Every finding on record at Cameron Regional Medical Center, Inc.

Based on policy review, record review, and interview, the hospice provider failed to develop an individualized plan of care (POC) that reflected the patient’s interventions based on problems identified in the initial, comprehensive, and updated comprehensive assessments, 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. --- Findings included: Review of the provider’s policy titled, “Comprehensive Assessment,” reviewed 05/05/2025, showed in part:- The comprehensive assessment must take into consideration the following factors;   * Complications and risk factors that affect care planning;   * Drug profile – A review of all the patient’s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy;     * Drug side effects; and    * Actual or potential drug interactions.   Findings included: Review of the provider’s policy titled, “Comprehensive Assessment,” reviewed 05/05/2025, showed in part:- The comprehensive assessment must take into consideration the following factors;   * Complications and risk factors that affect care planning;   * Drug profile – A review of all the patient’s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy;     * Drug side effects; and    * Actual or potential drug interactions. Review of the provider’s policy titled, “Initiating/updating care plans (guidelines)”, reviewed 05/05/2025, showed in part:- “Named” hospice staff will initiate hospice care plans in the “named” electronic medical record (EMR) upon admission and will update hospice care plans with each change/update to ensure continuity of care;- The admitting nurse will initiate the hospice care plans in the “named” EMR system; and- “Each visit, the hospice care plans (guidelines) will be updated/changed as necessary in the system and in addition the case manager will be responsible for verifying that care plans have been updated weekly or as changes arise”. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 03/12/2025 with a primary diagnosis diffuse large B-cell lymphoma (a fast-growing blood cancer that involves changes in your B cells, a particular type of white blood cell called lymphocyte) and resided in an apartment with his/her spouse.Review of the RN initial assessment, dated, 03/12/2025, showed, in part:- The patient had a fall resulting in a fracture to the left hip that required surgery prior to requesting to be placed back on hospice services;- The patient had a “sx dressing vacuum sealed” on the left hip during the comprehensive assessment; - There was an “allyven dressing present” to the patient’s coccyx that was “covering a thin fragile area of skin with one small 0.5cm (centimeter) slit;”- The integumentary assessment showed “sx incision to left hip with clean, dry intact vacuum sealed dressing. Allyven to coccyx for prevention of further skin breakdown from thin fragile skin area”;- The plan of care problems sections of the integumentary assessment showed, “there are no problems to display for this section”; - The patient had edema to bilateral lower extremities; - The patient required assistance with most activities of daily living (ADLs); - Was incontinent of bowel and bladder at times; - The patient had a history of constipation that was treated with Miralax (stool softener); - Appetite was fair; and- Regular diet with thin liquids. Review of the initial POC showed, in part:- Problem of impaired skin integrity identified on 03/12/2025 with interventions to assess for changes in skin integrity, teach and/or demonstrate good preventative skin care, provide/educate on wound care as ordered, and teach and/or encourage repositioning every two (2) hours as tolerated by the patient;- Problem of pain secondary to left hip fracture and repair was identified on 03/12/2025 with interventions to administer pain medication(s) as ordered;- The POC failed to include: * The patient’s diet of regular with thin liquids as noted in the initial assessment * Wound care interventions for the coccyx * Interventions for the patient’s left hip surgical incision * Interventions for edema * Interventions for occasional incontinence of bowel and bladder * The problem of constipation and patient-specific interventions. Review of the Aide care plan, dated 03/12/2025, showed, in part that the patient was to take sponge baths only due to post-op (operation) surgery dressing. The initial POC failed to include post-op interventions and/or orders for the patient to take sponge baths only.   Review of the RN skilled nursing visit note, dated 03/14/2025, showed in part, that the patient had requested strawberry ensure and the nurse delivered it to the patient during the visit.  Review of the clinical record failed to show an updated POC that showed the patient’s nutritional supplement of ensure with the flavor preference of strawberry.  Review of the RN skilled nursing visit note, dated 03/18/2025, showed, in part:- The patient reported “using wedge/ortho boot while s/p L hip fx repair, to prevent legs from crossing”; and- The nurse assessed the patient’s surgical site and there were no signs or symptoms of infection around the dressing (The dressing was not removed to assess the patient’s surgical incision). Review of the clinical record failed to show orders for the use of wedge/ortho boot and/or an updated POC with interventions related to the use of wedge/ortho boot while sleeping.  Review of the RN skilled nursing visit note, dated 03/21/2025, showed in part, that the patient was instructed to leave the dressing on until it comes off per discharge instructions. The clinical record failed to show discharge instructions related to the patient’s surgical incision and dressing and the POC failed to include interventions for the surgical site.  Review of the Aide care plan, dated 03/21/2025, showed, in part, left hip precautions included, “no adduction, internal rotation, or flexion greater than 90 degree. May ambulate patient in home with use of walker and gait belt”. The clinical record failed to show orders for hip precaution and the POC failed to include left hip precautions and use of a gait belt. Review of a document titled “Skilled nursing SOAP visit, dated 03/22/2025, showed in part: - The “pt/cg called on-call nurse that worked the previous night shift to report they found d/c paperwork from (named) hospital with instructions to remove dressing at doctor's discretion”; - “PCP (primary care provider) contacted and gave instructions to remove the dressing and assess for sutures/staples that may need removed”;- “PRN (as needed) visit to remove surgical dressing and assess”;- “Dressing removed per PCP's instructions on this date. Surgical incision site healing well with approximated edges, no surrounding redness/warmth, and no drainage. Education provided to pt on s/s to report, continued activity restrictions, and pt informed (he/she) can now take full shower with assistance”; - The PCP was updated following the dressing removal and no additional orders were received; and - The POC failed to show any activity restrictions.   Review of the RN skilled nursing visit note, dated 05/06/2025, showed in part, that the nurse set up the patient’s pillbox for the next week. The POC failed to include interventions for the nurse to fill the patient’s pillbox.   During an interview, on 05/14/2025 beginning at 10:00 AM, the RN coordinator stated that: - The POC did not include interventions for the patient’s left hip; - The referral did not contain orders for the left hip surgical site; - He/she informed the admitting nurse prior to the start of care that he/she needed to contact the physician to obtain orders for the left hip; - The admitting nurse never contacted the physician to obtain orders as instructed; - There were not any orders for sponge baths only and that is why the POC did not include that intervention; - The POC failed to include that POC and ensure but should have;- Interventions for bowel and bladder incontinence was not on the POC and should have been; - The patient purchased the wedge and ortho boot on their own and informed the nurse of it after using them but there was not an order received; and - The POC did not include the intervention for the nurse to fill the patient’s pillbox but they (staff) would start adding it to the POC.

Based on policy review, record review, and interview, the hospice provider failed to develop an individualized plan of care (POC) that reflected the patient’s non-pharmacological interventions to manage pain, in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included: Review of the provider’s policy titled, “Pain: Assessment, Documentation, Interventions and Follow Up,” reviewed 05/05/2025, showed in part: - To provide on the assessment of pain for all patients by addressing individual needs with respect to acute and chronic pain, initiating appropriate strategies and interventions, providing learning opportunities for staff, patients and families and monitoring and evaluating patient outcomes; - Care Plan;   * Include specific goals;   * Interventions updated on each visit;   * Pharmacological and non-pharmacological interventions;   * Medication use documentation; and   * Effectiveness of medication use and non-pharmacological interventions. Review of the provider’s policy titled, “Physician Orders,” reviewed 05/05/2025, showed in part the physician order will be documented in the Interdisciplinary Group (IDG) communication this includes medications, treatments, and preventatives. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 03/12/2025 with a primary diagnosis diffuse large B-cell lymphoma (a fast-growing blood cancer that involves changes in your B cells, a particular type of white blood cell called lymphocyte) and resided in an apartment with his/her spouse. Review of the registered nurse (RN) skilled nurse (SN) visit note, dated 03/28/2025, showed in part, that instruction was provided for the use of ice as needed to help with pain to the left hip, wrapping the ice in a towel prior to applying, and never to apply the ice directly to the skin.  Review of the clinical record failed to show orders for ice treatment.  During an interview, on 05/14/2025 beginning at 10:00 AM, the RN coordinator stated that: - There were not orders for ice treatment; and - He/she didn’t think that they (staff) realized that they had to have orders for ice treatment.

Based on job description review, policy review, record review, and interview, the hospice provider failed to ensure a complete, individualized written plan of care (POC) that included all of the patient’s medical equipment in, one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included: Review of the provider’s policy titled, “Physician Orders,” reviewed 05/05/2025, showed in part the physician order will be documented in the Interdisciplinary Group (IDG) communication this includes medications, treatments, and preventatives. Findings included: Review of the provider’s job description titled, “Registered Nurse (Supervising Nurse),” reviewed 03/12/2025, showed the supervising registered nurse (RN) job functions and responsibilities included, in part:- Maintain open communication with patients, families, physicians, and other team members and the interdisciplinary team to coordinate care;- Collaborate with other healthcare professionals on the interdisciplinary team, including physicians, social worker, and chaplain;- Attend interdisciplinary team meetings to coordinate plan of care; and- Coordinate patient care and referrals, assuring patient needs are continually assessed and individualized plan of care is developed, implemented and updated. Review of the provider's policy titled, “Initiating/Updating Care Plans (Guidelines),” reviewed 05/05/2025, showed in part: - The hospice staff will initiate hospice care plans in the electronic medical record (EMR) system upon admission and will update hospice care plans with each change/update to ensure continuity of care;  - The admitting nurse will initiate the hospice care plans in the EMR system; - Each visit, the hospice care plans will be updated/changed as necessary in the system and in addition the case manager will be responsible for verifying that care plans have been updated weekly or as changes arise;- the Hospice care plans will be reviewed by the team and/or updated at minimum every 14 days in the system and signed electronically; and- all core services can update the Hospice care plans every 14 days.  Review of the provider’s policy titled, “Physician Orders,” reviewed 05/05/2025, showed in part: - The physician order will be documented in the Interdisciplinary Group (IDG) communication this includes medications, treatments, and preventatives; and - If the order is not a medication the nurse must document in physician orders under the appropriate order title and in IDG.  RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 03/12/2025 with a primary diagnosis diffuse large B-cell lymphoma (a fast-growing blood cancer that involves changes in your B cells, a particular type of white blood cell called lymphocyte) and resided in an apartment with his/her spouse. Review of the medical social worker (MSW) visit note, dated 05/09/2025, showed in part, that a sit to stand lift and an air mattress would be ordered. Review of the clinical record failed to show the medical equipment on the POC.   During an interview, on 05/14/2025 beginning at 10:00 AM, the RN coordinator stated that: - The electronic medical record system does not allow medical equipment updates to the POC until the next recertification period; and - He/she would figure out a different way to have the equipment added to the POC.

Based on policy review, registered nurse (supervising nurse) job description review, record review, and interview, the hospice provider failed to ensure that the interdisciplinary group (IDG) maintained responsibility for coordinating and supervising the care and services of the patient, in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included: Review of the provider’s policy titled, “Respite Care Policy and Procedure,” reviewed 03/05/2025, showed in part the hospice designee will coordinate the transfer of the patient from respite setting to the home care setting at the end of the respite period. Findings included: Review of the provider's policy titled, “Initiating/Updating Care Plans (Guidelines),” reviewed 05/05/2025, showed that the hospice staff will initiate hospice care plans in the electronic medical record (EMR) system upon admission and will update hospice care plans with each change/update to ensure continuity of care. Review of the provider’s job description titled, “Registered Nurse (Supervising Nurse),” reviewed 03/12/2025, showed the supervising registered nurse (RN) job functions and responsibilities included, in part:- Maintain open communication with patients, families, physicians, and other team members and the interdisciplinary team to coordinate care;- Collaborate with other healthcare professionals on the interdisciplinary team, including physicians, social worker, and chaplain;- Attend interdisciplinary team meetings to coordinate plan of care; and- Coordinate patient care and referrals, assuring patient needs are continually assessed and individualized plan of care is developed, implemented and updated. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 04/01/2025 with a primary diagnosis of malignant neoplasm of prostate (a cancerous tumor that has developed in the prostate gland) and resided at home with his/her spouse. Review of a patient communication note dated 04/08/2025, showed in part: - A written prescription for oxycodone was received; and- “Will go ahead and have oxycodone filled as patient will be traveling next week and may not have enough hydrocodone to last until (he/she) gets back home.”  Review of the IDG plan of care (POC) failed to show any documentation and/or communication of the patients planned trip to Florida.  Review of the routine skilled nurse visit note on 04/18/2025 (11 days after the previous SN visit on 04/07/2025), showed in part: - The patient stated that he/she was taking pain medication every three (3) hours while in Florida; - The patient stated that while he/she was in Florida, he/she had a couple episodes where he/she was walking, became short of breath, and his/her legs became very shaky; and - The patient did not think that he/she would make it back to his/her condo.  Review of the clinical record failed to show:  - Documentation of communication with the IDG that the patient planned to travel to Florida; - Documentation of when the patient planned to leave and return from Florida; - Documentation that the IDG directed and coordinated the care of the patient while the patient was in Florida; and - Instructions provided to the patient and/or family regarding how to address any issues while the patient was in Florida.  During an interview on 05/14/2025 that began at 10:00 AM, the RN coordinator stated that:- The patient went to Florida for five (5) days sometime between the nursing visits on 04/07/2025 and 04/18/2025 but he/she was unsure of the exact dates the patient was gone;- The nursing visits were arranged so the patient wouldn’t miss any nursing visits while away; - The IDG discussed the patient’s plans for travel through (a named messaging system) and during morning meetings, but the discussions were not documented in the patient’s chart; - Medications were provided to ensure that the patient had enough while away; - If the patient was to have any issues while in Florida then he/she would have gone to the ER (emergency room); and- The education that was provided to the patient and spouse was not documented.

Based on job description review, policy review, record review, and interview, the hospice provider failed to ensure that the nursing needs of the patient were met as identified in the patient’s initial, comprehensive assessment, and updated assessments, in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included: Review of the provider’s policy titled, “Job Description,” reviewed 03/12/2025, showed in part:- The supervising registered nurse (RN) is responsible in overseeing the clinical care provided to hospice patients by other nursing staff, including hospice aides, ensuring quality care is delivered according to the patients plan of care, managing staff schedules, coordinating with other healthcare professionals on the interdisciplinary team, and maintaining compliance with regulations, all while providing leadership and guidance with other nursing staff involved in patient care; - Essential job functions/responsibilities;   * Delegate tasks to hospice aides; and   * Coordinate patient care and referrals, assuring patient needs are continually assessed and individualized plan of care is developed, implemented and updated.  Review of the provider’s policy titled, “Comprehensive Assessment,” reviewed 05/05/2025, showed in part:- to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the Hospice patients well-being, comfort and dignity throughout the dying process; - The comprehensive assessment must take into consideration the following factors;  * The nature and condition causing admission;   * Complications and risk factors that affect care planning; and * The need for referrals and further evaluation by appropriate health professionals.   Review of the provider’s policy titled, “Physician Orders,” reviewed 05/05/2025, showed in part the physician order will be documented in the Interdisciplinary Group (IDG) communication this includes medications, treatments, and preventatives.  RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 03/12/2025 with a primary diagnosis diffuse large B-cell lymphoma (a fast-growing blood cancer that involves changes in your B cells, a particular type of white blood cell called lymphocyte) and resided in an apartment with his/her spouse.  Review of the RN initial assessment, dated, 03/12/2025, showed, in part:- The patient had a fall resulting in a fracture to the left hip that required surgery prior to requesting to be placed back on hospice services;- The patient had a “sx dressing vacuum sealed” on the left hip during the comprehensive assessment; - There was an “allyven dressing present” to the patient’s coccyx that was “covering a thin fragile area of skin with one small 0.5cm (centimeter) slit;”- The integumentary assessment showed “sx incision to left hip with clean, dry intact vacuum sealed dressing. Allyven to coccyx for prevention of further skin breakdown from thin fragile skin area”;- The plan of care problems sections of the integumentary assessment showed, “there are no problems to display for this section”; and- The RN failed to show documentation that the left hip dressing was not to be removed in order to assess the incision and there was no documentation that the physician was contacted for orders to remove the dressing to the left hip and assess the surgical site incision.  Review of the plan of care failed to show interventions for the left hip surgical site. Review of the clinical record failed to show: - Orders for the surgical incision dressing and assessment included in the referral;   - Documentation of the physician being contacted to receive orders for the left hip surgical incision; and - An assessment of the surgical incision from 03/12/2025 to 03/22/2025.  During an interview, on 05/14/2025 beginning at 10:00 AM, the RN coordinator stated that: - The referral did not contain orders for the left hip surgical site; - He/she informed the admitting nurse prior to the start of care that he/she needed to contact the physician to obtain orders for the left hip; and - The admitting nurse never contacted the physician to obtain orders as instructed.

Based on policy review, record review, and interview, the hospice provider failed to prepare a complete and accurate hospice aide assignment in one of three records reviewed of patient's that were receiving hospice aide services (Record/Patient #4). This deficient practice has the potential to affect the quality of care of all the provider's patients who are receiving aide services. --- Findings included: Review of the provider’s policy titled, “Aide Care Plan,” reviewed 05/05/2025, showed in part the aide is to follow the aide care plan when providing care and update the nursing staff if there are any discrepancies during the visit. Findings included: Review of the provider’s policy titled, “Aide Care Plan,” reviewed 05/05/2025, showed in part:- The aide is to follow the aide care plan when providing care and update the nursing staff if there are any discrepancies during the visit; and- All sections of the aide care plan will be completed that pertain to the patient. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 04/09/2025 with a terminal diagnosis of inclusion body myositis (a degenerative muscle disease that causes gradual and painless weakening of your muscles). The patient resided in a long-term care facility (LTCF).  Review of the aide care plan dated 04/06/2025 showed, in part:- Interventions: provide nail care two times weekly;- Notify nurse if there is any bleeding during cares; and- The aide care plan failed to identify that clipping/trimming the patient’s nails was contraindicated due to the patient being on an anticoagulant (blood thinning medication). During an interview on 05/14/2025 at 10:25 AM the administrator stated that he/she:- Would have expected the aide care plan to be specific about not trimming/clipping the patient’s nails; and- Would have expected all safety precautions to have been on the aide care plan.

Based on policy review, record review, and interview, the hospice provider failed to ensure a copy of the discharge summary was provided to the hospice at the time of respite discharge in one of one respite record review (Record/Patient #6). This deficient practice has the potential to affect the coordination of respite care for all the provider’s patients. --- Findings included: Review of the provider’s policy titled, “Respite Care Policy and Procedure,” reviewed 03/05/2025, showed in part the hospice designee will coordinate the transfer of the patient from respite setting to the home care setting at the end of the respite period. RECORD/PATIENT #6:Review of the clinical record showed in part:- The patient was admitted to hospice services on 09/23/2024 with a terminal diagnosis of senile degeneration of the brain (a progressive decline in cognitive abilities that occurs with aging). The patient lived at home with their child, adult grandchild, and a great grandchild;- The patient began inpatient respite services on 10/21/2024 related to caregiver fatigue;- The patient completed five consecutive days of respite care;- The patient was discharged from inpatient respite on 10/25/2024; and- The clinical record failed to contain a discharge summary from the respite facility.  During an interview on 05/14/2025 at 10:30 AM, the administrator stated that:- They (hospice provider) did not have a copy of the discharge summary from the inpatient respite provider; - They would expect to receive a discharge summary from the inpatient respite provider at the time of discharge;- It requires a lot of follow-ups to obtain the discharge summary from the respite provider; and- He/she could add that to a checklist to make sure that it would get completed.

Based on employee file review and interview the agency failed to ensure one employee received the agency's emergency management training during orientation in one (Employee #1) of two employee files reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: EMPLOYEE #1: - Date of hire: 12/08/2021; and - No evidence of emergency preparedness training at orientation. During an interview on 08/02/2022, at 2:45 PM, the clinical director stated that he/she did not have evidence that the employee had emergency preparedness training during orientation.

Based on review of the agency's patient admission packet and home visit observation, the agency failed to include required information in the written notice of patient rights for patients admitted to hospice services in, but not limited to, one (Record/Patient #3) of three home visit observations. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the patient bill of rights section of the agency's admission packet showed that upon admission, the patient must be informed of the rights and responsibilities in receiving care. The information failed to include that the patient has the right to receive verbal and written notice of rights in advance of providing care in a language and manner the patient understands. RECORD/PATIENT #3: During a home visit observation on 08/02/2022, beginning at 10:45 AM, the patient rights information was reviewed. The information failed to include that the patient has the right to receive verbal and written notice of rights in advance of providing care in a language and manner the patient understands. The findings were reviewed with the clinical director on 08/03/2022, at 10:40 AM. The clinical director acknowledged the findings. No further information was provided.

Based on policy review, record review, and interview, the agency failed to ensure the social worker's (MSW) comprehensive assessment was completed within five days of election of hospice care in one (Record/Patient #2) 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, "Comprehensive Assessment," dated 09/10/2019, showed in part, the comprehensive assessment is completed by the Hospice IDG interdisciplinary group][ in consultation with the attending physician within 5 calendar days after election of hospice. RECORD/PATIENT #2: Review of the hospice election statement showed the effective date of election was 07/01/2022. Review of the initial MSW evaluation visit showed a date of 07/15/2022 (14 days after election of hospice care). During an interview on 08/02/2022, at 2:00 PM, the case manager stated that he/she would expect the MSW to visit the patient within five days to complete the comprehensive assessment. He/she stated that the spouse declined the MSW coming on 07/05/22. She believes the MSW then rescheduled the comprehensive assessment to the next week at the spouse's request.

Based on record review and interview, the agency failed to ensure the comprehensive assessment contained documentation to show imminence of death in, one (Record/Patient #2) out of five complete record reviews conducted. This deficient practice has the potential to affect the care provided to all the agency's patients. Findings included: The agency failed to provide the requested comprehensive assessment policy. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 07/01/2022. His/her primary diagnosis was Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). He/she resided in a home with his/her spouse and paid caregivers. Review of the initial comprehensive assessment dated 07/01/2022 failed to show documentation of the imminence of death. During an interview on 08/02/2022 at approximately 3:40 PM, the clinical director stated that he/she would look in the comprehensive assessments for the imminence of death. No further evidence was provided by the end of the survey.

Based on policy review, clinical record review, home visit observation, and interview, the agency failed to maintain an accurate/updated medication profile/plan of care (POC) 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, "Medication," dated 08/29/2019, showed the following: -Medication profiles would be maintained and updated for each patient every 14 days and with medication changes, at minimum; and -Periodic medication review will be done at the IDG (interdisciplinary group) meeting. RECORD/PATIENT #1: Observation on 08/02/2022 beginning at 9:11 AM, during the patient's home visit at a LTCF (Long-term Care Facility), showed the following discrepancies with the hospice medication profile: - The LTCF's medication administration record (MAR) showed the patient was taking Prednisone (steroid) 10 milligram (mg) one every other day. The agency's medication profile showed Prednisone 10 mg one daily; and - The agency's medication profile showed Miralax(laxative) 17 grams (gm) mixed with eight ounces of liquid once daily. The LTCF's MAR showed the Miralax had been discontinued on 07/27/2022. During an interview on 08/03/2022 at 11:00 AM, the clinical director stated the following: -The medication profile should be updated at least every 14 days and at each visit, and the nurse should check for new orders; -The agency did not have the correct Prednisone order; and -The agency failed to reconcile with the LTCF and get an order to discontinue the Miralax.

Based on policy review, record review, home visit observation, and interview the agency failed to develop an individualized plan of care (POC) 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 policy titled, "Initiating/updating care plans," dated 09/10/2019, showed the following: -Purpose: Staff will initiate hospice care plans in the electronic system upon admission and will update the care plans with each change/update to ensure continuity of care; -The admitting nurse will initiate the hospice plan of care in the electronic system; -Each visit, the hospice care plans will be updated/changed as necessary in the system; and -The hospice care plans will be reviewed by the team and/or updated at minimum every 14 days in the system and signed electronically. The agency's policy failed to mention the plan of care needed to be individualized for each patient. The policy failed to mention that the plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The policy failed to mention the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted on 07/06/2021, with a terminal diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and he/she resided in a long-term care facility (LTCF). Observation on 08/02/2022 starting at 9:11 AM, during the patient's home visit, showed the patient lying in a low bed with a low loss air mattress, two half siderails up on each side of the patient at the top of his/her bed, a fall mat to the left side of the patient's bed and the patient's bed was up next to the wall on the right side. Also noted the patient had a broda chair (a wheelchair that provides assistance tilt-in-space positioning chair functionality to people who sit all day) present at the end of his/her bed. Review of the plan of care (POC), dated 07/01/2022 to 08/29/2022, showed no interventions for the low bed, low loss air matrress, side rails, fall mat, or the broda chair. During an interview on 08/03/2022 at 10:06 AM, the clinical director stated that all interventions the patient was using should be on the POC. RECORD/PATIENT #3: Review of a skilled nurse (SN) visit dated 06/08/2022 showed the patient had a fall and had skin tears to the right arm, wrist, hand, and both elbows. Steri strips were applied to the skin tears on the upper arm and elbow and covered with a transparent dressing. Review of the IDG (interdisciplinary group) meeting summary note dated 06/14/2022, showed that the patient had a fall in the bathroom on 06/08/2022 that resulted in multiple skin tears to the arms and hands. Review of the POC dated 06/14/2022, showed no update to address falls or skin integrity. Review of the physician recertification dated 06/21/2022, showed in part, that the patient continued on hospice services for COPD (chronic obstructive lung disease) and CHF (congestive heart failure). The patient had lost 11 pounds in two months and appetite was poor. The patient was weak with an unsteady gait with recurrent falls. Review of the IDG meeting note dated 07/26/2022, showed the patient had lost 18 pounds in one month. Review of the POC dated 07/26/2022, showed no update to address the patient's weight loss. During an interview on 08/02/2022, at 3:28 PM, the clinical director stated that he/she would expect the POC to address falls, skin integrity, and nutritional interventions. The RNCM (registered nurse case manager) stated that the patient was very set in his/her ways and would not take nutritional supplements. RECORD/PATIENT #4: Review of the clinical record, showed the patient was admitted on 07/19/2022 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; lung disease characterized by long-term respiratory symptoms and airflow limitation) and he/she resided in a LTCF. Review of initial/comprehensive assessment, dated 07/19/2022, showed the following: -The patient was lethargic and not safe to give medications by mouth; -LTCF staff educated to give the patient small bites of applesauce prior to trying to give the patient his/her medications; -At risk for falls with a history of falls; -Incontinent of bowel and bladder; -Has a fractured right pelvic fracture from a fall; and -Has a bladder wall rupture from a fall. Review of the POC, dated 07/22/2022 failed to be individualized and include interventions for problems identified on the initial/comprehensive assessment. The POC failed to identify the patient was lethargic and not safe to give medications by mouth or include the intervention to give small bites of applesauce prior to trying to give medications by mouth. The POC failed to identify the patient was at risk for falls or had actual fall with injuries. The POC failed to identify the patient was incontinent of bowel and bladder and any interventions. The POC failed to identify the patient had a pelvic fracture and a bladder wall rupture and any interventions for either problem. During an interview on 08/03/2022 at 10:20 AM, the clinical director stated that he/she would expect the POC to be individualized and include any interventions for current problems. He/she agreed with the findings and did not provide anything further evidence at exit.

Based on clinical record review and interview, the agency failed to develop an individualized written plan of care (POC) for each patient that included interventions to manage pain and symptoms in, but not limited to, two (Records/Patients #4 and #5) of five full records reviewed. This deficient practice has the potential to affect the care provided to all of the agency's patients. Findings included: During an interview on 08/03/2022 at 10:05 AM, the clinical director stated that the agency did not have a pain policy. RECORD/PATIENT #4: Review of the clinical record, showed the patient was admitted on 07/19/2022 with a terminal diagnosis of of chronic obstructive pulmonary disease (COPD; lung disease characterized by long-term respiratory symptoms and airflow limitation) and he/she resided in a long-term care facility (LTCF) . Review of the initial/comprehensive assessment, dated 07/19/2022, showed the following: -Co-morbidities included: bladder injury, abdomen pain, and pelvic fracture; -Non-verbal pain indicators included: vocal (sighs, gasps, moans, cries), facial grimaces/winces (furrowed brow, narrowed eyes, clenched teeth, distorted expressions), and bracing (clutching or holding onto furniture, equipment, or affected area during movement; -Had right hip pain that was increased by movement, relieved by as needed (PRN) morphine (narcotic pain medication), the pain interferes with repositioning, and the origin was fractured pelvis; -Current pain medication: Morphine 20 milligram (mg)/milliliter (ml) 0.5 ml every two hours as needed for pain; -Target pain goal: 0 None; -A pain level of 10 warrants further attention; and -Used breakthrough medications once in the last 24 hours. Review of the plan of care (POC), dated 07/22/2022 failed to be individualized and include interventions to manage pain. During an interview on 08/03/2022 at 10:20 AM, the clinical director stated that he/she would expect pain to be on the patient's POC and include interventions to decrease or alleviate his/her pain and should have been on the POC dated 07/22/2022. RECORD/PATIENT #5: Review of the RN (registered nurse) recertification visit dated 06/07/2022, showed the patient denied pain. No further documented assessment of the patient's history of pain or whether facility staff had to utilize pain medications. The patient continued to have periods of confusion and forgetfulness at times. The charge nurse at the facility stated that the patient had spit at him/her three days ago. The patient had increased anxiety/agitation at times in the evening. The facility staff utilized lorazepam (anti-anxiety mediation) as needed. The assessment failed to include how often staff utilized the lorazepam and its effectiveness. Review of the skilled nurse (SN) visits from 06/15/2022 through 07/29/2022, showed the patient denied pain during the visits, pain was daily but not constant, to less often than daily, pain level was acceptable to the patient, and interventions were Tylenol (medication for mild pain) and morphine (narcotic medication for severe pain) by mouth. The assessments failed to include the patient's history of pain, whether pain medication had to be utilized, and how often. Review of the patient's current medication list showed the patient had orders for as needed use of morphine sulfate and Tylenol. Review of the updated POCs from 06/21/2022 through 07/22/2022, failed to include interventions and goals to address pain. Review of the IDG (interdisciplinary group) note dated 06/21/2022, showed the patient continued to have periods of increased confusion and periods of agitation in the evenings with use of as needed lorazepam. Review of the patient's current medication list showed an order for lorazepam 2 mg (milligram)/ml (milliliter) 0.5 ml every two hours as needed for pain or shortness of air. Review of the POC dated 06/21/2022, failed to include nursing interventions related to the patient's anxiety/agitation. Review of a SN visit dated 07/13/2022, showed that facility staff reported some increased anxiety in the afternoon. The nurse counted medications with the facility nurse and gave report on the patient's condition, but failed to address how often the lorazepam was being utilized and its effectiveness. During an interview on 08/03/2022, beginning at 10:30 AM, the clinical director stated that the POC should address pain and the patient's anxiety. He/she would expect staff to monitor how often the facility staff had to use the lorazepam and its effectiveness.

Based on record review and interview, the agency failed to implement plans of care (POC) that included anticipated measurable outcomes in, but not limited to, two (Records/Patients #1 and #2) of five full records reviewed. This deficient practice has the potential to affect the quality of care for all patients receiving services. Findings included: RECORD/PATIENT #1: Review of the clinical record, showed the patient was admitted on 07/06/2021 with a terminal diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and he/she resided in a long-term care facility (LTCF). Review of the interdisciplinary group (IDG) meeting, dated 07/05/2022, showed the following: -The nursing home staff reported the patient was becoming restless during an evening and they were utilizing as needed (PRN) lorazepam (anti-anxiety medication) and that had been effective; -The patient requires times two staff for assistance with transfers and uses a broda chair (a wheelchair that provides assistance tilt-in-space positioning chair functionality to people who sit all day) that requires staff to propel; -The patient requires one to two staff assistance with all activities of daily living (ADLs); -The patient is on a pureed diet with honey thick liquids and does cough with food and fluid at times; -The patient's extremities are often cool to the touch, capiliary refill (measures the time required for return of color after applying pressure, in order to monitor the amount of blood flow to tissues and assess dehydration) is sluggish at times, and staff are unable to obtain an oxygen saturation (shows the percentage of oxygen in blood) at times; and -Volunteer completed an initial visit on 06/20/2022, the volunteer offered companionship and attempted conversation. Review of the plan of care, dated 07/05/2022, 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 the problems identified during the 07/05/2022 meeting. Review of physician order, dated 07/13/2022, showed lorazepam 0.5 milligram (mg) one tab by mouth at bedtime nightly. Indication: Anxiety/restlessness. Review of the POC, dated 07/19/2022, 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 the anxiety/restlessness. RECORD/PATIENT #2: Review of the clinical record, showed the patient was admitted on 07/01/2021 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 IDG (interdisciplinary group) meeting, dated 07/12/2022, showed the following: -The patient is nonsensical and alert to self; -The patient requires times two people for assistance with transfers and uses a wheelchair propelled by caregiver; -The patient requires one to two staff assistance with all activities of daily living (ADLs) including meals; -The patient has a history of a seizure (a sudden, uncontrolled electrical disturbance in the brain); and -The patient has difficulties with swallowing at times. Review of care plan, dated 07/05/2022 showed the following goals and outcomes: -Goal identified as patient's skin will remain intact with the outcome timeframe listed as by time of death/discharge; -Goal identified Chaplain and family will address identified needs with the outcome timeframe listed as by time of death/discharge; -Goal identified as patient will remain free from fall related injuries with the outcome timeframe listed as by time of death/discharge; -Goal identified as MSW (social worker) will work with spouse to address needs with the outcome timeframe listed as time by time of death/discharge; and -The agency failed to ensure that the goals and outcomes for the patient were specific and measurable. Review of the plan of care, dated 07/26/2022, 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 the problems identified during the 07/05/2022 meeting. During an interview on 08/03/2022 at 10:06 AM, 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, the hospice's quality assessment and performance improvement (QAPI) program, home visit observation, and interview, the agency failed to: -Follow accepted standards of practice to prevent the transmission of infections, including the use of standard precautions (L579); - Provide documented evidence of a coordinated agency wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the hospice's quality assessment and performance improvement program (L580); - Provide documented evidence of a coordinated agency wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the hospice's quality assessment and performance improvement program and includes: *A method of identifying infections and communicable disease problems; and *A plan for implementing the appropriate actions that are expected to result in improvement of disease prevention (L581); and -Ensure their COVID-19 policy included a process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19 (L900). The cumulative effect of these deficient practices has the potential to affect the health and safety of all the agency's patients.

Based on home health standards, policy review, observation, and interview, the agency failed to ensure that accepted standards of practice to prevent the transmission of infections was followed in one (Record/Patient #1) of three home visits conducted. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of official reference: [Centers for Disease Control and Prevention] CDC (2022). Guidelines for Hand Hygiene in Healthcare Settings; Clinical indications for hand hygiene include: - Immediately before touching a patient; - After touching a patient or the patient's immediate environment; - After contact with blood, body fluid, or contaminated surfaces; and - Immediately after glove removal. Review of official reference: McGoldrick, M. Home Care Infection Prevention and Control Program showed the following: -Staff should use a surface barrier of a water-resistant material (e.g., plastic bag [tall kitchen size] on a roll, wax paper, disposable underpads [chux], etc.) under the bag and/or equipment used in patient care; -Perform hand hygiene; -Remove supplies from the bag and place them on a clean, dry surface, or a surface barrier as needed; and -Do not reenter the bag with gloves on. Remove gloves if worn, perform hand hygiene, and then reenter the bag. Review of the agency's policy titled, "Handwashing," dated as revised 08/2017, showed agency staff were to wash their hands upon entering/exiting patient rooms, before and immediately after contact with each patient and their immediate surroundings, when removing gloves, after aseptic procedures, and after each and every contact with material that may be contaminated and/or potentially infectious. Review of the agency's policy titled, "Bag Technique and care of supplies," dated 01/13/2022, showed the following: -The inside of the bag is considered a clean area; -Set bag on a clean surface. The bag is not to be placed on any floor surface. When cleanliness of the work area is questioned, place bag and supplies on area protected by paper towels, newspaper or plastic bag; -Wash hands; and -Open bag, removed needed supplies and/or equipment, and place them on a clean work area. RECORD/PATIENT #1: Observation on 08/02/2022, beginning at approximately 9:11 AM, during the patient's home visit in a LTCF (long-term care facility), showed hospice nurse Registered Nurse (RN) A: - Entered the patient's room and placed his/her bag on the bathroom door knob.Without washing his/her hands, reached into bag and pulled out pair of gloves and donned the gloves. He/she then reached back into the bag with gloved hands and pulled out supplies and placed on the patient's bedside stand. RN A failed to clean the surface or put a barrier down before placing the supplies on the bedside stand. The patient was in bed and on his/her right side. RN A took an automatic blood pressure (BP) cuff from container and placed on the patient's left wrist. After removing the BP cuff placed it back in container. RN A observed the patient's buttocks and noted the patient had some bowel movement (BM) in the anal region. RN A used wipes and cleaned the buttocks. RN A removed gloves, reached into bag and got hand sanitizer out and used it. RN A then reached back into bag and got another pair of gloves and put them on. RN A informed the patient he/she was going to change his/her protective pad that was underneath him/her. RN A picked up bottle of peri cleanser and wipes and sprayed several wipes. RN A was cleaning the patient's buttocks with the wipes and noted BM on the wipes. RN A used several wipes to clean the patient's buttocks until no BM was noted on them. RN A then without removing gloves, reached on the patient's bedside stand and picked up barrier cream and applied barrier cream to the patient's buttocks. RN A removed gloves and without washing his/her hands, put on another pair of gloves, then assessed the patient's feet. After assessing the patient's feet, RN A covered the patient with a sheet, removed his/her gloves, then go into the patient's bathroom and wash his/her hands. After washing his/her hands, RN A reached into her bag and pulled out two clear bags, one had gloves in it and the other was labeled "sani wipes", he/she placed both bags on the bedside table without cleaning the surface first and no barrier was present. RN A then wiped the BP cuff with sani wipe and he/she then wiped inside the container. After cleaning the container inside and out, put the BP cuff back inside it and then sat the container back on the bedside stand. RN A reached into trashcan and pulled out a trashbag and picked protective pad out of trashcan and put into trashbag, then removed one glove and informed SA (state agent) that he/she was going to the dirty utility and left the room. Upon returning to room did not wash hands, put on gloves and reached back into trashcan and fixed the trashbag that had the used wipes from peri care in it, as it had fallen down when he/she had removed previous trashbag. RN A then with same gloved hands, picked up supplies that he/she had cleaned and put them into his/her bag. After placing supplies back into his/her bag, RN A removed gloves and went into the patient's bathroom and washed his/her hands and then left the patient room. During an interview on 08/03/2022 at 10:06 AM, the clinical director stated the following: -Sani wipes were to be used on supplies before and after use; -The bedside stand and bedside table should have been cleaned prior to placing supplies on them or use a barrier on those surfaces; -Hands should be washed prior to and after patient contact and after gloves removed if been in contact with contaminated material; -Gloves should be changed between clean and dirty procedures; and -RN A should not have reached into his/her bag with gloved hands that were considered dirty.

Based on policy review, record review, and interview, the agency failed to maintain and provide documentation of a coordinated agency-wide program of surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that become an integral part of the agency's quality assessment and performance improvement (QAPI) program. This deficient practice has the potential to affect all patients receiving services from the agency. Findings included: Review of the agency's policy titled, "Infectious Control Tracking," dated as revised 09/06/2019, showed the following: -The hospice shall maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases that is an integral part of the hospice's QAPI program; and -Infections/communicable diseases will be monitored and included in the hospice QAPI program. Review of the agency's QAPI program, provided by the clinical director on 08/02/2022 at 2:00 PM failed to show infection control was part of the QAPI program. During an interview on 08/02/2022 at 2:37 PM, the clinical director stated that the infection control program was not part of the agency's QAPI program.

Based on review of policy review and interview, the agency failed to provide documented evidence of a coordinated agency wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the hospice's quality assessment and performance improvement (QAPI) program and includes: - A method of identifying infections and communicable disease problems; and - A plan for implementing the appropriate actions that are expected to result in improvement of disease prevention. This deficient practice has the potential to affect all patients, families, visitors and hospice personnel. Findings included: Review of the agency's policy titled, "Infections Control Tracking," dated as revised 09/06/2019, showed the following: -The hospice must maintain an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases; -The hospice shall maintain a coordinated agency wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases that is an intregral part of the hospice's QAPI program. It must include the following: *A method of identifying infections and communicable disease problems; and *A plan for implementing the appropriate actions that are expected to result in improvement and disease prevention; -Infections and communicable diseases will be identified by hospice staff; -Infections will be recorded in the electronic medical record (EMR) system; and -Infections/communicable diseases will be monitored and included in the hospice's QAPI program. During an interview on 08/02/2022 at 2:37 PM, the clinical director stated the following: -When a patient is placed on antibiotics, the nurse should put that patient's name in the EMR, and based off of how long the antibiotic is for, then they will do a follow up at the time the antibiotic is complete; and -He/she was over the infection control program and he/she had not been tracking and trending (investigating) to see if there was a particular staff member that was providing care to the patients with infections.

Based on policy review, review of the hospice's quality assessment and performance improvement (QAPI) program, and interview, the agency failed to ensure that the licensed professional services delivered by their health care professionals was practiced under the hospice's policies and procedures when the agency's clinical director failed to develop, implement, and maintain an effective, ongoing, hospice-wide data-driven QAPI program. This deficient practice has the potential to affect all the patients served by the agency. Findings included: Review of the agency's policy titled, "Quality Assurance Performance Improvement (QAPI)," dated 10/11/2019, showed in part the following: -The QAPI program is designed to be comprehensive and continuous, encompassing all systems of the agency, aiming for excellence, safety, and quality; -Governance and Leadership: The QAPI program will be led by the hospice director. The director will be held accountable for the monitoring, evaluation, resolution, training, documentation, delegation, and reporting to the agency staff and to the hospital Board of Directors; -The director is to gather data from necessary sources to review the subject from a holistic viewpoint: *New goals will be determined quarterly, aimed at improving quality of care and encompassing all aspects of the hospice; and *Adverse events: falls, infections, and medication errors, will be continuously monitored; -An excel spreadsheet will be used to monitor and measure the QAPI goal and will include the following information: what is being measured (include sample size), frequency of measurements, how it is being measured, who is responsible for the tracking, what is the performance goal or aim, how will the findings be tracked or displayed; -Areas for improvement will be prioritized based on a risk scale (1= very low, 5=very high) based on the needs and safety of the patients, families, agency staff, and organization; -Initiate the prioritization worksheet; -Initiating the goal setting worksheet to assist in the establishment of performance improvement projects (PIPs); -Create a project charter to establish goals, scope, timing, milestones, team roles, and responsibilities; -Monitoring/evaluating the effectiveness of the action: *Multiple plan-do-study-act (PDSA) tools may be used to implement an appropriate process to achieve the goal; and *Review and determine sustainability of the interventions in regards to the systems, people, environment, and measurement; and -Documentation of the review of the hospice's QAPI program. Review of the QAPI program on 08/02/2022 at 1:30 PM, failed to show an excel spreadsheet as per policy, it failed to show areas of improvement as per policy, it failed to show a prioritization worksheet as per policy, it failed to show how PIPs were determined, and the one PIP they had failed to show scope, timing, milestones, team roles, and responsibilities. During an interview on 08/02/2022 at 2:00 PM, the clinical director stated the following: -He/she was over the QAPI program; -Infection control was not part of the QAPI program; -He/she did not have an excel spreadsheet for the current PIP; -He/she did not have anything to show the scope, timing, milestones, team roles and responsibilities in regards to the PIP; and -He/she decided one of their PIPs regarding discharge because he/she saw a problem with follow through once a patient was discharged, but this PIP wasn't data driven and really did not know if there was ever any negative outcome from it.

Based on policy review, record review, home visit observation, and interview, the agency failed to ensure the nursing needs of the patient were met in, but not limited to, two (Records/Patients #1 and #5) 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, "Physician Notification," dated 02/01/2022, showed the following: -Clinicians will monitor, document, and report the patients' response to care and treatment to patient physician with each visit or as changes arise; and -Unanticipated change in patient condition that is not controlled by current medication orders or interventions. RECORD/PATIENT #1: Review of the clinical record, showed the patient was admitted to hospice on 07/06/2021, with a terminal diagnosis of Alzheimer's (a progressive disease that destroys memory and other important mental functions) and he/she resided in a long-term care facility (LTCF). Review of skilled nurse (SN) visits from 07/01/2022 to 08/02/2022 showed no documentation that the patient had edema and no documentation that the patient's heels were boggy (abnormal texture of tissues characterized by sponginess, usually because of high fluid content). Observation on 08/02/2022 beginning at 9:11 AM, during the patient's home visit, showed registered nurse (RN) A assessed the patient's feet, and reported to the facility charge nurse that the patient had three plus edema (assessed by applying pressure to the affected area, and how long it takes to rebound) to the right foot and one plus edema to the left foot, and that both heels were boggy. Review of SN visit from 08/02/2022, showed the patient had three plus edema of the right foot and one plus edema of the left foot and bilateral heels were boggy. Heel booties applied bilaterally. No documentation the physician was notified of the change in the patient's condition. During an interview on 08/03/2022 at 12:05 PM, the clinical director stated that the physician should have been notified of the changes in the patient's condition. RECORD/PATIENT #5: Review of the RN (registered nurse) recertification visit dated 06/07/2022, showed the patient denied pain. No further documented assessment of the patient's history of pain or whether the facility staff had to utilize pain medications and their effectiveness.. Review of the SN visits from 06/15/2022 through 07/29/2022, showed the patient denied pain during the visits, pain was daily but not constantly to less often than daily, pain level was acceptable to the patient, and interventions were Tylenol (mild pain medication) and morphine (severe pain medication) by mouth. The assessments failed to include the patient's history of pain, whether pain medication had to be utilized, how often and their effectiveness.. Review of the SN visits showed: - On 07/20/2022, the patient's last bowel movement (bm) was 07/14/2022 (six days). The patient's bowel sounds were normal. The patient ate a few bites at breakfast and his/her appetitie was declining. The nurse gave report to the facility nurse. No documentation of discussion of the patient's last bm on 07/14/2022 or whether a prn (as needed) laxative needed to be administered; and - On 07/22/2022, the last documented bm was 07/14/2022 (eight days) but facility staff had not been documenting everyday. The patient had positive bowel sounds and abdomen was soft and nontender. The nurse spoke with the facility nurse about the patient's current condition but no documented discussion regarding the patient's last bm or whether a prn laxative needed to be administered. Review of the current medication list showed an order for Miralax (laxative) 17 grams daily as needed for constipation. During an interview on 08/03/2022, beginning at 10:30 AM, the clinical director stated that he/she expected staff to assess whether the facility staff had to utilize pain medication and how often. They do count medications with the facility but should probably put that in their notes. He/she would expect staff to document they discussed the patient's last bm with the faciity nurse.

Based on policy review and record review the agency failed to ensure the hospice aide followed the plan of care (POC) assignment in one (Record/Patient #5) of four records reviewed that received aide services. This deficient practice has the potential to affect all patients receiving aide services. Findings included: Review of the agency's undated policy titled, "Aide Care Plan," showed in part that the aide care plan will be completed by the RN (registered nurse) on all patients that request aide services. The aide is to follow this aide care plan when providing care and update the nursing staff if there are any discrepancies during the visit.. RECORD/PATIENT #5: Review of the aide care plans dated 05/25/2022 through 07/20/2022, showed the RN assigned the aide to visit twice a week. The care plan included for the aide to address the patient's last bowel movement twice a week. Review of the aide visits showed on 06/23/2022, 06/30/2022, 07/12/2022, 07/15/2022, 07/19/2022, 07/21/2022. and 07/26/2022 the aide failed to document the patient's last bowel movement. During an interview on 08/03/2022 beginning at 9:20 AM, the clinical director stated that he/she expected the aides to follow the aide care plan.

Based on policy review, record review, and interview, the agency failed to ensure the registered nurse (RN) adequately evaluated the aides completed the tasks assigned by the RN in one (Record/Patient #5) of four records reviewed that received aide services. This deficient practice has the potential to affect all patients that receive aide services. Findings included: Review of the agency's undated policy titled, "Supervisory Visits for LPN (licensed practical nurse) and Aide," showed the aide is to furnish the care identified in the patient's plan of care. The RN is to identify if there are any needs that are not being met or changes that need to be made to the plan of care. Review of the aide care plans dated 05/25/2022 through 07/20/2022, showed the RN assigned the aide to visit twice a week. The care plan included for the aide to address the patient's last bowel movement twice a week. Review of the aide visits showed on 06/23/2022, 06/30/2022, 07/12/2022, 07/15/2022, 07/19/2022, 07/21/2022 and 07/26/2022 the aides failed to document the patient's last bowel movement. Review of the aide supervisory visits dated 07/07/2022, and 07/20/2022 showed the aide followed the care plan as instructed. There was no documentation the RN discussed the aide care plan with the aides. During an interview on 08/03/2022 beginning at 9:20 AM, the clinical director stated that he/she expected the RN to address documenting the patient's last bowel movement with the aides.

Based on requested job description review and interviews, the agency failed to ensure that the administrator was responsible for the day-to-day operation of the hospice. This deficient practice has the potential to affect all patients on service with the hospice. Findings included: During an interview on 08/03/2022 at 12:45 PM, the clinical director stated that the agency did not have a job description for the agency administrator. During an interview on 08/03/2022 at 10:42 AM, the clinical director stated the following: -He/she meets with the administrator weekly or every other week, at which time they discuss: census, patient admissions, patient complaints, and any problems; -He/she has been in the role of clinical director for not quite two years; -He/she does see patients and does take call on weekends; -He/she takes the hospice agency's quality assessment and performance improvement (QAPI) information to the hospital board meetings, but he/she denied going over QAPI specifically with the agency administrator prior to attending the hospital board meetings; -He/she does go to the hospital (where the agency administrator's office is) daily to pick up mail and will speak to the agency administrator or his/her assistant about things going on, policy review, and hiring; and -The agency administrator is also the hospital administrator. During an interview on 08/03/2022 at 11:48 AM, the agency administrator stated the following, when questioned how he/she was involved in the day-to-day operations of hospice: -He/she meets with every department head manager and goes over employee performance and evaluates each employee; -He/she meets every month or every other month with department heads to go over budget performance and will also review hospice services with the clinical director; -In the process of moving the hospice agency into another building; -Attend monthly board meetings and go over hospice services. Also every three to five months the board will go over hospice's performance; and -He/she meets with the agency clinical director regularly and go over any issues and how hospice services are going. During the same interview, the agency administrator stated the following (when questioned how is the governing body informed of the hospice's ongoing operations, including patient care delivery issues and QAPI activities): -QAPI is gone over at the board meetings; and -He/she asks the board if they have any questions regarding hospice. During the same interview, the agency administrator stated the following (when questioned if he/she knew what PIP or PIPs (Performance Improvement Project) the agency was currently working on): -He/she did not; and -He/she had confidence in the clinical director to determine those. During the same interview, the agency administrator stated the following, when questioned if he/she attended the IDG (interdisciplinary group) meetings: he/she denied attending the meetings. It should be noted that the agency administrator was not present during the survey process, until exit on 08/03/2022 at 1:03 PM.

Based on policy review, record review and interview, the agency failed to ensure physician orders were obtained in, but not limited to, two (Records/Patients #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 policy titled, "Physician Orders," dated 09/10/2019, showed in part that physician telephone orders will be received by a nurse, pharmacists, or other physicians and immediately reduced to writing, signed by the person receiving the order and signed by the prescriber within 21 days. The hospice staff member receiving the order will immediately document the order on the EMR (electronic medical record) system and send the order to order's manager. The hospice office manager will print the orders and fax them to the appropriate physician for signature. The physician order will be documented in the IDG (interdisciplinary group) communication. RECORD/PATIENT #3: Review of the skilled nurse (SN) visit notes showed: - On 06/08/2022, the patient fell and had skin tears to the right arm, wrist, hand, and both elbows. Steri strips (thin, adhesive strips that hold the edges of wounds together) were applied to the skin tears on the upper arm and elbow and covered with a transparent dressing; and - On 06/09/2022, the nurse cleansed the wounds with alcohol wipes, applied Telfa (non-stick bandage), ABD pad (large, absorbent) and wrapped with Kerlex (gauze wrap) and cleansed the left elbow with alcohol wipes, applied an adhesive island dressing (a non-stick pad with adhesive around the edges) and a geri sleeve (a sleeve placed around the arm to protect the skin/dressings). Review of the record showed no physician's order for treatment of the patient's skin tears. During an interview on 08/02/2022 at approximately 3:30 PM, the clinical director stated that he/she did not find an order for treatment of the patient's skin tears. He/she would expect there to be an order for the treatments. RECORD/PATIENT #4: Review of the skilled nurse (SN) note from 07/28/2022 showed the patient had wounds on his/her buttocks that were open and draining from where he/she had previously had a blister. The old dressing was removed and the patient's buttocks was gently cleansed, patted dry, and a new dressing was applied to buttocks. Review of the patient's physician's orders and medication profile failed to show an order for a dressing for the patient's buttocks. During an interview on 08/03/2022 at 11:00 AM, the clinical director stated that he/she would have expected staff to have an order for the dressing. He/she agreed with the findings, he/she could not find an order for the dressing.

Based on policy review, record review and interview, the agency failed to provide accurate documentation of communication with the patient, caregivers, or physician for two (Records/Patients #1 and #2) 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, "Registered Nurse," dated as revised 01/13/2022, showed in part that all documentation is completed accurately. Review of the agency's undated policy titled, "Medical Social Worker," showed in part that all documentation must be documented in the EMR [electronic medical record] within 72 hours, including all patient/caregiver visits/telephone contacts are recorded. RECORD/PATIENT #1: Review of the clinical record, showed the patient was admitted to hospice on 07/06/2021, with a terminal diagnosis of Alzheimer's (a progressive disease that destroys memory and other important mental functions) and he/she resided in a long-term care facility (LTCF). Review of the clinical record, showed the following: -The patient had a skilled nurse (SN) visit on 07/12/2022; -On 07/13/2022 the agency wrote an order for lorazepam (anti-anxiety) 0.5 milligram (mg) one tablet at bedtime; and -SN visit on 07/15/2022 showed there had been no medication changes since last visit. Review of LTCF record, showed an order to discontinue Miralax (laxative) 17 grams (gm) in eight ounces of fluid daily on 07/27/2022. Review of SN visit 07/29/2022, showed there had been no medication changes since last visit. During an interview on 08/03/2022 at 10:26 AM, the clinical director stated that documentation should be accurate and the visits on 07/15/2022 and 07/29/2022 should have shown there had been medication changes since the last visit. RECORD/PATIENT #2: Review of the clinical record, showed the patient was admitted to hospice on 07/01/2021 with a terminal diagnosis of Alzheimer's and he/she resided at home. During an interview on 08/02/2022 at 2:00 PM, the case manager stated that he/she believed the MSW (social worker) was unable to see the patient as scheduled and that the MSW then rescheduled the comprehensive assessment to the next week at the spouse's request. There is no documentation to show attempts to reschedule the comprehensive assessment with the spouse. He/she stated that the expectation would be for the MSW to document telephone contact for scheduling the visit.

Based on record review, and interview, the agency failed to document a discharge summary for one patient (Record/Patient #6) who revoked hospice services. This deficient practice has the potential to affect the post-hospice medical care of all the agency's live discharged patients. Findings included: RECORD/PATIENT #6: Review of the record showed the patient revoked hospice care on 06/02/2022, to seek further treatment. The record failed to include a discharge summary. During an interview on 08/03/2022 at approximately 10:45 AM, the clinical director stated that he/she did not find a discharge summary for the patient.

Based on clinical record review, home visit observation and interview, the agency failed to document instruction of the patient/family in the safe use of medical equipment or assess/document the understanding of the caregiver regarding use of the equipment in, but not limited to, one (Record/Patient #2) out of five complete record reviews. This deficient practice has the potential to affect the care provided to all the agency's patients. Findings included: RECORD/PATIENT #2: Review of the comprehensive plan of care dated 07/01/2022 showed a physician order for oxygen as needed (PRN) for comfort. Observation on 08/02/2022 at 11:00 AM, during the patient's home visit, the spouse stated the patient uses oxygen at 2 liters per nasal cannula every night while sleeping. Review of the clinical record, showed no documentation in the nursing visits to show the following: - The patient's caregivers were instructed on the use of the oxygen, oxygen concentrator and/or assessed for their ability to use it correctly; and - Patient or caregivers educated on the safe use of the oxygen concentrator or portable oxygen tanks. The findings were reviewed with the clinical director and case manager on 08/02/2022 at 3:30 PM. The clinical director stated that he/she could not find any additional documentation to show evidence that staff educated the patient or caregivers on the safe use of oxygen, the oxygen concentrator, or portable oxygen tanks.

Based on review of Missouri state law, policy review, employee file review, and interview the agency failed to obtain the results of the employee disqualification list (EDL) checks prior to hire in one (Employee #2) of two employee files reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of Section 192.2490.12 RSMo showed the statement, "No person, corporation, organization or association who received the employee disqualification list under subdivisions (1) to (5) of subsection 11 "of this section shall knowingly employ any person who is on the employee qualification list." Review of the agency's policy titled, "Personnel," dated January 18, 2012, showed in part that the department manager or their designated representative will see that one of the individuals authorized to check the EDL performs a check of the Missouri Department of Health and Senior Services EDL. These results must be obtained prior to the prospective employee's first day of work. EMPLOYEE #2: - Date of hire: 07/03/2018; and - EDL check 07/12/2018 (nine days after hire date). During an interview on 08/01/2022, at 4:35 PM, the clinical director stated that he/she would expect the EDL check to be completed prior to the employee being hired.

Based on policy review and interview the agency failed to ensure their COVID-19 policy included a process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "COVID-19 Vaccination Policy," revised 12/10/2021, showed in part that personnel who are granted an exemption may be required to comply with COVID-19 testing, masking, social distancing, or other measures as (named hospital) determines in its sole discretion. The policy failed to include what specific additional measures/precautions were in place to mitigate the spread of COVID-19 for unvaccinated staff. During an interview on 08/01/2022, at 4:10 PM, the clinical director stated that the agency did not have a specific policy for mitigation measures for unvaccinated staff. He/she had verbally informed unvaccinated staff of what is required as he/she received instructions from the hospital. During an interview on 08/02/2022, at 8:10 AM, the clinical director stated that unvaccinated staff were required to wear N95 (a specialized respirator mask) masks.