Brighton Hospice

“Based on interview, record review, and agency policy review, the hospice agency failed to conduct bereavement risk assessments upon admission for three of 19 patients (Patient (P) 18, P10, and P14) whose records were reviewed. The failure placed survivors at risk of having unmet bereavement needs. Findings include: 1. Review of P18’s “Patient Face Sheet,” located under the “Patient Face Sheet” tab of the electronic medical record (EMR), revealed P18 was admitted to hospice services on 06/25/24 with a diagnosis of senile degeneration of the brain. Review of P18’s initial “Skilled Nursing Visit Note,” dated 06/25/24 at 11:15 AM and located in the “Visit Management” tab of the EMR, revealed, “. . . Bereavement Risk Assessment Risk Assessment completed: No. Reason Bereavement Risk Assessment not completed: Completed by social worker . . .” Review of P18’s initial “Chaplain Visit Note,” dated 06/26/24 at 1:20 PM and located in the “Visit Management” tab of the EMR, revealed no documented evidence that a bereavement risk assessment was completed. Review of P18’s initial “Medical Social Worker Visit Note,” dated 06/28/24 at 9:30 AM and located in the “Visit Management” tab of the EMR, revealed, “. . . Bereavement Risk Assessment Risk Assessment completed: No. Reason Bereavement Risk Assessment not completed: Completed by chaplain . . .” Review of P18’s “Visit Management” and “Clinical Documents” tabs of the EMR revealed no documented evidence of an initial bereavement risk assessment. 2. Review of P10’s “Patient Face Sheet,” located under the “Patient Face Sheet” tab of the EMR, revealed P10 was admitted to hospice services on 10/09/24 with a diagnosis of Alzheimer’s disease with late onset. Review of P10’s initial “Skilled Nursing Visit Note,” dated 10/09/24 at 2:20 PM and located in the “Visit Management” tab of the EMR, revealed, “. . . Bereavement Risk Assessment Risk Assessment completed: No. Reason Bereavement Risk Assessment not completed: Completed by chaplain . . .” Review of P10’s initial “Medical Social Worker Visit Note,” dated 10/10/24 at 11:30 AM and located in the “Visit Management” tab of the EMR, revealed, “. . . Bereavement Risk Assessment Risk Assessment completed: No. Reason Bereavement Risk Assessment not completed: Completed by chaplain . . .” Review of P10’s initial “Chaplain Visit Note,” dated 10/10/24 at 11:50 AM and located in the “Visit Management” tab of the EMR, revealed no documented evidence that a bereavement risk assessment was completed. Review of P10’s “Visit Management” and “Clinical Documents” tabs of the EMR revealed no documented evidence of an initial bereavement risk assessment. 3. Review of P14’s “Patient Face Sheet,” located under the “Patient Face Sheet” tab of the EMR, revealed P14 was admitted to hospice services on 02/22/24 with a diagnosis of hypertensive heart and chronic kidney disease with heart failure. Review of P14’s initial “Skilled Nursing Visit Note,” dated 02/22/24 at 9:00 AM and located in the “Visit Management” tab of the EMR, revealed, “. . . Bereavement Risk Assessment Risk Assessment completed: No. Reason Bereavement Risk Assessment not completed: Completed by chaplain . . .” Review of P14’s initial “Medical Social Worker Visit Note,” dated 02/26/24 at 12:00 PM and located in the “Visit Management” tab of the EMR, revealed, “. . . Bereavement Risk Assessment Risk Assessment completed: No. Reason Bereavement Risk Assessment not completed: Completed by chaplain . . .” Review of P14’s initial “Chaplain Visit Note,” dated 02/26/24 at 1:15 PM and located in the “Visit Management” tab of the EMR, revealed no documented evidence that a bereavement risk assessment was completed. Review of P14’s “Visit Management” and “Clinical Documents” tabs of the EMR revealed no documented evidence of an initial bereavement risk assessment. During an interview on 12/18/24 at 5:50 PM, the Chaplain/Bereavement Coordinator (C/BC) stated it was the responsibility of each discipline to complete a bereavement risk assessment when a patient was admitted to hospice services. The C/BC stated it was his/her responsibility to make sure those assessments were put into the chart. The C/BC stated a good bereavement program started with a risk assessment being completed on admission. During an interview on 12/20/24 at 2:16 PM, Social Worker (SW)1 stated it was the responsibility of all disciplines to perform a bereavement risk assessment when a patient was admitted to hospice services. SW1 stated there had been a policy change, and it “used to be just chaplains,” but now socials workers and nurses were supposed to complete the risk assessment. SW1 stated the initial bereavement risk assessment was supposed to occur at the time of the initial assessment. SW1 was asked what system was in place for monitoring to ensure the risk assessment was completed. SW1 stated, “We talk about it at IDG [Interdisciplinary Group); they are a topic of conversation.” During an interview on 12/20/24 at 4:23 PM, the Executive Vice President (EVP) stated the nurse was responsible for completing the bereavement risk assessment, and the C/BC was responsible for verifying that it was complete. The EVP stated the agency would know that the risk assessment was not done if a patient did not have a score. The EVP stated the process had changed to the nurses completing the assessment within the last two months, corporate training had occurred, and the policy had been updated to reflect the changes. The EVP was asked to provide documentation of an initial bereavement risk assessment for P18, P10, and P14.During an interview on 12/20/24 at 4:26 PM, the EVP stated, “I did not find any other findings regarding the missing bereavement assessments. I echo your findings.” Review of the agency’s policy titled, “Bereavement Assessment,” dated June 2022, revealed, “. . . An initial bereavement risk assessment will be completed by the registered nurse and/or the social worker at the time of admission to hospice . . . The local bereavement designee will review the bereavement risk assessment to determine potential needs of the survivors . . .””

“Based on interview, record review, and review of agency policy, the hospice agency failed to regularly monitor quality indicators so that opportunities for improvement could be identified and prioritized. This had the potential to cause unmet care needs for 66 of 66 active patients served by the agency. Findings include: On 12/18/24, upon entrance to the agency, the agency was asked to provide evidence of the Quality Assurance and Performance Improvement (QAPI) activities for the period of 12/15/23 through 12/15/24. On 12/20/24, the agency provided “QAPI Agendas” for the first, second, and third quarters of 2024. Each agenda was dated 10/16/24. Review of the agendas revealed:First quarter volunteer cost savings percentage – 2.5%Second quarter volunteer cost savings percentage – 1.92%Third quarter volunteer cost saving percentage – 1.35% There was no documented evidence that the agency had monitored quality indicators from 01/01/24 through 10/16/24. During an interview on 12/20/24 at 4:46 PM, the Executive Vice President (EVP) stated the agency’s policy was to have bi-annual QAPI meetings; however, the State of Oregon required quarterly QAPI meetings. The EVP stated the agency reviewed data from the second and third quarter together during the meeting on 10/16/24, and when they did, they revisited the first quarter data because the Medical Director had not been present for the original first quarter review. The EVP stated the agency was measuring, tracking, and analyzing data related to infections, falls, occurrences, live discharges, revocations, staffing, and volunteer percentages. The EVP stated a Performance Improvement Plan (PIP) had been created to increase the agency’s volunteer percentage rate to five percent. The EVP provided documentation on the PIP related to volunteer hours. Review of the PIP revealed the plan was not initiated until 12/01/24. Review of the agency’s policy titled, “Improving Organizational Performance,” dated May 2024, revealed, “. . . Purpose To establish a performance improvement framework, which integrates activities to improve organizational performance, improve patient outcomes, improve patient safety, and reduce the risks for acquisition and transmission of infections . . . Senior management with Governing Body oversight will . . . Adopt a structured framework for performance improvement. The problem solving approach will stress the interrelationship of quality services provided, management activities, and sound business practice”

“Based on interview and document review, the hospice agency failed to take actions to improve volunteer hours. The agency’s volunteer hours fell below the minimum requirement nine out of 11 months before the facility initiated a performance improvement plan (PIP). This had the potential to cause 66 of 66 active patients to have unmet needs. Findings include: Review of the hospice agency’s document titled, “Minutes from Brighton Hospice Eugene Governing Board Meeting,” dated 12/07/23 and provided by the Executive Vice President (EVP), revealed, “. . . Volunteer hours were reviewed and the site is aware we need to be ramping up hours to mee [sic] the 5% requirements after the PHE [Public Health Emergency] which ends 12/31/23 and the site is in survey window now . . .” Review of the hospice agency’s document titled, “Volunteer Time and Cost Savings 2024,” provided by the Director of Clinical Services (DCS), revealed the agency’s monthly volunteer hour percentages were: January – 4%February – 0.64%March – 2.87%April – 5.18%May – 0.33%June – 0.26%July – 0.51%August – 1.68%September – 1.86%October – 4.10%November – 2.72% This was an average volunteer hour percentage of 2.19% for January 2024 through November 2024. Review of the hospice agency’s document titled, “Performance Improvement Project (PIP) Team,” dated 12/01/24 and provided by the EVP, revealed a PIP was initiated regarding volunteer hour percentages. This was 11 months after the concern had been presented at the governing board meeting. During an interview on 12/20/24 at 4:46 PM, the EVP stated the agency had made some changes in the volunteer program and he/she was working closely with the new volunteer coordinator to bring the percentage up to 5%.”

“Based on observation, interview, record review, and review of the Oregon Board of Nursing scope of practice for Certified Nurse Assistants (CNAs), the facility failed to ensure aide services provided to one of four patients (Patient (P) 7) observed receiving care were provided per the aide’s scope of practice. This had the potential for the patient to have adverse outcomes when services provided were outside of the scope of practice. Findings include: Review of the Oregon Board of Nursing Frequently Asked Questions for CNAs, located at https://www.oregon.gov/osbn/pages/faqs_cna.aspx revealed, “. . . Q. May a CNA perform nail care for residents with diabetes or for those on anticoagulants? A. Possibly, if the nurse has determined the client’s circulation isn’t compromised and has made this assignment to the CNA. The CNA authorized duties include nail care of persons with uncompromised circulation. The nurse must determine when it is appropriate to assign nail care to the CNA based on the client’s condition and facility policies . . .” Review of P7’s “Patient Face Sheet,” located under the “Patient Face Sheet” tab of the electronic medical record (EMR) revealed P7 was admitted to hospice services on 10/04/24 with a diagnosis of unspecified severe protein-calorie malnutrition and a pertinent diagnosis of type 2 diabetes mellitus. Review of P7’s “Interdisciplinary Care Plan,” located under the “Clinical Documents” tab of the EMR, revealed a problem related to diabetes. Interventions included assessing skin integrity with special attention to the feet. Another problem was the need for assistance with activities of daily living (ADLs). It was recorded that the CNA could trim or file any long or uneven fingernails or toenails. Review of P7’s “Clinical Documents” and “Visit Management” tabs of the EMR revealed no documented evidence P7’s feet had been assessed for circulatory concerns. During a home visit on 12/19/24 at 2:35 PM, CNA1 was observed providing personal hygiene for P7. After P7’s shower, CNA1 clipped the patient’s great toenails using clippers. During an interview on 12/20/24 at 12:47 PM, Registered Nurse (RN) 1, who was the patient’s case manager confirmed responsibility for reviewing P7’s care plan. RN1 confirmed that P7 had diabetes. RN1 stated he/she did not know the agency’s policy on allowing CNAs to clip or cut the nails of patients with diabetes. RN1 stated, “I know it can be a little dicey. Sometimes I don’t like to do it myself, but it has to be done.” RN1 was asked if he/she had assessed the patient’s feet for circulatory concerns. He/she stated the staff were watching for edema. RN1 confirmed the care plan did task the CNA with trimming the patient’s toenails. RN1 confirmed he/she had not had a conversation with the CNA regarding trimming or clipping the patient’s nails. During an interview on 12/20/24 at 1:15 PM, CNA1 stated he/she did not know the patient had diabetes. CNA1 stated that if the patient was diabetic, nail care should not be included in the CNA care plan. CNA1 stated he/she did not believe that nail care for diabetics was within the scope of practice for a CNA. During an interview on 12/20/24 at 4:30 PM with the Director of Clinical Services (DCS) and Executive Vice President (EVP), the DCS stated the agency’s policy was that a CNA could trim and file nails. The EVP stated, “Once they get to clippers, that goes beyond the scope of an aide. In the case of a diabetic that would not be prudent.””

“Based on interview, record review, and policy review, the hospice agency failed to meet the volunteer needs for one of three patients (Patient (P) 10) reviewed for volunteer services out of a total sample of 19 when they did not develop and implement effective volunteer recruiting efforts. Findings include: Review of P10’s “Patient Face Sheet,” located under the “Patient Face Sheet” tab of the electronic medical record (EMR) revealed P10 was admitted to hospice services on 10/09/24 with a diagnosis of Alzheimer’s disease with late onset. Review of P10’s “Medical Social Worker Visit Note,” dated 10/10/24 and located in the “Visit Management” tab of the EMR, revealed, “. . . Volunteer Needs Assessment. Needs identified: Companionship Action Taken: Referral made for volunteer services . . . pt [patient] has been self-isolating in her room more often and usually does not accept offers to come out of her room and engage in activity with community members . . .” Review of P10’s “Visit Management” tab of the EMR revealed P10 was matched with a volunteer on 10/31/24 and received three volunteer visits during November 2024. Review of P10’s “Communication Note,” dated 12/12/24 at 10:34 AM and located in the “Communication Notes” tab of the EMR, revealed, “[P10]’s previous volunteer is no longer available . . . now waiting to be matched with a volunteer . . .” During an interview on 12/18/24 at 11:45 AM, the Volunteer Coordinator (VC) stated the agency had six active volunteers at present and 16 patients were on the waiting list for a volunteer. The VC was asked what volunteer recruitment efforts were in place. The VC stated the agency posted volunteer positions on Indeed.com and Volunteermatch.com and posted fliers on community bulletin boards monthly. The VC was asked if the agency used social media in an effort to recruit volunteers. The VC stated, “That’s something I’ve asked about.” The VC stated that someone else did Facebook and Instagram postings, and that had fallen into the realm of the marketing department. The VC stated the marketing department was not posting on social media for volunteers. During an interview on 12/20/24 at 4:46 PM, the Executive Vice President (EVP) stated he/she was working closely with the VC to enhance the agency’s volunteer recruitment efforts. Review of the agency’s policy titled, “Volunteer Staff,” dated May 2024, revealed, “. . . There will be active and ongoing efforts to recruit, train, and retain volunteers . . .””

“Based on interview, document review, and policy review, the hospice agency failed to have volunteer hours that equaled five percent of total patient care hours. This had the potential to cause 66 of 66 active patients to have unmet needs. Findings include: Review of the hospice agency’s document titled, “Volunteer Time and Cost Savings 2024,” provided by the Director of Clinical Services (DCS), revealed the agency’s monthly volunteer hour percentages were: January – 4%February – 0.64%March – 2.87%April – 5.18%May – 0.33%June – 0.26%July – 0.51%August – 1.68%September – 1.86%October – 4.10%November – 2.72% This was an average volunteer hour percentage of 2.19% for January 2024 through November 2024. During an interview on 12/18/24 at 11:45 AM, the Volunteer Coordinator (VC) was asked how the agency was performing in regard to meeting the minimum of 5% volunteer hours. The VC stated, “Sad.” The VC stated a vigil program had been started in October, and the percentage went up, but there had been no vigil visits recently. The VC stated there had been a shift in leadership in the office, and that had affected the percentage as well. During an interview on 12/20/24 at 4:46 PM, the EVP confirmed the agency’s volunteer hours fell below the minimum requirement of 5%. The EVP stated the agency had made some changes in the volunteer program and he/she was working closely with the new volunteer coordinator to bring the percentage up to 5%. Review of the hospice agency’s policy titled, “Documentation of Volunteer Utilization,” dated May 2024, revealed, “. . . The hours of volunteer services will exceed 5% of the total patient care hours of paid and contracted hospice personnel . . .””