Sunrise Hospice

“Based on record reviews and interview, the hospice failed to ensure the Interdisciplinary Team (IDT) completed the patient’s initial comprehensive assessment within 5 days of the patient’s notice of election (NOE) for the hospice benefit for 1 of 14 patient charts reviewed. (Patient 11) Record review on 7/03/2024 at 10:36 AM of Patient #11 is conducted. Patient #11’s Notice of Election (NOE) was signed on 04/23/2024. Review of the chart revealed the Chaplain did not complete an initial comprehensive assessment until 04/29/2024, six days after the signed NOE. During an interview on 07/03/2024 at 11:30 AM, the Facility Administrator (FA) verified the findings. Facility policy, entitled “Admission to Hospice Care and Initial Assessment” states, “The hospice registered nurse will contact at least one other member of the interdisciplinary team (IDT) for input into the plan of care before the delivery of care. The two remaining core services must be contacted and provide input into the plan of care within two days of the start of care, either in person or by phone.””

“Based on observation, interview and record review, the hospice staff failed to provide and update the current medication list for 2 of 3 patient records reviewed. (Patient #5 and Patient # 9). Observations from 07/02/24 between 11:51 AM and 12:39 PM revealed inaccuracies in Patient #9’s hospice medication list. In an interview at 12:35 PM on the same day, the patient’s caregiver mentioned that Patient #9 takes Aspirin 81 mg orally three times a week, whereas the hospice medication list indicates Aspirin 81 mg is taken daily; Apixaban 2.5 mg is administered orally twice a day, but Apixaban is not included in the hospice medication list; Atorvastatin Calcium 80 mg is taken orally once a day, which is also not listed on the hospice medication list. The caregiver acknowledged the need to update the Aspirin dosage by stating, “I was supposed to call with updates to the Aspirin dose.” Findings included Observation on 07/02/24 from 10 AM to 11:15 AM showed Patient #5 hospice medication list with inaccuracies. During an interview on 07/02/24 at 11 AM, patient caregiver stated that Patient #8 taking amlodipine 5 mg tablet by mouth once a day, hospice medication lists amlodipine 10 mg tablet by mouth once a day; Metformin 500 mg 2 tablets by mouth twice a day, hospice medication lists metformin 500 mg 1 tablet by mouth twice a day.”

“Based on record review and staff interview, the Hospice facility did not establish defined goals for seven out of fourteen patient charts reviewed. (Patients #3, #4, #5, #10, #11, #12, and #13). The review of Patient 10’s medical record revealed the absence of Skilled Nurse (SN) goals in the Plan of Care (POC). The Administrator, during a 07/03/2024 interview at 12:30 PM, reported issues with the computer system’s importation of data. The examination of Patient 11’s medical record indicated missing SN goals in the POC for tracking interventions and patient progress. In an interview at 12:34 PM on 07/03/2024, the Administrator mentioned difficulties with the computer system’s data importation. The review of Patient #13’s medical record found no dated goals in the POC for the Interdisciplinary Team (IDT) to monitor interventions and patient progress. The Administrator, in a 12:36 PM interview on 07/03/2024, acknowledged problems with importing goals into the computer system. Review of Patient #3s medical record showed that there are no Skilled Nurse (SN) goals in the Plan of Care (POC). During an interview on 07/03/2024 at 12:15 PM, Administrator stated that there are problems with the computer system importing the dates. Review of Patient #4s medical record showed that there are no SN goals in the POC for the to measure interventions and patient progress. During an interview on 07/03/2024 at 12:17 PM, Administrator stated that there are problems with the computer system importing the dates. Review of Patient #5s medical record showed that there are no dated goals in the POC for the IDT to measure interventions and patient progress. During an interview on 07/03/2024 at 12:26 PM, Administrator stated that there are problems with the computer system importing the dates.”

“Based on interview and record review, the hospice Registered Nurse (RN) failed to provide specific instructions for patient care by the Certified Nurse Aide (CNA) for personal care for 11 out of 14 patient charts reviewed. (Patients #1, #2, #3, #4, #5, #6, #8, #9, #10, #11, and #12 ). Review of Patient #8 medical record on 07/02/24 at 8:30 AM showed that the Aide Plan of Care (POC) does not include a specific schedule for all assigned tasks and visit schedule with range of 2-3 visits each week. Ranges of visits schedule for the CNA are unacceptable. During an interview on 07/03/2024 at 12:36 PM, Administrator stated that problems with the computer system need to be fixed and educations is needed. Review of Patient #9 medical record on 07/02/24 at 2:23 PM showed that the the Aide Plan of Care (POC) does not include a specific schedule for all assigned tasks and visit schedule with range of 2-3 visits each week. Ranges of visits schedule for the CNA are unacceptable. During an interview on 07/03/2024 at 12:38 PM, Administrator stated that problems with the computer system need to be fixed and education is needed. Review of Patient #10 medical record on 07/03/24 at 9:30 AM showed that the Aide Plan of Care (POC) does not include a specific schedule for all assigned tasks and visit schedule with range of 1-2 visits each week. Ranges of visits schedule for the CNA are unacceptable. During an interview on 07/03/2024 at 12:36 PM, Administrator stated that problems with the computer system need to be fixed and education is needed. Review of Patient #11 medical record on 07/03//24 at 10:36 AM showed that the the Aide Plan of Care (POC) does not include a specific schedule for all assigned tasks and visit schedule with range of 1-3 visits each week. Ranges of visits schedule for the CNA are unacceptable. During an interview on 07/03/2024 at 12:40 PM, Administrator stated that problems with the computer system need to be fixed and education is needed. Review of Patient #12 medical record on 07/03/24 at 8:30 AM showed that the Aide Plan of Care (POC) does not include a specific schedule for all assigned tasks and visit schedule with range of 2-3 visits each week. Ranges of visits schedule for the CNA are unacceptable. During an interview on 07/03/2024 at 12:36 PM, Administrator stated that problems with the computer system need to be fixed and educations is needed. Findings included Review of Patient #1 medical record on 07/02/24 at 1:12 PM showed that the Aide Plan of Care (POC) does not include a specific schedule for all assigned tasks and visit schedule with range of 2-5 visits each week. Ranges of visits schedule for the CNA are unacceptable. During an interview on 07/03/2024 at 12:26 PM, Administrator stated that problems with the computer system need to be fixed and educations is needed. Review of Patient #2 medical record on 07/02/24 at 1:46 PM showed that the Aide POC does not include a specific schedule for all assigned tasks. During an interview on 07/03/2024 at 11:55 AM, Administrator stated that problems with the computer system need to be fixed and educations is needed. Review of Patient #3s medical record on 07/02/24 at 2:38 PM showed that the Aide POC does not include a specific schedule for all assigned tasks and visit schedule with range of 2-3 visits each week. Ranges of visits schedule for the CNA are unacceptable. During an interview on 07/03/2024 at 12:15 PM, Administrator stated that problems with the computer system need to be fixed and educations is needed. Review of Patient #4 medical record on 07/02/24 at 9:06 AM showed that the Aide POC does not include a specific schedule for all assigned tasks. During an interview on 07/03/2024 at 12:17 PM, Administrator stated that problems with the computer system need to be fixed and educations is needed. Review of Patient #5s medical record on 07/02/24 at 12 noon showed that the Aide POC does not include a specific schedule for all assigned tasks and visit schedule with range of 1-3 visits each week. Ranges of visits schedule for the CNA are unacceptable. During an interview on 07/03/2024 at 12:26 PM, Administrator stated that problems with the computer system need to be fixed and educations is needed. Review of Patient #6s medical record on 07/02/24 at 9:35 AM showed that the Aide POC does not include a specific schedule for all assigned tasks and visit schedule with range of 2-3 visits each week. Ranges of visits schedule for the CNA are unacceptable. During an interview on 07/03/2024 at 12:30 PM, Administrator stated that problems with the computer system need to be fixed and educations is needed. Findings include: Review of Patient #1’s medical record on 07/02/24 at 1:12 PM showed that the hospice aide Plan of Care (POC) does not include a specific schedule for all assigned tasks and the visit schedule contained ranges of 2-5 visits each week. During an interview on 07/03/2024 at 12:26 PM, the Administrator stated that problems with the computer system need to be fixed and education is needed. Review of Patient #2 medical record on 07/02/24 at 1:46 PM showed that the hospice aide POC does not include a specific schedule for all assigned tasks. During an interview on 07/03/2024 at 11:55 AM, the Administrator stated that problems with the computer system need to be fixed and education is needed. Review of Patient #3s medical record on 07/02/24 at 2:38 PM showed that the hospice aide POC does not include a specific schedule for all assigned tasks and the visit schedule contained ranges of 2-3 visits each week. Ranges of visits schedule for the CNA are unacceptable. During an interview on 07/03/2024 at 12:15 PM, Administrator stated that problems with the computer system need to be fixed and educations is needed. Review of Patient #4 medical record on 07/02/24 at 9:06 AM showed that the Aide POC does not include a specific schedule for all assigned tasks. During an interview on 07/03/2024 at 12:17 PM, Administrator stated that problems with the computer system need to be fixed and educations is needed. Review of Patient #5s medical record on 07/02/24 at 12 noon showed that the Aide POC does not include a specific schedule for all assigned tasks and visit schedule with range of 1-3 visits each week. Ranges of visits schedule for the CNA are unacceptable. During an interview on 07/03/2024 at 12:26 PM, Administrator stated that problems with the computer system need to be fixed and educations is needed. Review of Patient #6s medical record on 07/02/24 at 9:35 AM showed that the Aide POC does not include a specific schedule for all assigned tasks and visit schedule with range of 2-3 visits each week. Ranges of visits schedule for the CNA are unacceptable. During an interview on 07/03/2024 at 12:30 PM, Administrator stated that problems with the computer system need to be fixed and educations is needed. Review of Patient #8 medical record on 07/02/24 at 8:30 AM showed that the Aide Plan of Care (POC) does not include a specific schedule for all assigned tasks and visit schedule with range of 2-3 visits each week. Ranges of visits schedule for the CNA are unacceptable. During an interview on 07/03/2024 at 12:36 PM, Administrator stated that problems with the computer system need to be fixed and educations is needed. Review of Patient #9 medical record on 07/02/24 at 2:23 PM showed that the the Aide Plan of Care (POC) does not include a specific schedule for all assigned tasks and visit schedule with range of 2-3 visits each week. Ranges of visits schedule for the CNA are unacceptable. During an interview on 07/03/2024 at 12:38 PM, Administrator stated that problems with the computer system need to be fixed and education is needed. Review of Patient #10 medical record on 07/03/24 at 9:30 AM showed that the Aide Plan of Care (POC) does not include a specific schedule for all assigned tasks and visit schedule with range of 1-2 visits each week. Ranges of visits schedule for the CNA are unacceptable. During an interview on 07/03/2024 at 12:36 PM, Administrator stated that problems with the computer system need to be fixed and education is needed. Review of Patient #11 medical record on 07/03//24 at 10:36 AM showed that the the Aide Plan of Care (POC) does not include a specific schedule for all assigned tasks and visit schedule with range of 1-3 visits each week. Ranges of visits schedule for the CNA are unacceptable. During an interview on 07/03/2024 at 12:40 PM, Administrator stated that problems with the computer system need to be fixed and education is needed. Review of Patient #12 medical record on 07/03/24 at 8:30 AM showed that the Aide Plan of Care (POC) does not include a specific schedule for all assigned tasks and visit schedule with range of 2-3 visits each week. Ranges of visits schedule for the CNA are unacceptable. During an interview on 07/03/2024 at 12:36 PM, Administrator stated that problems with the computer system need to be fixed and educations is needed.”