Every finding on record at Burnet Hospice Care, Inc

Observed in Record Review. In 1 of 19 patient records reviewed, During RR#4HosNHV it was noted the initial RN assessment of the integumentary status lacked documentation of skin lesion locations and status for the terminal diagnosis of other specified malignant neoplasm of skin, unspecified, basal cell carcinoma of skin of unspecified parts of face with CTI documentation of progressive carcinomatous lesions of scalp, face and neck. This was discussed with the DPCS and Administrator.

Observed in Record Review. In 1 of 19 patient records reviewed, During RR#3HosNHV it was noted an infection notification note documented by an LVN after hours stated the patient had a upper respiratory infection (URI) with an order for a Z pak. In discussion with the DPCS, since the patient had no respiratory issues documented, it was identified that the clinical note documented was an error.

Observed in Record Review. In 1 of 19 patient records reviewed, During RRHosNHV#1 it was noted some of the goals on the June 2025 POC were not individualized and lacked relevant end dates to assess if accomplished as follows: MSW: Patient/caregiver will verbalize support related to the anticipatory grief and loss associated with terminal symptoms, and expand support network for increased assistance with meeting patient's caregiving needs over the next 4-6 weeks. Patient/caregiver/family to have effective emotional processing and appropriate emotional coping. The spiritual counselor (SC) established goals however they were SC interventions and not patient/family goal: SC will provide biweekly in-person visits and weekly calls offering scripture, prayer, and spiritual conversation, SC will offer regular emotional and spiritual support to PCG, addressing his needs during each contact. The RN established a goal for pain reduction that lacked individualized time frames to assess progress toward accomplishing the goal: Patient will experience a reduction in pain level, as evidenced by patient reporting that medications and other non-pharmacological interventions are effective this benefit period. This was discussed with the organization leadership.

Observed in Record Review. In 5 of 19 patient records reviewed, During RRhosNHV#1 it was noted a problem on the Plan of Care (POC) in June 2025 was identified as high risk for skin breakdown. The intervention section related to the high risk for skin breakdown was blank. The pain deficit on the POC lacked interventions related to the goal established of reporting non- pharmacologic interventions are effective this benefit period with the interventions for pain documented as Allow patient to participate in medication regime. The RN documented in the initial RN assessment that the patient had a loss of appetite, was cachexic and was eating pureed foods. The POC lacked nutritional assessment and interventions related to the nutrition deficit. The patient complained of dizziness with medication ordered however the POC was not updated to reflect assessment and interventions related to the dizziness. During RR#4HosNHV it was noted the patient terminal dx was malignant lesions of the face, scalp and neck however integumentary assessment and interventions were not added to the February 2026 POC until the middle of March 2026. During RR#4HosNHV it was noted the patient cardiac deficit identified on the POC included assessing the cardiac status however it lacked interventions to achieve the goal to maintain peripheral circulation as evidenced by capillary refill and palpable pulses. During RR#9HosNHV it was noted an order for wound care as follows: Cleanse wound on left shin area gently with normal saline during each dressing change, Apply Triple Antibiotic Ointment to wound bed as ordered, cover with dry sterile gauze dressing and secure appropriately however the order lacked the frequency of performing the dressing change. During RRHV#10Hos it was noted on the POC an intervention added in February 2026 to Re-evaluate the patient/family’s interest in spiritual care at each IDG meeting or upon a significant change in condition. There was lack of documentation from the spiritual counselor (SC) that this was addressed at each IDG from February 2026 to present. This was discussed with the DPCS and the Administrator.

Observed in Record Review. In 1 of 19 patient records reviewed, During RR#8HosNHV it was noted an order on the POC for pressure ulcer care every other day, cleanse area with NS, pat dry and apply a DSD. The SN documented during 2 visits in May that the pressure ulcer was cleansed with wound cleanser, xeroform applied and covered with a DSD. During one visit in June 2026 the SN documented wound cleansed with wound cleanser, calasoothe applied and covered with a foam dressing. In addition the patient visits were 2x/week however the wound care order was to be performed every other day. There was lack of documentation who would perform the wound care on non SN visit days. This was discussed with the DPCS.

Observed in Record Review. In 3 of 19 patient records reviewed, During RR#2HosNHV it was noted in May 2026 the patient sustained skin tears to the right lower extremity with wound care and dressing changes twice a week by the SN. The aide assignment form in April 2026 indicated the type of bath was a shower with a shower chair. The assignment form was not updated with direction to the aide of the presence on the wound dressings and when to call the RN if problems occurred. During RR#3HosNHV it was noted the aide assignment form lacked direction to the aide of the presence of a wound dressing on the patient's head and the presence of the JP drain posterior back and when to call the RN. During RR#5HOSNHV it was noted the patient was treated for a scabies infection in March 2026. There was lack of documentation that the aide assignment form was updated to include infection prevention measures for the aide to follow. This was discussed with the organization leadership.

Observed in Regulatory Review. During review of the volunteer program it was noted the volunteer hours did not meet or exceed the 5% of the total patient care hours of all paid hospice employees and contract staff for 2025. This was discussed with the organization leadership.

Observed in Document Review. During review of the patient admission information it was noted lack of documentation that the organization's written policies and procedures on the management and disposal of controlled medications for the patient or the patient’s representative and family were included in the admission packet or when narcotics were ordered. This was discussed with the organization leadership.

Based on observation, interview, and record review the Hospice Agency (HA) staff failed to review all medications the patients were taking and update the medication profiles with the currently used medications for two of eight sampled patients (Patient 2 and Patient 20). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. --- 1. A review of Patient 2's medical record form titled ";Patient Profile" indicated a start of care date of 10/8/2022 with a primary diagnosis of senile degeneration of brain (a decrease in the ability to think, concentrate, or remember). A review of Patient 2s medical record form titled ";Hospice Medication Profile (Cloud Search)" dated 1/31/2024 to 3/30/2024, indicated ";Ipratropium/albuterol (medication to facilitate breathing) 4x/day as needed, and Tylenol (pain medication) suppository every 4 hours as needed." During a joint home visit on 3/9/2024 at 11:45 a.m., with License Vocational Nurse 1 (LVN1) at Patient 2s residence, LVN1 completed Patient 2s medication reconciliation. The following medication inconsistencies were noted: -Scopolamine transdermal (medicated pain patch) 1mg/3 days on the medication list. LVN1 was unable to locate the medication. -Ipratropium/albuterol labeled every 4 hours as needed. The medication list indicated 4x/day as needed. -Tylenol suppository (for pain) labeled every 6 hours as needed, had expired on 4/2023. The medication list indicated Tylenol suppository every 4 hours as needed. During a concurrent interview with LVN1 stated, medications should be checked to prevent medication errors. 2. A review of Patient 20 medical record form titled ";Patient Profile" indicated a start of care date of 10/18/2022 with a primary diagnosis of senile degeneration of brain (a decrease in the ability to think, concentrate, or remember). A review of Patient 20s medical record form titled ";Hospice Medication Profile (Cloud Search)" dated 2/10/2024 to 4/9/2024, indicated ";Ativan (anti-anxiety medication) take 1 tab (tablet) and Acetaminophen 500 mg one tablet PRN as needed." During a joint home visit on 3/9/2024 at 1:40 p.m., with License Vocational Nurse 1 (LVN1) at Patient 20s residence, LVN1 completed Patient 20s medication reconciliation. LVN1 stated Patient 20s home medication list was dated 1//4/2023. The following medication inconsistencies were noted: -Ipratropium/Albuterol 0.5-3mg/3ml was on medication list. LVN 1 was unable to locate the medication. -Ativan labeled 1mg take ½ tab, had expired on 10/2023. The medication list indicated Ativan 1mg take 1 tab. -Acetaminophen 500mg labeled one tablet 4 times a day as needed. The medication list indicated Acetaminophen one tablet as needed. -Levsin (medication for excessive secretions) had expired on 10/18/2023. - Acetaminophen suppository had expired on 4/10/23. During an interview on 3/9/2024 at 2 p.m., with LVN1, stated patients' medications needed to be reconciliated every skilled nurse visit and every time there were changes in their medications. An updated medication list needs to be provided to the patients and their care givers to prevent errors and for patients safety. When medications expire their therapeutic doses can be affected, it can either increase or decrease.

Based on interview and record review, the hospice agency (HA) failed to ensure the hospice licensed nurse performed a comprehensive pain reassessment for two of 19 sampled patients (Patient 12 and Patient 14). This deficient practice placed the patient at risk for an ineffective pain management that could impact the patient's health status and wellbeing. --- Findings: a. During a review of Patient 12's Patient Profile indicated a start of care (SOC) date of 9/3/2023, with a terminal diagnosis of chronic systolic congestive heart failure (a serious condition that occurs when the heart does not pump blood effectively). During a review of Patient 12s Hospice Plan of Care (POC) dated 9/3/2023, indicated the frequency of visits for hospice skilled nurses to one visit per week for 13 weeks plus five as needed (prn which means ";as needed") visits, hospice aide to visit two times a week, social worker (MSW), and chaplain (SCC) to visit the patient once a month for three months and three as needed (prn) visits. During a review of Patient 12s care plan titled "Pain," initiated on 9/3/2023, indicated Patient 12 had pain in his left lateral foot. The care plan goal indicated patient will demonstrate/report pain is relieved/controlled by as evidenced by patient to report pain level 3/10 (mild) or less (on a pain scale of 0 to 10, 10 is worst pain, and zero no pain). The care plan interventions indicated to allow patient to participate in medication regimen, to assist caregiver to focus effort on comfort measures, and to educate family and caregiver on the side effects (unwanted, usually unpleasant, effects caused by medicines) of Norco (medicine used to relieve moderate to severe pain) and liquid Morphine (medicine used to relieve moderate to severe pain). During a review of the SN ";Hospice Nursing Clinical Note", dated 9/8/2023, indicated Patient 12 had pain 5/10 (moderate) on his left outer foot. There was no documentation what kind of non-pharmacological methods were provided for pain relief, or if the pain was relieved after interventions. There was no documented evidence of a follow-up pain evaluation/reassessment using the numeric pain scale to indicate the pain medication was effective. b. During a review of Patient 14's Patient Profile indicated an SOC date of 8/21/2023, with a terminal diagnosis of unspecified chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). During a review of Patient 14s Hospice POC (Plan of Care) dated 10/6/2023, indicated the frequency of visits for hospice skilled nurses to two times a week and three as needed (prn) visits, hospice aide to visit two times a week, the social worker to visit once a week and three as needed (prn) visits, and the chaplain to visit once a month and three as needed (prn) visits. During a review of Patient 12s care plan titled "Pain," initiated on 8/29/2023, indicated Patient 12 had severe pain in multiple locations. The care plan goal indicated patient will report pain being controlled with pain level of 2/10 (mild) or lower using numeric pain scale with current pain management medication. The care plan interventions indicated to administer and train patient on pain management medication and to assess effectiveness of pain relief measures each visit. During a review of the SN ";Hospice Nursing Clinical Note", dated 11/9/2023, indicated Patient 14 had pain on her back and neck 9/10 (severe). The SN narrative section indicated Patient 14 took Morphine tablet just prior to visit and reported pain was improving on SN departure. There was no documented evidence of a follow-up pain evaluation/reassessment using the numeric pain scale if pain medication was effective. During an interview and concurrent record review on 11/17/2023, at 12:35 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated the nurse should evaluate pain interventions, assess non - pharmacological and pharmacological interventions, and reassess pain level using the numeric pain scale if applicable which should be reflected in the nurse's notes. During a review of the agency's undated policy and procedure titled, "Pain Assessment", indicated all patients will receive pain assessments. When pain is identified, a more comprehensive pain assessment will be completed. Pain assessments will be appropriate to the patients age and will be documented to facilitate regular reassessment and follow-up by clinicians.

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation for Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), Care Planning, and Coordination of Services was met as follows: --- Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation for Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), Care Planning, and Coordination of Services was met as follows: 1. The HA failed to ensure patient care plan was developed and completed that included problems, interventions, and goals, for one of 19 sampled patients (Patient 8). (Refer to L545) 2. The HA failed to manage and monitor the use of psychotropic medications (any drug that affects mental function, behavior and mood for one of 19 sampled patients (Patient 8). (Refer to L549) The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure the highest quality of care are provided to the patients accurately assessed to receive hospice care and services. Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation for Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), Care Planning, and Coordination of Services was met as follows: 1. The HA failed to ensure patient care plan was developed and completed that included problems, interventions, and goals, for one of 19 sampled patients (Patient 8). (Refer to L545) 2. The HA failed to manage and monitor the use of psychotropic medications (any drug that affects mental function, behavior, and mood for one of 19 sampled patients (Patient 8). (Refer to L549) 3. The HA nursing staff failed to coordinate care and ensure the IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) was notified and the notification was documented when ordered home visit service was missed for one out of 19 sampled patients (Patient 11). (Refer to L554) 4. The HA failed to ensure home visit was conducted in accordance with the plan of care (POC) for one of 19 sampled patients (Patient 11). (Refer to L555) 5. The HA failed to provide continuous care services in accordance with the agencys policy and procedure for one of 19 sampled patients (Patients 19). (Refer to L556) The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure the highest quality of care are provided to the patients accurately assessed to receive hospice care and services.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure patient care plan was developed and completed that included identified problems, interventions, monitoring, and management of the patient's related condition for one of 19 sampled patients (Patient 8). This deficient practice had the potential to affect the necessary care and services needed to maintain the highest practicable physical, mental, and psychosocial well-being of Patient 8 certified to receive hospice care services. --- Findings: On 11/14/2023, at 11:00 a.m., a complaint validation survey was conducted at the hospice agency to investigate the complaint allegation. A review of Patient 8's demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated Patient 8 was admitted to the hospice agency on 5/26/2023, with a terminal diagnosis of cerebral infarction (occurs as result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). A review of Patient 8s POC (Plan of Care)/IDG (interdisciplinary group) Review, indicated an order for visits dated 6/19/2023, for routine level of care (routine visits from a home provided by licensed medical professionals under the direct supervision of a physician) by a skilled nurse (SN) once a week, Social Worker (MSW) to evaluate and assess for needs within five days of admission, and the Spiritual Care Coordinator (SC) for spiritual assessment within five days of admission to identify spiritual needs. A review of Patient 8's Physician's order dated 6/19/2023, indicated to administer Quetiapine Fumarate (Seroquel, a psychotropic medication [any drug that affects mental function, behavior, and mood]) 100 mg (milligram, a unit of measurement) one tablet every morning and at bedtime for anxiety and agitation. The common side effects of Seroquel included high sedation (sleepiness), orthostatic hypotension or low blood pressure caused by standing from a sitting or lying position. During an interview and concurrent record review with the DPCS on 11/17/2023, at 1:00 p.m., the DPCS stated that there was no plan of care developed for psychotropic medication management (Seroquel) for Patient 8. Further review of Patient 8s clinical record indicated there was no plan of care developed that included management of the identified psychological problem, monitoring of the effects and side effects of the medication (Seroquel), and interventions necessary in the palliation (relieve symptoms) and management of the terminal illness and related condition. A review of the agency's undated policy and procedure titled, "Plan of Care", indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.

Based on observation, interview, and record review, the Hospice Agency (agency providing care to terminally ill patients who has six months or less to live) failed to ensure the plan of care contained the management and monitoring of the use of psychotropic medications (any drug that affects mental function, behavior, and mood) for one of 19 sampled patients (Patient 8) by failing to: - Ensure indications for the use of psychotropic medications for the identified problem. - Ensure a signed informed consent (permission granted in the knowledge of the possible consequences) was completed for the use of psychotropic medications. - Monitor for specific target behaviors when using the psychotropic medications. - Monitor for potential side effects (undesirable effect) of psychotropics medications. - Ensure a Psychiatric (is a medical doctor who specializes in the mental health field) consult for evaluation of the patient's mental status and examination prior to prescribing the psychotropic medications. This deficient practice placed Patient 8 at risk for adverse drug reactions (unexpected negative reaction) that could jeopardize patient's health and safety. --- Findings: On 11/14/2023, at 11 a.m., a complaint validation survey was conducted at the hospice agency to investigate a complaint allegation. A review of Patient 8's demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated Patient 8 was admitted to the hospice agency on 5/26/2023, with a terminal diagnosis of cerebral infarction (occurs as result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). A review of Patient 8s POC (Plan of Care)/IDG (interdisciplinary group) Review, indicated an order for visits dated 6/19/2023, for routine level of care (routine visits from a home provided by licensed medical professionals under the direct supervision of a physician) by a SN (skilled nurse) once a week, Social Worker (MSW) to evaluate and assess for needs within five days of admission, and the Spiritual Care Coordinator (SC) for spiritual assessment within five days of admission to identify spiritual needs. A review of Patient 8's Physician's order dated 6/19/2023, indicated to administer Quetiapine Fumarate (Seroquel, a psychotropic medication [any drug that affects mental function, behavior, and mood]) 100 mg (milligrams, a unit of measurement) one tablet every morning and at bedtime for anxiety and agitation. A review of Patient 8s clinical record indicated there was no documentation to indicate the use of Seroquel medication. There was no signed informed consent (permission granted in the knowledge of the possible consequences) completed for the use of psychotropic medications. There was no monitoring for specific target behavior and potential side effects (undesirable effect) of the psychotropic medications. There was no evidence for referral to be consulted by a Psychiatrist (is a medical doctor who specializes in the mental health field) for evaluation of the patient's mental status and examination prior to prescribing the psychotropic medications. A review of Patient 8's Grievance Report Form dated 7/18/2023, indicated Patient 8's family member (FM 1) called the hospice agency on 7/17/2023, at 3:52 p.m., to make them aware that Patient 8 had suffered an unwitnessed fall out of his bed on 7/11/2023, while on Seroquel medication twice a day. FM 1 verbalized being upset and made a decision to revoke patient from hospice services. During an interview and concurrent record review with the DPCS on 11/17/2023, at 1:00 p.m., the DPCS stated there was no informed consent for the use of psychotropic medications for Patient 8. The DPCS stated there was no documented evidence for the monitoring, tracking of specific behaviors, and the side effects of the Seroquel. The DPCS further stated there was no psychiatric consult to evaluate the mental status prior prescribing Seroquel medication to Patient 8. A review of the hospice agency's policy and procedure "Psychotropic Medications" indicated that the hospice patients that reside in a skilled nursing facility must not receive psychotropic medication unless the medication is needed to treat a specific diagnosed and documented condition. A review of the agency's undated policy and procedure titled, "The Plan of Care", indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. According to the U.S. Food and Drug Administration (FDA) website, elderly patients with dementia (loss of memory and other mental abilities severe enough to interfere with daily life), related psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with external reality) treated with antipsychotic (a group of psychotropic medications prescribed for the treatment of certain mental disorders) drugs are at an increased risk of death. The FDA indicated consideration should be given to a slower rate of dose titration (changes to medication doses to achieve the best clinical response and a lower target dose) in the elderly. The FDA indicated Seroquel was for the treatment of schizophrenia (a mental disorder involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships) and bipolar disease (a mental condition marked by alternating periods of elation and depression[sadness). For elderly use to consider a lower starting dose (50 mg/day), slower titration and careful monitoring during the initial dosing period in the elderly. https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/020639s061lbl.pdf

Based on observation, interview, and record review, the hospice agency nursing staff failed to coordinate with the physician regarding care and services not rendered or any changes in the plan of care (POC) for two of 19 sampled patients (Patients 2 and Patient 11). - For Patient 2, the licensed nursing staff failed to notify the physician regarding patient's Ativan (a medication that reduces agitation, anxiety, insomnia) medication administered daily before bedtime instead of as needed for agitation. - For Patient 11, the licensed nursing staff failed to notify the physician regarding hospice staff's missed visits. These failures had the potential to result in patient's end of life care needs not met. --- Findings: During a review of Patient 11's Patient Profile indicated a start of care (SOC) date of 8/10/2023, with a terminal diagnosis of senile degeneration of brain, not elsewhere classified (the mental deterioration [loss of intellectual ability] that is associated with or the characteristics of old age). During a review of Patient 11s IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) Meeting Review form dated 8/30/2023, indicated the frequency of visits for hospice skilled nurses to visit two times a week plus 3 prn (pro re nata, which means ";as needed") to assess pain status each visit, to instruct patient/caregiver to adhere to oxygen safety precautions, to assess/monitor level of ADLs (activities of daily living, are activities related to personal care which includes bathing, grooming, dressing, toileting, and eating) and level of consciousness, and to instruct patient/caregiver in principles of safety, supervised and assisted activity. During a review of Patient 11s history of SN visits for the month of September 2023, indicated that for the week starting on 9/3/2023 (Sunday) and ending on 9/9/2023 (Saturday), SN visited Patient 11 only once. A further review of Patient 11s clinical record indicated there was no documented evidence that the agencys nursing staff had notified or communicated with the IDG about the missed visit in accordance with the agencys policy and procedure. During a concurrent interview and record review on 11/17/2023 at 12:35 p.m. with the Director of Patient Care Services (DPCS), the DPCS acknowledged the finding and stated for any missed visits, IDG should be notified promptly by the field nurses and notification should be documented in the patients electronic records. During a review of the agencys undated policy and procedure titled, ";Missed Visits", indicated missed visits will be communicated to the Interdisciplinary Group at the IDG meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. If a visit is missed and not rescheduled, the clinician will notify the IDG and clinical supervisor of the missed visit and reason for missed visit. During a review of Patient 2's Patient Profile indicated a start of care (SOC) date of 10/8/22, with a terminal diagnosis of senile degeneration of brain, not elsewhere classified (the mental deterioration [loss of intellectual ability] that is associated with or the characteristics of old age). During a review of Patient 2s IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) Meeting Review form dated 8/30/2023, indicated the frequency of visits for hospice skilled nurses to visit two times a week plus 3 prn (pro re nata, which means ";as needed") to assess pain status each visit, to instruct patient/caregiver to adhere to oxygen safety precautions, to assess/monitor level of ADLs (activities of daily living, are activities related to personal care which includes bathing, grooming, dressing, toileting, and eating) and level of consciousness, and to instruct patient/caregiver in principles of safety, supervised and assisted activity. A review of Patient 2's Physician's order dated 10/8/22, indicated to administer Ativan one mg (milligram) tablet one tab every 4 hours as needed for agitation. On 11/15/213, at 12 p.m., a home visit at Patient 2's residence at a boarding care facility with LVN 1. Patient 2 was observed lying on her bed, awake and alert. When interviewed, she stated she gets agitated at night that started since last week thinking of her daughter that passed away three months ago. On 11/15/23, at 12:45 p.m., during an interview with the facility's caregiver, she stated she has been giving Ativan 1 mg medication at bedtime daily since last week because Patient 2 kept thinking of her daughter and gets agitated, sad and could not sleep. A further review of Patient 2's clinical record indicated there was no documented evidence that the physician was notified of Patient 2's frequent Ativan medication intake before bedtime due to agitation from thinking of her daughter that passed away. On 11/17/23, at 12 p.m., during an interview with the DPCS (director of patient care services), the DOPCS stated the visiting nurse should have notified the physician regarding the patient's continuous agitated behavior at night time.

Based on interview and record review, the hospice agency failed to ensure care and services are provided in accordance with the plan of care (POC) for one of 19 sampled patients (Patient 11). This failure had the potential to negatively affect the patient's physical comfort, psychosocial well-being, and not receiving the necessary services timely. --- Findings: During a review of Patient 11's Patient Profile indicated a start of care (SOC) date of 8/10/2023, with a terminal diagnosis of senile degeneration of brain, not elsewhere classified (the mental deterioration [loss of intellectual ability] that is associated with or the characteristics of old age). During a review of Patient 11s IDG (Interdisciplinary Group, a team of hospice physician, hospice nurse, hospice aide, social worker, chaplain, volunteer, and bereavement specialist, responsible for the holistic care of the hospice beneficiaries) Meeting Review form, dated 8/30/2023, indicated the frequency of visits for hospice skilled nurses to visit two times a week and three prn (as needed) visits to assess pain status in each visit, to instruct patient/caregiver to adhere to oxygen (a treatment to provide person a supplemental oxygen [a gas essential to living organisms]) safety precautions, to assess/monitor level of ADLs (activities of daily living, activities related to personal care which includes bathing, grooming, dressing, toileting, and eating) and level of consciousness, and to instruct patient/caregiver in principles of safety, supervised and assisted activity. During a review of Patient 11s history of SN visits for the month of September 2023, indicated for the week of 9/3/2023 (Sunday) to 9/9/2023 (Saturday), SN visited Patient 11 only once instead of twice a week as indicated in the plan of care. During an interview and concurrent record review on 11/17/2023, at 12:35 p.m., with the Director of Patient Care Services (DPCS), the DPCS acknowledged the finding and stated patient care visit should be provided to patients according to the plan of care. During a review of the agency's undated policy and procedure titled, "The Plan of Care", indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.

Based on interview and record review, the hospice agency failed to provide continuous care services in accordance with the agencys policy and procedure for one of 19 sampled patients (Patients 19). This deficient practice placed the patient at risk for severe pain and respiratory distress (having trouble breathing). --- Findings: During a review of Patient 19's Patient Profile indicated a start of care date of 10/17/2023, with a terminal diagnosis of unspecified Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). During a review of Patient 19s ";Hospice Physician Order" form, dated 10/28/2023, indicated an order to start continuous care (CC) level of care (crisis-like level of care for short-term management of patient pain and/or symptoms) for caregiver relief effective date 10/28/2023 to 10/29/2023, and resume routine level of care (most common level of care in hospice, patient is generally stable and the patient's symptoms, like pain or nausea and vomiting, are adequately controlled) on 10/30/2023. During a review of Patient 19s CC Assessment Note completed by a registered nurse, dated 10/29/2023 at 4:15 p.m., indicated Patient 19 was in bed, minimally responsive, hypotensive (low blood pressure), heart rate fluctuating, and was on Morphine sulfate (medication used to help relieve moderate to severe pain) five milligram (mg, a unit of measure) every hour as needed for pain/SOB (shortness of breath)/comfort. The CC Assessment Note further indicated IDG (Interdisciplinary Group, a group of health care professionals with various areas of expertise responsible for the holistic care of the hospice beneficiary) team was updated regarding patient status and the plan for the next visit was to continue CC for pain management to achieve optimal comfort. During an interview with the Director of Patient Care Services (DPCS), on 11/15/2023 at 1:32 p.m., the DPCS stated continuous care service was being provided to patient based on the needs of the patient as determined by the evaluation and/or assessment by the hospice registered nurse (RN). The DPCS stated Patient 19 was transitioning to end of life and for caregiver relief and symptoms management, Patient 19 was placed on CC level of care on 10/28/2023, but resumed routine level of care on 10/30/2023. DPCS was unable to provide documented evidence a changed in the plan of care from CC level of care to routine level of care was communicated to Patient 19s family and/or caregiver. During an interview with Patient 19s family member (FM 2) on 11/17/2023 at 12:55 p.m., FM 2 stated they requested CC service for Patient 19 because she was actively dying and needed the assistance from the agency because it was too overwhelming for her being the only caregiver for Patient 19. FM 2 stated the nurses that care and did the assessment for Patient 19 agreed the need for continuous care service and was not expecting a hospice company would just stop the service without informing her or any of her family member. During a review of the agencys undated policy and procedure titled, ";Continuous Care Services", indicated continuous care will be available to patients receiving Medicare or Medicaid hospice benefits, or as other payers allow. The need for continuous care and the skill level of hospice personnel needed in the home will be evaluated daily by the hospice RN or designee and clearly documented in the patient care notes and plan of care.

Based on interview and record review, the hospice agency failed to ensure skilled nurse clinical visit notes were completed and documented timely for two of 19 sampled patients (Patient 11 and Patient 19). This failure had the potential to result in the lack of coordination of patient's clinical information and continuity of care services provided to the patients certified to receive hospice care benefits. --- Findings: a. During a review of Patient 11's Patient Profile indicated a start of care (SOC) date of 8/10/2023, with a terminal diagnosis of senile degeneration of brain, not elsewhere classified (the mental deterioration [loss of intellectual ability] that is associated with or the characteristics of old age). During a review of Patient 11s IDG (Interdisciplinary Group, a team responsible for the holistic care of the hospice beneficiary) Meeting Review form, dated 10/11/2023, indicated the frequency of visits for hospice skilled nurses to visit two times a week plus three prn (as needed) visits to assess/monitor level of ADLs (activities of daily living, activities related to personal care which includes bathing, grooming, dressing, toileting, and eating) and level of consciousness, to instruct patient/caregiver in principles of safety, supervised and assisted activity, to review medications and recommend change if needed, to train caregivers in management of confusion and anxiety including redirection, calm environment and emotional support, and to train family/patient/caregiver about disease progression and expected symptoms. During a review of Skilled nurse (SN) visit calendar for the month of November 2023, indicated there were no SN clinical visit notes submitted. b. During a review of Patient 19's Patient Profile indicated a start of care date of 10/17/2023, with a terminal diagnosis of Alzheimers disease, unspecified (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). During a review of Patient 19s IDG Meeting Review form, dated 10/18/2023, indicated the frequency of visits for hospice skilled nurses to visit two times a week and three prn (as needed) visits to instruct patient/caregiver on symptoms management for edema (swelling caused by too much fluid trapped in the body's tissues), chest pain, dizziness and energy conservation, to collaborate with physician, review medications and recommend/change if indicated, to assess vital signs (measure the basic functions of body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate) every visit, to assess/monitor level of ADLs (activities of daily living, activities related to personal care which includes bathing, grooming, dressing, toileting, and eating) and level of consciousness, to instruct patient/caregiver in principles of safety, supervised and assisted activity, and to administer medications per physician (MD) order for symptoms management. During a review of the Hospice Physician Order, dated 10/27/2023, indicated an order to increase SN frequency of visits to daily visits effective 10/26/2023. During a review of Skilled nurse (SN) visit calendar for the month of October 2023, indicated there were no licensed vocational nurse (LVN) clinical visit notes submitted daily on 10/26/2023, 10/27/2023, 10/28/2023, 10/29/2023, and 10/30/2023. During an interview and concurrent record review on 11/17/2023 at 12:35 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated the agencys policy for submission of SN visit notes was to submit within 48 hours after the service was rendered. The DPCS acknowledged the SN visit notes for Patient 11 and Patient 19 was not submitted in a timely manner. During a review of the agency's undated policy and procedure titled, "Entries into the Clinical Record", indicated hospice personnel providing direct patient care and supervisory functions have authority to make entries into the clinical record. Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. Entries into the clinical record will be made on the day care is provided to the patient. All documentation will be turned in to the office at the end of the workday.

Observed in Emergency Management Session. During discussion with the Quality Manager it was noted that the organization's Emergency Operations Plan did not describe how the organization would communicate with patients during an emergency.

Observed in Emergency Management Session. During discussion with the Quality Manager it was noted that the organization's Emergency Operations Plan did not describe how staff would be notified that emergency response procedures were initiated.

Observed in HR File Review. In 1 of 10 HR files reviewed, it was noted that the organization did not have documentation to show that staff were initially trained on their emergency management responsibilities. For example in record HR#9 the volunteer record did not contain documentation of training in emergency preparedness policies and procedures. This was confirmed with the Quality Manager/Interim HR present.

Observed in Record Review. In 1 of 1 patient records reviewed, that included revocation of hospice care, it was noted that while the organization had a revocation policy and process the policy was not followed. The organization's Revocation Policy stated A revocation of election of hospice care statement will be signed by the patient and will document the date, time, and reason for revocation. For example, during RR#3 the revocation document was signed and dated, but it did not include a time or reason for revocation.

Observed in Patient Home. In 3 of 3 home visits conducted, it was noted that the patient was not notified in advance of care to be provided or frequency of care. For example, in HV#1, HV#2, and HV#3 the home records included calendars to inform the patients and caregivers of planned staff visits and all of the calendars were blank with no information. Upon questioning the patients and caregivers stated that they were aware of visits when the staff called them. This was discussed with the DPCS.

Observed in Record Review. In 3 of 13 patient records reviewed, the patient record was inaccurate. For example in record HV#1 in the reassessment pain section the RN documented the highest level of pain as both a 6 and a 9 out of 10. In the same record, on the IDG documentation it stated that the patient was taking Methadone and Morphine for pain although the Methadone had been discontinued 2 weeks prior. In the same record, on a regular visit date the skilled nurse note recorded a level 6 pain with the patient's acceptable limit a 3 and the nurse documented on the same date that the pain control with Morphine was effective. For example, during home visit HV#2 the caregiver reported that the patient has been having issues with vomiting on and off for weeks and is only able to tolerate 1 can of tubing feeding a day. The nurse documentation did not contain discussion of the vomiting and reduced feeding. For example in record RR#3 the patient had cancer with pain issues and in 1 of the 3 nursing visit notes there was no pain assessment documented. Also in this record there was a nurse visit documented the day of revocation, however there was no discussion of the patient revoking hospice care.

Observed in Record Review. In 13 of 13 patient records reviewed, it was noted that the written plan of care was not based on the patient's goals and time frames. Each goal was expected to be achieved at the next recertification date. For example, in record HV#3 11 of 11 goals, in RR#5 10 of 10 goals, and in HV#2 17 of 17 goals were all dated to be achieved at the next recertification. This was confirmed with the Clinical Manager.

Observed in Patient Home. In 1 of 4 home visits conducted, the staff failed to perform hand hygiene consistent with policy. For example, during home visit HV#2 the LVN entered her nursing bag multiple times without performing hand hygiene. The organization's Bag and Trunk Technique policy stated that prior to accessing the bag hand hygiene was to be performed.

Observed in Data Session. During the Data session it was noted that the organization had not implemented a program that followed categories IA, IB, and IC of either the current Centers for Disease Control and Prevention (CDC) and/or the current World Health Organization (WHO) hand hygiene guidelines. For example the organization did have a Hand Hygiene policy and did observe hand hygiene with the staff and the information was in the staff human resource files. They had also completed a Hand Hygiene PIP in 2020 that stated the organization's goal was 100% compliance, however there was no documented implementation of hand hygiene guidelines. This was confirmed with the Quality Manager and Project Manager present.

Observed in Tracer Activities. During the Volunteer Program system tracer, it was noted that the organization did not have documentation of recruitment and retention related to hospice volunteers. This was confirmed with the Volunteer Coordinator Designee present.

Observed in Tracer Activities. A governing body (or designated persons so functioning) assumes full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations, and continuous quality assessment and performance improvement. CLD 418.52, 418.60 and 418.113

Observed in Tracer Activities. During contract review it was noted that the written agreement with an outside agency to provide supplemental staff did not include the required elements. For example, the supplemental staff contract did not include: A stipulation that services may be provided only with the authorization of the hospice; A stipulation that services will be delivered in accordance with the patient’s plan of care; The manner in which contracted services will be coordinated, supervised, and evaluated by the hospice; Requirements for documenting that services are furnished in accordance with the agreement. This was discussed with the DPCS and owner.

Observed in Record Review. In 1 of 3 home visits conducted, it was noted that medical equipment was provided by the organization and used for the patient's care, but the patient record did not contain information that reflected it. For example, during HV#2 there was suction equipment in the patient's room and the caregiver questioned the nurse about changing the tubing. The caregiver stated that they had been using the suction equipment multiple times a week, often daily, since it was delivered in 7 months ago. Upon record review there was no documentation of the suction equipment provided for the patient care.

Observed in Record Review. In 2 of 3 patient records reviewed, that included discharge from hospice, it was noted that the organization had not informed other service providers who would provide are about The reason for the patient’s discharge or transfer - A summary of care, treatment, or services it provided to the patient - The patient’s progress toward goals - A list of community resources or referrals made or provided to the patient. For example, in record RR#3 the patient revoked the hospice benefit to go to the emergency department for pain issues. The discharge summary was documented 8 days after the revocation. The organization's policy stated that the discharge summary was required to be completed within 72 hours. For example, in record RR#1 the patient was transferred to the hospital for further evaluation and treatment. The discharge summary was dated the day after transfer, but did not include the medication summary, the Plan of Care or orders. This was discussed with the DPCS and Clinical Manager.

Observed in Patient Home. In 3 of 3 home visits conducted, it was noted that the organization had not provided education based on the patient's needs. For example, during home visits HV#1, HV#2 and HV#3 there were no individualized disaster plans in the home records. For example, during visit RR#3 the patient had suction equipment in the home that the caregiver reported using daily, however there was no documentation of education related to use, care or maintenance of the equipment. This was discussed with the Clinical Manager and DPCS.

Observed in Patient Home. In 1 of 4 home visits conducted, it was observed that the staff failed to implement infection prevention and control activities. For example, during HV#2 the nurses placed a single barrier out and after using the equipment placed the contaminated items on the barrier. After use of all the equipment the nurse used wipes on the equipment and then the nurse placed the items back on the same contaminated barrier. The organization's Bag and Trunk Technique policy stated that equipment is to be placed on designated clean and dirty areas.