Revelation Hospice

“Upon observation, there was no evidence the Emergency Preparedness plan: • Is based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach • Includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care The risk assessment is subjective and generalized and the related plans are not comprehensive in management of consequences, but rather offer 1-2 step actions per type of emergency. Ex. if the patient has flooding, we will arrange for other housing for the patient to move to.”

“Upon observation, there was no evidence of emergency preparedness training and testing program that is based on the emergency plan, policies and procedures and the communication plan. Day 3 of survey, Emergency Revelation Hospice Plan was provided to surveyor, including Revelation office staff practice for Emergencies, which stated The office staff and board members were trained on emergency preparedness for fire, power outages and hand sanitizer in the eyes on 11/1/24. See below for the general guidelines we educated staff and patients about. There is no mention of visiting clinical staff participation. There is no evidence of any sort of analysis of activity to facilitate mitigation.”

“Upon personnel record review, 4 of 13 (Personnel #3, 6, 7, 8 ) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training Personnel #3, 6, 7, 8: Although the agency’s orientation checklist includes emergency preparedness training, the staff interviewed, were unable to specifically recall training, verbalize their role in emergency preparedness and/or recall participation in any real time events or drill exercises in preparation for emergent event.”

“Upon patient record review, 1 of 15 (Patient #7) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #7: Upon home visit observation, the patient has Oxygen at bedside via NC; NP references Oxygen rate of 2-4LPM prn. Hospice medication profile does not include flow rate or frequency.”

“Upon patient record review, 7 of 15 (Patient #1, 3, 6, 10, 11, 13, 15) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: Admitted 11/24/24 with Alzheimer’s and comorbidities of GI bleed requiring hospitalization earlier in year, AFIB, hypertension, GERD, arthritis. Problems, goals, and interventions include only altered mental status, self care deficit and spiritual needs. No safety or pain identified. Patient #3: Notice of election and SOC docs state 1/5/25. But actual documents have signatures for 1/6/25 and effective date of 1/6/25 however, plan of care dated 1/5. Patient #6: Admitted 12/11/24 with Alzheimer’s and comorbidities of UTI, NIDDM, No related problems, goals, interventions related to the UTI, NIDDM, only altered mental status and falls are identified problems. Patient #10: Admitted 10/11/24 with dementia, comorbidities and secondary diagnoses of altered skin integrity and increasing wounds, UTI requiring antibiotic, and indwelling Foley catheter. There are no problems, goals, and interventions related to altered skin integrity, UTI, Foley catheter. Patient #11: Admitted 10/4/24 with Encephalopathy, comorbidities and secondary diagnoses of psychosis, sepsis, UTI and indwelling Foley catheter. Patient c/o neck and back pain during initial assessment. There are no problems, goals, interventions related to sepsis, UTI, Foley, pain. Patient #13: Admitted 7/1/23 with CVA and comorbidities and secondary diagnoses of coccyx and back wound, tube feedings, There are no problems, goals, and interventions related to tube feedings. Patient #15: Admitted 10/31/24 with Lymphoblastoma Lymphoma, cancer prostate, thyroid, bone metastasis and decubitus. Initial SN comprehensive assessment identifies pain as an active problem for patient. Pain is primarily associated with decubitus of back. The altered skin integrity problem, goals, and interventions do not address pain/discomfort.”

“Upon patient record review, 15 of 15 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15: SN, MSW, SC Discipline frequencies stated and PRN checked. PRN is not a detailed statement of the scope and frequency needed. Note, Patient #7 SN 1/wk and 2 PRN but other disciplines stated and PRN checked.”

“Upon patient record review, 8 of 15 (Patient #5, 6, 7, 10, 11, 12, 13, 15) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #5: Initial assessment references that patient has oxygen at bedside. 12/18/24 SN visit notes reference O2 at 2 LPM continuous and that sat drop 88% without oxygen. DME orders include Oxygen concentrator, but there are no orders for flow rate or frequency. Patient #6: Observed Oxygen in home but no order. Son states patient does not use, but it was provided. There is order for concentrator. Patient #7: 6/23/23 order for Oxygen prn pulse ox<92. There is no dose/flow rate specified. Patient #10: Patient/ALF resident admitted with wounds and Neosporin treatment per initial SN assessment. There is no order for Neosporin. 11/6/24 SN visit documents Oxygen at 2L/min. There is no order. 11/11/24 SN visit referenced order for foam dressing for sacral pressure ulcer. There is no order. Admitted with indwelling Foley catheter care and no related orders. Patient #11: Admitted with indwelling Foley catheter and no related orders. Patient #12: 5/11/24 SN note patient has Oxygen 5LM/NC . There is no documented order. Patient #13: 7/1/23 order for Oxygen for hypoxia PRN. There is no flow rate or frequency specified. Patient has tube feedings and wounds on coccyx and right back without evidence of orders. Patient #15: Patient has decubitus midback. There are no orders for treatment being performed by ALF.”

“Upon patient record review, 3 of 15 (Patient #1, 5, 9) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient #1: Admitted 11/24/24. 1/8/25 POC Narrative update includes that patient suffering from insomnia- medication adjustments (Seroquel dose improved), lower back pain related to arthritis and is bedridden, c/o dizziness when turns in bed, incontinent bowl and bladder, skin intact at this time. 12/24/24 note patient has periods of visual and auditory hallucinations. No updates to Plan of Care problems, goals, and interventions. Patient #5: Admitted 10/29/24. Experienced UTI 12/21/24 requiring antibiotic. No update to Plan of Care problems, goals, interventions Patient #9: Admitted 11/25/24. 12/9/24 visit note Patient c/o pain related to shingles. No update to Plan of Care problems, goals, interventions.”

“Upon client record review, 7 of 15 (Patient #1, 3, 5, 9, 10, 12, 13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, 10, 12: Patient POC include MSW frequency of once per month and PRN. There are no documented visits by MSW and there is no documentation that patient declined the discipline and/or that frequency was updated. Patients # 3, 5, 9, 10, 12: Patients’ POC include SC frequency of once per month and PRN. There are no documented visits by SC and there is no documentation that patient declined the discipline and/or that frequency was updated. Patient #13: 1/5/24 SN note references PEG tube and diabetic source bolus feedings 325cc every 8 hours. SN states checked residual and placement and performed wound care. There are no orders for nurse to perform residual and placement checks for tube or wound care coccyx or right back wounds.”

“Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #5: Hospice aide used book bag for medical equipment and supplies. She placed the bag on patient sofa and on floor without barrier of any sort. Patient #6: Hospice aide used book bag for medical equipment and supplies. She placed the bag on patient bed and floor without barrier of any sort. The aide checked patient oxygen saturation and blood pressure. She placed equipment on bed and then directly into front pocket of book bag after using on patient. When questioned, she said she cleans it when she gets to car. However, the equipment was removed from the same front pocket, as it was replaced therefore, mixing dirty with clean space.”

“Upon patient record review, 5 of 15 (Patient #10, 11, 12, 13, 14) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patients #10, 11, 12, 13, 14: While there is evidence of initial and post death bereavement assessment, there is not evidence of specific and individualized bereavement plan of care based on the bereavement assessment. There was evidence of phone calls/and or attempts, to bereaved.”

“Upon personnel record review, 1 of 13 (Personnel # 6) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #6: Upon initial personnel file review, day 2, aide competency assessment form was totally blank. Day 3, a competency form was provided for hospice aide, with 10/11/24 date of hire. The column for task observation date is completed with 1/3/25, but column for RN signature included the hospice aide’s initials, and the line for RN signature was also signed by hospice aide. CEO/Admin signed at bottom of page, dating his signature as 1/16/25.”

“Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78 There is no documentation provided regarding volunteer cost savings.”

“Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice as evidenced by the inability to provide evidence of employed roles of bereavement coordinator, volunteer coordinator, and volunteer nor a personnel with signed job description for Alternate Administrator. Agency unable to provide all levels of care to patients, specifically GIP/Respite. There is lack of agency oversight regarding emergency preparedness and QAPI, patient and employee infection control (TB and hepatitis for employees), ethical concerns, fiscal affairs, state regulations, and patient care planning and needs.”

“Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance There was no bereavement coordinator confirmed with job description or competency in personnel files. MSW, initially reported to be Bereavement Coordinator, denied that to be her responsibility during interview. There was evidence that she performed initial and post death bereavement assessments, but she assumed office staff followed up. She denied completing bereavement plan of care. A spread sheet of phone calls made was provided to surveyor, but there was very little detail and no comprehensive description of bereavement program. Atrium Medical Center, presented as General Inpatient Contract, is not specific to inpatient level of care for acute symptom management, but rather for routine level of care. The CEO / Administrator reports that the facility is an acute care facility and does not provide rehab or long term care. Furthermore, the contract presented was signed by agency CEO/Administrator however, no signature by facility representative.”

“Upon patient record review, 1 of 15 (Patient #3) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient’s life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient’s conditions unrelated to the terminal illness Patient #3: Certification statement has incorrect certification period of 1/5-4/4/25. Patient signed documents 1/6/25 with an effective date of 1/6/25.”

“Upon patient client record review, 7 of 15 (Patient #2, 3, 4, 8, 10, 11, 14) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #2: Patient requested hospice addendum. No documented evidence it was provided Patient #3: Notice of election and SOC docs state 1/5/25. But actual documents have signatures for 1/6/25 and effective date of 1/6/25. Patient #4: Patient requested hospice addendum. No documented evidence it was provided. Patient #8: Informed Consent/Election of Hospice form is signed with MD choice blank. Neither I choose or I decline is completed Patient #10: Patient documents signed by daughter and dated 10/9/24. Election effective date is left blank. SOC identified is 10/11/24 in record and SN assessment was performed that date. Requested addendum but no evidence it was provided. (has all 5 pages of consent) Patient #11: Election effective date is blank. (missing pages 2, 3, 4 of consent) Patient #14: Patient requested hospice addendum. No documented evidence it was provided”

“Upon patient client record review, 5 of 15 (Patient #1, 2, 3, 4, 12) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1: Admissions forms included revocation of election to hospice care form with patient/caregiver signature and dated 11/21/24. Patient #2: Revocation form signed by patient as part of admission paperwork, but not dated. 12/3/24 SN visit note states patient will be in SNF for respite 12/6-12/11/24. No other documentation in record related to stay/coordination. MSW 12/2 note did not contain respite documentation. The 11/27 IDG did not contain respite documentation. The 12/11/24 IDG repeats that patient will be in respite, but does not state if occurred. Staff unable to confirm. Patient #3: PRN visit 1/8/25: narrative begins with admitted inpatient for dyspnea and requires oxygen supplementation at all times. Staff verifies that patient was not actually inpatient. Patient #4: Admissions forms included revocation of election to hospice care form with patient/caregiver signature and no date. Patient #12: SN visit 5/11/24 with time of 9a-12p. There is no narrative at all to specify patient status, details of care provided. Patient passed away later that evening.”

“Upon personnel record review, 4 of 13 (Personnel #1, 3, 4, 5) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements that the Supervising Nurse and/or Alternate Supervising Nurse met the qualifications as outlined in Texas §558.244. Personnel #1: MD License expired 8/31/22. Current license provided during survey Personnel #3 RN license expired 2/31/22. Current license provided during survey Personnel #4: Licensed expired 11/30/23. Current license provided during survey Personnel #5: RN/NP license expired 1/31/22. Current license provided during survey”