed the following: The section labeled Visit Frequency stated “;...AID 2-3 x week x 9 weeks [2-3 times a week, for 9 weeks]. P14s medical record revealed that the week of 10/27/24 – 11/2/24 the aide conducted no visits (three missed visits). There was no evidence of documentation of the missed visits in the clinical record or IDT notes. On 11/15/24 at 11:00 AM, an interview was conducted with Staff (S)13, Nurse Manager. When asked if staff was required to place missed visit notes in the patients medical record, S13 stated “;yes there should be clinical notes”. 11/15/24 at 2:00 PM, findings were confirmed with S3, Director of Hospice. Findings include: On 11/15/24 at 10:56 AM, a medical record review for Patient (P)1 was conducted. P1s “;Team Care Plan” for the certification period beginning 9/16/2024 revealed the following: The section labeled Visit Frequency stated “;...AID [Home Health Aide] 09-16-2024 2-3 x week x 9 weeks [2-3 times a week for 9 weeks]. P1’s medical record revealed that the week of 11/3/24 - 11/9/24 the home health aide (HHA) conducted one visit (one missed visit) and the week of 11/10/24-11/16/24 the HHA conducted no visits (two missed visits). The facility was unable to provide evidence of documentation of the missed visits in the clinical record or interdisciplinary team (IDT) notes. On 11/15/24 at 11:06 AM, Staff (S)13, Nurse Manager, confirmed the finding. On 11/15/24 at 1:18 PM, a medical record review for P13 was conducted. P13s “;Team Care Plan” for the certification period beginning 9/1/2024 revealed the following: The section labeled Visit Frequency stated “;...AID [Home Health Aide] 09-01-2024 2-4 x week x 9 weeks [2-4 times a week for 9 weeks]. P13’s medical record revealed that the week of 9/1/24 - 9/7/24 the HHA conducted no visits (two missed visits), the week of 9/8/24 - 9/14/24 the HHA conducted no visits (two missed visits), and the week of 9/15/24 - 9/21/24 the HHA conducted one visit (one missed visit). The facility was unable to provide evidence of documentation of the missed visits in the clinical record or the IDT notes. On 11/15/24 at 1:23 PM, S13 confirmed the finding. On 11/15/24 at 10:48 AM, an interview was conducted with S13 to discuss the process when HHA visits are missed. S13 explained that if there is a call out, it is discussed in morning huddle and in the IDT meetings and updated in the IDT notes. The scheduler will put in a “missed visit note” and makes an effort to send the patient a different provider when available. In the case of missed HHA visits, if there is no availability, the patient may receive additional nursing visits. The facility was unable to provide evidence of documentation for additional nursing visits for P1 and P13.”

“Based on medical record review and staff interviews, it was determined the facility failed to ensure appropriately authenticated and dated entries in clinical notes within the EMR (electronic medical record) in three of six medical records reviewed (Patient (P)4, P9, and P14). Findings include: On 11/14/24 at 10:30 AM, a review of P4s medical record revealed the following: Clinical notes in P4s medical record had no evidence of an electronic signature, date, or time on multiple interdisciplinary team (IDT) notes. On 11/14/2024 at 12:00 PM, a review of P14s medical record revealed the following: Clinical notes in P14s medical record had no evidence of an electronic signature, date, or time on multiple IDT notes. On 11/15/2024 at 10:00 AM, a review of P9s medical record revealed the following: Clinical notes in P9s medical record had no evidence of an electronic signature, date, or time on multiple IDT notes. On 11/14/2024 at 11:08 AM, during an interview with Staff (S)13, Nurse Manager, when questioned about how staff identifies who signed the IDT clinical notes, S13 stated, “;I can tell by the writing who wrote it.” S13 further stated, “;It is a glitch in our system.” On 11/15/2024 at 1:30 PM, an interview was conducted with S3, Director of Hospice. When questioned why some documentation did not have a signature, S3 stated, “;It is a glitch in the system” and S3 explained it has been an ongoing issue. S3 explained that sometimes the documentation will be in the system, then at other times, the documentation will not be in the system. S3 stated, “;You can see who wrote the documentation when in an IDT meeting, not always in the [name of software] system.”; 11/15/2024 at 2:10 PM, the above findings were confirmed with S3. NJAC 8:42C - 6.3(a)(9)”