Abounding Hospice Care Inc.

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 4 (25%) home visits observed revealed that the agency did not ensure that the patient had an accurate and updated mediation profile available in the home. Home Visit 1: The election of the hospice benefit was on 11/03/2023. During the home visit observation with Registered Nurse (Personnel Record 2) on 1/18/2024 it was revealed that the agency did not ensure that patient had an updated medication profile. The initial comprehensive assessment was on 11/03/2023. The medication profile in the home dated 11/16/2023 listed that the patient was currently taking Acetaminophen, Albuterol Sulfate, Amlodipine, Atorvastatin, Atrovent HFA, Brimonidine Tartrate-Timolol, Carbamide, Diclofenac, Lidocaine patches, Metoprolol, Oxygen, Tramadol, and Vitamin B12. In an interview with the patient’s daughter who is his primary caregiver, she stated the patient is only taking Metoprolol Succinate ER 200mg by mouth once a day, Benazotate 100mg by mouth three times a day as needed for cough, Atorvastatin 80mg by mouth once a day, and Tramadol HCI 50mg by mouth every 8 hours as needed for pain. During the interview with the nurse, he did not deny that the patient was only taking these four medications. There was no documented evidence of a medication profile update since 11/16/2023.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene, and other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review and observation. In 1 of 3 (33%) home visit observed revealed that the agency did not ensure hand hygiene was performed in accordance with agency policy. Agency policy IC.15 Hand Hygiene states in part, “All Hospice staff providing patient care will perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendations.” “Staff may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situations described; 1. Prior to initial entry into supply bag. 2. Immediately touching a patient. 6. After touching a patient or the patient’s immediate environment. 8. After removing gloves.” Home Visit 1: During the home visit observation with Registered Nurse (RN) (Personnel Record 2) on 1/18/2024, the RN was observed reaching into the supply bag and begin patient care without performing hand hygiene before providing care or after removing gloves per agency policy. Agency policy IC.15 Hand Hygiene states in part, “All Hospice staff providing patient care will perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendations.” “Staff may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situations described; 1. Prior to initial entry into supply bag. 2. Immediately touching a patient. 6. After touching a patient or the patient’s immediate environment. 8. After removing gloves.””

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered, and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) bereavement clinical records reviewed revealed that the agency did not follow the bereavement plan of care as written. Clinical Record 12: The election of the hospice benefit was on 04/05/2023 with a date of death as 04/16/2023. A review of the bereavement plan of care identified that a letters were to be sent on 8/18/2023, 11/10/2023; and a phone call on 11/12/2023. There was no documented evidence that any of these tasks were completed. In an interview with the Director of Clinical Services she agreed that the bereavement plan of care had not been followed appropriately.”

“It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by interview and document review. The Hospice Policy HR.19 stated, in part: “The hospice will document and demonstrate viable and ongoing efforts and ongoing efforts to recruit and retain volunteers.”. The Volunteer Coordinator, who is also the Administrator, stated during the interview on 01/19/2023 that they have not documented any recruitment efforts or retention since 2020. During review of the volunteer program there were only blank dated tracking sheets. No data or information had been entered pertaining to recruitment or retention. There was a performance improvement plan in place with no evidence that any efforts had been made toward improving. This standard was not met as evidenced by an interview on 1/19/2024 with the Administrator/Volunteer Coordinator and review of the hospice policy. The Hospice Policy HR.19 stated, in part: “The hospice will document and demonstrate viable and ongoing efforts and ongoing efforts to recruit and retain volunteers.”. The Volunteer Coordinator who is also the Administrator and CEO stated that they have not documented any recruitment efforts or retention since 2020. During review of the volunteer program there were only blank dated tracking sheets. No data or information had been entered pertaining to recruitment or retention. There was a performance improvement plan in place with no evidence that any efforts had been made toward improving.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. Documentation includes 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. This standard was not met as evidenced by an interview on 1/19/2024 with the Volunteer Coordinator/Administrator. A review of the Agency volunteer program revealed there was no documentation of volunteer hours worked or cost savings. The Volunteer Coordinator/Administrator stated that they have not documented any volunteer activities in 2022 or 2023 due to it being so hard to find volunteers. This standard was not met as evidenced by an interview on 1/19/2024 with the Volunteer Coordinator/Administrator and review of the documented volunteer program in which there was no documentation of volunteer hours worked or cost savings. The Volunteer Coordinator/Administrator stated that they have not documented any volunteer activities in 2022 or 2023 due to it being so hard to find volunteers.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by interview and personnel record review. In 3 of 7 (43%) personnel records reviewed revealed that the agency did not ensure that competencies for direct care patient staff were completed Personnel Record 2: A review of the RN Case Manager, DOH 11/01/2022, personnel record on 1/19/2024 revealed no documented evidence of annual competencies for 2023. Personnel Record 3: A review of the Chaplain/Bereavement Coordinator, DOH 09/07/2018, personnel record on 1/19/2024 revealed no documented evidence of annual competencies for 2023. Personnel Record 4: A review of the Director of Nursing, DOH 10/15/2020, personnel record on 1/19/ revealed no documented evidence of annual competencies for 2023. In an interview on 1/19/2024 with the Director of Nursing, she stated that these competencies had not been completed due to her “being very busy.” She states, “I am doing several different jobs, and I just can’t get it all done.” She confirmed that the agency policy states and competencies for direct patient care employees be done at hire and annually.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) discharged clinical records reviewed revealed that there were no physicians’ orders for a patient discharge. Clinical Record 14: The patient elected the hospice benefit on 3/5/2022 with a diagnosis of chronic obstructive pulmonary disease. The patient was discharged on 9/26/2023 due to being medically stable. The RN documented that a visit was made to deliver and sign the notice of discharge on 9/21/2023. There was no evidence of a physician’s order for discharge found in the clinical record or and discussion of discharge in the IDT meeting. In an interview and joint review of the clinical record on 1/19/2024 with the clinical director she confirmed that that there was no physician’s order written.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident, the most recent hospice plan of care. This standard was not met as evidenced by document review and interview. In 1 of 2 (50%) home visits in a nursing facility revealed that the agency did not ensure that the designated IDG member provided the most recent and updated plans of care. Home Visit 2: During a visit on 1/18/2024 to a skilled nursing facility with the social worker (Personnel Record 7), a review of the patient’s hospice information binder that is kept for communication with facility staff in the nursing area of the facility revealed was no evidence found that the agency had provided updated plans of care for the facility staff. The most current plan of care in the facility was dated 7/23/2023. During an interview with the Director of Nursing she stated she was not sure why these had not been updated. It is the hospice process for the staff to take out updated plans of care after every IDT meeting.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident, physician certification and recertification of the terminal illness. This standard was not met as evidenced by document review and interview. In 1 of 2 (50%) home visits in a nursing facility revealed that the agency did not ensure a copy of the physician recertification of the terminal illness for patient was provided to the nursing facility. Home Visit 2: During a visit on 1/18/2024 to a skilled nursing facility with the social worker (Personnel Record 7), a review of the patient’s hospice information binder that is kept for communication with facility staff in the nursing area of the facility revealed was no documented evidence that the agency had provided evidence of the recertification of terminal illness. The admission certificate of terminal illness was found, however no updates since the admission.”