Initial Comments:
Based on the findings of an unannounced onsite hospice state re-licensure survey conducted January 29, 2024, through February 1, 2024, Ascend Hospice was found to be in compliance with the requirements of 42 CFR, Part 418.113,Subpart D, Conditions of Participation: Hospice Care-Emergency Preparedness.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced hospice state re-licensure survey conducted January 29, 2024, through February 1, 2024, Ascend Hospice was found not to be in compliance with the requirements of 42 CFR, Part 418, Subparts A, C, and D, Conditions of Participation: Hospice Care.
Plan of Correction:
418.54(b) STANDARD
TIMEFRAME FOR COMPLETION OF ASSESSMENT
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The hospice interdisciplinary group, in consultation with the individual's attending physician (if any), must complete the comprehensive assessment no later than 5 calendar days after the election of hospice care in accordance with §418.24.
Observations:
Based on a review of hospice policy, clinical records (CR), and an interview with hospice staff, the hospice failed to ensure that the plan of care was developed in consultation with the Interdisciplinary Group (IDG) within five (5) days after the election of the hospice benefit for four (4) of fifteen (15) CR reviewed. (CR# 9, 10, 11, and 13).
Findings Included:
Review of hospice policy "PC.C31 Comprehensive Assessment of the Patient" on February 1, 2024, at approximately 2:30 P.M. stated, "Procedures: 2. The comprehensive assessment of the patient is completed by designated members of the IDG, in consultation with the patient's attending physician, no later than five calendar days after the patient elects the hospice benefit."
A review of clinical records was conducted on January 29, 2024, from approximately 11:15 A.M. to 3:30 P.M., January 31, 2024, from approximately 8:45 A.M. to 2:30 P.M., and February 1, 2024, from approximately 9:00 A.M. to 2:00 P.M. revealed the following:
CR #9, start of care and hospice benefit election November 20, 2023. An initial assessment by the chaplain was conducted on November 27, 2023, seven (7) days after the hospice benefit election date. There was no documentation the chaplain contacted the patient and/or family within the first five (5) days of hospice benefit election.
CR #10, start of care and hospice benefit election October 22, 2022. Orders for chaplain services and SW services were effective November 1, 2022. There was no documentation of an initial assessment conducted by the chaplain or the SW. A "regular visit" was conducted by the chaplain on November 23, 2022, twenty-two (22) days after hospice benefit election. A "regular visit" was conducted by the SW on November 21, 2022, twenty-one (21) days after the benefit election date. There was no documentation the chaplain or the SW contacted the patient and/or family within the first five (5) days of hospice benefit election.
CR #11, start of care and hospice benefit election July 12, 2023. There was no documentation of an initial assessment by the SW. There was no documentation the SW contacted the patient and/or family within the first five (5) days of hospice benefit election.
CR #13, start of care and hospice benefit election October 4, 2023. An initial assessment by the chaplain was conducted on October 18, 2023, fourteen (14) days after hospice benefit election. There was no documentation the chaplain contacted the patient and/or family within the first five (5) days of hospice benefit election.
An interview with the hospice Executive Directors, Senior VP of Operations, National Director of Clinical Operations, and the Patient Care Manager on February 1, 2024, at approximately 3:00 P.M confirmed the above findings.
Plan of Correction:Education provided in Psychosocial staff meeting on 2/14/2024 –regarding documentation of comprehensive assessment within 5 days or need to clearly document why the assessment visit will be planned for greater than 5 days post admission. Documentation was present in the chart-but as a journal note not a care coordination note. Educated team that any documentation regarding the comprehensive assessment must be in the care coordination notes for standardization of this type of communication.
Audit Plan: Director of Psychosocial services will review all admission charts for compliance with the 5 day comprehensive assessment for SW and Chaplain team for 3 consecutive months-and will review any exceptions to the 5 day timeframe for correct and clear documentation as to why the comprehensive assessment was not completed within the 5 day timeframe as per regulation. Policy PC.C31 reviewed with team members at the meeting on 2/14/2024.
Goal: 3 months of 100% compliance Months; Feb, March, April 2024 or continued auditing until 100% compliance achieved x 3 consecutive months. Any non-compliance found will be 1:1 reeducation/counseling for the identified team member
418.54(c)(6) STANDARD
CONTENT OF COMPREHENSIVE ASSESSMENT
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[The comprehensive assessment must take into consideration the following factors:]
(6) Drug profile. A review of all of the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. This includes, but is not limited to, identification of the following:
(i) Effectiveness of drug therapy
(ii) Drug side effects
(iii) Actual or potential drug interactions
(iv) Duplicate drug therapy
(v) Drug therapy currently associated with laboratory monitoring.
Observations:
Based on a review of agency policies, clinical records (CR), and an interview with the hospice staff, the agency failed to ensure the registered nurse conducted a review of all prescription and over-the-counter medications for two (2) of fifteen (15) clinical records (CR) reviewed (CR# 1 and 14 ).
Findings included:
Review of hospice policy "PC.M60 Medication- Profile" on February 1, 2024, at approximately 2:30 P.M. stated, "Policy: A patient-specific medication profile is maintained for each patient and reviewed, at a minimum, every fifteen days.... Procedures: 4. The patient's medication profile review includes, but is not limited to: a. determining accuracy and completeness of the profile."
Hospice policy "PC.M50 Medications-Management" stated, "Medications related to the palliation and management of the patient's terminal illness and related conditions are provided in accordance with the patient's plan of care and State and Federal laws and regulations... Procedures: 9. The RN (registered nurse) Case Manager monitors the medications, biologicals, and CAM (complimentary and alternative medicine) offered and dispensed to and used by the patient. 10. Medications, biologicals and CAM are included in the plan of care and reviewed during IDG (interdisciplinary group) meeting..."
A review of clinical records was conducted on January 29, 2024, from approximately 11:15 A.M. to 3:30 P.M., January 31, 2024, from approximately 8:45 A.M. to 2:30 P.M., and February 1, 2024, from approximately 9:00 A.M. to 2:00 P.M. revealed the following:
CR #1, start of care December 23, 2023. Certification period reviewed: December 23, 2023, through March 21, 2024. A home visit observation (OBS) was conducted on January 30, 2024, at approximately 9:20 A.M. at a skilled nursing facility (SNF). Review of "Hospice Plan of Care" (POC), hospice medication profile (MP) and the SNF physician's orders - medications revealed the following discrepancies:
The following medications were contained on the hospice plan of care (POC) and medication profile (MP) provided on January 29, 2024, but were not listed on the SNF medication orders provided on January 30, 2024:
Lorazepam 0.5 mg oral tablet, 1 tablet by mouth every six (6) hours as needed for anxiety/agitation
Prochlorperazine 10 mg oral tablet, 1 tablet by mouth every 6 hours as needed for nausea/vomiting
MiraLax oral powder for reconstitution 17 grams by mouth BID (two times per day) - for constipation
The following medications were listed on the hospice POC and MP, and on the SNF medication orders, with discrepancies in dosages or frequencies:
Levothyroxine 150 mcg (0.15 mg) oral capsule (thyroid medication) -listed on hospice POC/MP as one (1) capsule to be given on Sundays, listed on SNF orders one (1) capsule to be given daily.
Docusate-senna 50 mg-8.6mg oral tablet (laxative)- listed on hospice POC/MP one (1) tablet to be given bid (two times per day), listed on SNF orders two (2) tablets to be given daily.
Esomeprazole 40 mg (milligrams) oral delayed release capsule (for gastric reflux) listed on hospice POC/MP 40 mg to be given daily, listed on SNF orders 20 mg to be given BID.
Rocaltrol 0.5 mcg (micrograms) oral capsule (calcium supplement) listed on hospice POC/MP one (1) capsule to be given daily, listed on the SNF orders 1 mcg to be given daily.
Morphine sulfate 20mg/ml (milliliter) (narcotic pain medication) listed on hospice POC/MP 5 mg (0.25 ml) to be given every 3 hours as needed for pain or shortness of breath (SOB), listed on SNF orders 0.25 mg to be given every 2 hours as needed for pain.
The following medications are listed on the SNF orders, but are not listed on the hospice POC or MP:
Fleet enema 19 gram-7 gram/118 ml (Sodium phosphates), 1 rectal daily as needed for constipation.
Milk of Magnesia (laxative) 400 mg/5ml oral suspension (Magnesium hydroxide) 30 ml by mouth daily as needed for constipation one time daily if no BM (bowel movement) on day 4 of no BM (PRN- as needed, refer to instructions), for constipation.
Narcan 4 mg/actuation nasal spray (Naloxone) (for treatment of opiod overdose) 1 spray nares (nostril) every 3 minutes as needed for opiod suspected overdose - alternate nostrils every 3 minutes as needed until patient becomes coherent or emergency medical assistance arrive.
The following SNF orders are in conflict with a routine order for Acetaminophen 500 mg tablet (generic) - Give two 500 mg tablets to equal 1000 mg By Mouth Every 8 hours Q 8 hours For OSTEOMYELITIS (infection of the bone) OF VERTEBRA, LUMBAR REGION:
Tylenol 325 mg tablet (Acetaminophen) - 2 tabs (tablets) By Mouth Every 4 hours as needed for Pain DO NOT EXCEED 3000 MG APAP/24 Hours
Tylenol 325 mg tablet (Acetaminophen) - 2 tabs (tablets) By Mouth Every 4 hours as needed for Fever > (greater than) 100 (degrees) DO NOT EXCEED 3000 MG APAP/24 Hours
The routine ordered daily dosage of acetaminophen 1000 mg TID or Q8 hours is the maximum dosage of 3000 mg per 24 hours. The additional PRN orders for Tylenol would exceed the maximum daily dosage.
CR #14, start of care December 19, 2023. Certification period reviewed: December 19, 2023, through March 17, 2024. A home visit observation (OBS) was conducted on January 30, 2024, at approximately 10:15 A.M. at a SNF. Review of the hospice POC and MP and the SNF physician's orders - medications revealed the following discrepancies:
The following medications were contained on the hospice plan of care (POC) and medication profile (MP) provided on January 29, 2024, but were not listed on the SNF medication orders provided on January 30, 2024:
Glyburide-metformin 2.5 mg-500 mg oral tablet (for treatment of diabetes) daily at HS (bedtime)
Lorazepam 2 mg/ml oral concentrate, no dosage listed, every 4 hours PRN for anxiety
The following medications are listed on the SNF orders, but are not listed on the hospice POC or MP:
Empaglifozin oral tablet (diabetes medication) 10 mg, 1 tablet by mouth one time a day.
Latanoprost Opthalmic Solution 0.005% (glaucoma medication) Instill 1 drop in both eyes in the evening.
The following medication was listed on the hospice POC and MP, and on the SNF medication orders, with discrepancies in dosages or frequencies:
Levothyroxine 50 mcg (0.05 mg) oral tablet listed on hospice POC/MP as 1 capsule to be given daily, listed on SNF orders twice (duplicate order) as 2 tablets to be given by mouth in the morning every Monday, Wednesday and Friday, and 1 tablet to be given by mouth in the morning every Tuesday, Thursday, Saturday and Sunday.
An interview with the hospice Executive Directors, Senior VP of Operations, National Director of Clinical Operations, and the Patient Care Manager on February 1, 2024, at approximately 3:00 P.M confirmed the above findings.
Plan of Correction:Planned nursing staff meeting on 2/27/2024 to review policies PC.M60 and PC.M50 regarding completeness and correctness of the medication profile ongoing as part of the Comprehensive assessment process.
The respective Patient Care Managers have reviewed 1:1 with the RNCM assigned to the non-compliant findings of the surveyor.
The Patient Care Managers will be responsible to review med changes at IDT meetings as part of the patient reporting by the RNCM-if any discrepancies found-1:1 reeducation/ counseling will be completed by respective Patient Care Manager.
Auditing will be conducted on 20% of each RNCM caseload for correct and complete Medication profile, side effects, and adverse reactions or associated lab monitoring.
Goal: 100% compliance of reviewed charts for 3 months-Feb, March, April 2024-if not met continue auditing until 3 months consecutive 100% compliance is achieved.
PCM will also do an active medication review when completing in person supervisory visits with RNCM and LPN team members-1 supervisory visit per nurse will be conducted by respective Patient Care Manager with all the supervisory visits completed by April 15, 2024. Any noncompliance found will result in reeducation/counseling 1:1 with identified team member in noncompliance with policy and regulation.
418.56(b) STANDARD
PLAN OF CARE
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All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire.
Observations:
Based on review of agency policy, clinical records (CR), and interview with hospice, the hospice failed to follow the Hospice Plan of Care (POC) and/or Physician orders for frequency of services for three (3) of fifteen (15) clinical records (CR #2, 14, and 15).
Findings include:
Review of the agency policy "PC.P45 Plan of Care - Content" on February 1, 2024, at approximately 2:30 P.M. stated, "Procedures: 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."
A review of clinical records was conducted on January 29, 2024, from approximately 11:15 A.M. to 3:30 P.M., January 31, 2024, from approximately 8:45 A.M. to 2:30 P.M., and February 1, 2024, from approximately 9:00 A.M. to 2:00 P.M. revealed the following:
CR #2, start of care January 31, 2023. Certification period reviewed: November 27, 2023, through January 25, 2024. Massage therapy services were provided on December 7 and December 21, 2023, and Januray 4 and 17, 2024. There were no orders documented for massage therapy.
CR #14, start of care December 19, 2023. Certification period reviewed: December 19, 2023, through March 17, 2024. The POC contained orders for skilled nursing (SN) visits three (3) visits per week for one (1) week, two (2) visits per week for twelve (12) weeks, and 20 PRN (as needed) visits for decline in condition, changes to medication regimen, symptom management. Skilled nursing visits were provided as follows: Week 1 - three (3) visits, Weeks 2 and 3 - two (2) visits, Week 4 - one (1) scheduled visit and one (1) PRN visit, Week 5 - one (1) visit. There was no documentation of missed visits or physician orders to alter the frequency of the SN visits.
CR #15, start of care January 6, 2024. Certification period reviewed: January 6, 2024,through April 4, 2024. The POC contained orders for SN one (1) visit per week for one (1) week, three (3) visits per week for twelve (12) weeks, two (2) visits per week for one (1) week, and ten (1) PRN visits for decline in condition, changes to medication regime, symptom management. Week 2 there were four (4) SN visits and one (1) PRN visit documented. There was no documentation of physician orders to alter the frequency of the SN visits.
An interview with the hospice Executive Directors, Senior VP of Operations, National Director of Clinical Operations, and the Patient Care Manager on February 1, 2024, at approximately 3:00 P.M confirmed the above findings.
Plan of Correction:Education and review of policy PC.P45 was provided to all clinical team members on 2/22/2024-regarding following ordered frequency as per patient Plan of care and to adjust frequencies as needed to accurately reflect patient care needs. Educated on the correct use of prn visits vs scheduled frequency visits. 1:1 education re: CR # 2, #14, # 15 charts with respective disciplines with noncompliance re: frequency occurred immediately post survey.
Frequency education was also provided during Psychosocial Staff meeting on 2/14/2024.
Audit plan: Frequencies will be reviewed for all respective disciplines during all IDT meetings in March 2024 to validate compliance of all ordered discipline frequencies on POC. Respective clinician will correct any discrepancies found as part of IDT meetings going forward.
100% of charts will be reviewed as part of IDT meetings scheduled during March 2024-with goal of 100% compliance
418.60(a) STANDARD
PREVENTION
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The hospice must follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions.
Observations:
Based on review of agency policy, observation visits (OBS), and staff interviews, the agency failed to ensure staff followed infection control policy and procedure for bag technique for one (1) of three (3) OBS. (OBS #1).
Findings included:
Review of hospice policy "PC.W05 Wound Care Policy" on February 1, 2024, at approximately 2:30 P.M. contained no policy or procedure for performing wound care.
According to Heale (2018) "The wound, any supplies, and the environment should not be contaminated by each other. Wash hands before starting a procedure and decontaminate before and after glove changes... Fresh clean gloves are required if it is necessary to touch the wound directly. These gloves should not contact anything other than the wound or the sterile products being used on it... The outer surface of the dressing should not be touched by gloves used to clean the wound. This applies to tape and any wraps used for the dressing..."
Principles of Clean Dressing Technique Versus Asepsis Margaret Heale, RN, MSc, CWOCN, September 20, 2018.
Observation (OBS) visits conducted on January 30, 2024, from 9:20 A.M. to 12:45 P.M. revealed the following:
OBS #1, CR #1, on January 30, 2024, at approximately 9:20A.M. The registered nurse (RN) performed hand hygiene with sanitizer rather than washing with soap and water, donned gloves, assembled supplies, and placed a barrier under the patient's right arm. The RN removed and disposed of the old dressing, completed hand hygiene and donned clean gloves. The RN cleansed the wound, patted dry, and applied clean dressings per the physician's orders. The RN did not change gloves prior to applying the clean dressings. The RN attempted to unroll the tape to secure the dressing. The RN handed the tape to the patient, who also tried to unroll the tape without performing hand hygiene or donning gloves. A staff nurse from the facility arrived to give the patient their medications. The staff nurse took the tape without gloves, left the room and returned with another roll of tape. The RN used the tape that was provided by the staff nurse without changing gloves and without knowing where the roll of tape was prior to being brought to the patient's room.
An interview with the hospice Executive Directors, Senior VP of Operations, National Director of Clinical Operations, and the Patient Care Manager on February 1, 2024, at approximately 3:00 P.M confirmed the above findings.
Plan of Correction:Infection control policy PC.W05 and correct bag technique will be reviewed at Nursing staff meeting on 2/27/2024.
Plan: Supervisory visits for all RNCM and LPN team members will be arranged to observe a wound care visit including adherence to all elements of proper wound care management and infection prevention using standard precaution measures. These supervisory visits will be completed by April 30, 2024.
Goal: 100% compliance during the all supervisory visits-if not met –the respective non compliant clinician will be reeducated in non compliant elements and 2nd supervisory wound visit will be conducted within 10 days of first supervisory visit-must be 100% compliant or counseling/retraining will be required before the respective clinician will be allowed to perform any wound care visits.
418.64(b)(1) STANDARD
NURSING SERVICES
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§418.64(b) Standard: Nursing services
§418.64(b)(1) The hospice must provide nursing care and services by or under the supervision of a registered nurse. Nursing services must ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and updated assessments.
Observations:
Based on review of hospice policy, clinical records (CR) and staff interviews, the registered nurse failed to ensure that wound care was documented in accordance with hospice policy for five (5) of fifteen (15) CR reviewed. (CR # 1, 3, 7, 9, and 11).
Finding included:
Review of hospice policy "PC.W05 Wound Care Policy" on February 1, 2024, at approximately 2:30 P.M. stated, "Procedures: The following are required nursing actions when caring for a patient with a wound: 1. At the time of admission or when a wound has developed a complete wound assessment needs to be completed and documented in the patient's EMR (electronic medical record). 2. Each wound will be reassessed, measured and documented in the patient's EMR at a minimum every week. If the patient resided in a facility the RN Case Manager will coordinate with the facility RN on the day of the week the wound(s) will be reassessed, measured and documented on... 7. Assessment and required documentation of a wound include the following information: a. The location of the wound(s). b. Wound measurements including: 1. Length, width, depth; 2. Presence of tunneling or undermining. c. Description of any wound drainage... d. Wound bed tissue... e. Assessment of the wound edges... f. Assessment of the surrounding skin... g. Assessment of wound pain..."
A review of clinical records was conducted on January 29, 2024, from approximately 11:15 A.M. to 3:30 P.M., January 31, 2024, from approximately 8:45 A.M. to 2:30 P.M., and February 1, 2024, from approximately 9:00 A.M. to 2:00 P.M. revealed the following:
CR #1, start of care December 23, 2023. Certification period reviewed: December 23, 2023, through March 21, 2024. The Plan of Care (POC) contained orders skilled nursing visit one (1) per week for one (1) week, three (3) per week for one (1) week, two (2) per week for eleven (11) weeks, and one (1) per week for one (1) week starting December 23, 2023. Wound care was ordered for the right arm surgical wound to be cleansed with soap and water, pat dry with gauze, may apply skin prep periwound (around the wound area), cover with petroleum gauze and secure with ABD (abdominal pad dressing) and wrap with Kling (gauze wrap). Change two (2) times per week by hospice and PRN (as needed) for soiled/dislodged dressing by facility.
The initial skilled nursing assessment completed by the Registered Nurse (RN) on December 23, 2023, only documented wounds on the right knee and right arm. There was no documentation of a wound assessment, measurements, or wound care. A follow-up nursing visit conducted on December 24, 2023, documented "right arm 4 sutures. right knee 7 sutures", and contained a narrative note stating, "I cleaned and assessed right knee and right arm surgical dressing." December 26, 2023, January 4, January 9, January 12, and January 18, 2024, the nurse documented that wound care had been performed by facility staff prior to the nurse's arrival. December 29, 2023, and January 23, 2024, there was no documentation regarding the wounds. January 26, 2024, the nurse documented that wound care to right forearm had been completed prior to the nurse's arrival. A new wound was documented on the right side of the patient's head, with wound measurements documented.
CR #3, start of care September 28, 2023. Certification period reviewed: December 27, 2023, through March 24, 2024. The POC contained orders skilled nursing visit one (1) per week for one (1) week and two (2) per week for twelve (12) weeks starting December 27, 2023. Wound care was ordered for a sacral wound to cleanse the wound with wound cleanser, pat dry with gauze, may apply skin prep periwound. Apply barrier to wound bed. Secure with foam. Change every 3 days and PRN for soiled/dislodged dressing.
Skilled nursing assessments on December 27 and 29, 2023, documented the skin was intact. January 2, January 5, and January 8, 2024, the nurse documented that there were wounds, but no location, assessments or measurements were documented. January 12, 2024, the nurse documented redness, with no location identified. January 16, 2024, there was no documentation of wounds. January 18, 2024, the nurse documented "ulcers" with no location, assessment or measurements documented. January 23, 2024, the patient complained of sacral discomfort. No assessment was documented. On January 26, 2024, the nurse documented, "Continues to have increased skin breakdown on sacrum. Appearing to become a stage 2 wound on sacrum." No assessment, measurements or wound care was documented. January 30, 2024, the nurse completed a wound assessment with measurements, and documented wound care performed.
CR #7, start of care December 11, 2023. Certification period reviewed: December 11, 2023, through March 9, 2024. The POC contained orders for skilled nursing visits two (2) per week for thirteen (13) weeks starting December 11, 2023. An initial skilled nursing assessment completed on December 11, 2023, documented skin intact with bruises. No location was identified. The nurse documented on December 15, 2023, that bruising and redness were present on the left lower extremity. There was no documentation of bruising or wounds on December 18 or December 22, 2023. On December 27, 2023, the nurse documented, "Multiple areas on left outer ankle and top of left foot, appears venous stasis wounds. All scabbed over and open to air. Skin tear on the top of left hand/thumb, open to air." There was no assessment of the wound sites or wound care documented. December 28, 2023, January 4 and January 5, 2024, there was no documentation regarding wounds. January 8, 2024, the nurse documented the bilateral feet arterial wounds were "scabbed over". There was no documentation of the hand and thumb wounds. Wounds were documented on bilateral upper extremities, with no assessment or measurements, on January 11 and January 15, 2024, with wound care provided. Januray 12, 2024, the wounds were documented dressings clean, dry and intact. January 15, 2024, the nurse documented that the patient fell, sustaining skin tears to the left upper wrist, fingers, and knee. There was no documentation of wound assessments or measurements. A verbal order was obtained to cleanse the wounds with soap and water, pat dry, apply petroleum gauze, and cover with ABD and Kling. Wound care was provided. The nurse documented wound care to the left wrist, hand, and knee on January 22, January 23, January 25, and January 30, 2024, with no documentation of wound assessments, measurements, or the type of wound care provided.
CR #9, start of care November 20, 2023. Certification period reviewed: November 20, 2023, through February 17, 2024. The POC contained orders for skilled nursing visits three (3) per week for one (1) week, two (2) per week for twelve (12) weeks starting November 20, 2023. An intial skilled nursing assessment completed on November 20, 2023, documented wounds on skin assessment, with no documentation of location, measurements or assessment. Bruises, redness, pallor, and purpura checked on the wound form. On November 24, 2023, the nurse documented "Patient noted to have scabbing from scratches, , pt with no s/s of rash, appears to be systemic in nature. Wound care performed to R elbow wound, cleansed with wound cleanser, applied hydrocolloid dressing. 4x4 optifoam place on reddened stage I to sacrum." There was no documentation of wound assessment or measurements. There were no orders for wound care documented. November 28, 2023, the nurse documented, "Has itch all over his body, scratching himself all the time, skin is fragile, has scattered bruises to both arms, easily opens and bleeds on scratching." November 30, 2023, the nurse checked rash, itching, and pallor on the wound form, with no locations, assessments, or wound care documented. December 7, December 15, and December 19, 2023, the nurse continued to document scratches, itching, pallor, purpura on the wound form with no documentation of location or description of the rash. December 14 and December 21, 2023, there was no documentation of a skin assessment. On December 27, 2023, the nurse documented on the wound form that the patient had an ostomy, redness, pallor , scratches and scabbing. There was no previous mention of an ostomy. The nurse documented, "Pt covered with generalized scabbing from scratching. redness to sacrum appears resolved, now OTA (open to air), R (right) elbow wound also appears resolved."
CR #11, start of Care July 12, 2023. Certification period reviewed: July 12, 2023, through October 9, 2023. The POC contained orders for skilled nursing visits two(2) per week for thirteen (13) weeks, and one (1) visit per week for one (1) week starting July 12, 2023. An initial skilled nursing assessment completed on July 12, 2023, documented "dressing to left forearm due to cellulitis, unable to remove as it was stuck to his skin. Dressings on B/L (bilateral/both) forearms intact. Left forearm with cellulitis, treated with antibiotics." No wound assessment, measurements, or wound care was documented. On July 13, 2023, the nurse documented "Dressing to left forearm changed and redressed with a band aide no leakage from the site. Forearm red and warm to touch pt currently taking antibiotic for cellulitis to this arm. Right arm bandage removed with no skin disruption observed." No wound measurements were documented. July 17, 2023, the nurse documented "Pressure are on sacrum st I (stage one), old IV incision site wound on LFA (left forearm). Wound care provided for both sites." There was no documentation of wound measurements. July 21, 2023, the nurse documented, "iv site to left forearm observed with raised scab. Optifoam (dressing) placed for protective measure pt (patient)tolerated." July 24, 2023, the nurse documented the skin was intact. July 27, 2023, the nurse documented "Bruises, brush burn to left forehead.. orbital bruising to left eye noted as well as nose and brush burn to left forehead. due to 2 falls in the beginning of the week." No wound measurements or assessments were documented. July 28, 2023 the nurse documented " sacral area with dryness. Protective cream applied."
An interview with the hospice Executive Directors, Senior VP of Operations, National Director of Clinical Operations, and the Patient Care Manager on February 1, 2024, at approximately 3:00 P.M confirmed the above findings.
Plan of Correction:Wound policy PC.W05 reviewed with nursing team members immediately post survey–wound care policy and correct assessment timeframes of weekly were reviewed as well as review of all complete data that needs to be documented on the wound assessment form. In respective IDT meetings post survey-2/6/2024 PA AB, 2/8/2024 PADC and PA-YL, 2/14/2024 PA-PH –wound policy and assessment education was provided during IDT meetings.
Patient Care Managers provided 1:1 counseling to the respective RNCM for CR#1, 3 ,7,9 and 11 as identified as non-compliant during survey as well.
As part of the supervisory visits mentioned as part of POC for L0579-the chart frequencies for all dates post survey until supervisory date will be audited for weekly completion of wound assessment as part of the supervisory visit process. Goal: 100% compliance of all chart audits-if not 100% RNCM/LPN supervised will be reeducated/counseled on correct weekly documentation of wound per Ascend policy PC.W05
The policy and documentation expectations will be reviewed again during 2/27/2024 nursing staff meeting.
During IDT the PCM will utilize the active wound list from Kantime-and audit for weekly documentation as part of the IDT process-goal of 100% compliance will be met for 3 consecutive months from March, April, May 2024.
418.64(d)(1) STANDARD
COUNSELING SERVICES
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Counseling services must include, but are not limited to, the following:
(1) Bereavement counseling. The hospice must:
(i) Have an organized program for the provision of bereavement services furnished under the supervision of a qualified professional with experience or education in grief or loss counseling.
(ii) Make 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/MR when appropriate and identified in the bereavement plan of care.
(iii) Ensure that bereavement services reflect the needs of the bereaved.
(iv) Develop a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery. A special coverage provision for bereavement counseling is specified in §418.204(c).
Observations:
Based on review of hospice bereavement program, clinical records (CR), and staff interviews, the hospice failed to ensure that bereavement services were made available to the family following the death of the patient, in accordance with the bereavement program, for one (1) of two (2) bereavement CR reviewed. (CR #9).
Findings included:
A review of clinical records was conducted on January 29, 2024, from approximately 11:15 A.M. to 3:30 P.M., January 31, 2024, from approximately 8:45 A.M. to 2:30 P.M., and February 1, 2024, from approximately 9:00 A.M. to 2:00 P.M. revealed the following:
CR #9, start of care November 20, 2023, date of death January 1, 2024, contained no documentation of an initial bereavement assessment by the social worker. A bereavement telephone call was documented by the social worker on January 2, 2024. There was no documentation of a sympathy card sent to the family.
An interview was conducted with the Bereavement Coordinator on January 31, 2024, at approximately 11:25 A.M. and the bereavement program was reviewed. The Bereavement Coordinator stated that a bereavement call is placed to the family within the first 24 hours. A sympathy card is signed by all of the staff providing care to the patient at the next interdisciplinary group meeting, and mailed to the family. This should have been completed at the January 11, 2024, meeting. There was no documentation that the sympathy card was signed and sent to the family. The Bereavement Coordinator stated that a spreadsheet is kept to track bereavement activity, in addition to the bereavement section of the electronic medical record. The Bereavement Coordinator did not have documentation on the spreadsheet or the bereavment section of the electronic medical record to confirm that the sympathy card was sent to the family.
An interview with the hospice Executive Directors, Senior VP of Operations, National Director of Clinical Operations, and the Patient Care Manager on February 1, 2024, at approximately 3:00 P.M confirmed the above findings.
Plan of Correction:Education on use of Bereavement documentation module in Kantime has been scheduled for 2/23/2024 with corporate trainer, Bereavement coordinator, Director of Psychosocial services and ED of Clinical Operations. The Director of Psychosocial Services reviewed the survey finding CR 9 with staff, audits completed for all death for months of November, December 2023 and January 2024 to ensure that all bereavement charts were created.
Audit plan: Director of Psychosocial Services will audit all deaths reviewed at the respective IDT meetings for February, March and April 2024-if not 100% compliance-reeducation/counseling will
Goal: 100% of deaths have Bereavement chart created with correct documentation of bereavement status and initial bereavement POC created by the IDT meeting following the date of death. All documentation will be timely and complete in Kantime.
Initial Comments:
Based on the findings of an onsite unannounced hospice state re-licensure survey conducted January 29, 2024, through February 1, 2024, Ascend Hospice was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced hospice state re-licensure survey conducted January 29, 2024, through February 1, 2024, Ascend Hospice was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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