Quality Care Hospice LLC

“Observed in Record Review. In 1 of 2 live discharged patient records, During D/C# 2’s patient record review it was noted the organization had not ensured it respected the patient’s right to elect to receive hospice care. For example: review of D/C# 2’s patient record revealed D/C# 2 transferred to the hospital and family requested a revocation. While the organization had a clear revocation process D/C# 2’s revocation form was unsigned in the patient record. This was reviewed, discussed, and validated with the Executive Director and Clinical Director. Observed in Record Review. In 1 of 2 live discharged patient records reviewed, During D/C# 1’s patient record review it was noted the organization had not ensured it respected the patient’s right to participate in decisions about their care, treatment, or services by not providing a Notice of Medicare Non-Coverage (NOMNC) at least two days prior to being discharged. For example: review of D/C# 1’s patient record revealed D/C# 1 was discharged due to no longer meeting the hospice criteria. Further review of D/C# 1’s patient record revealed a NOMNC that was signed one day prior to discharge. This was reviewed, discussed, and validated with the Executive Director and Clinical Director.”

“Observed in Record Review. In 20 of 20 patient records reviewed, During review of all the patient records it was noted the organization had not ensured the plans of care were based on the patient’s goals and time frames, settings, and services required to meet those goals. For example: Goals were not measurable and included Pain will remain at comfortable level during care, patient will achieve optimal sleep/rest, fall prevention will be maintained, patient will receive optimal teaching and support as cardiac and pulmonary function change, spiritual needs will be met as determined by patient/caregiver. This was reviewed, discussed, and validated with the Clinical Director and Executive Director.”

“Observed in Record Review. In 4 of 10 active patient records reviewed, During RRHV# 2, RRHV# 3, RRHV# 6, and RR# 4’s patient records review it was noted the organization had not ensured the plan of care included interventions to manage pain and symptoms. For example: review of RRHV# 2’s start of care registered nurse comprehensive assessment revealed RRHV# 2 was diabetic, had a below the knee amputation, and was on an oral hypoglycemic medication daily. However, the plan of care revealed no documentation of goals or interventions to asses/manage hypo/hyperglycemia. Review of RRHV# 3’s start of care plan of care revealed wound care to be completed by the nurse each visit. However, during RRHV# 3’s home observation the registered nurse and RRHV# 3’s spouse shared the spouse wound care was daily and the spouse completed the wound care when the days the nurse did not visit. During RRHV# 6’s home observation RRHV# 6 was observed with a red and swollen peri-anal area. The RN stated RRHV# 6 had diarrhea 1-2 weeks prior to the home visit and they had been applying Vaseline and it was getting better. Review of RRHV# 6’s plan of care revealed no documentation of Vaseline to be used in the peri-anal area. Review of RR# 4’s plan of care revealed an order to clean the sacral wound with wound cleanser and apply calcium alginate with no further order such as a cover to the wound. This was observed, reviewed, discussed, and validated with the Clinical Director.”

“Observed in Patient Home. In 3 of 10 active patient records reviewed, During RRHV# 3 and RRHV# 6’s home observations it was noted the organization had not ensured it provided care, treatment, or services in accordance with the patient’s individualized plan of care. For example: review of RRHV# 3’s plan of care during the home observation revealed wound care orders to clean the wounds with wound cleanser, apply hydrogel, and cover with secondary covering of choice. However, during the home observation the registered nurse (RN) was observed applying hydrogel and then Vaseline/petroleum gauze to the wounds and covered the wounds with a border dressing. During RRHV# 6’s home observation RRHV# 6 was observed to have a red, swollen peri-anal area and the RN shared RRHV# 6 had diarrhea 1-2 weeks prior to the surveyor home observation and they had been putting Vaseline on the area. However, review of RRHV# 6’s plan of care revealed an order for zinc oxide to be applied to the area dated approximately a month prior to the surveyor home observation. RRHV# 6’s caregiver shared they had been instructed to put the Vaseline on the area to help it heal. The This was observed, discussed, and validated with the Clinical Director. Observed in Record Review. In 1 of 10 active patient records reviewed, During RR# 1’s patient record review it was noted the organization had not ensured care and services were provided according to the plan of care. For example: review of RR# 1’s plan of care revealed a SN frequency of 2 times a week. Review of RR# 1’s patient record revealed SN visit 3 times a week when a Hospice Aide Supervisory visit was to be completed. This was reviewed, discussed, and validated with the Clinical Director.”

“Observed in Patient Home. In 4 of 6 home visits conducted, During RRHV# 1, RRHV# 3, RRHV# 5, and RRHV# 6’s home observations it was noted the organization had not ensured staff followed the organization’s policies Hand hygiene and Bag Technique that included cleaning hands prior to entering the supply bag. For example: during RRHV# 1 and RRHV# 3 the registered nurse (RN) was observed entering the supply bag with gloves and removed a watch then cleaned the watch with a wipe and with the same gloves used to clean the watch the RN entered the bag and removed the thermometer and cleaned and continued to remove each piece of vital sign equipment with the same gloves used to clean each piece of equipment. During RRHV# 5’s home observation the Hospice Aide (HHA) was observed cleaning the peri-anal area and then with the same gloves re-positioning the patient. Then the HHA was observed cleaning the penis and with the same gloves repostioning the patient. During HV# 6’s home observation the RN was observed with clean gloves and then unzipped the nurse bag removed clean items and then zipped the bag and with the same gloves unzipped the bag and removed more clean items and did not perform hand hygiene prior to entering the bag after touching the outside of the bag. This was observed with the Clinical Director, discussed, and validated.”

“Observed in Record Review. In 7 of 20 patient records reviewed, During RRHV# 2, RRHV# 4, RRHV# 5, RRHV# 6, RR# 1, RR# 2, RR# 4’s patient records review it was noted the organization had not ensured registered nurse who is a member of the interdisciplinary group and is responsible for the hospice aide supervision prepared complete written patient care instructions for the hospice aide. For example: the hospice aide provided care to RR# 4 prior to the RN creating the written patient care instructions. Review of RR# 4’s patient record revealed a hospice aide care plan dated the same day the surveyor reviewed the record. However, further review of RR# 4’ patient record revealed two hospice aide visits completed and documented prior to the surveyor review of the record. Review of RRHV# 2’s patient record revealed RRHV# 2 had oxygen. However, review of RRHV# 2’s hospice aide care plan revealed no documentation of oxygen. Review of RRHV# 4’s patient record revealed RRHV# 4 was admitted with a wound and a PEG tube. Further review of RRHV# 4’s patient record revealed a hospice aide care plan dated at the start of care of approximately five months prior to the surveyor review of the record that revealed no documentation of a wound or a PEG tube. During RRHV# 5’s home observation RRHV# 5 was observed using a VPAP with continuous oxygen and had a dressing on the sacrum. Review of the hospice aide care plan revealed no documentation of the VPAP and no directions regarding if the VPAP could be removed during care. Review of RRHV# 6’s patient record revealed RRHV# 6 had a PEG tube with swallowing precautions. However, review of RRHV# 6’s hospice aide care plan revealed no documentation of swallowing precautions or a PEG Tube. Review of RR# 1’s hospice aide care plan revealed the task under ROM [range of motion] both arms and legs with no indication if “passive” or “active” ROM was the task to complete. Review of RR# 2’s patient record revealed RR# 2 was on oxygen and had a wound. However review of RR# 2’s hospice aide care plan revealed no documentation of oxygen or wound. This was observed, discussed, and validated with the Clinical Director.”

“Observed in Patient Home. In 1 of 20 patient records reviewed, During RRHV# 5’s home observation the organization had not ensured the hospice aide followed the written patient care instructions/hospice aide care plan. For example: during RRHV# 5’s home observation the hospice aid removed RRHV# 5’s continuous oxygen via VPAP for the entirety of the bed bath and grooming. RRHV# 5’s family member put the VPAP back on when RRHV# 5’s color changed. Review of the hospice aide care plan revealed not instructions on whether the oxygen via VPAP could be removed during bathing and grooming This was observed, discussed, and validated with the Director of Clinical.”

“Observed in Record Review. In 4 of 10 active patient records reviewed, During RRHV# 2, RRHV# 4, RRHV# 5, RRHV# 6’s patient records review it was noted the organization had not ensured the registered nurse supervised the hospice aide during an on-site visit to the patient’s home no less frequently than every 14 days. For example: review of RRHV# 2, RRHV# 4, RRHV# 5, RRHV# 6’s patient records revealed multiple hospice aide supervisory visits that were completed over the telephone and not on-site at the patient’s residence. This was reviewed, discussed, and validated with the Clinical Director.”