Every finding on record at Blue Haven Hospice LLC

Upon patient record review, 2 of 19 (Patient #1, #14) 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 #1:The medication profile listed "Pharmacy compounded medication" with instruction to use for seizures without evidence of the name of the medication. Patient #14: The medication profile listed Polyethylene glycol 17 gm powder with no evidence of instructions for a diluent.

Upon client record review, 1 of 19 (Patient #15) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #15: On 12-04-24, the MSW made a volunteer request and indicated on the plan of care that a plan of care for the volunteer would be established. On 01-02-25, the MSW made a visit, but there was no evidence of follow-up on the volunteer, no evidence of volunteer notes, a volunteer plan of care or frequencies.

Upon patient record review, 3 of 19 (Patient #1, #2,#3) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #1, #2,#3: There was no evidence of a bereavement assessment completed after the death of the patient.

Upon patient record review, 1 of 19 (Patient #12) did not have evidence in the patient record that hospice aide assignments and duties are: • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable. Patient #12: The aide care plan dated 05-02-24 indicated assignments of bed bath 3 x week, and sponge bath 2 x week, however, the aide frequency was 3 x week.

Upon patient record review 1 of 19 (Patient #12) 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 #12: On 3-31-25, 4-2-25 and 4-4-25 the aide indicated she was providing both a bed bath and a sponge bath.

Upon patient record review 1 of 19 (Patient #14) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #14: There was no evidence of a supervisory visit being completed from 03-04-25 until 03-27-25 indicating greater than 14 days.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel.

Upon patient client record review, 1 of 19 (Patient #18) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #18: The addendum for Hospice Non-covered items was incomplete with no evidence of a check indicating whether or not the addendum had been requested. Additionally, the Informed Consent/Election of Hospice Benefit signed 12-03-24 was incomplete on page 5/6 with no evidence of indication whether the patient selected an attending physician, and no evidence of a date of election.

Based on record review and interview, the agency failed to develop an individualized Plan of Care that included wound care treatments that were provided by hospice nurses in 1 (#2) of 2 patient records reviewed with wounds. The failure resulted in the deterioration of the wound. --- Patient #2: Record review of Patient #2's clinical record revealed a Plan of Care that was dated 7/13/2022. The Plan of Care listed the following interventions related to skin/membrane integrity: Assess skin integrity and effectiveness of skin care each visit Collaborate with the primary physician as needed Establish individualized regimen and education of primary caregiver re: same. Specify: Instruct in turning and repositioning every two hours instruct patient/family in principles of maintaining skin integrity The Plan of Care did not contain wound care treatments. Registered Nurse C conducted a skilled nurse visit on 7/21/2022. Registered Nurse C documented that Patient #2 had blanchable redness on coccyx and bilateral hips that was improving with current care of cream (unspecified) and Optifoam. Registered Nurse C conducted a skilled nurse visit on 7/25/2022. Registered Nurse C documented that Patient #2 had blanchable redness to coccyx and bilateral hips with was improving with cream (unspecified) and Optifoam. Licensed Vocational Nurse G conducted a skilled nurse visit on 7/25/2022. Licensed Vocational Nurse G documented that Patient #2 had opened areas to the buttocks. Licensed Vocational Nurse G cleaned the site (unspecified what was used to clean area) and applied cream (unspecified) and applied clean foam adhesive dressing. Patient #2's clinical record contained a Plan of care dated 7/27/2022. The Plan of Care listed the following interventions related to skin/membrane integrity: Assess skin integrity and effectiveness of skin care each visit Collaborate with the primary physician as needed Establish individualized regimen and education of primary caregiver re: same. Specify: Instruct in turning and repositioning every two hours instruct patient/family in principles of maintaining skin integrity The Plan of Care did not contain wound care treatments. Registered Nurse C conducted a skilled nurse visit on 8/2/2022. Registered Nurse C documented that the blanchable redness to the left hip was nearly resolved and that Patient #2 continued to have blanchable redness to the right hip and the Optifoam was changed and has new blanchable redness to the right should (sic) and that Optifoam was applied "to that as well." Coccyx was no longer blanchable. Patient #2 had developed blanchable redness on both heels. Registered Nurse H conducted a skilled nurse visit on 8/8/2022. Registered Nurse H documented that the redness Patient #2's left hip had resolved; Patient #2 had blanchable redness to the right hip, no drainage noted to the bandage, and that the dressing was left in place. Registered Nurse H documented blanchable redness to Patient #2's right shoulder and an Optifoam was in place. Registered Nurse H documented that the Coccyx had redness and that the areas to the feet were improved with the cream. Patient #2 continued with blanchable redness to the heels. Licensed Vocational Nurse I conducted a skilled nurse visit on 8/10/2022. Licensed Vocational Nurse I documented that wound care was provided to RFA (unknown meaning) and the right foot. Licensed Vocational Nurse G conducted a skilled nurse visit on 8/12/2022. Licensed Vocational Nurse documented that the wound to the coccyx was healing. Licensed Vocational Nurse G documented that a skin tear to right outer elbow and right outer foot were leaned and covered with a clean dressing. A referral was sent from the hospice agency to Wound Agency X on 8/10/2022. The hospice agency indicated that three wounds were to be assessed, the coccyx, the right hip, and the right shoulder. Nurse Practitioner F from Wound Agency X conducted an initial visit on 8/15/2022. Nurse Practitioner F documented that Patient #2 had a chronic non-healing Pressure Ulceration of the foot. The wound was a Stage III Pressure Ulcer that measured 2.0 centimeters (width) x 2.0 Centimeters (length) x 0.1 centimeters (depth). Nurse Practitioner F debrided the wound to the right lateral foot, cleaned with dermal wound cleanser, applied Tetracyte (topical antibiotic) and Collagen Puracol (wound dressing) to the wound bed followed by Cuticerin (impregnated gauze) then covered with CovRsite (secondary wound cover dressing). The wound care to the right foot was to be done 3 times per week. Nurse Practitioner F recommended that the skin tears on the coccyx and right arm be cleaned with Normal Saline or Dermal Wound Cleanser and covered with a tegaderm (transparent dressing) or small CovRSite dressing (no documentation of the frequency that this was to be performed). The order was received by the agency on a "Wound Agency X" form. The wound care orders from Nurse Practitioner F, dated 8/15/2022, to the right lateral foot, skin tears to the coccyx, and skin tears to the right arm, were the first wound care orders contained in Patient #2's Plan of Care. Licensed Vocational Nurse G conducted a skilled nurse visit on 8/19/2022. Licensed Vocational Nurse G documented that wound care was completed to the right hip (no order for wound care to right hip in the Plan of Care). Registered Nurse E conducted a skilled nurse visit on 8/22/2022. Registered Nurse E documented that the wound dressing was clean, dry, and intact and was changed by Nurse Practitioner F. Registered Nurse E documented that blanchable redness to Patient #2's left hip was nearly resolved. Patient #2 still had blanchable redness to the right hip, had new blanchable redness to the right should (sic), and that Optifoam was applied (the Plan of Care did not include an order for Optifoam to the right shoulder). Registered Nurse E documented that the coccyx was no longer blanchable, and that Patient #2's heels had developed blanchable redness. Nurse Practitioner f conducted a skilled nurse visit on 8/22/2022. Nurse Practitioner F documented wound care to Patient #2's right lateral foot wound. Record review of Patient #2's clinical record revealed a Plan of Care that was dated 8/24/2022. The Plan of Care listed the following interventions related to skin/membrane integrity: Assess skin integrity and effectiveness of skin care each visit Collaborate with the primary physician as needed Establish individualized regimen and education of primary caregiver re: same. Specify: Instruct in turning and repositioning every two hours instruct patient/family in principles of maintaining skin integrity The Plan of Care did not contain wound care treatments. Licensed Vocational Nurse I conducted a skilled nurse visit on 8/24/2022. Licensed Vocational Nurse I documented wound care to the right hip (the Plan of Care did not include an order for wound care to the right hip). Licensed Vocational Nurse G conducted a skilled nurse visit on 8/26/2022. Licensed Vocational Nurse documented that wound care was completed to the right hip (no order in the Plan of Care). Registered Nurse E conducted a skilled nurse visit on 8/29/2022. Registered Nurse E documented that the wound dressing was clean, dry, intact, and the dressing was changed by Nurse Practitioner F. Registered Nurse E documented that Patient #2 had blanchable redness to the right shoulder and an Optifoam was applied (no order in Plan of Care). Nurse Practitioner F conducted a visit on 8/29/2022. Nurse Practitioner F documented wound care to Patient #2's right lateral foot. A wound care order was written for the right lateral foot wound. Licensed Vocational Nurse I conducted a skilled nurse visit on 8/31/2022. Licensed Vocational Nurse I documented wound care to the right hip (no order in the Plan of Care). Licensed Vocational Nurse G conducted a skilled nurse visit on 9/2/2022. Licensed Vocational Nurse G documented that wound care was completed as ordered to the right hip. Registered Nurse E conducted a skilled nurse visit on 9/6/2022. Registered Nurse E documented the Patient #2's new wound to the right hip was still present with redness to the bony prominence, continued with non-blanchable redness to the right hip with new skin breakdown, coccyx had new skin breakdown, and Nurse Practitioner F was notified). Licensed Vocational Nurse I conducted a skilled nurse visit on 9/7/2022. Licensed Vocational Nurse I documented that wound care was completed to the right hip (no order included in the Plan of Care). Licensed Vocational Nurse G conducted a skilled nurse visit on 9/9/2022. Licensed Vocational Nurse G documented "dressing to buttocks to prevent further breakdown." Nurse Practitioner F conducted a visit on 9/9/2022. Nurse Practitioner F documented an initial evaluation of a pressure ulceration of the right hip. Nurse Practitioner F documented that the right hip wound measured 7.0 centimeters x 4.0 centimeters and had unattached edges. Nurse Practitioner F documented that the peri-wound color was hyperpigmented. Nurse Practitioner F recommended to keep area clean and dry. Nurse Practitioner F recommended that diaper rash cream be applied to the peri-wound area and cover with an ABD pad 3 times per week. Registered Nurse D conducted an on-call visit skilled nurse visit on 9/11/2022 due to Family Member calling the agency that the patient's left wound was worsening. Registered Nurse D documented that purulent drainage was present to the left hip wound and that the dressing was changed per Wound Agency X orders. An antibiotic was ordered through the pharmacy (the ordering provider was not documented). Registered Nurse D documented that a visit was planned with Wound Agency X on 9/12/2022. Registered Nurse E conducted a skilled nurse visit on 9/12/2022. Registered Nurse E documented that Nurse Practitioner F was present during the visit. Registered Nurse E documented that wound care was performed by Nurse Practitioner F. Nurse Practitioner F conducted a visit on 9/12/2022. Nurse Practitioner F documented that Patient #2's right lateral hip wound measured 5.62 centimeters (width) x 5.56 centimeters (length) x O centimeters (depth). The right hip wound was infected with a foul odor and moderated purulent drainage. Nurse Practitioner F documented that a follow-up visit was scheduled for 9/19/2022. Nurse Practitioner F documented that a discussion was had about sending Patient #2 to the hospital due to the deterioration of the hip. Patient #2 was transported and admitted to the hospital. During an interview on 12/14/2022 at 2:11 p.m. with Licensed Vocational Nurse G, the surveyor asked questions regarding Patient #2 wound and the wound care performed. Licensed Vocational Nurse G informed the surveyor that wound care was done per [Wound Agency X] orders. Patient #2 had a wound on the foot and one on the hip. When asked what wound care products were being used on the hip wound, Licensed Vocational Nurse G stated, "Curitex, like a vaseline gauze, the best I can describe it." Licensed Vocational Nurse G stated, I did it (wound care to the right hip) several times." During an interview on 12/14/2022 at approximately 2:33 p.m. with the Administrator/Director of Nursing, the surveyor discussed Patient #2's wound and the wound care performed by the hospice nurses. The surveyor discussed that the Plan of Care did not contain orders for wound care to the right hip until 9/9/2022 and that the nurses performed wound care to the right hip prior to 9/9/2022. The Administrator/Director of Nursing informed the surveyor that an order from the physician for wound care should have been included in the Plan of Care.

Based on record review and interview, the agency failed to provide ongoing sharing of information with a non-hospice provider that provided services that were unrelated to the terminal diagnosis and related conditions in 1 (#2) of 2 patient records reviewed where the patients had wounds. The failure resulted in the deterioration of the wound. --- Patient #2: Record review of Patient #2's record contained documentation of an initial registered nurse visit with the encounter type listed as RN (registered nurse) Admission Assessment completed by Registered Nurse C. Registered Nurse C documented that Patient #2 was admitted to the agency's services with a primary diagnosis of Senile Degeneration of the Brain. Registered Nurse C documented that Patient #1 had a skin issue identified as blanchable redness to the coccyx area; area was cleaned; cream was applied; and an Optifoam was applied. Patient #2's record contained documentation of a referral that was sent from the Registered Nurse C on 8/10/2022 to Wound Agency X. The referral requested wound care to 3 wounds: Coccyx, Right hip, and Right shoulder. Nurse Practitioner F, from Wound Agency X, conducted a visit on 8/15/2022. Nurse Practitioner F assessed a wound to Patient #2's right lateral foot. Nurse Practitioner F documented a recommendation to skin tears on Patient #2's coccyx and right arm. Nurse Practitioner F did not document an assessment of the coccyx wound. Nurse Practitioner F did not assess the wounds to Patient #2's Right Hip or Right Shoulder. Nurse Practitioner F conducted visits on 8/15/2022, 8/22/2022, and 8/29/2022 to Patient #2. Nurse Practitioner F did not assess the wounds to the Right hip and Right shoulder at these visits. Nurse Practitioner F did not assess the coccyx wound on 8/22/2022 and 8/29/2022. Registered Nurse E conducted a skilled nurse visit on 9/6/2022. Registered Nurse E documented that the new wound to Patient #2's right hip was still present with redness to bony prominence. Patient #2 still had non-blanchable redness to right hip with new skin breakdown, had blanchable redness to right shoulder, and a new wound consultation for Patient #2's right hip had been requested. Optifoam was applied to relieve pressure. Patient #2's coccyx had new skin breakdown and the Wound Agency X nurse practitioner was notified via phone call. Patient #2 had developed blanchable redness on bilateral heels. Patient #2's record did not contain evidence that the agency coordinated with Nurse Practitioner F and Wound Agency X that the wounds to the Coccyx, Right hip, and Right shoulder were not assessed by Nurse Practitioner F from Wound Agency X between 8/15/2022 (date of Nurse Practitioner F's first visit with Patient #2) through 9/5/2022. Nurse Practitioner F assessed the Right hip at a visit conducted on 9/9/2022. Nurse Practitioner F documented an initial evaluation of a developing pressure ulceration of the right hip, that was not associated with the admitting diagnosis. Nurse Practitioner F documented that the wound to the Right hip measured 7.0 centimeters (width) x 4.0 centimeters length. Nurse Practitioner F documented that the wound to the Right hip was a deep tissue pressure injury. Nurse Practitioner F documented that the wound edges were unattached, and that the peri-wound color was hyperpigmented. Nurse Practitioner F documented treatment orders as followed: "Cleanse wound: none, Dressings ordered: None, Dressing intervals none." Nurse Practitioner F documented the Plan of Care as followed: "Plan of Care, Wound status: initial evaluation, Referral recommendations: Keep the area clean and dry, Recommended Ancillary Consultations: None, Note: Recommended to apply diaper rash cream to the peri-wound and cover with an ADB pad 3 times a week. Secure with Primafix Plus as needed. Nurse Practitioner F did not assess the wound to the coccyx or right shoulder. Registered Nurse D conducted an on-call visit on 9/11/2022 after Patient #2's Family Member called the agency that the patient's wound was worsening. Registered Nurse D documented that purulent drainage was present to the left hip wound. Registered Nurse D documented that the dressing was changed per Wound Agency X's orders. An antibiotic was ordered through the pharmacy (not documented what provider ordered the antibiotic or what antibiotic was ordered). Nurse Practitioner F conducted a visit on 9/12/2022. Nurse Practitioner F documented the following: Right lateral hip measured 5.56 centimeters (length) x 5.61 centimeters (width), the wound was deteriorating, the wound was a Stage III, had a moderate amount of purulent drainage, wound was 100% slough, had a foul odor, had signs/symptoms of infection, wound duration was less than 30 days (referral was sent to Wound Agency X on 8/10/2022, greater than 30 days), and that conservative sharp debridement was performed. Nurse Practitioner F documented that all necrotic and devitalized tissue was removed to the level of healthy bleeding tissue. The debridement area extended down to the level of the subcutaneous tissue. The tissues debrided included slough and necrotic eschar. All surrounding hyperkeratotic skin was removed. Post debridement measurements were 5.56 centimeters (length) x 5.61 centimeters (width). Nurse Practitioner F documented that pus was coming out of part of the wound and that Patient #2 was scratching it profusely on arrival. Nurse Practitioner F documented that a lot of purulent drainage came out of the wound after debridement. Nurse Practitioner F did not assess the wound to the coccyx or right shoulder. Patient #2 was admitted to the hospital on 9/12/2022. During an interview on 12/14/2022 at 8:50 a.m. with the Administrator/Director of Nursing, the surveyor asked about Wound Agency X. The Administrator/Director of Nursing informed the surveyor that the agency used Wound Agency X and Wound Agency X nurse practitioners would see the patients weekly and the hospice nurses would see the Patients the rest of the week. Wound Agency X nurse practitioners would bill Medicare for their services. Hospice would not bill Medicare for Wound Agency X services. (Wound Agency X nurse practitioners were not contracted employees of the agency). During an interview on 12/14/2022 at 2:33 p.m. with the Administrator/Director of Nursing, the surveyor discussed the referral sent to Wound Agency X by the agency on 8/10/2022. The referral listed 3 wounds for the nurse practitioner to assess: the coccyx, Right hip, and Right shoulder. The nurse practitioner did not assess the right hip or right shoulder. The right hip wound was not assessed by the nurse practitioner until 9/9/2022. The agency did not coordinate with Nurse Practitioner F that Nurse Practitioner F was not addressing all the wounds that were listed on the referral. The surveyor asked why the nurse practitioner did not assess the wounds and what prompted the nurse practitioner to assess the right hip on 9/9/2022. The Administrator/Director of Nursing stated, "I have no idea. That would have been discussed between the Case Manager and the [Wound Agency X] nurse. I personally was not aware it was not being done." The agency had a policy that was titled "Coordination of Care" which was labeled PC.22 with a revision date of 5/1/2019. The policy read in part: "Purpose To ensure coordination of all care provided for patients receiving hospice services and/or services from other providers...II. The Agency will provide for an ongoing sharing of information with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. III. The hospice will develop and maintain a system of communication with each provider of care to ensure development of an integrated, coordinated plan of care (POC), achieving unduplicated services and facilitating effective coordination of patient services...Procedure...IV. The IDG will maintain responsibility for directing, coordinating, and supervising the care and services provided by all medical entities. V. The IDG will designate a staff member(s) to communicate and coordinate with outside entities to determine any duplication of service and to educate the entity of the role of the Agency in the patients care. VI. The IDG will ensure that the care and services provided are based on all assessments of the patient and familys needs and are provided in accordance with the POC. VII. All communications and coordination of care is documented in the clinical record."

Upon patient record review, 2 of 13 (Patient #6, 9) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #6: Start of Care 8/29/20. Bereavement risk assessment completed on 11/6/2020. Patient #9: Start of Care 8/4/20. Bereavement risk assessment completed on 8/30/20.

Upon patient record review, 1 of 13 (Patient #7) 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 Patient #7: Plan of care dated 3/21/22: Chaplain order 3 prn q 30 days.

Upon patient record review, 1 of 13 (Patient #3) 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 #3: O2 ordered as 2-4L NC as needed. No evidence of documentation for prn reason.

Upon observation, 2 of 3 applicable (Patient 1 and 3) there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1: SN placed barrier down between large bag and couch. Small bag which holds pulse ox, thermometer etc was placed directly on patient's tray table. Patient #3: SN placed backpack bag down on pt's chair then placed barrier on arm rest then transferred the backpack to the barrier.

Upon patient record review, 1 of 8 applicable (Patient #4) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #4: Aide care plan dated 11/12/21 documents Aide to provide bed bath or shower.

Upon patient record review 5 of 8 applicable (Patient #1, 2, 3, 4, 5) 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 #1: Hair care assigned 2x week on care plan dated 3/9/2022. Hair care performed, 5/3/22, 5/5, 5/6, 5/9, 5/10, 5/11, 5/12 and 5/13/2022. Patient #2: Plan of care dated 4/2/2022- Aide is ordered 2xwk. No evidence of second visit for week of 4/25/2022 or order to change frequency that week. Patient #3: Aide care plan effective 11/18/2019 assigns bed bath q visit. Shower performed on all visits 4/19-4/22, 4/25-4/29 and 5/2-5/6/22. Additionally linen change assigned 1xweek. Performed on each visit 5/9-5/12/2022. Patient #4: Aide ordered 2xweek. Aide performed one visit on 4/13/22. No evidence second visit or refusal of visit. Aide performed visits on 4/26, 4/27 and 4/29/22. No evidence of order to increase visits. Linen Change assigned 1x week. HHA performed each visit 5/9-5/12/22. Patient #5: Aide ordered 5x week as of 3/21/21. Aide did not perform care on 4/5/22 or 4/11/22 nor was there evidence of refusal of visits or order to change frequency.