Elara Caring

“Based on interview and record review, the agency failed to develop, establish, and maintain a comprehensive emergency preparedness program that complied with all applicable federal, state, and local emergency preparedness requirements in that: 1. The agency failed to complete an internal review of the plan at least annually, and after each actual emergency response, to evaluate its effectiveness and to update the plan as needed in 2022 and 2023. 2. The agency Administrator and Alternate Administrator failed to enroll in an emergency communication system in accordance with instructions from HHSC. These failures could place agency patients at risk of harm or not having their needs met during an emergency and/or disaster. Findings included: According to the Texas Administrative Code §558.256(j)(j) “;An agency must complete an internal review of the plan at least annually, and after each actual emergency response, to evaluate its effectiveness and to update the plan as needed”. According to the Texas Administrative Code §558.256(q)(1)(q) “;Emergency Response System (1) The agency administrator and alternate administrator must enroll in an emergency communication system in accordance with instructions from HHSC”. The Emergency Preparedness Plan reflected no evidence the agency conducted an annual review of the emergency preparedness plan for calendar year of 2022 and 2023, or after each actual disaster. The plan indicated an evaluation was completed 01/09/24, after an ice storm. There were no other evaluations of the EPP in the binder. The EPP gave no indication the Administrator or Alternate Administrator were signed up for the Emergency Preparedness Blackboard Connect Emergency Communication System. The EPP indicated the Alternate Administrator was the disaster coordinator. During an interview on 07/10/24 at 9:51 a.m., the Alternate Administrator said there was nothing for EPP prior to January. She said she started with the agency in January and there was nothing and she had to make a new folder. During an interview with the Alternate Administrator on 07/11/24 at 9:57 a.m., the surveyor asked the Alternate Administrator if she had enrolled in the Blackboard Connect Emergency Communication System in accordance with “Long-Term Care Regulatory Provider Letter” Number PL 22-32 sent out by Texas Health and Human Services to all provider types on November 28, 2022. The Alternate Administrator said she did not sign up for the blackboard emergency communication system because she didnt know she had to. She said she was not sure who at the agency signed up. During an interview with the Administrator on 07/11/24 at 11:28 a.m., the surveyor asked the Administrator if he had enrolled in the Blackboard Connect Emergency Communication System in accordance with “Long-Term Care Regulatory Provider Letter” Number PL 22-32 sent out by Texas Health and Human Services to all provider types on November 28, 2022. The Administrator said he was not signed up and had not heard anything about it. During an interview on 07/11/24 at 11:54 a.m., the Alternate Administrator said she did not know where the previous binder for EPP went. She said there was nothing else for EPP except what was in the book/binder. During an interview on 07/11/24 at 2:15 p.m., RN Case Manager C said she had not had to participate in EPP yet and she did not know of any disasters in the last 3 years. She said she had only been with the agency since March (2024). Record review of an Emergency Preparedness Plan policy dated 06/02/21 indicated “;1. Policy overview... the agency must conduct exercises to test the emergency plan at least annually, at least one of which will be a full-scale exercise that is community-based. The training and testing program will be reviewed and updated at least every 2 years. If the emergency preparedness policies and procedures are significantly updated, the home health agency will conduct training on the updated policies and procedures. The agency will maintain an emergency preparedness plan that is reviewed and updated at least annually... Emergency Preparedness Plan 1. The Agency will develop and maintain an emergency preparedness and response plan (EPP) which includes mitigation, preparedness, response and recovery... 10. The response and recovery phases of the plan must: A. The EPP will include a description of actions / responsibilities of agency Staff for each phase of the EPP, including mitigation, preparedness, response and recovery. Agency will include actions and responsibilities when warning of an emergency is not provided...” Record review of employee rosters provided by the agency did not indicate any current staff was with the agency in 2022 or 2023 except one hospice aide who was currently out on medical leave. The agency failed to provide documentation that the Administrator and the Alternate Administrator had enrolled in the emergency communication system in accordance with “Long-Term Care Regulatory Provider Letter” Number PL 22-32 sent out by Texas Health and Human Services to all provider types on November 28, 2022. Review of a December 2022 Winter Weather Overview accessed on 07/16/24 at https://www.tdem.texas.gov/disasters/december-2022-winter-weather indicated “;Extremely cold air mass shifted over Texas on December 22, 2022, causing temperatures to plummet across the state. Much of Texas endured temperatures below freezing - in some cases well below freezing - for dozens of hours. Wind chills below zero persisted across much of the northern half of the state through December 25, 2022. Most Texans faced frigid conditions through at least the morning of December 25, with morning lows around freezing on December 26 and December 27.””

“Based on interview and record review, the hospice failed to ensure all hospice care and services furnished to patients and their families followed an individualized written plan of care established by the hospice interdisciplinary group for 1 of 14 patients reviewed. (Patient #12) Patient #12 did not receive SN visits 1 time a week according to the POC. This failure could have led to needs being unmet at the end of life for Patient #12 and could place patients at risk of needs not met. Findings included: Record review of Patient #12s POC dated 02/08/24 to 04/07/24 indicated a SOC date of 02/08/24, and indicated she was 44 years old with diagnoses including malignant neoplasm of rectosigmoid junction (malignant tumor involving the rectum and sigmoid colon), secondary malignant neoplasm of right and left lung (lung cancer), secondary malignant neoplasm of genital organs, and secondary malignant neoplasm of liver (liver cancer). Record review of a POC Update Order for Patient #12 dated 04/08/24 to 06/06/24 indicated Patient #12 was ordered skilled nursing visits 1 time a week for 9 weeks effective 04/08/24. Record review of a Patient Calendar Report for Patient #12 dated 03/28/24 to 04/28/24 indicated Patient #12 was seen by a SN on 04/10/24 and then a SN death at home visit was completed on 04/28/24 (18 days later). The calendar did not indicate Patient #12 had any SN visits between 04/10/24 and 04/28/24. Record review of an IDG Summary Report for Patient #12 dated 04/08/24 indicated SN frequency was 1 time a week. The changes/declines since last IDG meeting indicated patient had needed increased pain medication secondary to advancing lung cancer with metastasis (spread) to liver. Patient noted increased fatigue over last two weeks. She noted spending a large portion of her time in bed sleeping. The plan for the next 2 weeks indicated monitor advancing pain. Record review of an IDG Summary Report for Patient #12 dated 04/22/24 indicated SN frequency was 1 time a week. The changes/declines since last IDG meeting indicated titrated patient Methadone (pain medication) to 50mg three times a day with Oxycodone 30mg every 4 hours as needed for breakthrough pain. The plan for the next 2 weeks indicated monitor for increased pain. Record review of a Discharge Summary Report for Patient #12 dated 04/28/24 indicated Patient #12 was discharged due to expired at home on 04/27/24 at 7:40 p.m. During an interview on 07/09/24 at 11:03 a.m., RN Case Manager C said patients were seen 1 time a week unless there was a significant change or infection. She said the POC would indicate 1 time a week and as needed. Attempted call to Patient #12s family member on 07/10/24 for interview, no answer. Surveyor left voicemail requesting return call. No return call was received. During an interview on 07/11/24 at 11:00 a.m., the Administrator/Supervising Nurse said visits went with frequency the case manager set. He said on initial admit the nurse would put out a calendar and scheduling and that was what the agency went by. The Administrator said acuity and needs determined increase in visits and visits could go up to daily at the end of life. During an interview on 07/11/24 at 11:15 a.m., the Administrator said the only reason visits would be done was if a patient refused but staff would try to reschedule, and the agency would try to adjust the frequency to match. He said there was no reason for a patient not to be seen at the end of life and the staff was usually out there daily unless a patient refused for privacy. He said at the end of life there were too many changes in a short time. The Administrator said Patient #12 was very young and passed away suddenly. He said the agency had started visits for 2 times a week then backed off to 1 time a week, then every other week. He said at that time the agency was seeing a decline, but it wasnt rapid that would need an increase in visits and there were no significant symptoms except uncontrolled pain relief. He said Patient #12 would cancel visits. During an interview on 07/11/24 at 11:19 a.m., the Administrator said Patient #12 would call and cancel visits up to 1 hour before. He said if a visit was canceled it would be documented in the system. He said pain control was Patient #12s primary complaint and it was pretty significant. The Administrator said Patient #12 would reach out to the agency if pain was increasing. He said Patient #12s family member called the agency and said patient went suddenly and was struggling to breathe. During an interview on 07/11/24 at 11:23 a.m., the Administrator said Patient #12 was seen every couple of weeks. He said she passed away suddenly. The Administrator said a decrease in frequency order should have been put in. During an interview on 07/11/24 at 11:30 a.m., the Administrator said in a patients calendar the SN plotted visit frequency. He said Patient #12 calendar it appeared she was being seen once every other week since the beginning of April then died 04/27/24. He said there had to be an order because the calendar frequency wouldnt have changed and there would have been missed visits. During an interview on 07/11/24 at 11:40 a.m., the Administrator said he was not seeing an order for decrease in visits on Patient #12. He said he did not think the calendar would change unless there was an order. The Administrator said the admitting nurse plotted visits and it would have been him for Patient #12. During an interview on 07/11/24 at 2:15 p.m., RN Case Manager C said visit frequency for patients were done upon admission and patients were ordered SN 1 time a week if a patient was not imminent (likely to occur at any moment) and if symptoms were controlled. She said a patient may not be seen every week if a visit wasnt assigned or if a patient requested not to be seen. She said if the order was put in for 1 time a week, the SN had to see patient 1 time a week. She said the patients calendar should reflect the frequency order. She said there was recently an incident where visits were not plotted due to a glitch in the system, so she had to notify her supervisor so they could schedule visits. RN Case Manager C said if a patient requested to be seen every other week, it had to be put in as a order because that was an ordered frequency and was put in as a physicians order. Record review of a Plan of Care policy dated 04/27/20 indicated “;1. Policy Overview: The care and services provided to patients and their families are in accordance with an individualized, written plan of care established by the hospice IDG in collaboration with the patients attending physician or allowed practitioner (if any), and, if appropriate, the patient and/or his/her representative... 6. Revisions to the plan of care are based on information from the patients updated comprehensive assessment and the patients progress toward outcomes specified in the plan of care...” Record review of a Plan of Care – Content policy dated 04/27/20 indicated “;...1. The patients plan of care includes all services necessary for the palliation and management of the terminal illness and its related conditions. 2. The plan of care includes, but is not limited to... b. a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs...””

“Based on record reviews and interviews, the hospice failed to ensure the licensed nurse, who received medication orders from the prescribing physician, recorded and signed the orders immediately upon receiving the orders so the prescribing physician could countersign the orders for 2 of 14 patients records reviewed. (Patient #1 & #4) 1. Patient #1s medical record did not include any orders for Oxycontin or Methadone (both pain medications). 2. Patient #4s medical record did not include any orders for Cephalexin (antibiotic). This failure could place patients at risk of medication errors or adverse reactions and prevented other agency staff members from being able to access information regarding the new medication orders. Findings included: Patient #1: Record review of Patient #1s POC dated 05/26/24 to 08/23/24 indicated a SOC date of 05/26/24, and indicated she was 62 years old with diagnoses including chronic obstructive pulmonary disease (causes airflow blockage and breathing), emphysema (lung disease that causes breathlessness), chronic right heart failure, anxiety disorder (feeling of fear, dread, and uneasiness), other chronic pain, long term (current) use of opiate analgesic (pain medications). The POC indicated Patient #1 was ordered skilled nursing visits 3 times a week for 1 week, then 2 times a week for 12 weeks. The POC included orders for the hospice nurse to instruct patient/caregiver on new and changed medications including purpose, length of therapeutic onset, schedule, importance of compliance, and side effects to report. Record review of an IDG Summary Report for Patient #1 dated 06/17/24 indicated pain continued to be controlled with Oxycontin. Record review of an IDG Summary Report for Patient #1 dated 07/01/24 indicated attempted to pivot to methadone but patient did not handle well, back to Oxycontin. Record review of Patient #1s Medication Report for active and discontinued medications dated 07/01/24 did not include any orders for Oxycontin or Methadone. Record review of Patient #1s medical record did not include any orders for Oxycontin or Methadone. Patient #4: Record review of Patient #4s POC dated 06/14/24 to 08/14/24 indicated a SOC date of 06/14/24, and indicated she was 92 years old with diagnoses including chronic obstructive pulmonary disease (causes airflow blockage and breathing), hypertension (high blood pressure), Alzheimers disease (progressive disease that destroys memory and other important mental functions), and history of urinary tract infections. The POC indicated Patient #4 was ordered skilled nursing visits 2 times a week for 1 week, then 1 time a week for 9 weeks. The POC included orders for the hospice nurse to instruct patient/caregiver on new and changed medications including purpose, length of therapeutic onset, schedule, importance of compliance, and side effects to report. Record review of a Patient Coordination Note Report dated 06/14/24 for Patient #4 by RN Case Manager C indicated MD ordered antibiotic upon admission due to UTI symptoms of odor, frequency, and urgency. The report indicated Keflex (name brand for cephalexin - antibiotic) 500mg 1 tablet by mouth twice daily for 10 days ordered. Record review of an Infection Report for Patient #4 dated 06/15/24 by RN Case Manager C indicated Patient #4 had a suspected site of infection for urinary with signs and symptoms including foul smelling urine, urinary frequency, and urinary urgency. The report indicated the antibiotic ordered on 06/15/24 was Cephalexin 500 mg tablet. Record review of Patient #4s Medication Report for active and discontinued medications dated 07/07/24 did not include any orders for Cephalexin. Record review of Patient #4s medical record did not include any orders for Cephalexin. During an interview on 07/11/24 at 10:45 a.m., the Administrator/Supervising Nurse said Patient #1 had been on Oxycontin since day 1 (SOC), and it was usually on the POC. The Administrator said the MD stopped the Oxycontin and put Patient #1 on Methadone to try. He said Patient #1 wasnt on Methadone long due to the costs, so it was stopped, and the patient was put back on Oxycontin. During an interview on 07/11/24 at 10:47 a.m., the Administrator said he did not see Oxycontin in Patient #1s medications or orders but he knew the doctor ordered it. During an interview on 07/11/24 at 10:49 a.m., the Administrator said the RN Case Manager would work with the doctor to get an order and was supposed to put the order in Home Care Home Base (electronic medical record) and send the order through. The Administrator said Patient #1 was his patient and it was his fault. He said he did not know why he wouldnt have put the order/medication in, and he must have missed it. The Administrator said a chart auditor was off site and audited 10 percent of charts. He said he thought they looked at orders and medications. He said the SN usually put orders in within 24 hours. During an interview on 07/11/24 at 10:59 a.m., the Administrator said medication lists were updated every visit and with changes. He said the missed mediation on Patient #1 would have been missed at the start of care and he must have missed it. He said the SN would get verbal orders and once the SN got a chance to put it in (the system), the SN would put the medication on the medication list. During a concurrent record review and interview on 07/11/24 at 11:00 a.m., Patient #1s orders were reviewed on iPrescribe (electronic system for prescribing medications) with the Administrator. The medication orders indicated an order dated 06/28/24 for Methadone 10mg tablet, 1 by mouth three times a day. Further review indicated an order for Oxycontin extended release 20mg tablets, 1 by mouth every 12 hours, 3 times a day, quantity of 42, start date 06/29/24 for 14 days. The Administrator said there was no way to print orders off iPrescribe. During an interview on 07/11/24 at 11:12 a.m., the Administrator said by not putting orders in other nurses would not be able to see the medication and order and it would affect the patient. He said by not updating the medication list any nurse following up may not know the patient and it could cause problems ordering medications or a patient being out of a medication because the nurse would not know the order was there. During an interview on 07/11/24 at 1:58 p.m., RN Case Manager C said when getting an order the SN would contact the doctor, tell him what was going on and see what his suggestion was, call the prescription into the pharmacy, and put the order in and profile the mediation with the start and stop date. She said she was not sure the time frame, but she put orders in when she received them, so she did not forget. She said there was 2 times last month she had to enter an order because it wouldnt go through when she had to order an antibiotic. RN Case Manager C said the supervisor (Administrator) asked her about an order and she told him she put it in 2 times, and she would put it in again. She said the Administrator said he couldnt review the medications. During an interview on 07/11/24 at 2:03 p.m., RN Case Manager C said if the order/medication was not in the system, the SN would have to go in and do an addendum. She said there were times the SN could enter “;stuff” and it may not take due to a glitch in the system. She said it was rare, but it had happened. RN Case Manager C said she charted the same day to increase accuracy and reduce errors. RN Case Manager C said when a patient was admitted, the medication list was reconciled and updated with any change in a medication, new medications, and updated. She said the medication list was reconciled at recertification of a patient. During an interview on 07/11/24 at 2:31 p.m., a facility representative for Patient #4 said on 06/17/24 Cephalexin 20 count (did not indicate dosage) was delivered to the facility for Patient #4. During an interview on 07/11/24 at 2:44 p.m. RN Case Manager C said a medication had to be entered 2 times or more, but she was unsure which patient it was on. She said during admission Patient #4 already had a prescription for the antibiotic (Cephalexin) but did not have the medication in the home/facility. She said the paper prescription was in the facility and she should have entered it into the medication profile. She said if she did not enter it, it was her fault, and she should have done it on admission and put the medication on the medication profile. RN Case Manager C said she would have contacted the doctor regarding the medication. She said the doctor had to read the admit note and signed off/okay medications. RN Case Manager C said it was her mistake for not adding the medication to the medication profile. Record review of a Physicians Orders policy dated 04/27/20 indicated “;... 3. Some of the reasons orders are obtained from physician or allowed practitioners include, but are not limited to: a. new medication, change in medication or discontinuance of medication... 4. Documentation of receipt of verbal orders and of written orders sent to the physician or allowed practitioner for signature is maintained in the patients clinical record. 5. When the signed order is returned, it is filed in the patients clinical record and the unsigned order is removed...” Record review of a Medications – Orders policy dated 12/17/20 indicated “;... 3. Verbal and signed orders for medications are documented in the patients clinical record and the medication profile is updated accordingly...” Record review of a Medications – Profile policy dated 04/29/21 indicated “;...A patient-specific medication profile is maintained for each patient and reviewed, at a minimum, every fifteen days. 2. Procedures: 1. When a patient is admitted to hospice, a medication profile is initiated to document all of the patient’s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. 2. The patients medication profile is reviewed by the IDG whenever there is a significant change and, at a minimum, every fifteen days...” Review of Cephalexin information accessed on 07/14/24 at https://medlineplus.gov/druginfo/meds/a682733.html indicated “;Cephalexin is used to treat certain infections caused by bacteria such as pneumonia and other respiratory tract infections; and infections of the bone, skin, ears, genital, and urinary tract. Cephalexin is in a class of medications called cephalosporin antibiotics. It works by killing bacteria...””