Marshfield Medical Ctr Rice Lake Hospice

“Observed in Record Review. In 2 of 2 active hospice patient records reviewed. the organization did not updated the plan of care based on information from update to the patients comprehensive assessment. On HSRRNHV #1, it was noted on the most recent recert assessment that patient had change in nutrition and this was not reflected in the current Plan of Care. On HSRRNHV #2, it was noted that the patient has had a teaching goal for CHF for over a year with no update to that plan. These observations were reviewed with the Clinical Supervisor.”

“Observed in Tracer Activities. the organization failed to provide a written definition of data and information to be collected during the comprehensive assessment that included the patient’s physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the patient’s well-being, comfort, and dignity throughout the dying process - The nature of the condition causing the patient’s admission to the hospice program, including the presence or absence of objective data and subjective complaints - Complications and risk factors that affect care planning - Functional status, including the patient’s ability to understand and participate in their care - Imminence of death. On review of the organizations policy for initial assessment filed to include the required elements only specifying time frames that the assessment was to be accomplished yet not defining the elements of the assessment. This observation was review with the Director of Home Care/Hospice and Clinical Supervisor.”

“Observed in Record Review. In 1 of 1 patient records reviewed, for live discharge for extended prognosis, the organization failed to respect the patient’s right to participate in decisions about their care, treatment, and services. On review of HosRRDC#2 there was no documentation that the Notice of Medicare Non-Coverage was signed by the patient/caregiver/POA two days prior to discharge as required. There was documentation that the POA was informed vis phone of the planned discharge and that NOMNC was mailed yet there was no documentation that the POA was informed of their right to appeal the decision nor was the document returned signed. This observation was reviewed with the Clinical Supervisor.”

“Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to ensure and document a patient specific comprehensive assessment and reassessment that identified the patient’s need for hospice and services. On review of HosRRNHV#14 the patient had a diagnosis of Alcoholic Cirrhosis with ascites yet there was no documentation of the severity of the ascites such as appearance, size, palpation, and presence of fluid wave. This observation was reviewed with the Clinical Supervisor. Observed in Patient Home. In 1 of 4 home visits conducted, the organization failed to ensure the staff conduct and document a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. On home observation for HosRRHV#2 the RN was observed to perform an incomplete patient assessment. There was no observation of assessment of lung sounds, heart sounds, respirations, or bowel sounds. The RN observed the skin on the feet and elbows yet failed to observe any other portions of the skin such as the sacrum or perineum. There were no vital signs taken as part of the assessment. This observation was reviewed with the Manager/Administrator of Home Health and Hospice.”

“Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to maintain complete and accurate patient records. On review of HosRRHV#2 in review of the documentation of each IDG meeting to review and update the comprehensive assessment, it was noted that the physician’s documentation was specific to a patient with a diagnosis of intrahepatic cholangiocarcinoma with metastasis to the lung along with related history and physical yet all documentation from the rest of the IDG team and the Certificate of Terminal Illness was noted the patient with a terminal diagnosis of Alzheimer’s disease. The discrepancy was throughout all IDG documentation from admission in January to the current IDG meeting. This observation was reviewed with the Clinical Supervisor.”

“Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to ensure the plan of care reflect patient and family goals that were specific, measurable, and time-bound. Throughout all records reviewed there was noted a lack of goals that were specific, measurable and /or time-bound. In HosRRHV#1 examples of goals that were not individualized, measurable, and time-bound were Patient will receive massage therapy for comfort by the end of the certification and Spiritual trust has been restored with no achieve by date. Similar goals that were not measurable were noted throughout all records reviewed. Throughout the records reviewed all goals established were noted not to be individualized and were set an achieve by date of the end of the certification period. These observations were reviewed with the Clinical Supervisor.”

“Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of HosRRHV#1 the documentation noted the patient with difficulty swallowing, poor appetite with the use of ensure as supplement, and high fall risk yet there were no care plans for nutrition or fall safety. There were orders to taper medications related to over sedation yet the issue was not reflected in the plan of care. In HosRRHV#2 the patient had a terminal diagnosis of Alzheimer’s yet the only clinical care plan was for skin integrity. There was documentation of weight loss, poor appetite and PRN visit for cough yet no care plans related to the issues established to guide the care. In HosRRHV#3 the patient was on bleeding precautions, there was documentation of a yeast infection, complaints of dizziness and an episode of COVID yet the issues were not reflected in the plan of care. Throughout records reviewed there was a pattern noted of issues documented in the record yet not reflected in the plan of care. Further examples of issues documented yet not reflected were: In HosRRHV#4 tube feedings, and dysphagia/aspiration precautions. In HosRRNHV#5 the use of oxygen and respiratory/shortness of breath. In HosRRNHV#6 issues with pain, nausea were not reflected. Fall safety had a goal but no interventions. In HosRRNHV#7 the patient was diabetic with orders for blood glucose monitoring yet no endocrine plan, and documented confusion related to an encephalopathy diagnoses yet no care plan to address established. In HosRRNHV#8 the terminal diagnosis was Parkinson’s that required medication adjustment with tapering doses yet no care plan to guide. In HosRRNHV#9 the patient had issues with CHF and COPD with oxygen use yet to cardiopulmonary care plan established. Additional examples of issues that were noted in the documentation yet were not reflected in the plan of care were noted in HosRRNHV#9, HosRRNHV#10, HosRRNHV#11, HosRRNHV#12, HosRRNHV#13 and HosRRNHV#14. These observations were reviewed with the Clinical Supervisor.”

“Observed in Record Review. In 3 of 14 patient records reviewed, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. On home observation and record review for HosRRHV#4 the patient had a G- Tube and the RN provided G Tube site care yet there were no orders for the care noted on the plan of care. In HosRRHV#3 there were orders noted on the plan of care for oxycodone as needed for pain, and oxycodone with acetaminophen as needed for pain yet there were no specific instructions to guide the patient/caregiver as to when to use which medication. Further, there were as needed orders for acetaminophen oral for pain/fever and per suppository for pain/fever along with the oxycodone with acetaminophen order but no specific instructions on when to choose which medication, nor any parameters for max dose of acetaminophen per day. In HosRRNHV#5 the order for oxygen read 1-6 liters per nasal cannula yet there were no specific instructions to guide the user as to which liter flow to choose. In HosRRNHV#14 there was an order for Oxygen 1-4 liters without any instruction as to what liter flow to choose. These observations were reviewed with the RN and Manager/Administrator for Home Health/Hospice.”

“Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to ensure the plan of care revisions were based on information from update to the patients comprehensive assessment and address the patient’s progress toward goals and outcomes. Throughout all clinical records reviewed there was a lack of updates to the plan of care as the care plans were noted to remain unchanged IDG to IDG without revisions based on changes in patient status and updates to the comprehensive assessment. There was no evidence noted in the record of progress toward goals. These observations were reviewed with the Clinical Supervisor.”

“Observed in Record Review. In 2 of 14 patient records reviewed, the organization failed to ensure the care and services were provided in accordance with the plan of care. On review of HosRRHV#2 the social worker was order a frequency of every other week yet there was no visit documented on the 2nd week of February leaving a 3 week gap in social worker contact. In HosRRNHV#12 the Chaplain frequency was ordered 12 visits in 86 days yet in the allotted period only 10 visits were documented. These observations were reviewed with the Clinical Supervisor.”

“Observed in Record Review. In 2 of 14 patient records reviewed, the organization failed to ensure all disciplines that provide care, treatment or services collaborate in the care of the patient and coordinate their efforts to support the goals outlined in the plan of care. On review of HosRRHV#2 there was documentation of a PRN skilled nursing visit made to assess the patient for a cough, yet there was no documentation that the physician was informed of the change in the patient status. In HosRRHV#3 during home observation the hospice aide was unable to perform the patient bath because the patient complaint of dizziness. The aide noted that patient frequently complained of dizziness and refused services yet there was no documentation noted in the clinical record that the dizziness had been reported to RN case manager. These observations were reviewed with the Clinical Supervisor.”

“Observed in Tracer Activities. The organization failed to compile and analyze data. During tracer activities for Data Management for Home Care and Hospice, the surveyor observed the HCO collected data on complaints however did not document that the data was analyzed to identify trends or variances. Upon conversation with the Home Care and Hospice Director he stated that he was investigation all complaints but there was no data to say how many complaints had been received in the last 3 years or if there were any trends related to those complaints. This was discussed and reviewed with the Home Care and Hospice Director.”

“Observed in Tracer Activities. The organization failed to implement activities for the prevention and control of infections and communicable disease. During tracer activities for Hospice, the surveyor observed the organization had only been collecting data on Catheter Associated Urinary Tract Infections and no other infections. Upon conversation with the Home Care and Hospice Director he stated that he wasn’t sure why they were collecting that. And he was unable to produce documentation of the data that was collected or any other infection data. This was discussed and reviewed with the Home Care and Hospice Director. Observed in Tracer Activities. The organization failed to document an infection prevention control program that was organizational wide and was an integral part of the organization’s quality assessment and performance improvement program. During tracer activities for Data Management, the surveyor observed the organization failed to document an infection control plan for the current year and the previous two years. Upon discussion with the Home Care and Hospice Director, the organization had been collecting data on catheter related urinary tract infections but did not have prioritization of infections, or analysis of what infections affected their patients. There was no documentation of an overall infection control plan. This was discussed and reviewed with the Home Care and Hospice Director.”

“Observed in HR File Review. During a review of two home health aid education records, for the required 12 total hours per year required specifically for home-health aids. the hospice e pharmacy surveyor noted that one of the home health aids had a training sheet on file, but no hours assigned to the education provided. The second home health aid had been employed for 11 months and still had no training record. However, they still had one more month to meet this requirement. Also, in talking with one of the clinical nurse managers, the employee was not aware that this 12-hour education was required for all home health aides. This omission was validated with the director and clinical manager at the time of the survey.”

“Observed in Record Review. In 3 of 12 patient records reviewed, the organization failed to ensure the quality of care and services provided by the hospice aide to ensure that services ordered meet the patient need were assessed by the RN no less frequently than every 14 days. On review of HosRRHV#1 there was a 15 day gap in aide supervisory visits in February. In HosRRHV#2 there was a 27 day gap from January to February in the RN aide supervisory visit. In HosRRNHV#5 the last aide supervisory visit documented was mid February leaving a 16 day gap to present day of survey. These observations were reviewed with the Clinical Supervisor.”

“Observed in Patient Home. In 2 of 2 home visits conducted, where medication reconciliation was conducted, the organization failed to ensure the patient record contain all information to reflect the patient’s care, treatment, and services. For example: on home observation of medication reconciliation for HosRRHV#1 the patient’s plan of care had orders for cholecalciferol (Vit D3) 25 mcg/1000units 1 daily yet the medication was not included in the facility medication records. On HosRRHV#4 during the observation for medication reconciliation the patient medication profile as part of the plan of care noted hydrocodone 5mg/acetaminophen 325 mg as needed for pain yet the patient’s wife stated the patient was not taking the medication and had not taken for a couple of months (prior to hospice admission). For the loperamide 2 mg order noted take 1 tab every 4 hours as needed, yet the patient wife noted he was taking 1/2 tab daily. These observations were reviewed with the RN and Manager/Administrator HH and Hospice.”