Every finding on record at Ancora Hospice & Palliative Services, LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements; herbal remedies and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review and interview. In 3 of 4 (75%) home visits revealed the agency did not ensure the drug profile contained the patient's current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. Home Visit 1: During Home Visit 1 (Clinical Record 1) on 09/17/2024 to observe the Hospice Aide (Personnel Record 12), the hospice medication list dated 09/17/2024 was compared to the skilled nursing facility (SNF) medication list dated 09/17/2024. The SNF list included the following medication(s): Miralax 17 grams every 24 hours as needed and Miralax 17 grams daily scheduled. Only the as needed Miralax was on the hospice list and not the scheduled dosage. Home Visit 2: During Home Visit 2 (Clinical Record 2) on 09/18/2024 to observe the Registered Nurse (Personnel Record 4), the hospice medication list dated 09/18/2024 was compared to the skilled nursing facility (SNF) medication list dated 09/18/2024. The SNF list included the following medication(s) not listed on the hospice list: Haldol 5 mg and Vitamin D 1 tablet) Home Visit 3: During Home Visit 3 (Clinical Record 3) on 09/18/2024 to observe the Spiritual Counselor (Personnel Record 5), the hospice medication list dated 09/18/2024 was compared to the assisted living facility (ALF) medication list dated 09/18/2024. The ALF list included the following medication(s) not listed on the hospice list: Supplemental nutritional drink 2 times daily dated 07/31/2024. During an interview and joint record review with the Chief Operating Officer on 09/18/2024, the medication list differences were confirmed and she agreed the lists needed to be reconciled.

It is required that each patient’s individualized written plan of care includes measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 5 of 19 (26%) clinical records reviewed revealed the agency did not ensure the patient's individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plans of care. Clinical Record 9: The patient elected the hospice benefit on 10/10/2023 for the diagnosis of respiratory failure. The plan of care dated 10/10/2023 included the respiratory goal of "Patient will receive optimal breathing patterns, airway patency and comfort." It did not include measurable outcomes or define "optimal" breathing patterns or comfort. Clinical Record 12: The patient elected the hospice benefit on 06/19/2024 for the diagnosis of end-stage renal failure. The plan of care dated 06/19/2024 included the goal of "Physical mobility. Optimal patient safety" but did not clarify how this would be accomplished, measured or individualized for the patient. Clinical Record 11: The patient elected the hospice benefit on 09/10/2024 for the diagnosis of malignant neoplasm of the bronchus of lung. The initial plan of care developed on 09/10/2024 included the goal: "Bowels will function per disease process." The "disease process" cannot be measured. Clinical Record 14: The patient elected the hospice benefit on 08/21/2023 for the diagnosis of malignant neoplasm of the bronchus of lung. The plan of care dated 08/21/2024 included the goal "Patient will have optimal pain control". The plan of care did not include the patient's stated, measurable, pain goal. The plan of care did not provide the pain scale to be used to accomplish this goal or describe the pain ratings. Clinical Record 17: The patient elected the hospice benefit on 01/19/2024 for the diagnosis of sepsis. The initial plan of care dated 01/19/2024 included the goal "Patient will have optimal pain control." The plan of care did not include the patient's stated, measurable, pain goal. The plan of care did not provide the pain scale to be used to accomplish this goal or describe the pain ratings. The Chief Operating Officer stated in an interview on 09/19/2024 during a joint clinical record review that the plan of care interventions and goals had not been developed with measurable outcomes or individualized.

It is required that written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, interview and observation. In 4 of 17 (24%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the registered nurse provided specific written instructions for the hospice aide. Clinical Record 1: The patient elected the hospice benefit on 09/06/2024 for the diagnosis of Parkinson's disease. The hospice aide care plan written by the registered nurse dated 09/06/2024 included the following task "Barrier cream to ________ (this was blank)". During Home Visit 1 on 09/17/2024 with Hospice Aide (Personnel Record 12)the skilled nursing facility aide and hospice aide utilized the Hoyer lift to move the patient from chair to bed. Specific instructions for the Hoyer lift were not noted on the aide care plan. Clinical Record 8: The patient elected the hospice benefit on 04/29/2024 for the diagnosis of chronic obstructive pulmonary disease. The aide care plan written by the registered nurse dated 04/29/2024 included the following tasks: "shower as directed, perineal care as directed, and bed bath as directed". The aide care plan did not include specific instructions for the "as directed" portions for each of these tasks. Clinical Record 10: The patient elected the hospice benefit on 01/18/2023 for the diagnosis of senile degeneration of the brain. The aide care plan written by the registered nurse dated 01/18/2023 included the relevant task of "foot care." A nursing visit dated 02/26/2023 noted "Wounds to right ankle covered with gauze." The aide care plan was not updated to include specific instructions for the aide regarding notification of the wound or notification to the nurse if the dressing on the ankle became soiled, dislodged, or wet. Clinical Record 15: The patient elected the hospice benefit on 02/02/2024 for the diagnosis of senile degeneration of the brain. The hospice aide care plan dated 02/02/2024 included the tasks of "Barrier cream to ________(this was blank) " but did not include specific instructions for the location of where to place the barrier cream. During an interview and joint record review with the Chief Operating Officer on 09/18/2024, it was confirmed the hospice aide care plans did not contain specific written instructions for the aide regarding the location of where to apply the barrier cream, the hoyer lift, the wound, or specific instructions for items listed "as directed".

It is required that hospice aides must report changes in the patient's medical, nursing, rehabilitative and social needs to a registered nurse. This standard was not met as evidenced by clinical record review and interview. In 3 of 17 (18%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the aide reported changes to a registered nurse. Clinical Record 7: The hospice aide care plan dated 06/26/2024 included the task of "file nails every visit". Hospice aide visit notes dated 07/22/2024 and 8/12/2024 marked the task as "refused". The record lacked documentation the aide had notified the registered nurse the patient had refused the task. Clinical Record 8: The hospice aide care plan dated 04/29/2024 included the tasks of "change linens and mouth care every visit." The hospice aide visit note dated 06/04/2024 noted these tasks were "not needed." The record lacked documentation the aide had notified the registered nurse the tasks had not been completed as ordered. Clinical Record 18: The hospice aide care plan dated 08/08/2024 included the tasks of clean nails and assist with bed pan every visit. The hospice aide visit note dated 09/11/2024 noted these tasks as "refused." The record lacked documentation the aide had notified the registered nurse the patient had refused the tasks, During an interview and joint record review with the Chief Operating Officer on 09/18/2024, it was confirmed the hospice aide(s) did not document the reporting of changes in the plans of care,

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. This standard was not met as evidenced by clinical record review and interview. One of 11 (9%) clinical records failed to provide documentation that an initial bereavement assessment was completed. Record # 79701: The hospice plan of care dated 10/12/21-1/9/22 was reviewed. The patient elected hospice care on 10/12/21. On 10/15/21 the MSW was unable to reach the spouse to schedule the initial visit. On 10/19/21 the patient’s spouse spoke with the MSW and stated she was open to the MSW visit and would look at her schedule and call MSW back to let her know when she would like a visit. The patient died 10/26/21. The clinical record failed to provide documentation that an initial bereavement assessment was completed by the MSW or RN. The agency policy Admission Procedure, review dated 9/8/2021 stated "SW or SCP refused: RN will address the initial bereavement assessment including spiritual, physical, emotional and culture factors within the hospice plan of care.” Interview with the CEO (RN), CMO and the Chief Operating Officer (COO, RN) on 11/10/21 confirmed this finding. The CEO, CMO, and COO confirmed that the initial bereavement risk assessment was not completed by the MSW because the patient kept “putting off” the MSW visit. The COO also confirmed the initial bereavement assessment was not completed by the RN.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids. This standard was not met as evidenced by observation and interview. One of 3 (33%) patients who received a home visit revealed the hospice organization did not ensure adherence to agency infection prevention and control policies and procedures. Patient #33884: During a home visit on 11/10/21 at 0945, the RN, Staff #72612 was observed placing a bag that contained the stethoscope, BP cuff, thermometer, and pulse oximeter on the floor with no barrier underneath. Subsequently, the stethoscope, BP cuff, thermometer and pulse oximeter was placed on the floor after being used for the patient assessment of vital signs. The agency policy Safe Handling of Potentially Contaminated Equipment/surfaces in Patient’s Environment, Cleansing of Non-critical Equipment (stethoscope, BP cuff, oximeter, etc.) & Bag Barrier Use revision dated 8/9/21 states in part “Upon arrival at the patient’s place of residence, barrier is taken out of bag, barrier is unfolded and placed on surface where bag is to sit.” The Chief Operating Officer (COO, RN) was interviewed on 11/10/21 after the home visit and acknowledged that [Staff #72612] should have used a barrier under the bag and not put the bag on the floor.

It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). The Interdisciplinary Group documents in the patient record that the policies and procedures for managing and disposing of controlled medications is provided and discussed. This standard was not met as evidenced by record review and interview. Eleven of 11 (100%) clinical records failed to provide documentation that the copy of the hospice’s written policies and procedures for the management and disposal of controlled medications provided to the patient on admission was discussed with the patient or family or patient’s legal representative(s). Records #25068 review of the care plan dated 9/29/21-12/27/21, #33884 review of the care plan dated 9/22/21-11/20/21, #35158 review of the care plan dated 10/21/21-1/18/21, #49767 review of the care plan dated 11/4/21-2/1/21, #50002 review of the care plan dated 10/14/21-1/11/22, #58257 review of the care plan dated 10/6/21-1/3/22, #70922 review of care plan dated 11/3/21-1/31/21, #77921 review of the plan of care dated 9/19/21-11/17/21, #79701 review of plan of care dated 10/12/21-1/9/22, #93362 review of care plan dated 10/19/21-1/16/22, and #99989 review of care plan dated 10/13/21-1/10/22. The agency policy Disposing of Drugs and Biologicals Policy and Procedures 418.106(e)2, review dated 8/31/2021 stated in part "Written education will consist of written policies and procedures for disposing of controlled drugs and biologicals and safe disposal methods. Documentation that education was provided, and that written information was provided will be documented in the patient’s EMR.” Interview with the Chief Operating Officer (COO, RN) on 11/9/21 confirmed this finding.