Every finding on record at Benton County Health Department

Based on policy review, employee file review, and interview, the provider failed to ensure all staff were provided emergency preparedness (EP) training in one of five employee files reviewed (Employee #4). This deficient practice has the potential to affect all the patients served by the provider.Findings included:Review of the provider’s policy titled, “Safety and EP,” revised 08/28/2001, showed in part the following:- Each Hospice employee is responsible to be knowledgeable of their individual role in the Safety and EP program; and-The EP plan shall be rehearsed at least annually.Review of the provider's policy titled, "Orientation, Training, Education, and Internship Programs," revised 09/01/2022, showed in part the following:- Each department employee will be required to complete emergency plan training; and- Trainings are mandatory. --- Employee #4 (E-4):Review of E-4’s employee file showed a hire date of 11/16/2019. The employee file failed to show emergency preparedness training was completed during orientation and failed to show training was completed every two years as required per federal emergency preparedness guidelines.During an interview on 05/28/2025 at 11:30 AM, registered nurse (RN)-A (known to the provider as the health educator) stated that E-4 was not trained on emergency preparedness during new employee orientation and did not participate in the annual training. RN-A also stated that he/she did not know that E-4 needed the training.

Based on policy review, record review, home visit observation, and interview, the provider failed to ensure that accepted standards of practice to prevent the transmission of infections and communicable diseases were followed in two of four home visit observations conducted (Records/Patients #1 and #4). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included: Review of the provider’s undated policy titled “Homecare Bag Technique,” showed in part the following:- Never set the bag on the floor.  Always choose a place to set the bag that gives you enough workspace, is close to the patient, and is away from children and pets; and - Spread an impervious (not allowing fluid to pass through) barrier on the surface before setting the bag down.   Review of the provider’s policy titled, “Infection Control,” last revised 12/02/2008, showed in part, the hospice must follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions.  Review of the provider’s undated policy titled “Universal Precautions for All Healthcare Workers,” showed in part the following:- Gloves should be changed after each client contact; and- When gloves are removed, thorough hand washing is required.  Gloves do not take the place of hand washing. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 04/24/2025 with a primary diagnosis of senile degeneration of the brain, not elsewhere classified.  The patient had an additional diagnosis of surgical repair of a left hip fracture.  He/she was confined to bed and lived with his/her adult child who assisted with activities of daily living (ADL’s). Review of the skilled nursing (SN) visit note, dated 05/03/2025, showed the patient’s daughter paged the nurse because she was worried about his/her left hip wound.  The nurse noted that, the previously closed, left hip surgical incision had opened and had bloody drainage.   Review of lab report of wound culture of the patient’s left hip wound, collected 05/16/2025, showed methicillin-resistant staphylococcus aureus (MRSA; a microorganism that has become resistant to a commonly used group of antibiotics), enterobacter cloacae complex (a multi-drug resistant bacteria naturally living in the intestines known to cause infections), and enterococcus faecalis (a species of bacteria naturally found in the intestines). Observation on 05/28/2025, beginning at 10:00 AM, showed patient was lying in bed, alert and oriented to person only and would grab the registered nurse’s (RN’s) hands while he/she provided care.  The RN put on gloves, checked the patient’s multiple wounds which were covered with dressings.  He/she touched the dressing on the patient’s left hip then arranged the bed covers, picked up the bed control from the floor and placed it back onto the bed, then touched the clean dressing supplies on the bedside table, showing the state agent (SA) what products were used to change the dressing.  The RN failed to remove his/her soiled gloves and perform hand hygiene until after touching the clean dressing supplies.   During an interview on 05/29/2025, at 11:07 AM, the administrator stated that the expectation was for the nurses to remove their gloves and wash their hands after touching the patient or patient’s dressing, prior to picking up the bed control or touching clean dressing supplies.        RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 05/07/2025 with a terminal diagnosis of Chronic obstructive pulmonary disease, unspecified (a group of lung diseases that block airflow and make it difficult to breathe). Observation on 05/28/2025 at 10:25 AM, showed the Spiritual Counselor (SC-B) placed his/her supply bag on the floor. SC-B then removed his/her prayer booklet from his/her supply bag and placed it on the patient's bedside table without a barrier. SC-B provided spiritual support for the patient. SC-B used hand sanitizer and wiped the prayer booklet with a sanitizer wipe and returned the booklet to the supply bag and used a sanitary wipe on the bottom of the bag. Per an interview during a home visit observation on 05/28/2025, SC-B stated that he/she always tried to wipe the bag with a sanitary wipe upon leaving a patient's home. During an interview on 05/29/25025 at 10:30 AM, the hospice registered nurse coordinator (RNC) stated that the supply bag should not be on the floor and that this is the [provider's] policy.   RNC stated that barriers should be used for all supplies used in the patient's home.  Findings included:Review of the provider’s undated policy titled, “Homecare Bag Technique,” showed in part the following:- Never set the bag on the floor; - Always choose a place to set the bag that gives you enough workspace, is close to the patient, and is away from children and pets; and - Spread an impervious (not allowing fluid to pass through) barrier on the surface before setting the bag down.  Review of the provider’s policy titled, “Infection Control,” revised 12/02/2008, showed in part, the hospice must follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions. Review of the provider’s undated policy titled, “Universal Precautions for All Healthcare Workers,” showed in part the following:- Gloves should be changed after each client contact; and- When gloves are removed, thorough hand washing is required.  Gloves do not take the place of hand washing. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 04/24/2025 with a primary diagnosis of senile degeneration of the brain, not elsewhere classified.  The patient had an additional diagnosis of surgical repair of a left hip fracture.  He/she was confined to bed and lived with his/her adult child who assisted with activities of daily living (ADL’s).Review of the skilled nursing (SN) visit note, dated 05/03/2025, showed the patient’s daughter paged the nurse because he/she was worried about his/her left hip wound.  The nurse noted that, the previously closed, left hip surgical incision had opened and had bloody drainage.  Review of lab report of wound culture of the patient’s left hip wound, collected 05/16/2025, showed methicillin-resistant staphylococcus aureus (MRSA; a microorganism that has become resistant to a commonly used group of antibiotics), enterobacter cloacae complex (a multi-drug resistant bacteria naturally living in the intestines known to cause infections), and enterococcus faecalis (a species of bacteria naturally found in the intestines).Observation on 05/28/2025 at 10:00 AM, showed patient was lying in bed, alert and oriented to person only and would grab the registered nurse’s (RN’s) hands while he/she provided care.  The RN put on gloves, checked the patient’s multiple wounds which were covered with dressings.  He/she touched the dressing on the patient’s left hip then arranged the bed covers, picked up the bed control from the floor and placed it back onto the bed, then touched the clean dressing supplies on the bedside table, showing the state agent (SA) what products were used to change the dressing.  The RN failed to remove his/her soiled gloves and perform hand hygiene until after touching the clean dressing supplies.   During an interview on 05/29/2025 at 11:07 AM, the administrator stated that the expectation was for the nurses to remove their gloves and wash their hands after touching the patient or patient’s dressing, prior to picking up the bed control or touching clean dressing supplies.   RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 05/07/2025 with a terminal diagnosis of chronic obstructive pulmonary disease, unspecified (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient resided at his/her home.Observation on 05/28/2025 at 10:25 AM, showed the spiritual counselor (SC)-B placed his/her supply bag on the floor. SC-B then removed his/her prayer booklet from his/her supply bag and placed it on the patient's bedside table without a barrier. SC-B provided spiritual support for the patient. SC-B used hand sanitizer and wiped the prayer booklet with a sanitizer wipe and returned the booklet to the supply bag and used a sanitizer wipe on the bottom of the bag. Per an interview during a home visit observation on 05/28/2025, SC-B stated that he/she always tried to wipe the bag with a sanitizer wipe upon leaving a patient's home. During an interview on 05/29/25025 at 10:30 AM, the provider administrator (PA) stated that the supply bag should not be on the floor and that this is the [provider's] policy. PA stated that barriers should be used for all supplies used in the patient's home.

Based on policy review, job description review, record review, home visit observation, and interview, the provider failed to ensure the clinicians followed the hospice's wound assessment policies and procedures (P&P) in two of five full records reviewed (Records/Patients #1 and #4). This deficient practice has the potential to affect all the patients served by the provider. --- RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 05/07/2025, with a terminal diagnosis of chronic obstructive pulmonary disease, (COPD - a group of lung diseases  that block airflow and make it difficult to breathe). Record showed the patient had a stage II (two) pressure injury (a partial thickness loss of the skin) with a wound measurement of 1.5 X 0.2 cm. The patient resided at his/her sister's home, with the sister being his/her primary caregiver. The patient is no longer able to ambulate and is bedboundReview of the document titled, "Skilled Nurse (SN) Visit," dated 05/08/2025 and 05/13/2025, failed to show a wound measurement to the left buttock.Review of the document titled, "SN Visit," dated 05/16/2025, showed a wound measurement of 1.2 X 0.2 cm to the left buttock.Review of the document titled, "SN Visit," dated 05/20/2025, 05/23/2025, and 05/27/2025, failed to show a wound measurement to the left buttock.During an interview on 05/29/2025 at 9:25 AM, the registered nurse coordinator (RNC) stated that he/she did not know the clinicians could bypass the wound measurements in the software system and he/she could not find any additional wound measurements in the system for the patient. He/she stated that they should measure the wounds every week per their policy, but he/she expected them to measure the wounds at every visit.   Findings included:Review of the provider’s undated policy titled, “Would Assessment Policy,” showed in part, the assessment of patient wounds included evaluation and obtaining measurements once a week or whenever changes occurred in the wound. Review of the undated job description of the registered nurse (RN), showed in part, that all functions shall be performed in accordance with the established policies and practices of [named provider] and/or the particular program in which the RN is assigned.  RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 04/24/2025 with a primary diagnosis of senile degeneration of the brain, not elsewhere classified.  The patient had an additional diagnosis of surgical repair of a left hip fracture.  He/she was confined to bed and lived with his/her adult child who assisted with activities of daily living (ADL’s). Review of the clinical record showed the following wounds were identified and measured on the following skilled nursing (SN) visit dates:- Wound #1 – a pressure ulcer (skin injury caused by unrelieved pressure) on the sacrum (an area of the lower back above the tailbone) was identified on 04/24/2025 * 04/24/2025 = 1 x 0.5 centimeters (cm)* 05/03/2025 = 1.4 x 1.9 cm* 05/20/2025 = healed* The SN failed to obtain weekly wound measurements- Wound #2 – a pressure ulcer on the left inner calf was identified on 04/24/2025* 04/24/2025 = 1 x 1 cm* The SN failed to obtain weekly wound measurements- Wound #3 – a pressure ulcer on the right lateral foot was identified on 04/24/2025 * 04/24/2025 = 1.5 x 1 cm* 05/16/2025 = 0.5 x 0.5 cm* The SN failed to obtain weekly wound measurements - Wound #4 – a pressure ulcer on the right lateral foot was identified on 04/24/2025* 04/24/2025 = 1 x 1 cm* 05/16/2025 = 0.5 x 0.5 cm*The SN failed to obtain weekly wound measurements- Wound #5 – a skin tear on the left forearm was identified on 04/29/2025* 04/29/2025 = 9 x 1 cm* 05/02/2025 = 9 x 1 x 0 cm* 05/03/2025 = 4 x 1.2 cm* 05/27/2025 = 3 x 0.5 cm* The SN failed to obtain weekly wound measurements- Wound #6 – a pressure ulcer on the coccyx (tailbone) was identified on 05/03/2025* 05/03/2025 = 1 x 6 cm* 05/20/2025 = healed* The SN failed to obtain weekly wound measurements Observation and interview on 5/28/2025, beginning at 10:00 AM, showed the RN failed to measure the patient’s wounds during the home visit and stated that the wounds were supposed to be measured once a week.  During an interview on 5/29/2025, at 9:25 AM, the administrator stated that he/she did not know the clinicians could bypass the wound measurements in the software system and he/she could not find any additional wound measurements in the system for the patient.  He/she stated that they should measure the wounds every week per their policy, but he/she expected them to measure the wounds at every visit.

Based on policy review, record review, and interview the hospice provider failed to forward a copy of the hospice discharge summary to the patient’s attending physician in one of four records reviewed for discharge/revocation (Record/Patient #10). This deficient practice has the potential to impact the continuity of care for all the patients who are live discharges from the provider.Findings included:Review of the provider’s policy titled, “Nursing Discharge Summary and Narrative,” revised 02/2013, showed in part the following:- The physician shall be notified in all instances of discontinuance of hospice care;- The notification shall be documented in the patient record;- The original [discharge summary] is to be incorporated within the patient’s medical record upon discharge; and- A copy of the nursing discharge narrative will be forward to the patient’s physician. --- RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 12/07/2023 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity). The patient was discharged on 03/04/2024 due to no longer having a terminal prognosis of six months or less. The patient resided in his/her home.Review of the interdisciplinary group (IDG) meeting notes, dated 03/02/2024, failed to show documentation that the attending physician was notified.During an interview on 05/29/2025 at 10:00 AM, the administrative assistant (AA) stated that there was not a discharge summary for the patient. AA stated that the information was not sent to the patient’s attending physician, but it should have been sent. He/she stated that he/she had drafted a new procedure for discharge summaries at the beginning of  05/2025, but had not started the in-service training. During an interview on 05/29/2025 at 11:50 AM, the administrator stated that they should be including all elements of the discharge summary and that the administrative assistant had created a checklist for a new procedure for the discharge summaries and were awaiting implementation of the new process.

Based on policy review, record review, and interview the hospice provider failed to ensure the discharge summary that was sent to the attending physician included a summary of the patient's stay including treatments, symptoms and pain management, a current plan of care, and the latest physician orders in four of four live discharge records reviewed (Records/Patients #7, #8, #9, and #10). This deficient practice has the potential to impact the continuity of care for all the patients who are live discharges from the provider.Findings included:Review of the provider’s policy titled, “Nursing Discharge Summary and Narrative,” revised 02/2013, showed in part the following:- The registered nurse (RN) shall complete a discharge summary and narrative upon the transfer, revocation or discharge of a Hospice patient;-  Purpose: to give [the] physician a complete and concise report of the patient's condition and care to ensure physician notification of patient's discharge from Hospice service;- The physician shall be notified in all instances of discontinuance of hospice care and such notification shall be documented in the patient record; and- The report includes a summary of the patient’s stay including treatments, symptoms and pain management, the patient’s current plan of care, the patient’s latest physician order, other documentation that will assist in the post-discharge continuity of care or requested by the attending physician or receiving facility. --- RECORD/PATIENT #7:Review of the clinical record showed the patient was admitted to hospice services on 02/11/2025 with a terminal diagnosis of congestive heart failure (CHF - a decrease in the ability of the heart to pump blood). The patient was discharged on 04/08/2025 when the patient was sent to the emergency department (ED) due to food lodged in the patient’s throat. The patient resided in his/her home.Review of the discharge visit, dated 4/08/2025, failed to show the following documents were sent to the hospital:- The current plan of care; and- A summary of the patient’s stay and treatments.RECORD/PATIENT #8:Review of the clinical record showed the patient was admitted to hospice services on 04/23/2025 with a terminal diagnosis of acute kidney failure. The patient was discharged on 04/30/2025 when the patient and the patient’s spouse both required medical assistance and were both transported by ambulance to the hospital. The patient resided in his/her home.Review of the discharge visit, dated 04/30/2025, failed to show the following:- The current plan of care sent to the hospital;- Notification to the hospital that medical records were available upon request; and- A summary of the patient’s stay and treatments sent to the hospital.RECORD/PATIENT #9:Review of the clinical record showed the patient was admitted to hospice services on 09/30/2023 with a terminal diagnosis of liver cancer. The patient was discharged on 10/07/2023 when he/she moved out of state to live with his/her adult child. Review of the journal notes, dated 10/06/2023, failed to show the following were sent to the receiving hospice services:- The current plan of care; - A summary of the patient’s stay and treatments; and- Recent physician’s orders.RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 12/07/2023 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity). The patient was discharged on 03/04/2024 due to no longer having a terminal prognosis (life expectancy) of six months or less. The patient resided in his/her home.Review of the interdisciplinary group (IDG) meeting notes, dated 03/02/2024, failed to show the following were sent to the attending physician:     - The patient's treatments, symptoms and pain management; - The current plan of care; and - Latest physician orders.During an interview on 05/29/2025 at 10:00 AM, the administrative assistant (AA) stated that there was not a discharge summary for the patient. The AA stated that he/she had drafted a new procedure for discharge summaries at the beginning of 05/2025 but had not started the in-service training. During an interview on 05/29/2025 at 11:50 AM, the administrator stated that they should be including all elements of the discharge summary and that the administrative assistant had created a checklist for a new procedure for the discharge summaries and were awaiting implementation of the new process.

Based on policy review, record review, home visit observation, and interview, the provider failed to provide the skilled nursing facility (SNF) with all the required hospice documentation in one of one SNF patient records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients residing in nursing facilities served by the provider. --- Findings included:Review of the provider's policy titled, "Hospice Care for Acute Care, Skilled Care or Residential Care Facility," dated 12/02/2008, showed in part the agency (provider) will provide the following documents to the SNF:- Physician certification and recertification; and- Hospice physician and attending physician orders. RECORD/PATIENT #2:Review of the clinical record showed the patient was recertified for hospice services on 05/17/2025 with a terminal diagnosis of acute and chronic respiratory failure (a condition where the lungs cannot adequately exchange oxygen and carbon dioxide in the blood) and hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). The patient resided at a SNF. Observation on 05/28/2025 at 3:10 PM, showed the hospice binder at the SNF failed to include the following documentation:- Physician certification and recertification; and- Hospice physician and attending physician orders.  Per an interview conducted during observation, the hospice registered nurse coordinator (RNC) confirmed that the documents were missing from the hospice binder and stated that the binder should have included the proper documents.

Based on record review and interview the agency failed to ensure coordination of care when the on-going sharing of information between all disciplines providing care failed to be provided in one (Record/Patient #1) of three records reviewed. This deficient practice has the potential to adversely affect communication and care to all the agency's patients. --- Findings included: RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 08/24/2022 with a terminal diagnosis of Pharynx cancer (cancer of the throat). The patient lived alone at home. Review of Skilled Nurse visit note dated 10/06/2022 stated that he/she had redness and swelling of the left eye, the clinical record failed to show any previous documentation of swelling of the left eye as well as physician notification of this change in condition failed to be documented. Review of physician order dated 10/10/2022 stated new medication order of Gentamicin Sulfate eye drops (antibiotic) four times a day for seven days. Review of Hospice Plan of Care dated 10/11/2022 showed Skilled Nurse to asses and monitor eye pressure behind left eye, Interview on 10/11/2022 at approximately 1:30 pm, the administrator stated she would expect to see documentation of notifying the physician of the change in condition prior to the interdisciplinary group (IDG) meeting. He/she agrees there wasn't any documentation of physician notification and that he/she was there for IDG meeting and knows that the provider was notified at the meeting. He/she also stated that the provider gave the verbal order for the antibiotic eye drops during the IDG meeting.

Based on personnel file review, and interview, the agency failed to ensure one (Employee #1) employee received emergency preparedness training every two years as required of four personnel files reviewed. This deficient practice has the potential to affect the care and services provided to all patients during an emergency. Findings included: EMPLOYEE #1: - Date of hire: 01/30/2017; and - No evidence of emergency preparedness training since 02/29/2020. During an interview on 08/31/2022 at 8:50 AM, the employee health nurse stated he/she schedules trainings for the health department and sends the schedule out to the staff. If the employee missed the scheduled emergency preparedness training it is his responsibility to make it up. During an interview at 11:12 AM, the administrator stated that he/she did not have documentation that the employee received emergency preparedness training after February 2020.

Based on policy review, record review, and interview the agency failed to provide a complete comprehensive assessment including all physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. This was evidenced by an incomplete comprehensive skin assessment on one patient (Record/Patient #1) of five complete records reviewed. This deficient practice has the potential to affect the care provided to all patients served by the agency. Findings included: Review of the agency's policy titled, "Plan of Care/Comprehensive Assessment," dated revised 02/2013, showed in part the following: -This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions focusing on pain and skin integrity; and -The comprehensive assessment must identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice on 07/12/2022 with a terminal diagnosis of breast cancer. Review of the initial/comprehensive assessment dated 07/12/2022 showed the patient had no skin concerns/issues. Review of the skilled nurse (SN) visit dated 07/14/2022 showed the patient had a left breast incision under his/her breast that was healing well. The patient also has an incision near his/her left axilla (armpit) where a lymph node had been removed that was healing well. Noted a few scabbed areas, but no drainage noted. The agency failed to document or assess these areas on the initial/comprehensive assessment. During an interview on 08/31/2022 at 11:15 AM the administrator stated that he/she expected a head to toe skin assessment be completed on the initial/comprehensive assessment. He/she agreed that the initial/comprehensive assessment was not complete since it did not have the two incisions on it.

Based on policy review, record review, home visit observation, and interview the agency failed to maintain an accurate/updated medication profile in, but not limited to, two (Records/Patients #1 and #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Plan of Care/Comprehensive Assessment," dated revised 02/2013, showed in part: -The comprehensive assessment must take into consideration the following factors: *Drug profile. A review of all of the patient's prescription and over-the-counter drugs, herbal remedies, and other alternative treatments that could affect drug therapy; and -The Registered Nurse (RN) and every team member including volunteers, therapists, etc., are to document changes in the patient condition that indicate the need to revise the plan of care (POC). Reviews are documented in the medical record. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 06/28/2022 with a terminal diagnosis of lung cancer. The patient resided in his/her home alone. Per interview conducted during a home visit observation on 08/29/2022 beginning at 12:05 PM, a review of the patient's medications with the RN showed: -Tylenol extra strength 500 mg (milligrams) one every night at bedtime per the patient, but the hospice medication profile showed Tylenol extra strength 500 mg two tablets every six hours as needed for pain. The patient stated that he/she had been taking just one Tylenol at bedtime for awhile now; -Lorazepam (antianxiety) 0.5 mg 1/2 tablet at bedtime every night per the patient, but the hospice medication profile showed Lorazepam 0.5 mg by mouth every four hours as needed for anxiety or restlessness. The patient stated that he/she had been taking 1/2 tab of the Lorazepam every night at bedtime for at least a couple weeks now; -Hospice medication profile showed Cholecalciferol (vitamin D) 25 mcg (micrograms) one daily, but the patient stated that he/she had not been on that for awhile now; and -Hospice medication profile showed Omeprazole (proton-pump inhibitor) 20 mg delayed release one daily, but the patient stated that he/she only used as needed. RECORD/PATIENT #3: Review of the clinical record, showed the patient was admitted on 04/07/2022 with a terminal diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and he/she resided at home. Observation on 08/30/2022 beginning at 9:00 AM, during the patient's home visit, showed the following discrepancies between the hospice medication profile dated 08/29/2022 (provided by the agency), and the medication profile in the home dated 04/07/2022: -The hospice medication profile showed an order for Oxygen 2-5 liters per minute as needed, the in home medication profile failed to show the order for oxygen; -The hospice medication profile showed Albuterol Sulfate (treat or prevent bronchospasm) 2.5 milligrams (MG)/3 milliliters (ML) inhalation solution- Inhale 1 unit 3 times a day as needed for wheezing, the in home medication profile failed to show the order; -The hospice medication profile showed Tramadol Hydrochloride (narcotic pain reliever) 50 MG tablet one tab every 8 hours as needed for pain, the in home medication profile failed to show the order; -The hospice medication profile showed Acetaminophen (pain reliever/fever reducer) 500 MG/15 ML liquid- Give 15 ML every 6 hours as needed for pain, the in home medication profile failed to show the order; and -The patient's caregiver reported he/she had been using Calmoseptine (skin protectant cream) since starting hospice services, the in home medication profile and the hospice agency medication profile failed to show the order for Calmoseptine. During an interview on 08/30/2022 at 12:10 PM, the clinical director stated that he/she expected the medication profile to be reviewed at least weekly and every time a medication is changed. He/she expected the in home medication profile and the agency profile to match.

Based on policy review, record review, and interview, the agency failed to: -Ensure that the plan of care specified the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessments (L538); - Failed to ensure the interdisciplinary group provided a patient's primary care-giver(s) appropriate education (L544); - Develop an individualized plan of care based on problems identified in the initial, comprehensive and updated comprehensive assessments, that included all services necessary for the management of the terminal illness (L545); - Implement plans of care that included anticipated measurable outcomes (L548); - Ensure that the plan of care included all physicians orders for medications and treatments (L549); and - Ensure that the revised plan of care included information from the patient's updated comprehensive assessment and noted the patient's progress toward outcomes and goals specified in the plan of care (L553); and - Ensure ongoing sharing of information between all disciplines providing care (L557). The cumulative effect of these deficient practices has the potential to affect all patients served by the agency.

Based on policy review, record review, and interview, the hospice provider failed to ensure that the plan of care specified the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessments in, but not limited to, two (Records/Patients #1 and #4) of five full record reviews conducted. This deficient practice has the potential to affect the care provided to all patients on service with the hospice provider. Findings included: Review of the agency's policy titled, "Plan of Care/Comprehensive Assessment," dated revised 02/2013, showed in part: -All hospice care and services furnished to patients and their families must follow an individualized written plan of care (POC) established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire; -The initial POC/Comprehensive Assessment is developed after the registered nurse's (RN) initial comprehensive assessment with input from the patient and family, that identifies the patient's/family's goals and interventions based on the problems and needs for hospice care and services, and shall include the patient's/family's need for physical, psychosocial, emotional, and spiritual care with input from the patient and family, in collaboration- in person or by phone- with medical director, attending physician, or social worker on day of admission; -This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions focusing on pain and skin integrity; -Purpose: To provide written, individualized POC/Comprehensive Assessment for each patient for all hospice personnel to utilize. Assessment of the patient's individual needs and identifying services including the management of discomfort and symptom relief; -Complete assessment of patient/family needs as related to care of patient and the services required to meet those needs; -Identification of problems and goals based on assessment; -Identification of the patient's/family's problems and needs; -Identification of discipline involved for each deliverable service: Reassessment, planning of activities, provisions for physical, emotional, social, and spiritual support, nutritional requirements, and any safety measures to protect against injury; and -Goal statements with treatment modalities and interventions are in the POC identifying responsible person(s) assigned, whether that be staff members, family, or caregivers. POC shall include all physician orders. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 06/28/2022 with a terminal diagnosis of lung cancer. The patient had co-morbidities of hemoptysis (coughing up blood), abdominal aortic aneurysm (an enlargement of the aorta, the main blood vessel that delivers blood to the body, at the level of the abdomen, can be life-threatening if it bursts), dorsalgia (backpain), and chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient lived alone at home. Review of the initial/comprehensive assessment, dated 06/28/2022, showed the following: -Had moderate amount of thick bloody/red sputum; -Was incontinent and incontinence was being managed by incontinence pads, proper skin care, and toilet; -Had dysphagia (difficulty swallowing). The patient reported he/she coughs at times while drinking due to narrowing of the throat; -Had constipation with treatment of stool softener; -Had nausea daily, but not constantly; and -At risk for falls. Review of the initial POC, dated 06/29/2022, failed to show goals and interventions, including non-medicinal for hemoptysis, abdominal aortic aneurysm, dorsalgia, incontinence, dysphagia, constipation, nausea, and falls. During an interview on 08/30/2022 at 12:10 PM, the clinical director stated that the POC should have included goals and interventions, including non-medicinal for hemoptysis, abdominal aortic aneurysm, dorsalgia, incontinence, dysphagia, constipation, nausea, and falls. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice on 07/12/2022 with a terminal diagnosis of breast cancer. The patient lived alone at home. Review of the initial/comprehensive assessment, dated 07/12/2022, showed the following: -The patient reported history of depression; -Integumentary: Within normal limits. No concerns noted during assessment; -Cardiovascular: Dizziness and patient reported edema (swelling) to bilateral lower extremities at times. No edema noted at the time of visit; -Oxygen Use: Oxygen at 3 to 4 liters per nasal cannula continuous; -Patient smokes daily; -Patient complained of urinary retention (difficulty urinating and completely emptying the bladder); and -Neurological: Tremors to bilateral hands causing difficulty with fine motor skills; and -At risk for falls. Review of the initial POC, dated 07/13/2022, showed Oxygen 2 to 5 liters per nasal cannula as needed. The initial POC failed to show: -Correct oxygen use; and -Goals or interventions for depression, dizziness, edema, smoking safety, urinary retention, tremors, and falls. Review of the skilled nurse (SN) visit, dated 07/14/2022, showed left breast incision under breast healing well. Also has an incision near left axilla where they removed the lymph node. Both are healing well, had a few scabbed areas still. Review of the POC, dated 07/18/2022, failed to show goals or interventions for breast incisions. During an interview on 08/31/2022 at 11:15 AM, the administrator stated that the POC should have included goals and interventions for depression, dizziness, edema, smoking safety, urinary retention, tremors, falls, breast incisions, and the oxygen order should have coincided with the comprehensive assessment.

Based on policy review, record review, home visit observation, and interview, the agency failed to provide education and training for the patient as appropriate to their responsibilities in one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Plan of Care/Comprehensive Assessment," dated revised 02/2013, showed in part: -All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group (IDG) in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire; and -The hospice must ensure that each patient and the primary care giver(s) receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 06/28/2022 with a terminal diagnosis of lung cancer. The patient had co-morbidities of hemoptysis (coughing up blood), abdominal aortic aneurysm (an enlargement of the aorta, the main blood vessel that delivers blood to the body, at the level of the abdomen, can be life-threatening if it bursts), dorsalgia (backpain), and chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient lived alone at home. Review of the initial/comprehensive assessment, dated 06/28/2022, showed the following: -Respiratory Findings: Cancer and COPD; -Respiratory Findings/Treatments: Inhalation therapy and oxygen. Per social worker, a respiratory therapist will see the patient caregiver to further educate on portable oxygen; -Oxygen use: 2 liters per nasal cannula intermittently; -Oxygen equipment: Concentrator and portable tanks; -Instruction provided regarding: Oxygen safety; and -Other action taken: Respiratory therapist to meet with patient/caregiver today to further educate regarding portable oxygen. Review of skilled nurse (SN) visit, dated 07/25/2022, showed the patient questioned te nurse about what he/she was to do if the power went out and he/she was utilizing his/her oxygen. The patient informed the nurse that the power had went out briefly that morning and he/she was unsure what to do. The nurse informed the patient that he/she could transition over to portable tank and then showed the patient how to turn the flow rate on. The nurse also informed the patient to use his/her life alert button (wearable device that allows the user to call for emergency help with the press of a button). During an interview on 08/30/2022 at 12:15 PM, the clinical director and administrator both stated that the agency does not utilize a respiratory therapist and the education regarding what to do with oxygen during an emergency should have been taught on the initial/comprehensive visit by the nurse.

Based on policy review, record review, and interview, the agency failed to ensure the agency developed an individualized plan of care (POC) in, but not limited to, two (Records/Patients #1 and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Plan of Care/Comprehensive Assessment," dated revised 02/2013, showed in part: -All hospice care and services furnished to patients and their families must follow an individualized written plan of care (POC) established by the hospice interdisciplinary group (IDG) in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire; -The scope and frequency of services and items needed to meet the patient's/family's needs and by whom the services will be provided, prescribed and required medical equipment, supplies, medications, treatments and the level of care are all specified under the POC which is established prior to initiation of care and is regularly reviewed by the physician and the patient care coordinator who are responsible for the care of the patient; and -Goal statements with treatment modalities and interventions are in the POC identifying responsible person(s) assigned, whether that be staff members, family, or caregivers. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 06/28/2022 with a terminal diagnosis of lung cancer. The patient had co-morbidities of hemoptysis (coughing up blood), abdominal aortic aneurysm (an enlargement of the aorta, the main blood vessel that delivers blood to the body, at the level of the abdomen, can be life-threatening if it bursts), dorsalgia (backpain), and chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient lived alone at home. Review of the initial/comprehensive assessment, dated 06/28/2022, showed the following: -The patient had oxygen on at 2 1/2 liters per nasal cannula; -The patient had a loose rattling cough that was productive of bloody sputum, which the patient stated that he/she had since March 2022; -The patient admitted he/she was not using his/her Albuterol (bronchodilator) treatments. The nurse encouraged the patient to implement this to manage his/her current respiratory symptoms; -The patient complained of a headache, but the skilled nurse (SN) noted that the patient's blood pressure was slightly elevated at 140/94 and the patient denied taking his/her blood pressure medication that morning; -The patient has Tramadol (narcotic analgesic) available for pain, but patient stated that he/she does not like taking narcotics and prefers to use Tylenol (pain reducer or fever reliever) to manage his/her pain; -The SN advised the patient that he/she had sent a request to the primary care physician (PCP) regarding adding Lorazepam (antianxiety) to assist with anxiety/restlessness as needed; -The patient reported his/her appetite was poor, but does like using Boost (name brand nutrition supplement) for caloric purposes. The SN provided the patient with several bottles of Boost; and -The patient did report a problem with constipation recently which required the patient to do a digital extraction of the stool. Teaching completed on bowel regimen options. The patient currently uses stool softeners and laxatives, the SN advised that they could add suppositories as needed as well. Review of the initial POC, dated 06/29/2022, showed the following: -SN to assess and evaluate; and -Medical social worker (MSW) to assess and evaluate. The initial POC failed to be individualized and show an oxygen order or the frequency of the SN or MSW. Further review of the POC, dated 07/04/2022, showed in part, the following: -Problem: COPD; -Interventions for COPD: 1. Assess patient's use of inhalation therapy and its effectiveness. 2. Assess need and proper use of durable medical equipment (DME)/assistive devices. 3. Assess for signs/symptoms of respiratory infection; -Problem: Impaired Respiratory Status; -Interventions for Impaired Respiratory Status: 1. Teach cancer disease process including prognosis, symptoms, and complications; -Problem: Cancer; -Interventions for Cancer: 1. Assess current pain management regimen including: relief measures, side effects. Make changes in treatment as needed. 2. Teach energy conservation techniques; -Problem: Pain management; and -Interventions for Pain management: 1. Assess pain severity, frequency, location, quality, precipitating factors, and side effects of pain. 2. Teach pain management and comfort measures. The POC failed to be individualized and include interventions that were specific to the patient. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice on 07/12/2022 with a terminal diagnosis of breast cancer. The patient had co-morbidities of chronic respiratory failure with hypoxia (lungs do not get enough oxygen into the blood and it makes it difficult to breathe on own) and COPD. The patient lived alone at home. Review of the initial/comprehensive assessment, dated 07/12/2022, showed the following; -Respiratory: Shortness of breath with minimal exertion; -Oxygen Use: Oxygen 3 to 4 liters/minute (LPM) per nasal cannula, continuously; -Musculoskeletal: Ambulatory with assistive device. Endurance- fair, requires occasional assistance and/or rest periods. Coordination/Balance- Poor, needs assistance to prevent from falling. Findings: Fibromyalgia (widespread muscle pain and tenderness); -Patient able to safely self-administer his/her medications in the home; and -The patient is alert and oriented, however is forgetful at times as to whether he/she has already taken his/her medications or not. Educated on the use of and the benefits of a medication planner. The patient verbalized an understanding and that he/she was willing to try a medication planner. Review of the initial POC, dated 07/13/2022, showed the following: -Oxygen as needed for dyspnea (shortness of breath) per nasal cannula 2 to 5 LPM; -Contact medical director (MD) if vitals outside of acceptable parameters; and -MSW to assess and evaluate. The initial POC failed to be individualized and show the correct oxygen the patient was utilizing, the vital sign parameters, and the frequency of the MSW. Further review of the POC, dated 07/18/2022, showed in part, the following: -Problem: COPD; -Interventions for COPD: 1. Teach regarding activities and energy management. 2. Teach COPD disease process including prognosis, symptoms, complications; -Problem: Cancer; -Interventions for Cancer: 1. Assess pain including: pain level, frequency, location, quality, precipitating factors, and side effects. 2. Teach pain management and comfort measures; -Problem: Pain management; -Interventions for Pain management: 1. Assess pain severity, frequency, location, quality, precipitating factors, and side effects of pain. 2. Teach pain management and comfort measures; -Problem: Anxiety/Stress related to terminal illness; and -Interventions for Anxiety/stress: 1. Assess patient's coping mechanisms. 2. Assess for signs/symptoms of anxiety, fear, and agitation and assist patient/caregiver in dealing with their anxiety and feelings. 3. Teach patient/caregiver on anxiety reduction and coping skills. The POC failed to be individualized and include interventions that were specific to the patient. During an interview on 08/30/2022 at 12:15 PM, the clinical director and administrator both stated that they expected the POC to be individualized and agreed with the findings.

Based on policy review, record review and interview, the agency failed to implement plans of care (POC) that included anticipated measurable outcomes in, but not limited to, one (Record/Patient #3) of five full records reviewed. This deficient practice has the potential to affect all the agency patients. Findings included: Review of the agency's policy titled, "Plan of Care/Comprehensive Assessment," dated revised 02/2013, showed in part: - Content of plan: *All pertinent diagnosis, including mental status; *Realistic and achievable goals; *Identification of problems and goals based on assessment; and *Goal statements with treatment modalities and interventions are in the Plan of Care identifying responsible person(s) assigned, whether that be staff members, family, or caregivers. RECORD/PATIENT #3: Review of the clinical record, showed the patient was admitted on 04/07/2022 with a terminal diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and he/she resided at home. Review of the interdisciplinary group (IDG) meeting, dated 07/04/2022, showed the following: -The patient requires a mechanical lift for transferring from the bed to chair; -Requires assistance with all activities of daily living (ADLs); -Patient needed to be fed and was not eating a much as previously; and -Patient had become less responsive to verbal stimuli. Review of the POC, dated 07/04/2022, showed no documented measurable outcomes, (goals or interventions were not specifically established, evaluated, and/or updated to show whether or not outcomes were achieved) for the problems identified during the 07/04/2022 meeting. Review of the POC, dated 07/18/2022, showed no documented measurable outcomes (goals and interventions were not specifically established, evaluated, and/or updated to show whether or not outcomes were achieved) for identified problems. During an interview on 08/30/2022 at 2:06 PM, the clinical director stated that the plan of care should include measurable goals/outcomes and should address interventions to help achieve those goals. He/she stated if the patient was not progressing towards the goal/outcome then there should be a note explaining why not and then the plan of care should be revised.

Based on policy review, record review, home visit observation, and interview, the agency failed to ensure that the plan of care (POC) included all physicians orders for medications and treatments in, but not limited to, one (Record/Patient #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Plan of Care/Comprehensive Assessment," dated revised 02/2013, showed in part: - Content of plan: *All pertinent diagnosis, including mental status; *Frequency of services, treatment, and medications; and *Goal statements with treatment modalities and interventions are in the POC identifying responsible person(s) assigned, whether that be staff members, family, or caregivers. POC shall include all physician orders. RECORD/PATIENT #3: Review of the clinical record, showed the patient was admitted on 04/07/2022 with a terminal diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and he/she resided at home. During home observation on 08/30/22 at 9:15 AM the Medical Social Worker (MSW) asked the caregiver about current medications and reviewed the agency's list. The caregiver stated that he/she and other caregivers were using Calmoseptine (skin barrier cream) on buttocks to avoid skin break down. Review of the documents titled, "Interdisciplinary Group Meeting," dated 07/04/2022, 07/18/2022, 08/01/2022, and 08/15/2022 showed that the documents failed to contain orders for the use of the Calmoseptine for the patient. The clinical record failed to contain a physician order for Calmoseptine Barrier Cream. During an interview on 08/30/2022 at 2:06 PM, the clinical director stated that he/she would have expected the plan of care to contain orders for the use of Calmoseptine.

Based on policy review, record review, and interview, the agency failed to ensure the interdisciplinary group (IDG) discussed/documented changes regarding the patient's status and updated the plan of care (POC) in one (Record/Patient #1) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Plan of Care/Comprehensive Assessment," dated revised 02/2013, showed in part: -The hospice IDG, in collaboration with the individual's attending physician (if any), must review, revise and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 14 days; -A revised plan of care must include information from the patient's progress toward outcomes and goals specified in the plan of care; and -Documentation on the plan of care shall reflect the changing needs of the patient/family and the services required to meet those needs. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 06/28/2022 with a terminal diagnosis of lung cancer. The patient had co-morbidities of hemoptysis (coughing up blood), abdominal aortic aneurysm (an enlargement of the aorta, the main blood vessel that delivers blood to the body, at the level of the abdomen, can be life-threatening if it bursts), dorsalgia (backpain), and chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient lived alone at home. Review of skilled nurse (SN) visit, dated 07/01/2022, showed the patient reports his/her appetite as poor, but does like the Boost (name brand nutrition supplement) shakes. SN encouraged the patient to increase his/her calories along with protein and recommended peanut butter crackers or something similar to keep at chair side. Review of IDG meeting on 07/04/2022 failed to show the POC was revised to include any new interventions for the patient's poor appetite. Review of SN visit, dated 07/18/2022, showed the patient complained of frequent stools, he/she had four stools that day. SN instructed the patient to monitor his/her intake of protein shakes as this may contribute to frequent bowel movements. Patient stated that his/her appetite remains poor, but that he/she was still drinking Boost along with water. Review of Medication profile, dated 07/18/2022, showed the following: -Dulcolax (laxative) chew 1,200 mg (milligram) tablet, chew 2 to 4 tablets by mouth daily as needed for constipation; and -Senna S (stool softener with laxative) 50 mg-8.6 mg, one daily as needed for constipation. Review of SN visit, dated 07/21/2022, showed the patient reported having bloody sputum this morning. SN informed the patient to always report if he/she has more than a small amount of blood in his/her sputum. The patient also stated that he/she had a hard time coughing up the sputum due to it being thick. Physician was notified and an order was received for Mucinex (controls cough and thins mucus) 600 mg, one every 12 hours as needed for expectorant and benzonatate (cough suppressant) 100 mg, one three times a day as needed for cough. Review of SN visit, dated 07/25/2022, showed the patient had been taking benzonatate, but was unable to take the Mucinex due to it being too big of a tablet. SN informed the patient that he/she would get the liquid form of Mucinex and bring to his/her next visit. Review of IDG meeting on 08/01/2022 failed to show the POC was revised to include any new interventions for the patient's bloody sputum, the patient's loose stools, or non-medicinal interventions for cough and thick sputum. Review of SN visit, dated 08/01/2022, showed the patient stated that at times he/she had increased trouble swallowing his/her food. SN instructed the patient on eating softer foods that are easier to swallow. Review of SN visit, dated 08/11/2022, showed that the patient reported that he/she had been nauseated and vomited on 08/08/2022 after SN visit. The patient also complained of being very fatigued. The patient stated that he/she still had a poor appetite and was not even wanting to drink the Boost anymore. Review of IDG meeting on 08/15/2022 failed to show the POC was revised to include any new interventions for the trouble swallowing, the nausea, the vomiting, or the poor appetite. Review of SN visit, dated 08/15/2022, showed the patient reported that he/she was having difficulty swallowing water without choking and coughing. Also reported that it was getting difficult to tolerate his/her nutritional shakes secondary to nausea and spitting it back up. The patient was on the phone with his/her family member and the family member also reported the nausea. SN informed the family member that the agency was going to add Thick-It (name brand food and beverage thickener) to the patient's liquids and that he/she would be dropping a container of Thick-It off that afternoon. The patient was agreeable. Review of SN visit, dated 08/22/2022, showed the patient reported having dizziness and drowsiness and sleeping more than normal over the last few days. Family member present and discussed and reviewed medications with the nurse and felt the dizziness and drowsiness was associated with the benzonatate and montelukast (anti-inflammatory). The patient and family member wants both medications discontinued. Review of SN visit, dated 08/25/2022, showed the patient reported nausea with dry heaves today and yesterday. Physician notified regarding nausea. SN advised the patient to eat some ice chips in the meantime. Review of POC, dated 08/30/2022 failed to show the POC was revised to include any new interventions for difficulty swallowing, dizziness, drowsiness, fatigue, or nausea with dry heaves. During an interview on 08/30/2022 at 12:15 PM, the clinical director and administrator both stated that the POC should be updated and revised with any changes in the patient's condition and/or treatment. They both agreed with the findings and stated that the POC should have been revised to include all the above.

Based on policy review, record review, and interview the agency failed to ensure coordination of care when the on-going sharing of information between all disciplines providing care failed to be provided in one (Record/Patient #1) of five records reviewed. This deficient practice has the potential to adversely affect communication and care to all the agency's patients. Findings included: Review of the agency's policy titled, "Interdisciplinary Group (IDG)," dated revised 12/02/2008, showed in part: -Purpose: To provide coordination and appropriate delivery of hospice services; and -The hospice must develop and maintain a system of communication and integration, in accordance with the hospice's own policies and procedures, to: *Ensure that the IDG maintains responsibility for directing, coordinating, and supervising the care and services provided; *Ensure that the care and services are provided in accordance with the plan of care; *Ensure that the care and services provided are based on all assessments of the patient and family needs; *Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement; and *Provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 06/28/2022 with a terminal diagnosis of lung cancer. The patient had co-morbidities of hemoptysis (coughing up blood), abdominal aortic aneurysm (an enlargement of the aorta, the main blood vessel that delivers blood to the body, at the level of the abdomen, can be life-threatening if it bursts), dorsalgia (backpain), and chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient lived alone at home. Review of plan of care (POC) dated 07/04/2022, showed the medical social worker (MSW) was to visit twice monthly for three months. Review of skilled nurse (SN) visit, dated 07/28/2022 showed the patient requested that the MSW no longer make visits. Review of IDG meeting, dated 08/01/2022, failed to show documentation that the patient requested the MSW no longer make visits. The POC from this meeting still showed the MSW was to visit two times monthly. Review of communication note, dated 08/09/2022, showed the nurse informed the MSW that the patient only wants visits PRN (as needed). Submitted request to physician. During an interview on 08/30/2022 at 12:15 PM, the administrator stated that he/she would have expected communication to take place on 07/28/2022 between the SN and the MSW to let the MSW know the patient no longer wanted MSW visits twice monthly.

Based on record review and interview, the agency failed to ensure the skilled nursing needs of the patient were met in one (Record/Patient #4) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice on 07/12/2022 with a terminal diagnosis of breast cancer. The patient had co-morbidities of chronic respiratory failure with hypoxia (lungs do not get enough oxygen into the blood and it makes it difficult to breathe on own) and chronic obstructive pulmonary disease (COPD - lung disease that blocks airflow). The patient lived alone at home. Review of plan of care (POC) for certification period 07/12/2022 to 10/09/2022, showed assess skin with each visit. Review of initial/comprehensive assessment, dated 07/12/2022, showed no full skin assessment. Review of skilled nurse (SN) visit, dated 07/14/2022, showed incision under left breast healing well. Also has an incision near left axilla (armpit) where they removed the lymph node that is healing well. The patient has a few scabbed areas remaining. No drainage noted. The review of systems failed to show a complete review for the integumentary system. Review of SN visit, dated 07/18/2022, showed incision under left breast almost healed. The patient reported the incision drained a white colored fluid the other night. Incision left upper chest almost healed. Areas well approximated. The review of systems failed to show a complete review for the integumentary system. Review of SN visit, dated 07/21/2022, showed the patient has an almost healed incision near his/her left axilla and an almost healed incision under left breast. Both areas well approximated. The review of systems failed to show a complete review of the integumentary system. Review of SN visit, dated 08/04/2022, failed to show a skin assessment. During an interview on 08/31/2022 at 11:15 AM, the administrator stated that he/she expected the skin to be assessed at every visit as per POC.

Based on agency policy, clinical record review, and interview, the hospice failed to ensure that written patient care instructions from the registered nurse for the hospice aide were appropriate and accurate in one (Record/Patient #3) of the three records reviewed for aide services. This deficient practice has the potential to affect all patients served by the agency receiving aide services. Findings included: Review of the agency's policy titled, "Hospice Aide Services," dated revised 12/02/2008, showed that the registered nurse (RN) provides written instructions for the individual patient care. RECORD/PATIENT #3: Review of the clinical record, showed the patient was admitted on 04/07/2022 with a terminal diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and he/she resided at home. Review of the Hospice Plan of Care dated 04/09/2022 showed the aide was to: -Recognize and report any changes in the patient's skin conditions; -Transfer to bed/chair with assistance: Use Hoyer (mechanical) lift; - Change adult diapers; - Document bowel movements; - Incontinent care; - Assist patient with dressing; - Oral care; - Shampooing - Blood pressure, pulse, respirations, temperature; and - Universal precautions. The written aide care plan failed to identify patient's need for shower or bed bath. There are no changes or updates to the aide care plan from the initial start of care (SOC) date to reflect the patient's condition to include his/her decline in verbal communication. Review of patient's clinical record showed the hospice aide visits on 07/18/2022, 07/21/2022, 07/25/2022, 07/28/2022, 08/08/2022, 08/11/2022, 08/15/2022, and 08/22/2022 failed to document the patient's last bowel movement. During an interview on 08/30/2022 at 02:06 PM, the clinical director stated that he/she would expect all tasks on the aide assignment sheet to be specific and not allow for the aides to use make a judgement in the provision of care and that the patient's last bowel movement date to be documented.

Based on review of a written agreement for general inpatient care (GIP, short-term care for symptom management) and interview, the agency failed to ensure the agreement with the hospital included the requirement that the hospice must retain administrative management for oversight of services. The deficient practice has the potential to affect patients receiving GIP service with the hospice provider. Findings included: Review of the agency's inpatient acute care agreement with the hospital dated 01/11/1996, showed the contract failed to ensure hospice retains administrative management for oversight of services. During an interview on 08/31/2022 at 10:15 AM, the administrator stated that he/she could not find the missing information and agreed with the findings. He/she stated that the agency needed to update the inpatient acute care agreement.

Based on policy review, record review, and interview, the agency failed to ensure documentation was accurate and timely in, but not limited to, three (Records/Patients #1, #3, and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's undated policy titled, "Clinical Records," showed in part: -Purpose: To provide accurate documentation of services, care, and condition of each patient; -Record is complete, clear, legible, promptly and accurately documented, readily available, and systematically organized and dated in accordance with hospice policy and currently accepted standards of practice to facilitate retrieval; -Complete documentation of all assessments, services and events must be done within forty-eight hours; -Each individual record is detailed, accurate, and reflects the physical condition of the patient; and -Medical records are reviewed for accuracy and completion. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted on 06/28/2022 with a terminal diagnosis of lung cancer. The patient resided at home alone. Review of interdisciplinary group (IDG) meeting, dated 07/04/2022, showed the following: -Problem: Activities of Daily Living (ADL's)-Home health aide (HHA); Discipline: Certified Nurse Assistant (CNA); -Goals: 1. Maintain clean, safe environment (Start date: 06/29/2022). 2. Promote healthful environment (Start date: 06/29/2022); and -Interventions: No interventions. Review of IDG meeting, dated 07/18/2022, showed the following: -Problem: Activities of Daily Living (ADL's)-Home health aide (HHA); Discipline: Certified Nurse Assistant (CNA); -Goals: 1. Maintain clean, safe environment (Start date: 06/29/2022). 2. Promote healthful environment (Start date: 06/29/2022); and -Interventions: 1. Do patient laundry (Start date: 07/05/2022). 2. Clean living area of the patient (Start date: 07/05/2022). 3. Make patient bed (Start date: 07/05/2022). 4. Clean bathroom after patient care (Start date: 07/05/2022). Review of IDG meeting, dated 08/01/2022, showed the following: -Problem: Activities of Daily Living (ADL's)-Home health aide (HHA); Discipline: Certified Nurse Assistant (CNA); -Goals: 1. Maintain clean, safe environment (Start date: 06/29/2022). 2. Promote healthful environment (Start date: 06/29/2022); -Interventions: 1. Do patient laundry (Start date: 07/05/2022). 2. Clean living area of the patient (Start date: 07/05/2022). 3. Make patient bed (Start date: 07/05/2022). 4. Clean bathroom after patient care (Start date: 07/05/2022); and -Prep note: 07/28/2022- Patient sitting at his/her kitchen table and the care giver was draining the patient's pleurx catheter (a thin flexible tube that is placed in your chest to drain fluid from your pleural space). The patient has 2 to 3 plus edema (swelling) in both legs and feet. Legs are shiny. The patient is out of his/her morphine (narcotic). Review of the clinical record failed to show an order for a HHA, a pleurx catheter, or an order for morphine. During an interview on 08/30/2022 at 12:10 PM, the clinical director and administrator stated that: -Patient #1 had refused HHA from the beginning of service and there was never an order for a HHA; -The IDG meetings above were not accurate and should not have included a problem, goals, or interventions for ADL's; and -The prep note dated 07/28/2022 was the wrong patient and should not have been in Patient #1's record. RECORD/PATIENT #3: Review of the clinical record showed the following: -The medical social worker (MSW) visit was done on 04/07/2022 and charted by MSW on 04/11/2022, 3 days later; -The MSW visit was done on 04/13/2022 and charted by the MSW on 04/18/2022, 5 days later; -The skilled nurse (SN) visit was done on 04/29/2022 and charted by the SN on 05/03/2022, 4 days later; -The SN visit was done on 05/06/2022 and charted by the SN on 05/10/2022, 4 days later; -The SN visit was done on 05/12/2022 and charted by the SN on 05/16/2022, 4 days later; -The SN visit was done on 05/31/2022 and charted by the SN on 06/04/2022, 4 days later; -The SN visit was done on 06/10/2022 and charted by the SN on 06/14/2022, 4 days later; -The MSW visit was done on 06/17/2022 and charted by the MSW on 06/21/2022, 4 days later; -The MSW visit was done on 07/08/2022 and charted by the MSW on 07/11/2022, 3 days later; -The MSW visit was done on 07/29/2022 and charted by the MSW on 08/03/2022, 5 days later; and -The MSW visit was done on 08/16/2022 and charted by the MSW on 08/22/2022, 6 days later. During an interview on 08/30/2022, beginning at 2:06 PM, the clinical director stated that he/she had the expectation of charting to be completed within 48 hours per policy. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted on 07/12/2022 with a terminal diagnosis of breast cancer. The patient resided at home alone. Review of the admitting orders, dated 07/12/2022, showed the following: -Oxygen 3 to 4 liters intranasally continuous; -Oxygen as needed for shortness of breath per nasal cannula at 2 to 5 liters; and -Contact medical director (MD) if vitals are outside of acceptable parameters. Review of SN visit, dated 08/04/2022, showed hospice aide (no order for) arrive to give the patient his (patient is a her) bath. During an interview on 08/31/2022 at 11:15 AM, the administrator stated that the admitting orders should have been clarified and only had one oxygen order and that there should have been parameters for the vitals. He/she also stated that the patient did not have a hospice aide and was a female. He/she agreed that the note was not accurate.

Based on policy review, review of a written agreement for respite services (inpatient care for caregiver relief) and interview, the agency failed to ensure the agreement with the skilled nursing facility (SNF) included the requirement that the discharge summary be available to the hospice at the time of discharge. The deficient practice has the potential to affect patients receiving respite services in a SNF. Findings included: Review of the agency's respite care agreement with the SNF dated 04/23/2018, showed the contract failed to include that there be a copy of the discharge summary provided at discharge. During an interview on 08/31/2022 at 10:15 AM, the administrator stated that he/she could not find in the agreement where it said the SNF would provide the agency a discharge summary and that he/she agreed with the findings.

Based on policy review, review of a written agreement for general inpatient care (GIP, short-term care for symptom management) and interview, the agency failed to ensure the agreement with the hospital included the requirement that the inpatient provider has identified an individual within the facility who is responsible for the implementation of the provisions of the agreement. This deficient practice has the potential to affect all inpatient/respite patients served by the agency. Findings included: Review of the agency's inpatient acute care agreement with the hospital dated 01/11/1996, failed to include the provision that the inpatient provider has identified an individual within the facility who is responsible for the provisions of the agreement. During an interview on 08/31/2022 at 10:15 AM, the administrator stated that he/she could not find the missing information and agreed with the findings. He/she stated that the agency needed to update the inpatient acute care agreement.

Based on policy review, record review, and interview, the agency failed to ensure the coordinated task plan of care (POC) with the long term care facility (LTCF) included the frequency of visits for the social worker and chaplain, and failed to show accurate frequency of visits for the hospice aide in one (Record/Patient #2) of one applicable records reviewed of patients that resided in a LTCF. This deficient practice has the potential to affect all patients residing in a LTCF. Findings included: Review of the agency's policy titled, "Coordinated Task Form-Instructions," dated 03/2022, showed in part: - The hospice agency will coordinate services with each LTCF provider. The hospice and LTCF provider will jointly and collaborative efforts between the LTCF provider and the hospice, by documenting which services will be provided, by whom, the frequency of services, updates when changes occur, dated signatures of both LTCF provider and hospice staff; and - The coordinated task form will be initiated by hospice provider upon start of care in the LTCF and will be continuously updated with any changes as needed. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice on 08/01/2022 with a terminal diagnosis of severe protein-calorie malnutrition. The patient resided in a LTCF. Review of the plan of care dated 08/01/2022 through 09/29/2022, showed the following: - Hospice aide two times a week for one week and discontinued 08/09/2022; - Hospice aide one day a week for seven weeks for, but not limited to, shower, shampoo, and nail care beginning week of 08/15/2022; - Medical social worker one time a month times one month and two as needed visits and then two times a month for one month and two as needed visits for emotional support and/or teaching beginning week 08/01/2022; and - Chaplain one time a month for one month and then two times a month for one month and two visits as needed for spiritual support beginning week of 08/06/2022. Review of the hospice/long term care coordinated task plan of care maintained in the hospice binder at the LTCF dated 08/08/2022, failed to include the social worker and chaplain and frequency of visits. The hospice aide was to provide bath/shower on Monday and Wednesday (the orders were for once a week). During an interview on 08/30/2022, beginning at 10:00 AM, the LTCF administrator and director of nursing stated that they did not know the hospice aide was only visiting once a week to give the patient a shower. During an interview on 08/30/2022 at 3:20 PM, the administrator stated that the coordinated task plan should include all disciplines and frequency of visits. He/she would have expected the task plan to be updated to show the hospice aide was providing visits one time a week instead of two.

Based on review of a nursing home agreement, record review, home visit observation, and interview the agency failed to ensure the long term care facility (LTCF) hospice patient record contained a copy of all required hospice documents in one (Record/Patient #2) of one applicable record of patients that resided in a LTCF. This deficient practice has the potential to affect all patients that reside in a LTCF. Findings included: Review of the agency's nursing home agreement between the hospice and the LTCF dated 04/23/2018, showed in part that the facility will designate a staff member who will directly collaborate with hospice to coordinate effective patient care and the responsibility of this staff member is to obtain the required hospice election form and physician certification and recertification. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice on 08/01/2022 with a terminal diagnosis of severe protein-calorie malnutrition. The patient resided in a LTCF. Review of the hospice record maintained at the LTCF, during a home visit observation on 08/30/2022 beginning at 10:00 AM, showed it failed to contain the following required information: - Hospice election form; and - Physician certification of terminal illness. During an interview on 08/30/2022, at approximately 10:00 AM, the facility's charge nurse and the agency's chaplain stated that they were unable to find the hospice election form or physician certification in the LTCF hospice binder. During an interview on 08/30/2022 at 3:20 PM, the administrator stated that the required information should be in the facility record.