Every finding on record at Ancora Home Health & Hospice, LLC

Based on record review, observation, and interview, the hospice agency failed to ensure nursing care that optimized dignity and personal privacy at one of three skilled nurse home visits with hospice patients (Patient #16) was completed at an assisted living facility (ALF). This failed practice placed Patient #16 at risk for psychological harm from feelings of poor self-esteem and/or self-worth and a potential for a poor quality of life. --- Findings: Record review from 3/6-13/25 of Record #16 revealed a start of care (SOC) date of 2/26/25 with a benefit period of 2/26/25-5/26/25. The patient's terminal diagnosis was Parkinson's Disease. During an observation on 3/7/25 at 8:30 AM, Licensed Nurse (LN) #1 was observed to locate Patient #16 at his/her residence: an Assisted Living Facility (ALF). LN #1 went to Patient #16's room and found the patient was not present in his/her room. LN #1 proceeded to the ALF dining room and located the patient, who was seated alone at a small table. Patient #16 was finishing breakfast. The patient agreed, when LN #1 asked, to be assessed. LN #1 did not offer a choice of returning to the patient's room for privacy. LN #1 stated, "I heard you were short of breath yesterday." LN #1 proceeded to take the patient's vital signs with a rolling vital sign tower. LN #1 obtained the patient's oxygen saturation rate and found the oxygen saturation rate to be 93%. LN #1 asked Patient #16 if he/she wanted oxygen. Patient #16 agreed to the oxygen, and LN #1 stated he/she would get the oxygen concentrator. There were four ALF dining room attendants from the ALF in the dining room as well as seven patients sitting at nearby tables with one patient about ten feet from Patient #16. LN #1 took the patient's blood pressure. "Your blood pressure is good,' LN #1 stated. LN #1 palpated Patient #16's abdomen and asked the patient, "Are you constipated? How is your appetite?" LN #1 stated, "The abdomen feels soft and does not appear full." Patient #16 denied being constipated and stated his/her appetite was good. LN #1 looked at both feet by removing his/her socks and sandals. LN #1 asked, "Do you feel anxious at all?" Patient #16 denied any anxiety. LN #16 proceeded to listen to Patient #16's abdomen with the stethoscope and stated the abdomen sounded fine. "Do you want to work on breakfast?" LN #1 asked. The patient stated, "Yes." LN #1 applied gloves and disinfected the vital sign tower and rolled it to the supply room. After obtaining the oxygen concentrator and rolling that to the dining room, LN #1 placed the oxygen tubing onto the patient. During an interview on 3/12/25 at 2:38 PM, the Administrator stated, when asked if a home visit should be conducted in a public place like an ALF dining room, "If patient is able to give consent we would allow this, but otherwise it should be private." The undated Admission folder included a section titled "Patient Rights and Responsibilities" revealed, "Your rights: Respect and Consideration - You have the right to ... be treated with respect and consideration, recognition of your individuality and dignity...have an environment that preserves dignity and contributes to a positive self-image... Privacy and Security - You have the right to personal privacy and security during home care visits." Review of the policy "Patient Bill of Rights," revised July 2020, revealed, "Hospice protects and promotes the rights of each individual in its care."

Based on record review and interview, the hospice agency failed to include the physician certification of terminal illness in two of 20 records (#15 and #16) reviewed. This failed practice had the potential to delay hospice care that was consistent with the patient and family needs. --- Findings: Record #15 Record review on 3/6-13/25 revealed Patient #15 was admitted to the hospice with a terminal diagnosis of malignant neoplasm of the right breast. The start of care (SOC) date and election date were 2/7/25. Further review of the record revealed a lack of a written certification of terminal illness completed by the physician in the record. Record #16 Record review on 3/6/25 - 3/13/25 revealed Resident #16 was admitted to the hospice with a terminal diagnosis of Parkinson's Disease. The SOC date and election date were 2/26/25. Further review of the record revealed a lack of a written certification of terminal illness in the record completed by the physician in the record. During an interview on 3/6/25 at 3:30 PM, the Executive Director (ED) stated the past medical director was having difficulty getting the written certificates of terminal illness completed. Another physician has taken over the role of Medical Director. The ED stated that these CTIs were not completed and not found in the clinical records for patients #15 and #16. Review of the hospice policy titled "Certification/Recertification of Terminal Illness, Brief Narrative Statement and Face-to-face evaluations," revised July 2020, revealed, "In order to be eligible to elect Hospice care under Medicare, a patient must be certified as terminally ill ... Hospice will obtain written certification of terminal illness for each of the periods listed, even if a single election continues in effect for two, three or four periods. Hospice will obtain the written or verbal certification no later than two (2) calendar days after the period begins. If Hospice cannot obtain the written certification within the two (2) calendar days, it will obtain oral certification within two (2) calendar days, and written certification prior to submitting a claim for payment. The initial certification may be completed up to 15 days before hospice care is elected ..."

Based on record review and interview, the hospice agency failed to ensure clinical record documentation was legible, clear, complete and appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice for one of 20 records reviewed (#6). This failed practice resulted in the potential for the patient needs not to be met or incorrect care to be provided. --- Findings: Record review on 3/6-13/25 revealed Patient #6 had an election date and start of care date on 1/8/25. Patient #6's terminal diagnosis was hypertensive chronic kidney disease. Further record review revealed a "Plan of Care Order," dated 2/4/25 for the Benefit Period of 1/8/25-3/8/25 with an order for hospice aide one times a week. Record review revealed an "Aide Supervisory Visit," completed by Licensed Nurse (LN) #1 on 1/27/25. This aide supervisory visit reviewed care given by Hospice Aide #1. There were no aide visits noted in the record on 1/27/25 or before this date. There was no aide care to be supervised at this aide supervisory visit. Further record review revealed the first Hospice Aide visit found in the clinical record. This aide visit was completed 2/5/25 by Hospice Aide #1 and was signed by Hospice Aide #1. The aide comments were as follows: "Patient was asleep. CG[caregiver] said, [he /she] was told not to disturb [him/her] on [his]her] sleep, checked patient and asked the caregiver what is the best time [he/she] could get [his/her] shower. CG said [he/she] just got [his/her] bed bath yesterday. RN notified about the visit and task declined. Thank you." During an interview on 3/13/25 at 11:50 AM, the Administrator and Branch Administrator, when asked why the aide supervisory visit had been completed before an aide visit had occurred stated that it must have been an error. Review of the agency's policy, "Patient Record Content," revised July 2020, revealed, "Hospice will provide an accurate and current patient record for every patient seen by Hospice ... Hospice will initiate and maintain an individual and accurate patient record containing past and current findings for each patient receiving care in compliance with all federal/state laws and regulations." Review of the agency's policy, "Hospice Aide Supervision," revised July 2020 revealed, "Hospice aides are closely supervised to ensure their competence in providing care. At least every 14 days the registered nurse[RN] makes an onsite home supervisory visit to assess relationships and determine whether goals are being met .. the RN must assess an aide's ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include, but is not limited to following the patient's plan of care for completion of tasks assigned to the hospice aide by the RN, creating successful interpersonal relationships with the patient and family, demonstrating competency with assigned tasks..."

Based on record review, interview, and policy review, the facility failed to ensure evacuation plans were completed for 2 (Patients #1 and #8) of 9 active records. Specifically, the facility failed to complete evacuation plans in the patients' electronic health records (EHR). This failed practice had the potential to create miscommunications between the staff and patients and could potentially cause a delay in Hospice care services to the patients during an emergency and possible evacuation. Findings: Patient #1 Record review on 5/16-20/22 revealed Patient #1 elected hospice and started care on 3/25/22. The patient's diagnoses included other symptoms and signs involving cognitive functions following other cerebrovascular disease (stroke), dementia, retention of urine unspecified, and fall history. Review of "Individual Patient Emergency Preparedness Plan," dated 03/25/22, revealed "If necessary, patient will evacuate to: Relative/Friend (Name/Phone Number): [field left blank], Hotel (Name/Phone Number): [field left blank], Shelter (Location): [field left blank]." During an interview on 5/19/22 at 9:23 AM, the Administrator stated that the evacuation plan was not completed for Patient # 1. Patient # 8 Record review on 5/16-20/22 revealed Patient #8 elected hospice and start of care on 04/06/22. The diagnoses included acute kidney failure with tubular necrosis, retention of urine, and dementia. Record review on 5/19/22 at 12:42 PM revealed Patient #8 did not have a completed evacuation plan in the EHR. During an interview on 5/20/22 at 10:59 AM the Clinical Director (CD) stated that an evacuation plan was not found in the EHR. During a follow-up interview on 5/20/22 at 2:46 PM the CD confirmed that there was no evacuation plan for Patient #8. Review on 5/20/22 of the facility policy "Emergency Operations Plan and Policies-Related Documents: Individual Patient Emergency Preparedness Plan form," revised on August 2020, revealed "#5. Mitigation activities ...The plans for patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment ..." .

Based on observation, interview, and record review the hospice failed to ensure 1 of 1 patient (# 2), observed with a Licensed Nurse (LN #1) visit at an assistant living facility (ALF), was treated with dignity and privacy. This failure had the potential to affect the patient's right to privacy, dignity, self - respect and quality of life specifically when private details about the patient's nursing assessment could be overheard by others. Findings: On 5/17/22 at 11:00 AM, LN# 1 was observed to complete Patient #2's nursing assessment in the ALF's common day room. Patient #2 was seated on a couch in the day room with another resident of the ALF. It was also observed that there were two caregivers and five other patients seated on couches and chairs in this common day room at the facility. LN #1 questioned an ALF caregiver seated at a desk behind the patient about the patient's condition including his/her bowel movement status and latest shower. The ALF caregiver replied, when questioned about the patient's latest bowel movement and shower, that the patient had a bowel movement yesterday evening and a shower yesterday. All ALF staff members and patients, present in the room, were able to hear the answers to these questions and see the nurse's assessment as the assessment occurred. Also included in the assessment, completed by LN #1, was a blood pressure assessment, oxygen saturation assessment, foot and ankle assessment, and lung sound auscultation. On 5/17/22 at 2:30 PM, LN #1, when questioned about the lack of privacy and dignity at the home visit with Patient #2, stated "I should have kept that quiet." On 5/18/22 at 2:46 PM, when asked if the nurse should conduct visits and nurse assessments with patient privacy and dignity, the Administrator stated nursing visits should be completed with privacy and dignity. A review on 5/18/22 of the undated Hospice Admission Booklet included a section titled "Patient Rights and Responsibilities" which stated, "Your rights ... Respect and Consideration - you have the right to ... have an environment that preserves dignity and contributes to a positive self - image ... Privacy and Security - You have the right to: Personal privacy and security during home care visits." .

Based on record review, interview, and policy review the facility failed to ensure the spiritual section of the comprehensive assessment was completed within 5 calendar days from election of hospice for 2 (Patients #1 and #8) out of 9 active records. Specifically, the Chaplain/Spiritual Coordinator did not complete the assessment within 5 calendar days. This failed practice had the potential to delay spiritual needs of the patient and family. Findings: Patient #1 Record review on 5/16-20/22 revealed Patient #1 elected hospice and started care on 3/25/22. This patient had diagnoses that included other symptoms and signs involving cognitive functions following other cerebrovascular disease (stroke), dementia, retention of urine unspecified, and fall history. Record review of "IDG Meeting [Interdisciplinary group, made up of the Medical Director, Registered Nurse, Social Worker, Chaplain/Spiritual Coordinator and others]," dated 04/05/22, stated, "Spiritual Coordinator- Will have first visit and do assessments on Monday, March 4, 2022." Record review revealed the Chaplain/Counselor Assessment occurred on 04/06/22. This was completed 12 days after the election of hospice. During an interview on 5/17/22 at 10:00 AM Patient # 1's representative #1 stated the resident and family did not require the use of Chaplain/Spiritual services at this time. During an interview on 5/19/22 at 11:45 AM the Chaplain/Spiritual Coordinator stated he/she did not document a phone call that the family had requested the first visit to be on 4/6/22. Patient #8 Record review on 5/16-20/22 revealed Patient #8 elected for hospice and started care on 04/06/22. This patient had diagnoses that included acute kidney failure with tubular necrosis, retention of urine, and dementia. Record review of "Missed Visit Form (Chaplain/Counselor Assessment)," dated 04/12/22, revealed, "Traveled to Patient: Yes, Attempt made: 15:30, Reason: No answer to Locked Door, Comments: Was supposed to go over today and visit patient. I was supposed to call first. I called twice and then I went to the house and knocked on both the front and back door. No one answered." The Chaplain/Spiritual Coordinator completed this missed visit form for the Chaplain / Counselor assessment that had not been completed. During an interview on 5/20/22 at 3:03 PM the Administrator agreed that the Chaplain had not completed the assessment within the 5-day time period. Review of policy "Initial Assessment/Comprehensive Assessment," revised July 2020, revealed "The Hospice IDG, in consultation with the patient's attending physician (if any), must complete the comprehensive assessment no later than 5 calendar days after patient's election of Hospice care." .

Based on record review, interview, and policy review the facility failed to perform the scope and frequency of nursing visits necessary to meet the needs of the patient for 1 out of 4 closed records (Patient #10). This failed practice had the potential for the patient to not receive care and treatment which could worsen the patient's condition and cause the patient additional discomfort and pain. Findings: Record review on 5/16-20/22 revealed Patient #10 elected for hospice and had a start of care on 01/07/22. This patient had diagnoses that included dementia with Lewy bodies, chronic pain, and moderate protein-calorie malnutrition. Review of "Plan of Care Order," dated 02/23/22, revealed, "Services- Service Type Skilled Nursing 2-3/wk [2-3 times per week] plus 2 PRN [as needed] amount." Review of "Plan of Care Order," dated 03/09/22, revealed, "Services- Service Type Skilled Nursing 2-3/wk [2-3 times per week] plus 2 PRN [as needed] amount." Review of nursing notes for the end of February through the month of March revealed skilled nursing notes completed for 2/23/22, 3/3/22, 3/9/22, 3/16/22, 3/24/22 and 3/30/22. There was only 1 skilled nurse visit a week for the time frame of 2/23/22 - 3/30/22. During an interview on 5/20/22 at 10:59 AM the Clinical Director stated, "It does say skilled nursing 2-3/week, we are out of compliance." Review of the policy titled "Physician Orders" revised July 2020 stated, "Care and services provided will be provided according to physician orders." .

Based on record review, observation, and interview the facility failed to ensure the content of the plans of care were individualized and complete for 4 of 9 active records reviewed (#1, #2, #5 and #6). This failure had the potential for the patients to not receive care and treatment needed which could worsen the patients' conditions and cause further discomfort and pain and a lack of quality care and treatment. Findings: Patient #1 Record review on 5/16-20/22 revealed Patient #1 elected for hospice and had a start of care on 3/25/22 with diagnoses that included other symptoms and signs involving cognitive functions following other cerebrovascular disease (stroke), dementia, retention of urine unspecified, and fall history. This record failed to include a complete individualized plan of care for this patient. Patient # 1's plan of care included wound care orders after the wound had been healed and treatment was no longer needed. This was evidenced by the following clinical documents and interviews: Review of "Plan of Care Order," dated 5/17/2022, revealed, "Problems, Wound care, Description: Patient has impaired Skin integrity as evidenced by: left hand skin tear ... Identified 03/25/2022 ... Intervention type - other: SN [skilled nurse] may provide wound care to skin tear as needed: change dressing - gauze and tegaderm prn [as needed] ... Activities ... 4/12/22 Wound appears closed and healing." Review of "IDG [Interdisciplinary Group/Team Meeting] Meeting [s]," dated 04/19/2022 and 05/03/2022, revealed, "Problems, Wound care, Description: Patient has impaired Skin integrity as evidenced by: left hand skin tear ... Resolved: [left blank] ... Activities: ... 4/18/22- Left hand site healed." Review of "RN- Skilled Nursing Visit," dated 04/18/2022, revealed, "Skin ...Comments: Left hand skin tear healed ...Problem: Wound care ... Resolved: [left blank] ..." Review of "RN- Skilled Nursing Visit," dated 04/22/2022, revealed, "Skin ...Comments: Left hand skin tear healed." During an observation on 5/17/22 at 9:06 AM revealed there was no skin tear on left hand and no dressing present. During an interview on 5/18/22 at 2:46 PM the Administrator stated that wound care orders such as for Patient #1 should not be present in the continued plan of care if resolved. Patient # 2 Clinical record review on 5/17/22 revealed Patient #2 was admitted on 2/8/22 with a diagnosis of unspecified Alzheimer's Disease. Review of the Plan of Care order dated 5/17/22 for the benefit period of 5/9/22 - 8/6/22 failed to reveal any orders for a bed alarm or side rails or wound care orders without specific interventions.The care plan revealed that the patient had a right eye wound identified on 5/14/22. The intervention stated, "SN [skilled nurse] to provide wound care to right eyebrow PRN [as needed]." During an observation on 5/17/22 at 11:00 AM, it was observed that Patient #2 had a laceration with sutures on the left side of the forehead and another laceration with steristrips over the right eyebrow area. The bed was observed to have a bed alarm placed on the bed and was fitted with 1/4 side rails on each side of the bed. Licensed Nurse # 1 was observed to care for Patient # 2 at a home visit by completing an assessment of the patient and assessing the patient's bed and bed alarm. Review of the Plan of Care order dated 5/17/22 for the benefit period of 5/9/22 - 8/6/22 failed to reveal any orders for a bed alarm or side rails or complete wound care orders for observed head wounds. One care plan item revealed that the patient had a right eye wound that was identified on 5/14/22. The intervention stated, "SN [skilled nurse] to provide wound care to right eyebrow PRN [as needed]." The wound care needed was not described. During an interview on 5/18/22 at 3:00 PM, the administrator confirmed that the plan of care orders were not complete regarding the side rails, care for the head wounds, and bed alarm. Patient # 5 Clinical record review on 5/20/22 revealed Patient #5 was admitted on 12/15/20 with a diagnosis of anoxic brain injury. Review of the RN (Registered Nurse) Recertification dated 4/1/22 revealed the patient had a tube feeding of 335 ml hr (milliliter/hour) and received tube feeding for nutritional intake. The summary revealed that the patient is ventilator dependent, dependent on tube feeding, and received fluid pushes. Review of the Plan of care order dated 5/18/22 revealed the patient received tube feedings daily. This plan of care did not list the type of tube feedings or the frequency and duration of the feedings and details about the water flushes. There were no included orders for emergency trach care, the type of trach used, tracheostomy care, and orders for suctioning if needed. During an interview on 5/20/22 at 11:15 AM, the Clinical Director stated, when asked if this plan of care was individualized, that the specifics needed such as type of feeding and trach care were not on the plan of care. Patient #6 Record review on 5/16-20/22 revealed Patient #6 elected for hospice and had a start of care on 4/28/22 with diagnoses that included chronic foot wound, osteomyelitis (bone infection), pressure ulcer of other site stage 4 (rating scale is from 1-4, with 4 being the worst of these injuries that may impact muscle, tendons, ligaments and bone), other chronic pain, and cellulitis (a bacterial infection of the body's tissue) of the left lower limb. Review of "Written Certification," for the Certification Period of 4/28/2022-07/26/2022, revealed "...[Patient # 6]... Presents to ER [Emergency Room] with a left foot wound that was recently noticed by [family member] but patient states has been there for a year...Open wound noted to medial aspect of left ball of foot." This was signed by the Medical Director on 4/28/22. Review of "IDG [Interdisciplinary Group/Team Meeting] Meeting" documents dated 05/03/2022, stated, "Wound, Description: Patient has impaired skin integrity as evidenced by: (Wound type and locations.) [This document failed to include the wound type and location under the description.]...Interventions, Intervention Type: Clean with wound cleanser and dress with foam dressing. [The intervention section failed to describe how often the wound care would be completed and type of wound cleanser to be used.] Review of a "Plan of Care Order," document dated 05/03/2022 lacked how often the wound care would be completed. Review of a "Plan of Care Order" document dated 5/16/22 included locations of wounds including inner left knee, inner right knee, and medial aspect of ball of left foot. This order document did not include how often the skilled nurse was to complete wound care of these wounds or what type of wound cleanser to use. During an interview on 5/19/22 at 4:20 PM the Administrator stated the plan of care order for Patient #6 was incomplete with the frequency of wound care and dressing changes. Review of the policy titled "Physician Orders" revised July 2020 stated, "IDG plan of care is established in consultation with the physician, Medical Director, Hospice staff, the patient and members of the patient's family. The plan of care may include: Diagnoses, types of services required, frequency of visits and duration, nutritional requirements, specific procedures deemed essential, medications and treatments, equipment and supplies required [enteral and IV pumps and settings, oxygen including flow rate, delivery device, hours of use, hospital bed, etc ... " .

Based on record review, observation, interview, and policy review the facility failed to ensure accepted professional standards of practice of the care of the urinary catheter to prevent contamination and infections for 1 of 1 active records (Patient #1) observed for a Hospice Aide (HA #1) during a home visit. This failed practice placed the patient at risk of contamination and development of urinary tract infections. Findings: Record review on 5/16-20/22 revealed Patient #1 elected for hospice/start of care on 3/25/22 with diagnoses that included other symptoms and signs involving cognitive functions following other cerebrovascular disease (stroke), dementia, retention of urine unspecified, and fall history. Review of the "Aide Care Plan," dated 03/25/22, revealed "Elimination- Assist w/ bed pan, Catheter care every visit, Incontinent care every visit." During an observation on 5/17/22 at 9:06 AM Patient #1 was observed lying in bed with the urinary catheter bag placed on the bed near his / her feet. The catheter bag was positioned at the same level as the bladder so urine was unable to flow downward away from the bladder. Continued observation on 5/17/22 from 9:14-9:24 AM revealed that while Patient #1 was being transferred to the wheelchair for a shower, HA #1 placed the urinary catheter bag and catheter tubing on the floor. During this time, the urinary catheter was dragging and getting tangled up in the wheels of the wheelchair. Once Patient #1 had entered the walk-in shower HA #1 proceeded to place the urinary catheter bag onto the floor outside the shower. HA #1, while dressed in his / her street shoes, then stepped on the urinary catheter bag and tubing repeatedly while giving Patient #1 a shower. Further observation on 5/17/22 at 9:36 AM revealed HA # 1 transferred Patient #1 back into the bedroom for cares/dressing for the day and placed the urinary catheter bag and tubing back on the floor. During an interview on 5/17/22 at 9:53 AM when asked about training with urinary catheter care HA #1 stated he/she would perform peri - care and wipe down the urinary catheter tubing. During an interview on 5/17/22 at 10:00 AM Patient #'s Representative stated Patient #1 had a history of chronic urinary tract infections. During an interview on 5/17/22 at 2:11 PM Licensed Nurse (LN) #1 stated the duties of the HAs for urinary catheter care included: cleaning the insertion site, keeping the catheter tubing clean, and draining the Foley bag (urinary catheter bag) of urine. LN #1 stated that the HAs were supervised by the Registered Nurses (RNs) at least once a month. During an interview on 5/18/22 at 2:46 PM, after a discussion about the catheter bag on the floor, the Administrator agreed the urinary catheter bag should not be on the floor. Review on 5/20/22 of facility's procedure, "Bedside drainage bag attached to catheter," undated, revealed: "#9. Hang the drainage bag by its hook on the side of the bed. Remember to keep the bag below the bladder level at all times to reduce the risk of infection. But do not put the bag on the floor." .