St Luke’s Hospice

“Upon patient record review, 1 of 29 (Patient #24) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient # 24: RN documented phone call received from facility 12/01/23 (Friday). Facility stated that patient had developed rhonchi to his upper and lower lobes and that he now had a productive loose cough. Facility nurse requesting recommendation for attending to prescribe Mucinex and Hyoscyamine. Hospice nurse contacted hospice NP and subsequently advised facility nurse of NP recommendations. There was no follow up hospice nursing visit until 12/4/23 (Monday). During 12/04/23 SN visit, family informed nurse that facility PA had arrived to room prior to her visit and added another round of Prednisone. Nurse documented was unable to find PA or charge nurse in the building to discuss his plan of care. Family requested medication changes, nurse discussed, but not clear if those changes implemented that visit. SN documented patient to be comfortable during the RN visit. MSW Visit note 12/05/23: MSW documented that daughter ... was present for visit. She further documented that Patient was awake, however, did not respond to hospice team’s greeting or basic questions. Daughter reports that patient has been sleeping majority of time.... Hospice team provided safe space for her to openly express her concerns and wish to change hospice.... had bad weekend with chest congestion.... did not feel supported by hospice.”

“Upon patient record review, 1 of 29 (Patient #24) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient # 24: RN documented phone call received from facility 12/01/23 (Friday). Facility stated that patient had developed rhonchi to his upper and lower lobes and that he now had a productive loose cough. Facility nurse requesting recommendation for attending to prescribe Mucinex and Hyoscyamine. Hospice nurse contacted hospice NP and subsequently advised facility nurse of NP recommendations. There was no follow up hospice nursing visit until 12/4/23 (Monday). During 12/04/23 SN visit, family informed nurse that facility PA had arrived to room prior to her visit and added another round of Prednisone. Nurse documented was unable to find PA or charge nurse in the building to discuss his plan of care. Family requested medication changes, nurse discussed, but not clear if those changes implemented that visit. SN documented patient to be comfortable during the RN visit. MSW Visit note 12/05/23: MSW documented that daughter ... was present for visit. She further documented that Patient was awake, however, did not respond to hospice team’s greeting or basic questions. Daughter reports that patient has been sleeping majority of time.... Hospice team provided safe space for her to openly express her concerns and wish to change hospice.... had bad weekend with chest congestion.... did not feel supported by hospice.”

“Upon patient record review, 1 of 29 (Patient #24) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient # 24: RN documented phone call received from facility 12/01/23 (Friday). Facility stated that patient had developed rhonchi to his upper and lower lobes and that he now had a productive loose cough. Facility nurse requesting recommendation for attending to prescribe Mucinex and Hyoscyamine. Hospice nurse contacted hospice NP and subsequently advised facility nurse of NP recommendations. There was no follow up hospice nursing visit until 12/4/23 (Monday). MSW Visit note 12/05/23: MSW documented that daughter ...was present for visit. She further documented that Patient was awake, however, did not respond to hospice team’s greeting or basic questions. Daughter reports that patient has been sleeping majority of time.... Hospice team provided safe space for her to openly express her concerns and wish to change hospice.... had bad weekend with chest congestion.... did not feel supported by hospice.”

“Upon patient record review, 6 of 29 (Patient #6, 8, 9, 14, 19, 22) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 6: Patient admitted 12/29/23 with chronic/non-healing sacral wound. Wife performing wound care in home. There is no related problem, goals, interventions on plan of care. Patient #8: Patient admitted 12/21/23, with existing chin wound and heel blister. There are no related problems, goals, interventions on plan of care. Patient #9: Patient admitted 12/20/23 with portacath and colostomy (that he is able to manage). No related problems, goals, interventions on plan of care.. Patient #14 Patient admitted 12/06/23 with drain of liver abscess RUA. RN referenced order to flush drain with saline RUA in initial comprehensive assessment. Patient family managing flushes, but there were no related problems, goals, interventions on plan of care. Patient #19 Patient admitted with right chest drain. There are no related problems, goals, interventions on plan of care. Patient #22: Patient admitted 1/19/24. Has Tenckhoff drain, long term pleural drain, Foley catheter and sacral wound. There were no related problems, goals and interventions on plan of care.”

“Upon patient record review, 6 of 29 (Patient #6, 8, 9, 14, 19, 22) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 6: Patient admitted 12/29/23 with chronic/unhealing sacral wound. Wife performing wound care in home. There is no related problem, goals, interventions on plan of care. Patient #8: Patient admitted 12/21/23, with existing chin wound and heel blister. There are no related problems, goals, interventions on plan of care. Patient #9: Patient admitted 12/20/23. Had Portocath and colostomy (that he is able to manage) at time of admission. No related problems, goals, interventions on plan of care. Patient #14 Patient admitted 12/06/23 with drain of liver absess RUA. RN referenced order to flush drain with saline RUA in initial comprehensive assessment. Patient family managing flushes, but there were no related problems, goals, interventions on plan of care. Patient #19 Patient admitted with right chest drain. There are no related problems, goals, interventions on plan of care. Patient #22: Patient admitted 1/19/24. Has Tenckhoff drain, long term pleural drain, Foley catheter and sacral wound. There were no related problems, goals and interventions on plan of care.”

“Upon patient record review, 6 of 29 (Patient #1, 7, 11, 14, 17, 18) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1, 7, 11, 14: Initial spiritual frequency is 1 to 3 visits as needed. There is no base frequency and there is not update to frequency. Patients #17, 18: Admitted 2/3/24 and 2/2/24 respectively. IPU Records have no documented visit frequency for SN, HA, SC, MSW.”

“Upon patient record review, 7 of 29 (Patient #2, 6, 8, 10, 11, 14, 19) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2: 1/5/24 SN Visit note included documentation of wound care for BL Buttocks - cleanse with soap and water and apply zinc oxide every shift. There is no documented order for the zinc oxide in the hospice plan of care. Patient #6: Admitted 12/22/23. Initial SN assessment includes that Patient admitted with chronic sacral wound - wife has been managing at home. “Patient does have a sacral wound on his buttock area on the left interior side of his buttocks.. Patient is using wound cleanser, patted dry with 4x4 gauze, 2x2 silver Alginate and 4x4 foam dressing. Wound is 7 cm long 3 cm wide about 1 cm tunnel.” There is no documented order for wound care. Patient #8: Patient admitted 12/21/23, with existing chin wound and heel blister. Rx order for SilvaSorb Gel - Apply 1 dose topically every evening. Route apply externally. Zinc oxide Balmex = apply 1 app topically 2x/day. topically for skin protection Location and indications for neither are specified in order. Patient #10, 22: Zinc Oxide Balmex. Apply 1 app topically 2x/day topically for skin protection. Order does not include specific location. Patient #11: Initial order for oxygen at 3L. 1/15/24, O2 SN note documents that patient O2 was infusing at 6L with no order documented for increase at that time. Patient #14: Patient admitted 12/06/23 with drain of liver absess and SN initial comprehensive assessment documented “Noted order to flush drain with 10 cc saline RUA....Patient family managing flushes. Upon staff interview, the order was noted from pre-hospice care setting, but was not transferred/documented in hospice physician orders. Patient #19: Patient has long term pleural drain in place. There was a 6/4/23 order to drain Pleurix drain q 3 days up to 1 liter. The drain is “dry” at this point, but not removed. Interview with staff revealing the order to drain q 3 days should have been discontinued. SN documented pulmonary drain site cleaned (1/29, 1/31/24). There was no order specific to current site care.”

“Upon patient record review, 8 of 29 (Patient #2, 6, 8, 10, 11, 14, 19, 22) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2: 1/5/24 SN Visit note included documentation of wound care for BL Buttocks - cleanse with soap and water and apply zinc oxide every shift. There is no documented order for the zinc oxide in the hospice plan of care. Patient #6: Admitted 12/22/23. Initial SN assessment includes that Patient admitted with chronic sacral wound - wife has been managing at home. “Patient does have a sacral wound on his buttock area on the left interior side of his buttocks.. Patient is using wound cleanser, patted dry with 4x4 gauze, 2x2 silver Alginate and 4x4 foam dressing. Wound is 7 cm long 3 cm wide about 1 cm tunnel.” There is no documented order for wound care. Patient #8: Patient admitted 12/21/23, with existing chin wound and heel blister. Rx order for SilvaSorb Gel - Apply 1 dose topically every evening. Route apply externally. Zinc oxide Balmex = apply 1 app topically 2x/day. topically for skin protection Location and indications for neither are specified in order. Patient #10, 22: Zinc Oxide Balmex. Apply 1 app topically 2x/day topically for skin protection. Order does not include specific location. Patient #11: Initial order for oxygen at 3L. 1/15/24, O2 SN note documents that patient O2 was infusing at 6L with no order documented for increase at that time. Patient #14: Patient admitted 12/06/23 with drain of liver absess and SN initial comprehensive assessment documented “Noted order to flush drain with 10 cc saline RUA....Patient family managing flushes. Upon staff interview, the order was noted from pre-hospice care setting, but was not transferred/documented in hospice physician orders. Patient #19: Patient has long term pleural drain in place. There was a 6/4/23 order to drain Pleurix drain q 3 days up to 1 liter. The drain is “dry” at this point, but not removed. Interview with staff revealing the order to drain q 3 days should have been discontinued. SN documented pulmonary drain site cleaned (1/29, 1/31/24). There was no order specific to current site care.”

“Upon patient record review, 8 of 29 (Patient #2, 6, 8, 10, 11, 14, 19, 22) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2: 1/5/24 SN Visit note included documentation of wound care for BL Buttocks - cleanse with soap and water and apply zinc oxide every shift. There is no documented order for the zinc oxide in the hospice plan of care. Patient #6: Admitted 12/22/23. Initial SN assessment includes that Patient admitted with chronic sacral wound - wife has been managing at home. “Patient does have a sacral wound on his buttock area on the left interior side of his buttocks.. Patient is using wound cleanser, patted dry with 4x4 gauze, 2x2 silver Alginate and 4x4 foam dressing. Wound is 7 cm long 3 cm wide about 1 cm tunnel.” There is no documented order for wound care. Patient #8: Patient admitted 12/21/23, with existing chin wound and heel blister. Rx order for SilvaSorb Gel - Apply 1 dose topically every evening. Route apply externally. Zinc oxide Balmex = apply 1 app topically 2x/day. topically for skin protection Location and indications for neither are specified in order. Patient #10 and #22: Zinc Oxide Balmex. Apply 1 app topically 2x/day topically for skin protection. Order does not include specific location. Patient #11: Initial order for oxygen at 3L. 1/15/24, O2 SN note documents that patient O2 was infusing at 6L with no order documented for increase at that time. Patient #14: Patient admitted 12/06/23 with drain of liver abscess and SN initial comprehensive assessment documented “Noted order to flush drain with 10 cc saline RUA....Patient family managing flushes. Upon staff interview, the order was noted from pre-hospice care setting, but was not transferred/documented in hospice physician orders. Patient #19: Patient has long term pleural drain in place. There was a 6/4/23 order to drain Pleurix drain q 3 days up to 1 liter. The drain is “dry” at this point, but not removed. Interview with staff revealing the order to drain q 3 days should have been discontinued. SN documented pulmonary drain site cleaned (1/29, 1/31/24). There was no order specific to current site care.”

“Upon patient record review, 2 of 29 (Patient #2, 9) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient #2: SOC 12/28/23. 01/05/24 note includes buttocks wound with order to cleanse with soap and water and apply zinc oxide each shift. IDG Care Plan not updated with related problems, goals and interventions from updated assessment. Patient #9: SOC 12/19/23. Patient had CADD pump initiated for pain management 1/22/24. RN inadvertently included reference to subcu pain management, as opposed to portoacath access in related problems, goals and interventions for IDG Care Plan.”

“Upon patient record review, 2 of 29 (Patient #2, 9) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient #2: SOC 12/28/23. 01/05/24 note includes buttocks wound with order to cleanse with soap and water and apply zinc oxide each shift. IDG Care Plan not updated with related problems, goals and interventions from updated assessment. Patient #9: SOC 12/19/23. Patient had CADD pump initiated for pain management 1/22/24. RN inadvertently included reference to subcu pain management, as opposed to portocath access in related problems, goals and interventions for IDG Care Plan.”

“Upon patient record review, 2 of 29 (Patient #2, 9) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient #2: SOC 12/28/23. 01/05/24 note includes buttocks wound with order to cleanse with soap and water and apply zinc oxide each shift. IDG Care Plan not updated with related problems, goals and interventions from updated assessment. Patient #9: SOC 12/19/23. Patient had CADD pump initiated for pain management 1/22/24. RN inadvertently included reference to subcu pain management, as opposed to portocath access in related problems, goals and interventions for IDG Care Plan.”

“Upon patient record review, 5 of 29 (Patient #12, 13, 16, 17, 18) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #12: Assignment includes assist with bath and assist with shower. There is no statement addressing patient/CG’s cognitive ability. Patient #13: Assignment includes assist with bath and assist with shower. There is no statement addressing patient/CG’s cognitive ability. Patient #16: Assignment includes assist with bath and assist with shower. There is no statement addressing patient/CG’s cognitive ability. Patient #17, 18: Inpatient records do not include frequency of which tasks are to be performed. Agency has practices in place, example assessing/reporting baths are offered/provided daily, but not clearly assigned frequency in aide assignment.”

“Upon patient record review 4 of 29 (Patient #2, 4, 6, 7) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #2: HA assignment to provide assistance with bath, shampoo, dressing, apply lotion. bed linens, transfers. HA documented not needed 1/17/24 Patient #4: HA assignment to clean/tidy room and change linens. HA documented “not needed” for both 12/31/23 visit Patient #6: HA assignment for HA to encourage and offer fluid intake to patient, to assist shampoo and change linens. HA documented not needed for these tasks 1/12/24 Patient #7: HA assignment to clean/tidy room and change linens 1/23/24. HA documented not needed for these tasks 1/23/24”

“Upon observation, there was no evidence the hospice inpatient facility tests their power systems in accordance with NFPA 99 and NFPA 110 including the maintenance and testing of alternate power sources and transfer inspection and testing and maintenance and testing of circuitry. In compliance with 6.4.4.2 record keeping, a written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. The agency policy is to perform inspection of electrical outlets in all patient rooms annually, the agency is unable to provide written records of inspection for 2023, last performed inspection record was 3/1/22 and did not include room 14.”

“Upon observation, there was no evidence the hospice inpatient facility tests their power systems in accordance with NFPA 99 and NFPA 110 including the maintenance and testing of alternate power sources and transfer inspection and testing and maintenance and testing of circuitry. In compliance with 6.4.4.2 record keeping, a written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. The agency policy is to perform inspection of electrical outlets in all patient rooms annually, the agency is unable to provide written records of inspection for 2023, last performed inspection record was 3/1/22 and did not include room 14.”

“Upon observation, there was no evidence the building service equipment of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. Existing Construction In compliance with 19.7.8, portable space heaters are prohibited in all healthcare occupancies. During the inspection it was observed that a standing upright portable heater was located in the office of the nurse manager and underneath a desk. A second upright portable heater was located in the office of the nurse practitioner, also underneath a desk. Both offices are located within the protected smoke compartment of the facility. (Items removed prior to surveyor leaving the facility.)”

“Upon observation, there was no evidence the hazardous areas of a facility are provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. Existing Construction In accordance with 19.3.2.6 dispensers shall not be installed over an ignition source. During the inspection of the facility it was observed in room 14 that an ABHR dispenser is secured to a wall that is directly above an electrical outlet, an ignition source. (Corrected prior to surveyor leaving the facility.)”

“Upon observation, there was no evidence the hazardous areas of a facility are provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. In compliance with 19.7.8, portable space heaters are prohibited in all healthcare occupancies. During the inspection it was observed that a standing upright portable heater was located in the office of the nurse manager and underneath a desk. A second upright portable heater was located in the office of the nurse practitioner, also underneath a desk. Both offices are located within the protected smoke compartment of the facility. (Items removed prior to surveyor leaving the facility.) In accordance with 19.3.2.6 dispensers shall not be installed over an ignition source. During the inspection of the facility it was observed in room 14 that an ABHR dispenser is secured to a wall that is directly above an electrical outlet, an ignition source. (Corrected prior to surveyor leaving the facility.)”