Maple Creek Hospice

“Based on observations, record reviews, interviews, and policy reviews, the hospice agency failed to meet the Condition of Participation Interdisciplinary Group, Care Planning, and Coordination of Services. The agency failed to 1.) ensure that safety/physical, psychosocial, and spiritual needs were met for a patient; 2.) educate a patient and caregiver; 3) ensure care plans for patient problems were developed; and 4). obtain an order for speech therapy for a patient including scope and frequency of services. This deficient practice had the potential to affect all 14 patients receiving services from the hospice agency. Findings include: 1. The hospice agency’s interdisciplinary group (IDG) including nursing, social work, chaplain, and medical director failed to ensure the safety/physical, psychosocial, and spiritual needs were met for one of three home hospice patients. (Refer to L539). 2. The hospice agency failed to educate one of 10 active patients reviewed on oxygen use for shortness of breath. (Refer to L544). 3. The hospice agency failed to ensure that care plans for patient problems were developed for two of 10 active sampled patients. (Refer to L545). 4. The hospice agency failed to obtain an order for speech therapy to include the scope and frequency of services for one of 10 active patients reviewed. (Refer to L547).”

“Based on policy review, observations, CaringInfo website (National Alliance for Care at Home) review, and interviews, the hospice agency failed to ensure that a Do Not Resuscitate (DNR) or a Portable Orders for Life Sustaining Treatment (POLST) code status form used for Emergency Medical Service (EMS) was available in two of three (Patient (P) 8, and P10) observed home hospice patients. This deficient practice had the potential for patients to be given cardiopulmonary resuscitation (CPR) against the patient’s wishes of being a DNR. Findings include: Review of the agency’s policy revised 07/19/24 titled “Patient Rights,” indicated “Purpose: 1. To provide an atmosphere of respect and caring and to ensure that each patient’s ability and right to participate in medical decision making is maximized and not compromised as a result of admission for care, treatment and/or services to Maple Creek Home Health and Hospice Agency. 2. To ensure that the patients wishes about his/her care, treatment and services are respected in accordance with usual and acceptable standards of practice, ethics, and applicable law. 3. To assure compliance with the Patient Self-Determination Act (PSDA) and any other applicable laws, regulations, and standards.” 1. During an observation of P8’s home hospice visit performed by Registered Nurse (RN) 1 on 12/12/24 at 11:00 AM, it was revealed there was no DNR form located in P8’s home. During an interview at P8’s home on 12/12/24 at 11:30 AM, the Administrator2/Master of Social Work (MSW) 1 confirmed there was no DNR or POLST form located in P8’s home. Review of P8s medical record under the “;Misc.” tab reviewed a DNR form. 2. During an observation of P10’s home hospice visit performed by RN2 on 12/12/24 at 1:00 PM, it was revealed there was no DNR form signed by a physician located in P10’s home. Review of P10s medical record under the “;Misc.” tab reviewed a DNR form. During an interview at P10’s home on 12/12/24 at 1:20 PM, the Administrator2/MSW1 confirmed there was no signed DNR or POLST form located in P10’s home. Review of the “National Alliance for Care at Home,” (a program of the National Hospice and Palliative Care Organization (NHPCO) document titled “UTAH Advance Directive Planning for Important Healthcare Decisions,” https://www.caringinfo.org, revealed “Ambulance and hospital emergency department personnel are required to provide cardiopulmonary resuscitation (CPR) unless you have a separate physicians order, which are typically called “;prehospital medical care directives” or “;do not resuscitate orders.” DNR forms may be obtained from your state health department or department of aging . . . Another form of orders regarding CPR and other treatments are state-specific POLST. Both a POLST and a DNR form MUST be signed by a healthcare provider and MUST be presented to the emergency responders when they arrive. These directives instruct ambulance and hospital emergency personnel not to attempt CPR (or to stop it if it has begun) if your heart or breathing should stop beating.””

“Based on observations, record reviews, policy review, and interview, the hospice agency failed to refer two of three patients (Patient (P) 8 and P10) observed during home visits out of a total sample of 15 to a physical therapist for a safety assessment. This deficient practice had the potential to cause harm during transfers and ambulation to patients and caregivers. Findings include: 1. During an observation of P8’s home hospice visit, performed by a Registered Nurse (RN) on 12/12/24 at 11:00 AM, the patient’s family member informed us (two surveyors, RN, and (Administrator 2/Master of Social Work (MSW)1) that P8 had fallen 38 times in the past four years. Both P8 and P8’s spouse (the primary caregiver) were using a rollator when ambulating. There were multiple throw rugs in the home adding to the dangers of ambulating with a rollator. Review of P8’s “Plan of Care Order,” dated 12/10/24 and found in P8’s electronic medical record (EMR) under the “Care Plan” tab, indicated P8’s primary diagnosis was heart failure (can cause shortness of breath when ambulating) with comorbidities including orthostatic hypotension (blood pressure quickly drops upon standing and can cause dizziness or fainting), unspecified falls with subsequent encounters, macular degeneration (can cause difficulty seeing), overactive bladder (frequent and urgent need to urinate), and dementia. P8’s primary diagnosis and comorbidities contribute to increased falls during transferring and ambulating. Review of P8’s “Medications,” dated 12/10/24 and found in P8’s EMR under the “Care Plan” tab, indicated P8 was taking lorazepam (for anxiety and causes drowsiness), morphine (for pain or shortness of breath and causes drowsiness), methadone (for pain and causes drowsiness), and Eliquis (prevent blood clots and common side effects are bleeding). P8’s medications, except for Eliquis, may contribute to increased falls during transferring and ambulating. Due to the side-effect of increased bleeding with Eliquis, a fall can cause P8 to suffer uncontrolled bleeding. During an interview at P8’s home on 12/12/24 at 11:40 AM, the Administrator2/MSW1 revealed that a physical therapy consultation had not been requested and agreed that a physical therapy consultation for safety with transfers and ambulating was warranted for both P8 and P8’s caregiver. 2. During an observation of P10’s home hospice visit, performed by an RN on 12/12/24 at 1:00 PM, P10 was unable to get up out of the chair and transfer to the walker without assistance. The patient lived alone and had caregivers during portions of the day but not at night. Review of P10’s “Patient Profile,” dated 10/17/24 and found in P10’s EMR under the “Miscellaneous” tab, indicated P10’s primary diagnosis was hemiplegia and hemiparesis (loss of motor skills on one side of the body) following unspecified cerebrovascular disease (stroke) affecting the right dominant side. P10’s primary diagnosis may contribute to falls during transferring and ambulating. Review of P10’s “SN SOAP Visit,” dated 11/08/24 and found in P10’s EMR under the “Skilled Nursing” tab, indicated “[P10] continues to deny any pain, but you can physically see that walking with [his/her] walker is hard, and gets fatigued. [The hospice aide] explained that in the shower when [he/she] would help get him up, [P10’s] knees would almost buckle and would need to sit back down. [Aide] explained it’s getting harder to lift [P10] alone.” During an interview on 12/13/24 at 3:30 pm, the Administrator2/MSW1 confirmed that interventions, including a physical therapy consultation, should have been completed due to the hospice aide’s report of having increased difficulty transferring P10 in the shower. Review of the agency’s policy titled, “Coordination of Services for Hospice,” revised 11/2019, indicated, “ . . . Services will be integrated through various disciplines whether provided directly or under arrangement to assure the identification of the patient’s needs and factors that could affect patient safety and treatment effectiveness and the coordination of care by all disciplines. These services include but are not limited to, managing the patients’ schedules, management of pain during physical therapy or physical care, working with the patient to recommend and make safety modifications at home, assure that the staff who provide care are communicating any patient concerns and patient progress toward the identified goals with others involved in the care plan . . .””

“Based on record review, interview, and facility policy review, the facility failed to ensure the Interdisciplinary Group (IDG) meetings were held at least every 15 days to update the comprehensive assessment for five patients (Patient (P)1, P2, P3, P5 and P6) out of 15 patients reviewed for IDG meetings. This had the potential for the patients to experience unmet care needs. Findings include: 1. Review of P2’s physician “Order,” located in the electronic medical record (EMR) under the “Orders” tab, revealed P2 was admitted to Hospice services on 11/05/24 with a diagnosis of Alzheimer’s disease. Review of P2’s “Comprehensive Assessment,” dated 11/06/24 and located in the EMR under the “Assessment” tab, revealed the assessment was completed by the IDG members. Review of P2’s “IDG Meeting” notes, located in the EMR under the “IDG//Plan of Care (POC)” tab, revealed P2 had an “IDG Meeting” on 11/12/24. The next “IDG Meeting” was held on 12/05/24, more than 15 days after the meeting on 11/12/24. 2. Review of P5’s physician “Order,” located in the EMR under the “Orders” tab, revealed P5 was admitted to Hospice services on 11/11/24 with a diagnosis of Alzheimer’s disease. Review of P5’s “Comprehensive Assessment,” dated 11/11/24 and located in the EMR under the “Assessment” tab, revealed the assessment was completed by the IDG members. Review of P5’s “IDG Meeting” notes, located in the EMR under the “IDG/POC” tab, revealed P5 had an “IDG Meeting” on 11/12/24. The next “IDG Meeting” was held on 12/05/24, more than 15 days after the meeting on 11/12/24. During an interview on 12/13/24 at 11:45 AM the Administrator 2/Social Worker (MSW1) confirmed P2 and P5 had “IDG Meetings” on 11/12/24 and did not have another meeting until 12/05/24, which was more than 15 days after the first one. She stated they complete “IDG Meetings” every other Tuesday, and both P2 and P5 should have had “IDG Meetings” on 11/26/24. Review of the facility policy titled, “[Facility Name] Hospice Services,” revised 09/20/19 and reviewed 10/30/20, revealed, “. . . The IDT (interdisciplinary team) will consist of Medical Director, RN [Registered Nurse], SW [Social Worker], and counselor . . . The IDT will meet no less than every 15 days and more frequently if the patients care plan significantly changes . . .””

“Based on observation, record review, policy review, and interview, the hospice agency’s interdisciplinary group (IDG) including nursing, social work, chaplain, and medical director, failed to ensure the safety/physical, psychosocial, and spiritual needs were met for one of three (Patient (P) 10) observed home hospice patients. This deficient practice had the potential to adversely affect the patient’s quality of life. Findings include: During an observation of P10’s home hospice visit, performed by Registered Nurse (RN)2 on 12/12/24 at 1:00 PM, P10 was sitting in a chair in the living room and had right-sided paralysis and expressive aphasia (difficulty speaking). P10 was unable to get up and ambulate independently, was unable to prepare or retrieve food or beverages without assistance and was unable to take medications without assistance. P10 exhibited extreme frustration due to the inability to verbally communicate his/her needs. After several minutes of trying to verbally communicate something, the Administrator 2/Master of Social Work (MSW) 1 realized that the patient was saying the chaplain’s name. The chaplain had been visiting the patient weekly and had not visited for the last two weeks. The Administrator2/MSW1 then informed the patient that the chaplain had resigned from the company. The Administrator2/MSW1 informed the surveyor that the patient’s caregiver had recently passed away, leaving P10 with hired caregivers during the day, but the patient was alone at night. Review of P10’s “Patient Profile,” dated 10/17/24 and found in P10’s electronic medical record (EMR) under the “Miscellaneous” tab, indicated P10’s primary diagnosis was hemiplegia and hemiparesis (loss of motor skills on one side of the body) following unspecified cerebrovascular disease (stroke) affecting the right dominant side, aphasia (difficulty speaking), and dysphagia (difficulty swallowing). Review of P10’s “SN (skilled nurse) SOAP Visit,” dated 11/08/24 and found in P10’s EMR under the “Skilled Nursing” tab, indicated “[P10] continues to deny any pain, but you can physically see that walking with [his/her] walker is hard, and gets fatigued. [The hospice aide] explained that in the shower when [he/she] would help get him up, [P10’s] knees would almost buckle and would need to sit back down. [Aide] explained it’s getting harder to lift [P10] alone.” Review of P10’s “ST (speech therapy) Visit,” dated 11/08/24 and found in P10’s EMR under the “Speech Therapy” tab, indicated, “. . . The pt was referred for a ST treatment session to address speech intelligibility deficits . . .” Review of P10’s “IDG Meeting,” dated 11/26/24 and found in P10’s EMR under the “IDG” tab, indicated, “Patient is very difficult to understand and takes a lot of patients [sic] to understand what [he/she] is saying . . . Patient had an accident of bowel incident. Impaired functional status requires assistance with ADL’S [sic] and is not eating a lot.” There was no documentation indicating that the IDG meeting included discussions regarding a plan for P10 during the night-time hours, a plan for the patient to ensure medications are being taken, a plan for the patient and hospice aide’s safety during transfers, and a discussion with the speech therapist regarding a plan for the patient so the RN could ensure the patient was adhering to the speech therapists prescribed recommendations. During an interview on 12/13/24 at 11:00 AM, Administrator 2/MSW1 agreed that an in-dept IDG meeting, including registered nurses, social workers, and the Medical Director needed to take place to ensure P10’s safety, psychosocial, and spiritual, needs were met. Administrator2/MSW1 also advised that the patient was unable to read or write, and there were concerns of financial exploitation by family members. Review of the agency’s policy titled, “Interdisciplinary Group,” reviewed 10/30/20, indicated “PURPOSE: To identify/designate an interdisciplinary group or groups who will provide the care and services offered by hospice and to supervise the hospice care and services . . . The IDT (interdisciplinary team) will consist of a medical director, RN, SW, and counselor . . . Responsibilities Include but are not limited to: 1. Participate in the establishment of the plan of care. 2. Participate in the periodic review and updating the plan of care for each individual patient. 3. Responsible for coordinating and supervising hospice care and services . . . 6. Directing, coordinating, and supervising hospice care services . . . 9. Identifying obstacles to and solutions for access of care issues . . .””

“Based on record review, interview, and policy review, the hospice agency failed to educate one of 10 active patients (Patient (P) 8) reviewed for oxygen use for shortness of breath out of a total sample of 15 . This deficient practice had the potential for the patient to experience unnecessary symptoms. Findings include: Review of the agency’s policy titled, “Coordination of Services for Hospice,” revised 11/2019, indicated, “ . . . Ensure that each patient and caregiver when applicable receive ongoing education and training provided by the HHA as appropriate regarding the care and services identified in the care plan as well as education and training as necessary . . . “ Review of P8’s “Plan of Care Order,” dated 12/10/24 and found in the electronic medical record (EMR) under the “Plan of Care” tab, revealed a care plan entry for “shortness of breath.” Under the “activities” section of the care plan, the Registered Nurse (RN) documented the following: 02/20/24 - “RN educated patient to call RN if shortness of breath worsens.” 03/18/24, 03/20/24, and 03/25/24, -“Patient still has shortness of breath when ambulating.” 05/28/24 - “RN educated patient to call if she has chest pain, or if her dizziness and shortness of breath are severe and she needs an assessment.” 06/20/24 - “Patient has supplemental oxygen available.” 06/24/24 - “Patient has oxygen available for intermittent use.” 07/16/24 - “Patient has supplemental oxygen if needed.” 09/26/24 - “[P8] has oxygen available if needed.” 9/24/24 = “[P8] has oxygen and Morphine available.” 10/07/24, 10/22/24, and 10/29/24 - “[P8] has oxygen available if needed.” 11/19/24 - “[P8] has oxygen available for her shortness of breath if needed.” 11/26/24 - “[P8] had conversational dyspnea today.” There was no documented education on oxygen safety, when to use the oxygen, how to use the oxygen, and what liter flow to place the oxygen on. During an interview on 12/13/24 at 11:35 AM, the Administrator 2/Master of Social Work (MSW) 1 confirmed that the RNs did not educate P8 on oxygen safety, when to use the oxygen, how to use the oxygen, and what liter flow to place the oxygen on.”

“Based on policy review, record review, and interviews, the hospice agency failed to ensure that care plans for patient problems were developed for two of 10 (Patient (P) 8, and P10) active sampled patients. This deficient practice had the potential to adversely affect the patients quality of life. Findings include: Review of the agency’s policy titled “Care Planning (Plan of Care)” revised 10/01/19 indicated, “ . . . The plan of care is developed and individualized for each patient and family, reflects patient/family goals based upon problems identified in the initial/updated assessments and includes all services necessary for palliation and management of the terminal illness and related conditions.” 1. Review of P8’s “Plan of Care Order” dated 12/10/24 and found in P8’s Electronic Medical Record (EMR) under the “Care Plan” tab, under “DME (durable medical equipment),” indicated P8 had an oxygen concentrator in the home. Under “Problems,” there was no care plan developed for supplemental oxygen use. 2. Review of P10’s “Medication Profile,” found in P10’s EMR under the “Care Plan” tab indicated that nystatin cream was ordered on 10/01/24 for skin irritation/redness and triamcinolone cream was ordered for a yeast infection. Review of P10’s “Plan of Care Order,” found in P10’s EMR under the “Care Plan” tab indicated that a care plan was started on 01/19/24 for “skin irritation.” On 03/28/24, the Registered Nurse (RN) documented that the problem was “resolved.” During an interview on 12/12/24 at 3:30 PM, Certified Nursing Assistant (CNA)1 explained that he/she has been “placing cream on the patient’s [P10’s] groin daily because [he’s/she’s] reddened in the area.” During an interview on 12/12/24 at 1:20 PM, the RN2 stated, “the aide puts the cream on the patient’s perineum area after a shower. Review of P10’s “ST (speech therapy) Visit,” dated 11/08/24 and found in P10’s EMR under the “ST” tab, indicated the ST diagnosis was dysphagia (difficulty swallowing), aphasia (difficulty speaking), and apraxia (difficulty forming sounds). There was no care plan for speech therapy. During an interview on 12/12/24 at 3:00 PM, the Administrator (2)/Master of Social Worker (MSW)1 confirmed that a care plan for oxygen use should have been developed for P8. The RN should not have resolved the care plan for P10’s skin irritation, and there should have been a care plan developed for P10 for speech therapy.”

“Based on policy review, record review, and interview, the hospice agency failed to obtain an order for speech therapy to include the scope and frequency of services for one of 10 (Patient (P) 10) active patients reviewed. This deficient practice had the potential to adversely affect the coordination of care between the hospice disciplines. Findings include: Review of the agency’s policy titled “Clinical and Nursing” revised 01/2019 indicated, “To ensure patients receive care and treatments as ordered by a physician. Physician orders shall be incorporated into the plan of care. Physician orders may include: Dietary and nutritional requirements, medications, visit type and frequency, treatments, supplies and/or prognosis.” Review of P10’s “ST (speech therapy) Visit” dated 11/08/24 and found in P10’s Electronic Medical Record (EMR) under the “ST” tab, indicated the ST diagnosis was dysphagia (difficulty swallowing), aphasia (difficulty speaking), and apraxia (difficulty forming sounds). There was no physician’s order including scope and frequency of services for speech therapy. During an interview on 12/13/24 at 11:00 AM, the Administrator (2)/Master of Social Work (MSW) confirmed there were no orders, including the scope and frequency, for speech therapy.”

“Based on policy review, observation, record review, and interview, the hospice agency failed to meet one of three (Patient (P) 10) patient’s spiritual needs. This deficient practice had the potential to cause spiritual distress to the patient. Findings include: Review of the agency’s policy titled “Spiritual Care and Counseling Services” reviewed 10/30/20 indicated, “A qualified counselor will be available to the patient/family, hospice staff and volunteers, as needed, to assess and address their needs in minimizing the stress and problems that arise from the terminal illness, related conditions, and the dying process. This includes spiritual counseling to meet the spiritual needs of the patient and family.” During an observation of P10’s home hospice visit performed by Registered Nurse (RN)2 on 12/12/24 at 1:00 PM, P10 was sitting in a chair in the living room and had right-sided paralysis and expressive aphasia (difficulty speaking). P10 exhibited extreme frustration due to the inability to verbally communicate his/her needs. After several minutes of trying to verbally communicate something, the Administrator (2)/Master of Social Work (MSW 1 realized that the patient was saying the chaplain’s name. The chaplain had been visiting the patient weekly and had not visited for the last two weeks. The Administrator2/MSW1 then informed P10 that the chaplain had resigned from the company and there was no alternate plan offered to the patient. Review of P10’s “IDG (Interdisciplinary Group) Meeting” dated 12/5/24 and found in P10’s Electronic Medical Record (EMR) under the “IDG” tag indicated that P10 was ordered chaplain visits two to four times a month and four prn (as needed) visits were ordered. During an interview on 12/13/24 at 11:00 AM, Administrator2/MSW1 agreed that an in-dept IDG meeting, including registered nurses, social workers, and medical director needs to take place to ensure P10’s spiritual needs are met.”

“Based on policy review, documentation review, and interview, the hospice agency failed to ensure two of two nursing staff (Certified Nursing Assistants (CNA) 1 and CNA 2) received the required 12 hours of annual training. This deficient practice had the potential to cause harm to patients’ receiving CNA services. Findings include: Review of the agency’s policy titled “Home Health and Hospice Certified Nursing Assistant (CNA)” reviewed 10/30/20 indicated, “Complete 12 hours of training during a 12-month period that may occur while the aid is providing patient care, in person in services or through the UHPCO training website. Aid training will be done under the supervision of the D.O.N. [Director of Nursing] (Sec. 484.36) [name of hospice agency] will retain record of completed training for each aid that shows requirements of training have been met.” Review of the agency’s binder labeled “CNA Training” indicated that CNA1 and CNA2 received hospice aide training; however, there was no documentation of the number of hours it took to complete each training course. During an interview on 12/11/24 at 2:10 PM, the Administrator (2)/Master of Social Work (MSW) confirmed that there was no documentation indicating how many hours of training the CNAs receive annually.”

“Based on record review and interview, the agency failed to complete a discharge summary for two of two patients (Patient (P) 12 and P13) reviewed for revocation of services out of a total sample of 15. There was no documentation in the record of the summary of the patient’s stay, treatments, pain management, physician orders, or current plan of care. Findings include: 1. Review of the electronic medical record (EMR) for P12, under the “Miscellaneous” tab revealed P12 was admitted to Hospice services on 07/30/24 with a diagnosis of Parkinson. It was recorded P12 revoked the hospice benefit on 11/26/24. Review of P12’s EMR revealed no documented evidence that a discharge summary that included a summary of the patient’s state, the current plan of care, treatments, pain management, and physician orders was completed. Interview on 12/12/24 at 2:30PM, theAdministrator2/MSW1 confirmed they failed to document a discharge summary 2. Review of the EMR for P13, under the “Miscellaneous” tab, revealed P13 was admitted to Hospice services on 08/24/24 with a diagnosis of cancer. It was recordedP13 revoked the hospice benefit on 10/31/24. Review of P13’s EMR revealed no documented evidence that a discharge summary that included a summary of the patient’s state, the current plan of care, treatments, pain management, and physician orders was completed. Interview with Administrator2/MSW1 on 12/12/24 at 2:30 PM confirmed the agency failed to complete a discharge summary which included treatments, symptoms and pain management, the patients current plan of care and physician orders upon revoking the hospice benefit. The agency failed to provide a policy for completing discharge summaries prior to survey teams exit on 12/13/24.”