Every finding on record at Atlantic Hospice, Inc.

Upon patient record review, 2 of 27 (Patient #2, 15) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #2: 1/4/24 order Juven 7 gram-7 gram-1.5 gram oral powder packet oral 1 packet 2 times daily supplement. Start 1/3/24. Give 1 packet by mouth twice daily for supplement. The hospice medication profile does not include to dilute/reconstitute. Patient #15: During patient visit to ALF, there was discussion between RN and daughter and RN and Med Tech regarding patient's 12.5 Fentanyl patch. The patch is not listed on hospice medication profile. Profile was updated before end of survey.

Upon patient record review, 2 of 27 (Patient #5, 7) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #5: 1/6/24 557 pm triage on call note. Received call from CG reporting extreme change in condition.... requesting nursing visit.... RN to initiate visit. There is no evidence of a follow up visit until 1/9/24. Documented patient comfortable and no reference to prior follow up concern or visit. Patient #7: 2/10/24 triage call r/t nebulizer "ends are frayed"...will do visit. Team made aware. There is no documented evidence of visit and/or follow up.

Upon patient record review, 7 of 27 (Patient #4, 5, 6, 7, 9, 14, 16) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patients # 4, 5, 6. 7. 9, 14, 16: SC and MSW frequencies for 1/month and 6 PRN for additional support. The PRN frequency is too broad to meet the specific patient and family needs.

Upon patient record review, 2 of 27 (Patient #2, 15) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2 ; 1/4/24 order Juven 7 gram-7 gram-1.5 gram oral powder packet oral 1 packet 2 times daily supplement. Start 1/3/24. Give 1 packet by mouth twice daily for supplement. The hospice order does not include to dilute/reconstitute. 1/4/24 Wound care orders for Sacral and left buttocks wound include Santyl 250 unit/gram topical ointment 1 application 2x daily to wounds left buttock sacrum-topically twice daily effective 1/3/24 and Calcium Alginate 4x4 bandage topical 1 application 2x daily. Dakin's solution 0.25% topical,1 application 2x daily to wounds of sacrum and left buttock topically, effective 1/3/24. Facility record current includes Dakin's solution only with fluffed gauze. RN states Calcium Alginate and Santyl were discontinued and hospice orders were not updated accordingly. The hospice orders were updated during visit. Patient #15: During patient visit and during medication review, hospice nurse discussed Fentanyl patch with med tech. Fentanyl was not included in hospice orders or med profile. It was confirmed that patient was using Fentanyl 12.5 mcg topically and changed q72 hrs. Hospice RN updated order 3/8/24.

Upon patient record review 2 of 27 (Patient #2, 3) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #2: SOC 1/3/24: 1/22/24 Assignment sheet. Pt weight every Monday and shampoo every Monday and Thursday. 2/12/24 (Monday) Patient weight and shampoo marked as "not due" Patient #3: SOC 1/5/24. HA 2xwk beginning 1/8/24. Only visits were 1/9 and 1/11/24. No documentation to clarify discontinuation of services. Orders/IDG POC not updated regarding frequency and reasoning.

Upon client record review, 1 of 27 (Patient #2) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #2: SOC 1/3/24. Patient admitted with sacral, buttocks wound requiring wound treatment. During patient visit, it was reported that the SNF consistently performs wound care. The hospice orders/POC do not clearly delineate responsibility to SNF nurse.

Based on staff interview, review of video surveillance footage, and review of facility documentation, it was determined that the facility failed to ensure the protection of patients' rights. --- Findings include: 1. The facility failed to conduct a full and thorough investigation into the alleged abuse of a hospice patient. (Refer Tag - 0509) 2. The facility failed to ensure that all employees providing patient care completed education and training for abuse and neglect. (Refer Tag- 0517)

Based on staff interview, review of video surveillance footage, and review of facility documents, it was determined that the facility failed to conduct a full and thorough investigation into the alleged abuse of a hospice patient. --- Findings include: On 5/30/23, Staff #1 (S1), Chief Executive Officer, provided a 22-second video clip for review that was given to the agency by Patient #1's (P1) daughter and S1 stated that the video clip provided was from the alleged incident that occurred on 4/17/23. Staff #2 (S2), an Administrator, stated that there was a camera located in the patient's room that would provide 24-hour audio and video surveillance by the patient's family. A review was conducted of the video footage in the presence of S1 at 1:46 PM. The video footage showed Staff #4 (S4), a hospice aide, sitting next to P1. S4 was heard telling P1 that she had "nice legs" and that P1's legs were "nice and meaty." P1 verbally responded to S4, but it was unclear what the patient had said. S4 then appeared to move his hand to touch the patient in the abdominal and upper leg area while telling the patient "You've got some meat on your bones." As P1 was verbally responding to the hospice aide, the video ended. P1's daughter notified the hospice agency the same day that the alleged event took place, and the hospice agency immediately placed S4 on a suspension of duties pending an investigation. Upon request, S1 and S2 provided an incident report for review that indicated that the facility investigation was incomplete. Per S1 and S2, the facility started to conduct an investigation, but the investigation was deemed incomplete due to the following reasons: -This incident was reported to the local police and the local authorities were conducting a full investigation. -S4 quit his/her position with the hospice agency on 4/18/23, prior to the completion of the investigation. Staff #3 (S3), Director of Human Resources, confirmed the above findings and stated that the hospice agency did not reach out to S4, but was aware that the police had. S3 stated that the facility was not aware of the outcome of the police investigation by the facility was now closed. Facility policy titled, Abuse, Neglect, Mistreatment and Exploitation, effective date 1/2019, states, "... PROCEDURES: ... 5. The administrator immediately ... investigates alleged violations involving persons providing services ... and immediately acts to prevent potential further violation(s) during the investigation ... 7. If necessary, the Administrator will seek consultation to ensure an alleged violation is thoroughly investigated in order to verify whether or not it occurred and that it is constituted abuse, neglect, mistreatment or exploitation ..."

Based on staff interview, review of video surveillance footage, and facility document review, it was determined that the facility failed to ensure that one of 25 employees caring for a patient had education and training for abuse and neglect. --- Findings include: On 5/30/23, Staff #1 (S1), Chief Executive Officer, provided a 22-second video clip for review that was given to the agency by Patient #1's (P1) daughter and S1 stated that the video clip provided was from the alleged incident that occurred on 4/17/23. Staff #2 (S2), an Administrator, stated that there was a camera located in the patient's room that would provide 24-hour audio and video surveillance by the patient's family. A review was conducted of the video footage in the presence of S1 on 5/30/23 at 1:46 PM. The video footage showed Staff #4 (S4), a hospice aide, sitting next to P1. S4 was heard telling P1 that [the patient] had "nice legs" and that P1's legs were "nice and meaty." P1 verbally responded to S4, but it was unclear what the patient had said. S4 then appeared to move his/her hand to touch the patient in the abdominal and upper leg area while telling the patient "You've got some meat on your bones." As P1 was verbally responding to the hospice aide, the video ended. A review of the education file for each staff member that had cared for P1 since his/her admission to the hospice agency was reviewed. S4's personnel file noted that S4 was hired at the facility on 9/28/21 and quit his/her position on 4/18/23 after being suspended from duties earlier on the same day pending an investigation into the allegation of abuse and inappropriate behavior with a patient. S4 had no prior issues or warnings regarding his behavior documented in his/her personnel file. S4's last annual evaluation was completed on 9/28/22 and S4 was noted to have above average scores. Further review of S4's education history noted that S4 had not completed the abuse and neglect training for the previous year (2022), despite the agency's representatives reaching out to him/her. S4 also had not yet completed the abuse and neglect training for the current year (2023) prior to leaving the hospice agency on 4/18/23. Upon request, Staff #3 (S3), Director of Human Resources, provided an email that was sent to S4 on 12/23/22 that stated, "... you have modules incomplete for 2022 ... education is a requirement that was due on 10/31/22. Be advised of the final deadline of 12/31/22 to complete annual training ... per company procedure: 'Failure to complete the training within the timeline will result in progressive discipline up to and including termination of employment.'" Upon request, S3 was unable to provide any further documentation of follow-up or disciplinary actions taken with S4 for the incomplete education modules for 2022.