Helping Hands Hospice

“Based on record review and interviews, the facility failed to ensure that data is collected and analyzed for performance and quality improvement. This deficient practice can lead to poor operational performance and poor quality of care for all patients. The findings are: A. Record review of the facility’s policy titled “;Quality Assessment and Performance Improvement (QAPI) Plan, Data Collection, from Policies and Procedures Manual for Hospice 2009 MED-PASS. Inc (Revised June 2018) page 10.1.5” 3. “;Data collection will be ongoing and frequency will be determined by the process improvement activity and approved by the Governing Body.” B. During an interview with the administrative assistant on 12/03/2024 at 3:36 pm stated the facility is currently not reviewing QAPI (Quality Assessment and Program Improvement) and performance improve projects”

“Based on record review and interview, the facility failed to ensure that performance improvement projects are conducted annually addressing the scope, complexity and past performance of hospice operations and services. This deficient practice can result in poor operational performance and poor quality of care for all patients. The findings are: A. Record review of the facility’s policy titled “;Quality Assessment and Performance Improvement (QAPI) Plan, Performance Expectations, Policies and Procedures Manual for Hospice© 2009 MED-PASS, Inc. (Revised June 2018) page 10.1.7 PERFORMANCE EXPECTATION 1. For each process identified to be improved, mechanisms to identify levels, patterns or trends in that process that will trigger further evaluation of the process will be identified. Performance expectations may include, but are not limited to: • Thresholds. • Setting upper and lower control limits. • Percentages. • Ratios. • Setting performance goals for further evaluation. • Identification of patterns/trends. 2. Sample size will be determined for each process improvement activity to adequately represent the process and will be randomly selected. For each established process to be improved, the performance expectation will be determined. The frequency of data collection and analysis will be specified for each process. The QAPI committee, and/or those involved in patient care, will analyze the data collected to pursue opportunities for improvement and identify important problems. 3. A summary of data collection, analysis, recommendations for improvement and report of cumulative findings will be prepared by the QAPI committee. The reports are forwarded to the Governing Body. Failure to achieve expected levels of performance will be documented and an explanation delineated to identify opportunities for improvement. B. During an interview with the administrative assistant on 12/03/2024 at 3:36 pm stated the facility is currently not reviewing QAPI (Quality Assessment and Program Improvement) and performance improve projects.”

“Based on record review and observation the facility failed to monitor, manage and maintain expired patient care supplies. This deficient practice could lead to infection for all patients receiving care. The findings are: A. Record review of the facilitys policy titled “;Supply Maintenance, Procedure, At the Hospice Site(s), page 5.14.1” states: 1. All medical supplies, especially sterile items, will be properly stored in a clean, dry area and handled in a sanitary manner protected from potential contamination as indicated by the manufacturer. 2. Supply packaging will remain intact while stored. If outer package is damaged or opened, supply will be removed and discarded. 3. Supplies will be checked for expiration date prior to use. If outdated, the supplies will be immediately removed from stock and discarded. 4. New medical supplies will be stored behind older supplies to assist in a timely rotation of supplies. 5. Staff will inspect packages of sterile items for evidence of interruption or exposure to liquid prior to use. 6. Staff using sterile medical supplies will handle items in a manner to protect sterility and prevent contamination. If supplies are taken from Hospice to the patient’s environment, staff assures appropriate and safe delivery of supplies. Supplies will be placed in a plastic or paper bag and placed in a clean area of the car for transport. B. During observation on 12/03/2024 at 2:30pm, of supply room the following was revealed: 1. ReadyBath Cap, Conditioning shampoo cap. One use package. Expired 04/2023 2. PeriGuard Ointment Skin Protectant, DermaRite. Soiled and ointment oozing from cap. 3. Derma Klenz, wound cleaner. Bottle half full-on shelf with new full bottles (for single patient use only). Open bottle breaks sterility and can cause cross-contamination. 4. Integrity, wound cleaner. Bottle ¼ full on shelf with new full bottles.(for single patient use only). Open bottle breaks sterility and can cause cross-contamination.”

“Based on record review and interview the facility failed to have an initial Certification of Terminal Illness that specified if a patient (P) had an anticipated 6 months or less to live for 3 (P4, P6, and P10) of 14 (P1-P14) patients being reviewed for initial certification of terminal illness. This deficient practice could possibly lead to a delay in patient care. The findings are: A. Record review of the facilitys policy titled “;Certification/Recertification of Terminal Illness” under section 1 stated “;In order to be eligible to elect Hospice care under Medicare, a patient much be certified as being terminally ill” under section 5 stated “;The written certification must specify that it is anticipated that the patients life expectancy is 6 months or less, if the illness runs its normal course.” B. Record review of P4s medical record revealed a form titled “;Hospice Plan of Care and Certification”, but it did not certify that P4 was terminally ill and did not certify that P4 had a life expectancy of 6 months or less to live. C. Record review of P6s medical record revealed a form titled “;Hospice Plan of Care and Certification”, but it did not certify that P6 was terminally ill and did not certify that P6 had a life expectancy of 6 months or less to live. D. Record review of P10s medical record revealed a titled “;Hospice Plan of Care and Certification”, but it did not certify that P10 was terminally ill and did not certify that P10 had a life expectancy of 6 months or less to live. E. During an Interview on 12/03/24 at 3:15 PM with S1, Clinical Staff Member, S1 confirmed that P4, P6, and P10 did not have a certification that certified that all three patients are terminally ill and have a life expectancy of 6 months or less to live.”

“Based on record review and interview the facility failed to provide a symptom management related to the patients terminal illness by not responding to the patients needs in a timely manner. This deficient practice is likely to lead to all patient needs not being met. The findings are: A. Record review of the facilitys policy titled On-Call Services (services to address the patients immediate needs) Not Dated, Reference number 5016 stated, “;Hospice provides on-call coverage 24 hours a day.” Procedure stated, “;The patient may reach the on-call number provided on the admission to the Hospice program.” B. Record review of the facilitys policy titled Hospice Nursing Care Reference number 3011, Not Dated, stated under Procedure; “;The Hospice nurse is available 24 hours to meet the physical, psychosocial, spiritual and practical needs of patients, families or caregivers.” C. During an interview on 05/01/2024 at 3:00 pm, P3 stated he knows the on-call number and has called it a few times. When called, P3 just got a voicemail and gets a return call a few hours later or the next day. When asked if calling the on-call were emergent calls, P3 stated “;yes.””

“Based on record reviews and interviews the facility failed to ensure that 1 (P [patient] 2) of 9 (P1-P9) patients reviewed had an Interdisciplinary group meeting with all qualified personnel. This deficient practice is likely to lead to a patients hospice needs remaining unmet and the Interdisciplinary Group being unaware of the patients hospice needs. The findings are: . A. Record review of the facilitys policy titled “;Interdisciplinary Team Coordination of Care” Policy #5003 not dated, stated “;Hospice uses a comprehensive, coordinated healthcare process and an interdisciplinary team to provide services and aid patients, families or caregivers” and “;The interdisciplinary team consists of physicians, nurses, social workers, certified home hospice aids, clergy, counselors, volunteers, and therapists” B. Record review of the facilitys policy titled “;Interdisciplinary Team Meeting” Policy #5004, not dated, stated “;The team meets bi-weekly [every other week].” C. Record review of P2s Medical Record , under the “;Admission Profile” revealed P2 was admitted to the hospice service on 12/04/23 and discharged from service on 12/24/23. P2s medical record did not contain any documentation of Interdisciplinary Team Meetings. D D. During an interview on 04/30/24 at 12:56 PM, with Staff (S)3, Director of Nursing, S3 confirmed that there was no documented Interdisciplinary Group Meetings for P2.”

“Based on record review and interviews the facility failed to develop a written Plan of Care for 1 (P[patient] 2) of 9 (P1-P9) patients reviewed for a Plan of Care. This deficient practice is likely to result in the patients care needs being unmet. The findings are: The findings are: A. Record review of facilitys policy titled “;Interdisciplinary Team Plan of Care” Not dated, stated “;Hospice establishes an individualized plan of care with patient, family or caregiver on the day of admission. The interdisciplinary team reviews the plan within 3 days of the admission to Hospice.” B. Record review of P2s medical record under “;Admission Profile” revealed that P2 was admitted on 12/04/23 and discharged on 12/24/23. P2s medical record did not have a written Plan of Care . C. During an interview on 05/01/24 at 8:31 AM, with Staff (S)4, facility administrator, S4 confirmed that P2 did not have a Plan of Care.”

“Based on record review, observation and interview the facility failed to monitor, manage and maintain expired patient care supplies. This deficient practice could lead to infections and ineffective treatment for all patients receiving care. The findings are: A. Record review of the facilitys policy titled “;Supply Maintenance number 5.14.1.”; Revised 2014, stated “;At the Hospice Site: 1. Hospice maintains and delivers supplies according to applicable federal/state laws and regulations. 2. Supplies will be checked for expiration date prior to use. If outdated, the supplies will be immediately removed from stock and discarded. B. During an observation on 04/30/2024 at 10:00 AM, of the supply room, the following was revealed: 1. Eight (8) boxes of insulin syringes (syringe used to administer diabetic medication) with the label from an (Name of Pharmacy) with a patients name on them. These insulin syringes had an expiration date of 06/2014. 2. Central Line (tube going into heart for administration of medications) dressing change kit (Sterile Dressing) with an expiration date of 09/2014. 3. Box of Mepilex Border dressings (dressing to cover a wound) with an expiration date of 10/28/2023. 4. Adaptec Rope (dressing used for wound) with an expiration date 02/2022. C. During an interview on 04/30/24 at 10:00 AM, with Staff (S)3, Director of Nursing (DON), DON confirmed there is no system in place to monitor supplies for expiration dates and that the patients syringes should not have been in the storage room and have such an expired date. S3 stated “;Staff could have pulled the expired items and taken them to a patient for use.” S3 stated “;I had no idea that there were so many expired supplies.””

“Based on record review and interviews the facility failed to ensure medical social services are provided to the patients by a qualified social worker. This deficient practice is likely to lead to patients and their families having unmet social service needs. The findings are: A. Record review of the facilitys policy titled “;Psychosocial Services” Policy #3015, not dated, stated “;Hospice provides psychosocial services by a qualified social worker” and “;These services are provided according to the interdisciplinary team plan of care.” B. Record review of the facilitys staff list revealed the facility did not have a qualified social worker on staff. C. During an interview on 05/03/24 at 8:31 AM, with Staff(S)4, Facility Administrator, S4 confirmed that there is no social worker on service, and they have not had a qualified social worker since December of 2023.”

“Based on record reviews and interviews the facility failed to ensure there was a qualified Hospice Aid to provide patient care to all patients. This deficient practice is likely to lead to all patient’s showers, hygiene and personal needs not getting met. The findings are: A. Record review of the facilitys document titled “;Home Hospice Aide” not dated, under “;Job Summary” stated “;Successful completion of an approved practical training program with a total of at least 75 hours of combined classroom and supervised clinical training with demonstrated knowledge of necessary skills.” B. Record review of the Personnel File for Staff (S)5, home hospice aide, revealed S5 did not have any training to be a Home Hospice Aide. C. During an interview on 05/03/24 at 8:31 AM, with S4, Facility Administrator, when asked if S5 had completed a training program, S4 stated “;She [S5] had not previously done HHA [home hospice aid] training.” When asked about the amount of training provided, S3 stated, “;about 60 hours of training.” S4 confirmed that the facility could not provide documentation of the training provided to S5. D. During an interview with S5 on 05/02/24 at 9:55 AM, S5 confirmed she had not completed the training program.”