Interim Healthcare Hospice

“Based on record review and interview, the agency failed to ensure emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events were conducted for 05/12/2023 to 08/07/24 for all patients and employees. Findings: A review of administrative records related to emergency preparedness showed no documentation of emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events for 05/12/2023 to 08/07/24. On 08/07/24 at 12:00 p.m., Staff B stated: The agency had no emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events for 05/12/2023 to 08/07/24.”

“Based on record review and interview, the hospice failed to ensure delivery of medication for symptom control was received by the patient/caregiver within 2 hours of order for one (Patient #3) of 19 patients. Findings: Patient #3 A review of a POC dated 06/10/23 to 09/07/23 showed documentation of an SN visit frequency of two times a week. Documentation showed a clinical note dated 07/12/23 at 12:00 a.m., the patient was apneic with symptoms of increased anxiety documented as agitation and restlessness, an order for lorazepam (an anxiety medication) was ordered to be delivered by the pharmacy. A SN visit note at 8:00 a.m. documented the patient was apneic, non-responsive and restless; daily SN visits were ordered. A clinical note at 10:20 a.m. documented the patient was experiencing increased agitation and restlessness and the lorazepam that was ordered had not been delivered by the pharmacy. An order for Dilaudid (a pain medication) and an additional order for lorazepam (an anxiety medication) was ordered to be delivered STAT (immediately [within 2 hours]) to the pharmacy for the patient. Additional documentation showed the medication was received by the pharmacy at 1:20 p.m. (13 + hours after initial order, 3 hours after the second order). Documentation showed no communications with the contracted pharmacy (name withheld). Administrative records (Complaints, Incidents and Grievances) showed no documentation of the incident. On 08/07/24 at 3:00 p.m., Staff B stated medications ordered by the hospice are to be delivered by the contracted pharmacy to the patient/caregiver within 2 hours.”

“Based on record review and interview, the hospice failed to ensure completion of initial assessments/plan of care no later than 5 calendar days after the election of the hospice benefits for two (Patients #1 and #2) of 19 patients. Findings: Patient #1 A review of the clinical record showed an election of the hospice benefit on 10/12/21 with POC from 10/12/21 to 01/09/22. Documentation showed a psychosocial assessment by the LCSW was completed on 10/20/21 (8 days after the hospice election date). Documentation showed no patient or caregiver refusal of assessments and showed no communications or notifications to the physician. On 08/07/24 at 1:05 p.m., Staff A stated the spiritual component of the initial POC was not completed within the first five days after the election of the hospice benefit for patient #1. Patient #2 A review of the clinical record showed an election of the hospice benefit on 12/07/21 (documentation showed a date of 12/12/21) with POC from 12/07/21 to 02/04/22. Documentation showed a spiritual assessment by the Chaplain was completed on 12/20/21 (13 days after the hospice election date). Documentation showed no patient or caregiver refusal of assessments and showed no communications or notifications to the physician. On 08/07/24 at 1:12 p.m., Staff A stated the spiritual component of the initial POC was not completed within the first five days after the election of the hospice benefit for patient #2.”

“Based on record review and interview, the hospice failed to ensure development of a bereavement POC for 12 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 and 19) of 19 patients. Findings: Patient #1 A review of the clinical record showed a bereavement assessment dated 10/20/21. Documentation showed no bereavement POC and no subsequent development by the IDG of a bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #2 A review of the clinical record showed a bereavement assessment dated 12/20/21. Documentation showed no bereavement POC and no subsequent development by the IDG of a bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #3 A review of the clinical record showed a bereavement assessment dated 06/14/23. Documentation showed no bereavement POC and no subsequent development by the IDG of a bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #4 A review of the clinical record showed a bereavement assessment dated 01/10/22. Documentation showed no bereavement POC and no subsequent development by the IDG of a bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #5 A review of the clinical record showed a bereavement assessment dated 02/08/24. Documentation showed no bereavement POC and no subsequent development by the IDG of a bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #6 A review of the clinical record showed a bereavement assessment dated 02/14/24. Documentation showed no bereavement POC and no subsequent development by the IDG of a bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #7 A review of the clinical record showed a bereavement assessment dated 09/12/23. Documentation showed no bereavement POC and no subsequent development by the IDG of a bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #8 A review of the clinical record showed a bereavement assessment dated 08/22/23. Documentation showed no bereavement POC and no subsequent development by the IDG of a bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #9 A review of the clinical record showed a bereavement assessment dated 10/14/22. Documentation showed no bereavement POC and no subsequent development by the IDG of a bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #10 A review of the clinical record showed a bereavement assessment dated 08/01/24 (date of initial comprehensive assessment was 07/30/24). Documentation showed no bereavement POC and no subsequent development by the IDG of a bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #11 A review of the clinical record showed a bereavement assessment dated 06/22/24. Documentation showed no bereavement POC and no subsequent development by the IDG of a bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #12 A review of the clinical record showed a bereavement assessment dated 10/26/22. Documentation showed no bereavement POC and no subsequent development by the IDG of a bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #13 A review of the clinical record showed a bereavement assessment dated 05/06/24. Documentation showed no bereavement POC and no subsequent development by the IDG of a bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #14 A review of the clinical record showed a bereavement assessment dated 07/23/24. Documentation showed no bereavement POC and no subsequent development by the IDG of a bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #15 A review of the clinical record showed a bereavement assessment dated 02/15/23. Documentation showed no bereavement POC and no subsequent development by the IDG of a bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #16 A review of the clinical record showed a bereavement assessment dated 09/05/23. Documentation showed no bereavement POC and no subsequent development by the IDG of a bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #17 A review of the clinical record showed a bereavement assessment dated 07/16/24. Documentation showed no bereavement POC and no subsequent development by the IDG of a bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #18 A review of the clinical record showed a bereavement assessment dated 07/11/23. Documentation showed no bereavement POC and no subsequent development by the IDG of a bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #19 A review of the clinical record showed a bereavement assessment dated 07/15/24. Documentation showed no bereavement POC and no subsequent development by the IDG of a bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. On 08/07/24 at 11:30 a.m., Staff F stated: 1. Bereavement program activities are initiated after a patient has deceased and; 2. Patient family members or significant others identified as the bereaved receive standardized bereavement letters, information mail outs and some telephone contacts over a 13-month period from the date the patient has deceased. At 1:05 p.m. to 2:12 p.m., Staff A stated for patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 and 19: 1. Had no bereavement POCs. 2. Bereavement program activities are initiated after a patient has deceased and; 3. Patient family members or significant others identified as the bereaved receive standardized bereavement letters, information mail outs and some telephone contacts over a 13-month period from the date the patient has deceased.”

“Based on record review and interview, the hospice failed to ensure: 1. Aide visits were provided in accordance with the plan of care for four (Patients #8, 10, 11 and 15) of 19 patients; 2. SN visits were provided in accordance with the plan of care for two (Patients #3 and 15) of 19 patients; 3. Chaplain visits were provided in accordance with the plan of care for two (Patient #8 and 16) of 19 patients and; 4. MSW visits were provided in accordance with the plan of care for three (Patients #8, 15 and 16) of 19 patients. Findings: Patient #3 A review of a POC dated 10/12/21 to 01/09/22 showed documentation of an SN visit frequency of two times a week. Documentation showed during the week of 06/30/24 to 07/06/24 a SN visit was missed on 07/04/24 due to the holiday (two visits ordered, one visit conducted). Documentation showed no communications between the IDG and showed no changes in the ordered SN visit frequencies. On 08/07/24 at 1:20 p.m., Staff A stated SN visits were not provided in accordance with the POC for patient #3. Patient #8 A review of a POC dated 10/12/21 to 01/09/22 showed documentation of an aide visit frequency of one week one, then two times a week for eight weeks; and a Chaplain visit frequency of one time a week; and a MSW visit frequency of one time a month for two months. Documentation showed during the weeks of 06/16/24 to 06/22/24 an aide visit was missed on 06/20/24 (two visits ordered, one visit conducted), 06/30/24 to 07/06/24 an aide visit was missed on 07/04/24 due to the holiday (two visits ordered, one visit conducted), 07/07/24 to 07/13/24 an aide visit was missed on 07/10/24 (two visits ordered, one visit conducted), 07/14/24 to 07/20/24 an aide visit was missed on 07/19/24 (two visits ordered, one visit conducted), 07/20/24 to 08/03/24 an aide visit was missed on 07/30/24 (two visits ordered, one visit conducted); and 06/13/24 to 06/15/24 an chaplain visit was not scheduled (one visits ordered, no visit conducted), 06/16/24 to 06/22/24 an chaplain visit was not scheduled (one visits ordered, no visit conducted), 06/30/24 to 07/06/24 an chaplain visit was not scheduled (one visits ordered, no visit conducted), and 07/28/24 to 08/03/24 an chaplain visit was not scheduled (one visits ordered, no visit conducted); and during the weeks of 06/13/24 to 07/13/24 no MSW visit was scheduled (one visits ordered, no visit conducted). Documentation showed no communications between the IDG and showed no changes in the ordered SN, aide, chaplain or MSW visit frequencies. On 08/07/24 at 1:55 p.m., Staff A stated SN, aide, chaplain or MSW visits were not provided in accordance with the POC for patient #8. Patient #10 A review of a POC dated 07/30/24 to 10/27/24 showed documentation of an aide visit frequency of one week one, then two times a week for 12 weeks. Documentation showed during the week of 07/30/24 to 08/03/24 no aide visit was conducted (one visit ordered, no visit conducted). Documentation showed no communications between the IDG and showed no changes in the ordered aide visit frequency. On 08/07/24 at 2:04 p.m., Staff A stated aide visit was not provided in accordance with the POC for patient #10. Patient #11 A review of a POC dated 06/18/24 to 09/15/24 showed documentation of an aide visit frequency of one week one, then two times a week for 12 weeks. Documentation showed during the week of 06/23/24 to 06/29/24 an aide visit was missed on 06/25/24 (two visits ordered, one visit conducted), 06/30/24 to 07/06/24 an aide visit was missed on 07/04/24 due to the holiday (two visits ordered, one visit conducted), 07/07/24 to 07/13/24 an aide visit was missed on 07/10/24 (two visits ordered, one visit conducted), 07/14/24 to 07/20/24 an aide visit was missed on 07/17/24 (two visits ordered, one visit conducted), 07/21/24 to 07/27/24 an aide visit was missed on 07/23/24 (two visits ordered, one visit conducted) and 07/28/24 to 08/03/24 an aide visit was conducted on 08/01/24 (two visits ordered, one visit conducted). Documentation showed no communications between the IDG and showed no changes in the ordered aide visit frequency. On 08/07/24 at 2:05 p.m., Staff A stated aide visit was not provided in accordance with the POC for patient #11. Patient #15 A review of a POC dated 06/07/24 to 08/05/24 showed documentation of an aide visit frequency of one week one, then three times a week for eight weeks; a SN visit frequency of two times a week for eight weeks; and a MSW visit frequency of one time a month for two months. Documentation showed during the weeks of 06/30/24 to 07/06/24 an aide visit was missed on 07/03/24 and 07/04/24 (three visits ordered, one visit conducted); 06/30/24 to 07/06/24 an SN visit was missed on 07/04/24 (two visits ordered, one visit conducted); and during the weeks of 06/07/24 to 07/25/24 one MSW visit was missed on 06/07/24 (one visits ordered, no visit conducted). Documentation showed no communications between the IDG and showed no changes in the ordered aide and MSW visit frequencies. On 08/07/24 at 2:15 p.m., Staff A stated SN, aide and MSW visits were not provided in accordance with the POC for patient #15. Patient #16 A review of a POC dated 06/27/24 to 08/25/24 showed documentation of an MSW visit frequency of one time a month for two months; and a chaplain visit frequency of two times a month for two months. Documentation showed during the time period of 06/27/24 to 08/03/24 an MSW visit was missed on 07/29/24 (one visit ordered, no visit conducted) and a chaplain visit was conducted on 07/16/24 (two visits ordered, one visit conducted). Documentation showed no communications between the IDG and showed no changes in the ordered chaplain or MSW visit frequencies. On 08/07/24 at 2:20 p.m., Staff A stated chaplain or MSW visits were not provided in accordance with the POC for patient #16.”

“Based on record review and interview, the hospice failed to ensure plans of care were fully developed to include service discipline frequencies and durations to meet individualized patient care for one (Patients #1) of 19 patients. Findings: Patient #1 A review of a POC dated 10/12/21 to 01/09/22 with IDG updates on 10/13/21 and on 10/27/21 showed no documentation of SN, chaplain or MSW service discipline visit frequencies and durations. Documentation showed no communications between the IDG related to service discipline frequencies and durations. On 08/07/24 at 1:05 p.m., Staff A stated the POC for patient #1 did not show visit frequencies or durations for SN, chaplain or MSW service disciplines.”

“Based on record review and interview, the hospice failed to ensure patient refusal of hospice aide services was communicated and addressed by the IDG for two (Patients #8 and 11) of 19 patients. Findings: Patient #8 A review of a POC dated 06/13/24 to 08/11/24 with IDG updates on 06/26/24, 07/10/24 and on 07/24/24 showed documentation of an aide visit frequency of one week one, then two times a week for eight weeks and a chaplain visit frequency of one time a week. Documentation showed aide service discipline missed visits of 06/20/24, 07/04/24, 07/10/24, 07/19/24 and on 07/30/24; and chaplain service missed visits during 06/13/24 to 06/15/24 an chaplain visit was not scheduled (one visits ordered, no visit conducted), 06/16/24 to 06/22/24 an chaplain visit was not scheduled (one visits ordered, no visit conducted), 06/30/24 to 07/06/24 an chaplain visit was not scheduled (one visits ordered, no visit conducted), and 07/28/24 to 08/03/24 n chaplain visit was not scheduled (one visits ordered, no visit conducted). Documentation showed no communications between the IDG and showed no changes in the ordered aide or chaplain visit frequencies and showed no coordination of care with the patient/caregiver to resolve issues with missed aide and chaplain service discipline visits. On 08/07/24 at 1:55 p.m., Staff A stated the IDG should have shown documentation of attempts to resolve the aide and chaplain missed visits and the IDG should have decreased the aide visit frequency and/or discontinued the aide service discipline based on the patients/caregivers requests for patient #8. Patient #11 A review of a POC dated 06/18/24 to 09/15/24 with IDG updates on 06/20/24, 07/17/24 and 07/31/24 showed documentation of an aide visit frequency of one week one, then two times a week for 12 weeks. Documentation showed aide service discipline missed visits on 06/25/24, 07/04/24, 07/10/24, 07/17/24 and on 07/23/24. Documentation showed no communications between the IDG and showed no changes in the ordered aide or chaplain visit frequencies and showed no coordination of care with the patient/caregiver to resolve issues with missed aide and chaplain service discipline visits. On 08/07/24 at 2:05 p.m., Staff A stated the IDG should have shown documentation of attempts to resolve the aide missed visits and the IDG should have decreased the aide visit frequency and/or discontinued the aide service discipline based on the patients/caregivers requests for patient #11.”

“Based on record review and interview, the hospice failed to ensure and maintain evidence that its QAPI Program showed measurable improvement in indicators related to improved palliative outcomes and hospice services for all patients and employees. Findings: A review of administrative record documentation showed no measurable improvements in indicators related to improved palliative outcomes and hospice services for: 1st quarter (January to March) and 3rd quarter (July to September) 2022; and 2nd quarter (April to June), 3rd quarter (July to September) and 4th quarter (October to December 2023. Additional requests for administrative records yielded no results. On 08/07/24 at 3:50 p.m., Staff B stated the hospices QAPI program for 2022 and 2023 showed no measurable improvement in indicators related to palliative outcomes and hospice services.”

“Based on record review and interview, the hospice failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. Findings: A review of administrative record documentation showed no QAPI program data collection sources, analysis/reporting of collected data or reporting activities for QAPI indicators related to improved palliative outcomes and hospice services for: 1st quarter (January to March) and 3rd quarter (July to September) 2022; and 2nd quarter (April to June), 3rd quarter (July to September) and 4th quarter (October to December 2023. Additional requests for administrative records yielded no results. On 08/07/24 at 3:50 p.m., Staff B stated the hospices QAPI program for 2022 and 2023 showed no collection sources, analysis/reporting of collected data or reporting activities for QAPI indicators related to palliative outcomes and hospice services.”

“Based on record review and interview, the hospice failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for all patients and employees. Findings: A review of administrative records showed no governing body oversite of the ongoing QAPI program which identified the hospice that included data collection, analysis and reporting activities for the hospice for: 1st quarter (January to March) and 3rd quarter (July to September) 2022; and 2nd quarter (April to June), 3rd quarter (July to September) and 4th quarter (October to December 2023. Additional requests for administrative records yielded no results. On 08/07/24 at 3:50 p.m., Staff B stated the governing body meeting minutes for the hospice showed no documentation of governing body oversite of QAPI program activities that included review and approval of data collection, analysis, implementation and follow up of QAPI activities for: 1st quarter (January to March) and 3rd quarter (July to September) 2022; and 2nd quarter (April to June), 3rd quarter (July to September) and 4th quarter (October to December 2023.”

“Based on record review and interview, the hospice failed to ensure its infection control program included surveillance monitoring and reporting was included in QAPI program activities for all patients and employees. Findings: Administrative records which showed documentation the Hospices infection control program surveillance data was included in QAPI program activities for: 1st quarter (January to March) and 3rd quarter (July to September) 2022; and 2nd quarter (April to June), 3rd quarter (July to September) and 4th quarter (October to December 2023). Additional requests for administrative records yielded no results. On 08/07/24 at 3:50 p.m., Staff B stated there was no infection control program surveillance data included in QAPI program activities for: 1st quarter (January to March) and 3rd quarter (July to September) 2022; and 2nd quarter (April to June), 3rd quarter (July to September) and 4th quarter (October to December 2023.”

“Based on record review and interview, the hospice failed to ensure provision of a completed summary of care to the receiving service provider at the time of transfer/discharge from the hospice for two (Patients #4 and #5) of 19 patients. Findings: Patient #4 A review of the clinical record showed the patient was transferred from the hospice on 03/07/24 to another hospice service provider. Documentation showed no transfer/discharge summary was provided to the hospice service provider. On 08/07/24 at 1:24 p.m., Staff A stated the hospice failed to provide a completed summary of care to the receiving service provider at the time of transfer/discharge for patient #4. Patient #8 A review of the clinical record showed the patient was transferred from the hospice on 05/01/24 to home health services. Documentation showed no transfer/discharge summary was provided to the home health service provider. On 08/07/24 at 1:27 p.m., Staff A stated the hospice failed to provide a completed summary of care to the receiving service provider at the time of transfer/discharge for patient #8.”

“Based on observation, record review and interview, the hospice failed to ensure the IDG communicated and coordinated the patients care with the residential care facility (Nursing Home, name withheld) for three (Patients #8, 9 and #11) of 19 patients. Findings: On 08/07/24 at 9:00 a.m., the OSDH surveyor entered the residential care facility (Nursing Home, name withheld). Hospice home charts (binders) were reviewed for two (Patients #8 and 9); and Patient #11 had no hospice home chart (binder). At 9:20 a.m., NH staff A stated the hospice was supposed to leave written reports (communication sheets) after each home visit for all patients on their services. Patient #8 A review of the NH hospice chart (binder) showed documentation of the last POC update by the IDG was dated 01/10/24. Documentation showed the last written report of care by the hospice was dated 05/09/24. A review of a POC dated 06/13/24 to 08/11/24 with IDG updates on 06/26/24, 07/10/24 and on 07/24/24 showed orders for SN visit frequency of one week one, then two times a week for eight weeks; aide visit frequency of one week one, then two times a week for eight weeks; chaplain visit frequency of one time a week for eight weeks and a MSW visit frequency of one time a month for two months for palliation and management of terminal illness related to breast cancer. Documentation showed no IDG communications or coordination of care with the residential care facility (Nursing Home, name withheld). On 08/07/24 at 1:55 p.m., Staff A stated documentation showed no IDG communications or coordination of care with the residential care facility (Nursing Home) for patient #8. Patient #9 A review of the NH hospice chart (binder) showed documentation of the last POC update by the IDG was dated 01/17/24. Documentation showed the last written report of care by the hospice was dated 02/28/24. A review of a POC dated 06/18/24 to 09/15/24 with IDG updates on 06/20/24, 07/17/24 and 07/31/24 showed orders for SN visit frequency two times a week for eight weeks, ten one week one; aide visit frequency of two times a week for eight weeks, then one week one; chaplain visit frequency of one time a month for two month and a MSW visit frequency of one time a month for two months for palliation and management of terminal illness related to hypertension with heart disease. Documentation showed no IDG communications or coordination of care with the residential care facility (Nursing Home, name withheld). On 08/07/24 at 2:02 p.m., Staff A stated documentation showed no IDG communications or coordination of care with the residential care facility (Nursing Home) for patient #9. Patient #11 NH hospice chart (binder) was requested. NH had no hospice chart (binder) and showed no documentation of the POC or last update by the IDG and no written report of care (communication sheets) by the hospice. A review of a POC dated 06/18/24 to 09/15/24 with IDG updates on 06/20/24, 07/17/24 and 07/31/24 showed orders for SN visit frequency two times a week for eight weeks, ten one week one; aide visit frequency of two times a week for eight weeks, then one week one; chaplain visit frequency of one time a month for two month and a MSW visit frequency of one time a month for two months for palliation and management of terminal illness related to sarcopenia. Documentation showed no IDG communications or coordination of care with the residential care facility (Nursing Home, name withheld). On 08/07/24 at 2:15 p.m., Staff A stated documentation showed no IDG communications or coordination of care with the residential care facility (Nursing Home) for patient #11.”