Healthkeepers Hospice

“Observed in Record Review. In 2 of 5 patient records reviewed, the Surveyor observed that not all care required for the patients had been addressed in the Plan of Care (POC) with orders and interventions. For example, in RRHV#1 the clinician had been observed providing wound care to the left ball of foot; however, there had been nothing on the POC to address wound care. In RRNHV#2, the clinician documented the patient had signs and symptoms of a urinary tract infection and provided education on prevention. The clinician also documented that the family had contacted the primary physician (PCP) and a urinalysis had been ordered. The Clinician had not documented communication or order from the PCP in the patient record. This was validated with the Consultant assisting with the Documentation review.”

“Observed in Tracer Activities. The Surveyor reviewed the QAPI program last updated by the HCO December 2024. There is presence that performance improvement projects had been identified; however, there was no documented data collection available for the surveyor to review. This was validated with the QAPI Coordinator assisting with the Documentation review. Observed in Tracer Activities. The surveyor reviewed the QAPI program with the goals established and monitoring requirements. The HCO had not maintained documentation of the quality assessment and performance improvement program as the Director of Nursing position had been vacant since the middle of November 2024 and the Medical Director now taking responsibility had not documented completion of the tasks. This was validated with the QAPI Coordinator assisting with the documentation review and the Administrator.”

“Observed in Tracer Activities. Hospice core services were not provided by the organization on a routine basis. The Organization had a period of approximately 3 months where they had been without a Medical Social Worker to provide support to the patients. A new MSW had been hired as of February 2025; however, the period of time prior to this date had been without the needed services. In addition, the organization has been without a Spiritual Care Provider for the past 6 months without providing a replacement for spiritual services. This was validated with the Consultant assisting with the Documentation review and the Administrator.”

“Observed in Tracer Activities. The Surveyor reviewed 3 Bereavement Records and the program policies in place. At this time, there is no organized bereavement program in place as the Spiritual Care provider position has been vacant since October 2024. This was validated with the Administrator and Consultant. Observed in Tracer Activities. The Surveyor reviewed the Bereavement Program. The Spiritual Care Provider left the HCO employment in October 2024. There had been no one assigned to provide bereavement services since that time. The Medical Social Worker had been trying to assist, but did not have the qualifications according to HCO policy to provide bereavement services. This was validated with the Consultant assisting with the Documentation review.”

“Observed in HR File Review. In 2 of 2 HR files reviewed, the Surveyor noted Job duties assigned to employees who had not received documented training to complete. For example, in HR#1, the Medical Social Worker had been assisting with the Bereavement Program; however, she had not received any training to conduct such activities. In HR#2, the Medical Director had been assigned by the Governing Board to oversee the QAPI program. There had been no job description or competency completed with the new assigned duties. This was validated with the Administrator.”

“Observed in Record Review. In 1 of 5 patient records reviewed, The HCO has not been recording orders unless they are from their medical director. In RRNHV#2, the had a patient with symptoms of a Urinary Tract Infection (UTI). The family had called their PCP for a urinalysis. the clinician documented the signs and symptoms of the UTI and that the family had called their PCP and that a urinalysis had been ordered; however, there was no order to support obtaining the UA and in discussion, the HCO informed the surveyor that there is no process in place to capture orders from the non-hospice MD. They have not been obtaining orders from other MD’s.”

“Observed in Record Review. In 3 of 3 patient records reviewed, it was noted that the organization did not ensure that the plan of care goals included outcome measures for specific care activities. For example, during the review of the medical record for RRNHV#1, it was noted that the problem list included the following areas of concern: Poor appetite, Generalized debility, and Pain. The plan of care did not include goal statements to evaluate care, treatment, and services related to pain, generalized debility, and poor appetite. 

Example #2: A review of the medical record for RRNHV#2, revealed that the problem list included decreased cognition related to Alzheimer’s Dementia. The plan of care did not include a goal statement to evaluate care, treatment, and services related to Alzheimer’s Dementia. 

Example #3: A review of the medical record for RRNHV#3, revealed that the patient’s problem list included decreased cognition related to Dementia, nutritional deficit, and safety concerns related to potential for falls. The plan of care did not include goal statements to evaluate care, treatment, and services related to Dementia, nutritional deficit, and risk for falls. This observation was reviewed with agency leadership.”

“Observed in Record Review. In 3 of 15 patient records reviewed, the organization had not prepared a written plan of care. In the chart for RRNHV#10, there was no plan of care for the patient admitted one week prior to the survey. In the chart for RRNHV#8, the patient was assessed to be at high risk for pressure ulcers and had a non-pressure stage 3 wound upon admission. The RN documented care to the wound during the admission visit, however there was no order for wound care and no POC, despite the patient having been admitted more than 2 weeks before the survey. In the chart for RRNHV#6, the patient was admitted to the organization thirty-one days prior to the start of the survey, yet the patient did not yet have a plan of care as confirmed with the Director of Nursing.”

“Observed in Emergency Management Session. The organization had not developed a written staffing plan for managing all staff and volunteers based on the settings and services provided to meet patient care needs during the duration of an emergency or disaster incident or during a patient surge. The plan did not include the following: Methods for contacting off-duty staff; Use of volunteer staffing, such as staffing agencies, and those deployed as part of the disaster medical assistance teams. This was discussed with the Administrator. Observed in Emergency Management Session. The organization’s staffing plan did not address the management of all staff and volunteers as follows: Reporting processes; Roles and responsibilities for essential functions; Integrating staffing agencies, volunteer staffing, or deployed medical assistance teams into assigned roles and responsibilities; Verifying the identity and licensures of volunteer practitioners (such as nurses, respiratory therapists, physical therapists). This was discussed with the Administrator.”

“Observed in Emergency Management Session. The organization’s communications plan did not include a method for sharing and/or releasing location information and medical documentation for patients under the organization’s care to the following individuals or entities, in accordance with law and regulation: Patient’s family, representative, or others involved in the care of the patient; Disaster relief organizations and relevant authorities; Other health care providers. This was discussed with the Administrator. Observed in Emergency Management Session. The organization’s plan for providing patient care and clinical support did not include written procedures and arrangements with other health care providers for how it will share patient care information and medical documentation and how it will provide transportation to other health care facilities to maintain continuity of care. This was discussed with the Administrator.”

“Observed in Record Review. In 1 of 15 patient records reviewed, the hospice had not conducted and documented a patient-specific comprehensive assessment that identified the patient’s need for hospice care and services. The assessment did not include the patient’s need for physical, psychosocial, emotional, and spiritual care, including the following: Factors that alleviate or exacerbate physical symptoms. In the chart for RRNHV#8, the pain assessment in the comprehensive assessment failed to assess for quality of pain, alleviating factors, the patient’s pain goal, how the pain impacted his ability to perform ADL’s, etc. This was discussed with the Director of Nursing. Observed in Record Review. In 1 of 15 patient records reviewed, the hospice had not conducted and documented a patient-specific comprehensive assessment that identified the patient’s need for hospice care and services. In the chart for RRHV#2, there was no documented fall risk assessment. During the home visit, the patient had full bed rails present. This was discussed with the DON.”

“Observed in Record Review. In 12 of 12 patient records reviewed, for which a plan of care existed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for RRHV#2, there were no time frames associated with the anticipated achievement of patient goals of care. In the chart for RRHV#1, there were no goals on the current hospice plan of care. The RN created a pressure ulcer care plan with measurable, time based goals upon a change in the patient condition, however the care plan was not included on the hospice plan of care. In the charts for RRHV#3, RRHV#4, RRNHV#5, RRNHV#7, RRNHV#9, RRNHV#11, RRDC#12, RRDC#13, RRBR#14 and RRBR#15 while the care plans had goals, the goals did not have measurable time frames and had not been included on the POC. This was discussed with the DON.”

“Observed in Record Review. In 2 of 12 patient records reviewed, for which a plan of care existed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: A statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs. In the chart for RRHV#3, the POC did not include the four times weekly aide visits. In the chart for RRDC#12, the aide frequency of visits was not on the plan of care. This was confirmed with the Director of Nursing.”

“Observed in Record Review. In 9 of 12 patient records reviewed, for which a plan of care existed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: Medications and treatment necessary to meet the patient’s needs. In the chart for RRHV#1, the patient was assessed to be at risk for pressure ulcer development at the admission. The RN did documented education about pressure ulcer prevention and the patient was on pressure relief mattress during the home visit. These interventions however were not on the plan of care. The plan of care was not updated with orders for wound care once the patient developed a wound. The patient was assessed to be on oxygen during the admission assessment. The plan of care did not include any orders for oxygen. During the home visit, it was confirmed with the nursing facility staff that the patient was taking Benzonatate 200mg TID and Donepazil 10mg @HS, which were not on the Hospice POC. In the chart for RRHV#2, there were no orders for the site care to the G-tube provided during the home visit, nor were there orders for the free water that the patient receives daily via the feeding tube as verified with the nurse during the visit. In the chart for RRHV#3, the plan of care included the problem list, but no interventions. The oxygen order which was documented on the initial physician assessment was not on the POC; there was no order for the free water that the patient is receiving 4 times/day via the G-tube. The patient has a pressure reduction mattress, but the other interventions for pressure ulcer prevention do not appear on the POC. In the chart for RRHV#4, the patient was at risk for pressure ulcer development, falls and used oxygen. The care plan interventions for these identified problems/potential safety risks were not included on the POC. Additionally, the order for prn Novolin was incomplete as there was no specific indicator for when the prn dose should be given to the patient. In the chart for RRNHV#5, the physician documented an order for oxygen during his evaluation visit at the time of admission, however that oxygen order was not incorporated into the plan of care and was missing the frequency of administration. Additionally, the patient was as risk for pressure ulcers and a knowledge deficit related to oxygen safety. The interventions related to these treatments/potential problems were not included on the POC. In the chart for RRNHV#9, the there was no order for oxygen, nor interventions related to pressure ulcer risk reduction on the POC. In the chart for RRNHV#11, there were no treatment interventions on the plan of care for the bedbound patient with ALS. In the chart for RRDC#12, the patient was at high risk for pressure ulcer development, yet the interventions taught by the nurse and the physician in the documentation were not included on the POC. This was discussed with the Director of Nursing.
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“Observed in Record Review. In 2 of 15 patient records reviewed, the interdisciplinary group, in collaboration with the patient’s attending physician, if any, had not reviewed and revised the plan of care as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. No reviews were not documented in the chart for RRNHV#6 who was admitted to the organization approximately 30 days prior to the survey, and did not yet have an individualized plan of care. In the chart for RRNHV#8, the patient had been admitted 19 days before the chart review, yet there had been no review of the plan of care as there was not yet an individualized plan of care developed. This was discussed with the Director of Nursing.”

“Observed in Record Review. In 2 of 2 patient records reviewed, when the care of the patient was transferred to another Medicare/Medicaid-certified facility, the hospice had not provided the receiving facility with a copy of the hospice discharge summary and, if requested, a copy of the patient’s clinical record. In the charts for RRDC#12 and RRDC#13 a discharge summary was not provided to the receiving hospital. It was confirmed with the DON that there is not a process to do this when the transfer is initiated by the patient or family.”

“Observed in Record Review. In 1 of 15 patient records reviewed, when a verbal or electronic order was received, the individual who received it did not record and sign it immediately and did not have the prescriber sign it in accordance with state and federal regulations. In the chart for RRHV#1 approximately four months prior to the survey, the RN identified a new pressure ulcer and documented an order was received and care provided, however a verbal order was never documented and sent to the ordering physician. This was discussed with the Director of Nursing.”