1st Care Palliative and Hospice Services

“Based on review of policies/procedures, clinical record (CR) reviews and interview with the director the agency failed to ensure the comprehensive assessment included a review of all of the patient’s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. This includes, but is not limited to, identification of the following: (i) Effectiveness of drug therapy (ii) Drug side effects (iii) Actual or potential drug interactions (iv) Duplicate drug therapy (v) Drug therapy currently associated with laboratory monitoring for (10) ten of (10) clinical records reviewed. Review of policy Medications Profile on 3/6/24 at 1:00 PM states, “4. The patients medication profile review includes but is not limited to: b. monitoring medication effectiveness, actual or potential medication-related effects and untoward interactions...f. identifying duplicate drug therapy and drug therapy associated with laboratory monitoring.” Review of clinical records on 3/5/24 from 11:00 AM through 3:00 PM & 3/6/24 from 12:00 PM though 2:00 PM revealed the following: CR#1 Start of care 2/19/24, the patient’s medication profile review did not include identifying effectiveness of drug therapy, duplicate drug therapy and drug therapy associated with laboratory monitoring. CR#2 Start of care 2/1/24, the patient’s medication profile review did not include identifying effectiveness of drug therapy, duplicate drug therapy and drug therapy associated with laboratory monitoring. CR#3 Start of care 2/20/24, the patient’s medication profile review did not include identifying effectiveness of drug therapy, duplicate drug therapy and drug therapy associated with laboratory monitoring. CR#4 Start of care 3/19/22, the patient’s medication profile review did not include identifying effectiveness of drug therapy, duplicate drug therapy and drug therapy associated with laboratory monitoring. CR#5 Start of care 7/28/23, the patient’s medication profile review did not include identifying effectiveness of drug therapy, duplicate drug therapy and drug therapy associated with laboratory monitoring. CR#5 Start of care 2/19/24, the patient’s medication profile review did not include identifying effectiveness of drug therapy, duplicate drug therapy and drug therapy associated with laboratory monitoring. CR#6 Start of care 4/25/23, the patient’s medication profile review did not include identifying effectiveness of drug therapy, duplicate drug therapy and drug therapy associated with laboratory monitoring. CR#7 Start of care 10/10/22, the patient’s medication profile review did not include identifying effectiveness of drug therapy, duplicate drug therapy and drug therapy associated with laboratory monitoring. CR#8 Start of care 6/22/23, the patient’s medication profile review did not include identifying effectiveness of drug therapy, duplicate drug therapy and drug therapy associated with laboratory monitoring. CR#9 Start of care 12/6/23, the patient’s medication profile review did not include identifying effectiveness of drug therapy, duplicate drug therapy and drug therapy associated with laboratory monitoring. CR#10 Start of care 11/19/21, the patient’s medication profile review did not include identifying effectiveness of drug therapy, duplicate drug therapy and drug therapy associated with laboratory monitoring. Interview with the director during the clinical record reviews confirmed the above findings”

“Based on review of policies/procedures, clinical record (CR) reviews and interview with the director the agency failed to ensure a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs for (6) six of (10) clinical records reviewed CR# 1, CR#2, CR#4, CR#5, CR#6, CR#7 Review of policy Plan of Care on 3/6/24 at 2:00 PM states, “1. The patient’s plan of care specifies the care and services necessary to meet the needs of the patient/family as identified in the initial, comprehensive and updated assessment of the patient.” Review of clinical records on 3/5/24 from 11:00 AM through 3:00 PM & 3/6/24 from 12:00 PM though 2:00 PM revealed the following: CR#1 Start of care 2/19/24, the patient’s plan of care failed to include a duration for skilled nursing and social work visits. CR#2 Start of care 2/1/24, the patient’s plan of care failed to include a duration for skilled nursing, home health aide and social work visits. CR#4 Start of care 3/19/22, the patient’s plan of care failed to include a duration for skilled nursing, chaplain and social work visits. CR#5 Start of care 7/28/23, the patient’s plan of care failed to include any visits to be provided to the patient. CR#6 Start of care 4/25/23, the patient’s plan of care failed to include a duration for skilled nursing & home health aide visits. CR#7 Start of care 10/10/22, the patient’s plan of care failed to include a duration for skilled nursing & home health aide visits. Interview with the director during the clinical record reviews confirmed the above findings”

“Based on review of policies/procedures, clinical record (CR) reviews and interview with the director the agency failed to ensure that care and services are provided in accordance with the plan of care for (8) eight of (10) clinical records reviewed (CR#1, CR#2, CR#4, CR#5, CR#6, CR#7, CR#8, CR#10). Review of policy Plan of Care on 3/6/24 at 2:00 PM states, “1. The patient’s plan of care specifies the care and services necessary to meet the needs of the patient/family as identified in the initial, comprehensive and updated assessment of the patient.” Review of clinical records on 3/5/24 from 11:00 AM through 3:00 PM & 3/6/24 from 12:00 PM though 2:00 PM revealed the following: CR#1 Start of care 2/19/24, the patient’s plan of care failed to include a duration for skilled nursing and social work visits. CR#2 Start of care 2/1/24, the patient’s plan of care failed to include a duration for skilled nursing, home health aide and social work visits. CR#4 Start of care 3/19/22, the patient’s plan of care failed to include a duration for skilled nursing, chaplain and social work visits. CR#5 Start of care 7/28/23, the patient’s plan of care failed to include any visits to be provided to the patient. CR#6 Start of care 4/25/23, the patient’s plan of care failed to include a duration for skilled nursing & home health aide visits. CR#7 Start of care 10/10/22, the patient’s plan of care failed to include a duration for skilled nursing & home health aide visits. CR#8 Start of care 6/22/23, the patient’s plan of care included chaplain visits twice a month. There was no documentation that the chaplain made a visit to the patient in the month of January 2024. CR#10 Start of care 11/19/21, the patient’s plan of care included chaplain visits twice a month. There was no documentation that the chaplain made a visit to the patient in the month of January 2024. Interview with the director during the clinical record reviews confirmed the above findings”

“Based upon review of agency policy, home visits, and interview with the director, the agency failed to show evidence that infection control measures were followed for bag technique for one (1) one of (3) three home visits observed. (observation #3, employee #13). Review of agency policy on 3/7/24 at 11:00 AM titled “ Clinical Bag Technique” stated “ Procedure 2. Select a flat secure work surface to place bag and set up work area. Use discretion and consideration when placing bag on patient’s furniture, Never place bag on the floor.” Observation during home visit conducted on 3/7/24 at approximately 10:15AM revealed EMP # 13 had the clinical bag on the patient’s floor Interview with the director on 3/7/24 at approximately 11:00 AM confirmed above findings.”

“Based on a review of policies, clinical records (CRs), and interview with the director, the hospice failed to ensure that a registered nurse documented an on-site visit to the patient’s home no less frequently than every 14 days (two weeks) to assess the quality of care and services provided by the home hospice aide (HHA) for three (3) of four (4) CRs reviewed having home health aide services. (CR #8, CR#9, CR#10) Review of policy, “Hospice Aide Supervision” on 3/7/24 at approximately 1:00 PM states, “Hospice aides are supervised by a registered nurse in a manner and frequency that assures the safety of patients and the quality of aide services provided. n 1. A registered nurse makes an on site visit to the patient’s home no less than every 1 days to ensure that the services ordered by the IDG and provided by the hospice aide are meeting the patient’s need.” Review of clinical records on 3/5/24 from 11:00 AM through 3:00 PM & 3/6/24 from 12:00 PM though 2:00 PM revealed the following: CR#8 Start of care 6/22/23. Certification period reviewed 1/18/24-3/17/24. The registered nurse conducted skilled nursing visits on 1/19/24, 1/23/24, 1/26/24, 1/29/24, 2/2/24, 2/6/24, 2/9/24, 2/12/24, 2/14/24, 2/16/24, 2/20/24, 2/23/24 & 2/26/24. There was no documentation of a hospice aide supervision from 1/19/24 through 2/26/24 CR#9 Start of care 12/6/23. Certification period reviewed 12/6/23 through March 4, 2024. The registered nurse conducted skilled nursing visits on 2/1/24, 2/5/24, 2/8/24, 2/12/14, 2/15/24, 2/19/24 & 2/21/24. There was no documentation of a hospice aide supervision from 2/1/24 through 2/21/24 CR#10 Start of care 11/19/21. Certification period reviewed 1/8/23 through 3/7/24. The registered nurse conducted skilled nursing visits on 2/1/24, 2/5/24, 2/7/24, 2/9/14, 2/11/24, 2/13/2, 2/15/24, 2/17/24, 2/19/24, 2/22/24, 2/25/24, 2/28/24 & 3/1/24. There was no documentation of a hospice aide supervision from 2/1/24 through 2/21/24 3/1/24 Interview with the director during the clinical record reviews confirmed the above findings”

“Based on review of policies and procedures, personnel files and interview with the director, the hospice failed to provide orientation about the hospice philosophy to all employees and contracted staff who have patient and family contact for (3) three of (8) eight personnel (PF#4, PF#5, PF#8) Review of policy Orientation Program on 3/6/24 at 2:00 PM states, “Hospice provides an orientation program intended to ensure that all newly hired employees have the training and competency necessary to perform their jobs effectively. 1. All newly hired employees participate in an orientation program prior to providing patient care or assuming administrative responsibilities. 2. All employees are oriented to: a. the hospice philosophy of care.” Review of personnel files on 3/4/24 at 1:00 PM revealed the following: PF#4: Date of hire 12/18/23, there was no documentation this employee was oriented to the hospice philosophy of care. PF#5: Date of hire: 12/12/22, there was no documentation this employee was oriented to the hospice philosophy of care. PF#8: Date of hire: 2/1/11, there was no documentation this employee was oriented to the hospice philosophy of care. Interview with the director on 3/4/24 at approximately 2:00 PM confirmed the above findings”

“Based on review of policies and procedures, personnel files and interview with the director, the hospice failed to provide orientation that addresses the employee’s specific job duties for (3) three of (8) eight personnel (PF#4, PF#5, PF#8) Review of policy Orientation Program on 3/6/24 at 2:00 PM states, “Hospice provides an orientation program intended to ensure that all newly hired employees have the training and competency necessary to perform their jobs effectively. 1. All newly hired employees participate in an orientation program prior to providing patient care or assuming administrative responsibilities. 2. All employees are oriented to: a. the hospice philosophy of care....3. Patient care employees receive orientation appropriate to their job functions.” Review of personnel files on 3/4/24 at 1:00 PM revealed the following: PF#4: Date of hire 12/18/23, there was no documentation this employee was oriented to the employee’s specific job duties PF#5: Date of hire: 12/12/22, there was no documentation this employee was oriented to the employee’s specific job duties PF#8: Date of hire: 2/1/11, there was no documentation this employee was oriented to the employee’s specific job duties Interview with the director on 3/4/24 at approximately 2:00 PM confirmed the above findings”