Every finding on record at Angelical Hospice

Based on interview and record review, the home health agency (HHA) failed to ensure that all staff members had annual training for emergency and disaster preparedness program. This failure had the potential for staff to lack the necessary skills needed to provide patient safety during a disaster and emergency situation. Findings: During an interview and concurrent record review on 8/15/2022 at 2:29 p.m. with the Administrator (Adm), the Emergency Preparedness binder was reviewed and the Admin was unable to present a documented evidence of the emergency preparedness training/disaster drill for all staff members. The Adm stated that not all staff were able to be trained and that it was important so staff could be aware of what to do during a disaster. A review of the Hospice agency's undated policy, titled "Emergency Disaster Preparedness Plan", indicated to inservice the staff on the Emergency Plan and conduct the annual Earthquake Disaster Drill.

Based on observation, interview and record review, the hospice agency failed to notify the physician regarding a midarm circumference reading during a SN (skilled nursing ) visit, for one out of 11 patients (Patient 6). This deficient practice placed the patient at risk for inadequate nutrition and hydration and decreased quality of life. Findings: On 8/11/2022 at 10:00am, a home visit was conducted with License Vocational Nurse (LVN 1) at Patient 6's board and care facility. Patient 6 was alert, oriented and was observed lying on bed under a blanket. LVN 1 took Patient 6's vital signs and MAC (used to monitor weight loss). LVN 1 stated Patient 6's MAC was 25 centimeters. A review of Patient 6's face sheet indicated start of care (SOC) on 4/1/2022 with primary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure). A review of Patient 6's Plan of Care (POC)/Interdisciplinary Group (IDG) dated 8/8/2022, indicated a home health aide (HHA) visit twice a week and Skilled Nurse (SN) visit was once a week with two additional visits as needed. The POC/IDG indicated to maintain blood pressure within individually acceptable range of Systolic Blood Pressure 91-159 mmHg and diastolic blood pressure 61-100 mmHg. The POC indicated patient will maintain mid-arm circumference (MAC, used to monitor weight loss) measurement of 28 cm and increase food proportions intake from 30% to 40% to greater than 50%. A further review of Patient 6's clinical record indicated that there was no documented evidence the physician was notified regarding Patient 6's MAC measurement of 25 cm. During an interview on 8/11/2022 at 2:05pm, the Director of Patient Care Services (DPCS) stated there was no indication on the POC when to notify the physician if the MAC went below the goal of 28 cm. The DPCS stated that the SN should have notified the office and the physician, obtain an order, discuss with the Interdisciplinary Group and update the plan of care accordingly. A review of Agency's policy, titled "Change of Condition (undated)," indicated, the clinician is responsible for any specific treatment would notify the attending physician of significant changes in the patient's condition.

Based on observation, interview and record review, the hospice agency (HA) failed to ensure there was a physician's order to check the blood sugar level for one of eleven patients, Patient 9. This deficient practice had the potential to violate one of patient's rights and the patient's treatment plan. Findings: A review of Patient 9's profile indicated a start of care (SOC) date of 5/26/2022, with diagnoses that included acute on chronic diastolic congestive heart failure (heart failure) and type 2 Diabetes Mellitus (an abnormal blood sugar levels). A review of Patient 9's Plan of Care (POC) for the certification period 5/26/2022 to 8/23/2022 included an order for a skilled nurse (SN) to visit once a week and as needed. The POC indicated to assess patient status for ongoing care, optimal blood sugar management and to monitor/assess effectiveness of current and new medication/treatment. A review of the clinical records for Patient 9's SN notes indicated blood sugar was taken on SN visits with no physician's order dated 5/26/2022, 7/7/2022, and 7/26/2022. During an interview on 8/15/2022 at 1:30 pm, the Director of Patient Services (DPCS) stated the SN should have communicated with the physician and Hospice Agency Office to verify or obtain order before checking the patient's blood sugar during SN visits. A review of the facility's policy and procedure titled, "Home Glucose Monitoring", dated/revised October 2015, indicated blood glucose monitoring utilized as a screening tool will be followed with confirmation testing, as ordered by the physician (or other authorized licensed independent practitioner), prior to care treatment decisions.

Based on observation, interview, and record review, the hospice agency failed to develop and implement the individualized plan of care (POC) for three of eleven sampled patients (Patient 1, Patient 2, and Patient 3) by failing to ensure: a). Patient 1 and Patient 2 received anticoagulant (blood thinners-to prevent and treat blood clots) medications as indicated in the plan of care. b). Patient 3 was administered oxygen five liters as ordered for shortness of breath. This failure had the potential to cause serious complications that could affect the patients' health status and well-being. Findings: a) A review of Patient 1's Patient Profile indicated a start of Care date (SOC) of 6/23/2022 with diagnoses that include Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), hypertensive heart disease (heart conditions caused by high blood pressure), and peripheral vascular disease (PVD) (a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm). A review of Patient 1's Plan of Care (POC) for the certification period from 6/23/2022 to 9/20/2022, included an order for a licensed vocational nurse (LVN) to visit once per week with three additional visits as needed (PRN) to assess all systems, evaluate patient care needs, and to provide pain management and comfort measures. A review of Patient 9's Medication Profile file indicated to administer Clopidogrel (anticoagulant) 75 milligram (mg), one tablet, by mouth once a day, for peripheral vascular disease (PVD). On 9/7/2022 at 3:00 pm, a home visit was conducted at Patient 1's home residence accompanied by Licensed Vocational Nurse (LVN 1). Patient 1 was observed sitting in a reclining chair with a plate of food on a folding table in front of him. Patient 1 was alert and oriented and was hard of hearing. Further review of Patient 1's clinical record indicated there was no care plan developed to identify and address the use of anticoagulant medications. During an interview on 9/8/2022 at 11:13 pm, the Director of Patient Care Services designee (DPCSD) stated it was important to educate the patient and caregiver on patients taking anticoagulants regarding safety precautions such as bruising, bleeding, diet restriction and fall precautions. The DPCSD stated these safety measures and patient/caregiver education should have been included in the care plan. A review of the hospice agency's policy, "The Plan of Care" dated 12/2011, indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The policy indicated the plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. b). A review of Patient 3's face sheet indicated Patient 3 was admitted to the hospice agency on 8/18/20, with a primary diagnosis of unspecified malignant neoplasm of the colon (a cancer of the colon or rectum located at the lower end of the digestive tract). A review of Patient 3's "Interdisciplinary Group (IDG) /Update to Plan of Care (POC)" dated 7/5/22 indicated the Skilled Nurse (SN) was to visit Patient 3 once a week for 60 days and as needed, to administer medications during care and follow the medication regimen as prescribed. The physician's orders dated 8/18/22, included in the plan of care indicated to administer oxygen five liters via nasal cannula as needed for shortness of breath to Patient 3. . A review of Patient 3's Visit Notes dated 8/31/22, indicated Patient 3 was assessed as having moderate shortness of breath. However, there was no documented evidence the visiting nurse administered oxygen as ordered for Patient 3. On 9/9/22, at 2 p.m., during an interview with the DPCS (Director of Patient Care Services), she stated the visiting nurse should have documented that oxygen five liters was provided as ordered to relieve Patient 3 from having shortness of breath. c). A review of Patient 2's clinical record indicated a start of care date (SOC) of 6/18/22, with a primary diagnosis of malignant neoplasm of unspecified kidney (a disease in which malignant (cancer) cells are found in the lining of tubules (very small tubes) in the kidney. There are two kidneys, one on each side of the backbone, above the waist. Tiny tubules in the kidneys filter and clean the blood). A review of Patient 2's Plan of Care (POC) for certification period from 6/18/2022 to 9/15/2022, included an order for a Skilled Nurse (SN) to visit once a week for 90 days and three additional visits as needed (PRN) to assess all systems, evaluate patient's care needs and to provide pain management and comfort measures. On 9/7/2022 at 1:30 p.m., a home visit was conducted with Skilled Nurse 1 (SN 1) at Patient 2's residence. Patient 2 was alert, oriented and was sitting on a sofa in the living room. SN 1 checked Patient 2's vital signs and assessed Patient 2's skin integrity for any bruising or bleeding. A review of Patient 2's Medication Profile indicated to administer Warfarin (anticoagulant) four milligrams (mg) 1 tablet by mouth daily. Further review of Patient 2's clinical record indicated no care plan was developed identifying the use of the anticoagulant medications. During an interview on 9/9/2022 at 11:30 a.m., the Director of Patient Care Services designee (DPCS) stated patients on an anticoagulant should have a care plan to check for signs and symptoms of bleeding and unusual bruising on body areas.

Based on observation, interview, and record review, the home health agency (HHA) failed to implement Coronavirus Disease 19 (COVID-19, a respiratory viral infection that affects primarily the lungs and results in cough and difficulty breathing) policy and procedures. This failure had the potential to spread the COVID-19 infection to the other employees and to the patients under the agency's care. Findings: During an observation on 5/10/2022 at 1:30 pm, upon entrance to the hospice agency office, there was no screening performed for COVID-19 signs and symptoms and no temperature check was done. During an interview on 5/15/2022 at 2:00 pm, the DPCS stated the staff should have performed COVID-19 screening on staff and visitors. DPCS stated it was important to check for COVID-19 symptoms and temperature to prevent the spread of infection. A review of the facility's policy and procedure titled, COVID-19 Screening, undated, indicated Angelical Hospice, Inc. provided procedures to perform efficient screening of Covid-19 to prevent the Covid-19 spreading in the office, to protect office staffs, care staffs and visitors. The policy indicated all employees should remain alert of the pandemic of Covid-19 and take immediate action if they note the following symptoms and monitoring for these symptoms: Cough, fever (over 100.4 °F), shortness of breath, sore throat, muscle aches or body aches, fatigue, and headache. The policy indicated visitors should also be checked the body temperature and should be recorded. The policy indicated if any employee or visitor is confirmed with the temperature more than 100.4 °F, she/he is not allowed to enter the office.