Every finding on record at Abbey Road Hospice, LLC

Based on observations, chart reviews, and interview, the hospice failed to ensure its Registered Nurse staff documented continuous assessments of the hospice patient's needs for coordination with other members of the hospice Interdisciplinary Group (IDG) for 3 of 11 hospice patients. (Patient #3, #4 and #5) The findings include: Patient #3 On 4/12/2022 at 9:33 AM, observations during a home/facility visit with Patient #3 revealed the patient had a dressing on the patient's left lower extremity stump with drainage noted on the dressing. On 4/12/2022 at 11:47 AM, review of Patient #3's chart revealed the patient was admitted to hospice service on 9/27/2021 with diagnosis of Chronic Obstructive Pulmonary Disease(COPD) and Pneumonitis due to inhalation of food. The hospice episode reviewed from 3/26/2022 to 5/24/2022 revealed a nurse note dated 3/29/2022 that reads, "patient does cough sometimes with feeding. Left below the knee amputation stump has a vertical oblong wound 1.8 by 1.4 cm(centimeters) with a bone fragment that is sharp sticking out ...remains on continuous oxygen." Review of the patient's Plan of Care (POC) for the present episode (3/26/2022 to 5/24/2022) had no nursing interventions or goals for nutrition, integumentary, and respiratory. Pain was the only goal with interventions. On 4/12/2022 at 1:47 PM, the Certified Executive Officer (CEO) revealed "Needs to be more specific". Patient #4 On 4/11/2022 at 12:55 PM, review of Patient #4's chart revealed the patient was admitted to hospice service on 1/14/2022 with diagnosis Cerebral Atherosclerosis. The episode from 2/17/2022 to 4/17/2022 was reviewed and revealed a nurse note dated 3/14/2022 that showed "has very small skin tear on right knee resolving ...redness of buttocks was improved through last week but redness worsened this morning." The patient's POC for the present episode (2/17/2022 to 4/17/2022 ) had no nursing interventions or goals for integumentary. Pain was the only goal with interventions. There was no documentation of wound measurements. On 4/12/2022 at 1:47 PM, the Certified Executive Officer (CEO) revealed "needs to be more specific." On 4/12/2022 at 2:55 PM, RN #1 verified the finding. Patient #5 On 4/11/2022 at 2:00 PM, review of Patient #5's chart revealed the patient was admitted to hospice service on 2/8/2022 with diagnosis Senile Degeneration of the brain. The episode from 2/8/2022 to 5/8/2022 was reviewed and revealed a nurse note dated 3/16/2022 that showed "skin tear at dorsalis of wrist is covered with a clear film dsg(dressing) and is becoming pale pink. No active drainage or bleeding at site." Review of the patient's POC for the present episode (2/8/2022 to 5/8/2022) had no nursing interventions or goals for integumentary. Aide supervision was the only goal with interventions. On 4/12/2022 at 1:47 PM, the Chief Executive Officer (CEO) revealed "needs to be more specific." On 4/12/2022 at 3:06 PM, RN #1 verified the finding.

Based on chart reviews and interviews, the hospice failed to ensure a Skilled Nurse (SN) updated the patient's Plan of Care (POC) with all services necessary and individualize care for 3 of 11 hospice patients. (Patient #3, #4, and #5) The finding includes: Patient #3 On 4/12/2022 at 11:47 AM, chart review revealed a SN note dated 3/29/2022 that reads, "Patient does cough sometimes with feeding. Left below the knee amputation stump has a vertical oblong wound 1.8 by 1.4 cm(centimeters) with a bone fragment that is sharp sticking out ...remains on continuous oxygen." The patient's POC had no goals or interventions for nutrition, integumentary, or respiratory problems. There were no physician orders in the patient's chart for wound management. The SN failed to address all of the patient's needs. On 4/12/2022 at 1:47 PM, the Certified Executive Officer (CEO) verified the findings. Patient #4 On 4/11/2022 at 12:55 PM, review of Patient #4 chart revealed a SN note dated 3/14/2022 that reads, "has very small skin tear on right knee resolving ...redness of buttocks was improved through last week but redness worsened this morning." Review of the patient's POC for present episode had no goals or nursing interventions for integumentary. Pain was the goal with interventions. There were no physician orders for wound management. On 4/12/2022 at 1:47 PM, the Certified Executive Officer (CEO) revealed "Needs to be more specific." On 4/12/2022 at 2:55 PM, Registered Nurse(RN) #1 verified the finding. Patient #5 On 4/11/2022 at 2:00 PM, review of Patient #5 chart revealed a SN note dated 3/16/2022 that reads, "skin tear at dorsalis of wrist is covered with a clear film dsg and is becoming pale pink. No active drainage or bleeding at site". Review of the patient's POC had no goal or nursing interventions for integumentary. Aide supervision was the only goal. There were no physician orders for wound management. On 4/12/2022 at 1:47 PM, the Certified Executive Officer (CEO) revealed "needs to be more specific." On 4/12/2022 at 3:06 PM, RN #1 verified the finding.

Based on review of the hospice's bereavement data, chart review, and interview, the hospice failed to provide counseling services following the patient's death for 2 of 2 applicable patients. (Patient #10 and #11) The finding includes: Patient #10 On 4/12/2022 at 10:25 AM, review of Patient #10's chart revealed the patient expired in the facility on 2/25/2022. There was no evidence documented that the family was contacted to offer and/or determine the family's need for Bereavement services. The hospice had no documentation of the patient's Bereavement Plan of Care (POC). On 4/13/2022 at 12:01 PM, the Chief Executive Officer (CEO) reported, "We send them (family of deceased) an email questionnaire to fill out in 21 days from death. We don't keep that in the chart. We don't make an in-person visit or call unless they request it. It's all email. Our coordinator just coordinates all the mailings and email." The CEO reported the Bereavement Coordinator is not a licensed professional and has no training specifically in grief or loss. Patient #11 On 4/12/2022 at 11:35 AM, review of Patient #11's chart revealed the patient expired in a facility on 3/8/2022. There was no evidence documented that the family was contacted to offer and/or determine the family's need for Bereavement services. The hospice had no documentation of the patient's Bereavement POC. On 4/13/2022 at 12:01 PM, the CEO reported "We send them (family of deceased) an email questionnaire to fill out 21 days after death. We don't keep that in the chart. We don't make an in-person visit or call unless they request it. It's all email. Our Coordinator just coordinates all the mailings and email." The CEO reported the Bereavement Coordinator is not a licensed professional and has no training specifically in grief or loss.

Based on review of the hospice's Volunteer data and interview, the hospice failed to use volunteers in an appropriate administrative role for 1 of 1 volunteer reviewed. The finding includes: On 4/13/2022 at 12:26 PM, review of the hospice's volunteer program data revealed the Volunteer Coordinator uses one volunteer to empty garbage and recycle cardboard 3 times a week, but codes the time as administrative hours. On 4/13/2022 at 12: 38 PM, the Chief Executive Officer revealed "I guess we could use him to make copies and answer the phone." and verified the finding.

Based on review of the hospice's volunteer data and interview, the hospice failed to provide documentation for recruitment and retention efforts for volunteers for the hospice. The finding includes: On 4/13/2022 at 12:26 PM, review of the hospice's volunteer program data revealed the hospice had no documentation for recruitment and retention of volunteers for its volunteer program. On 4/13/2022 at 12: 38 PM, the Chief Executive Officer (CEO) revealed the volunteer program has only one active volunteer.

Based on review of the hospice training data and interview, the hospice failed to provide the in- services training in the hospice philosophy and symptom management for the staff for 4 of 4 long term facilities where their hospice patients reside. The finding includes: On 4/13/2022 at 10:00 AM, review of the hospice's training data revealed the hospice had no documentation for training the staff on the hospice philosophy and symptom management in facilities where the hospice's patients reside. On 4/13/2022 at 10:15 AM, the hospice Administrator revealed "We(Hospice) haven't done any training." and verified the finding.