Every finding on record at Capital Hospice

Based on clinical record review and interview it was determined the agency failed to ensure the Interdisciplinary Group (IDG) completed the patient's comprehensive assessment no later than five (5) days of election of hospice for one (1) of six (6) clinical records in the survey sample (Clinical record for Patient #1). --- Findings: The clinical record of Patient #1 with an election of hospice benefit date of September 06, 2024 failed to contain documentation the agency's Medical Social Worker (MSW) completed the patient's comprehensive assessment within five (5) days of election of the hospice benefit. The first documentation of MSW involvement was on September 12, 2024 (day 6). On January 03, 2025 at 10:33 AM, Staff Member #6 revealed this was a management error. The MSW normally covering this area was on PTO (Paid Time Off) and confirmed the MSW assessment was one (1) day late.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following, measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 5 of 6 (83%) clinical records reviewed revealed that the agency did not ensure that the written plan of care contained measurable outcomes anticipated from implementing and coordinating the plan of care. This is a continued required action Clinical Record 1: The patient elected the hospice benefit on 11/19/2024 with a diagnosis of malignant neoplasm of female breast. On the plan of care dated 11/19/2024 problems identified included, impaired mobility. The goal written was: “patient/caregiver will demonstrate understanding of impaired mobility treatment plan.” Another problem was infusion line care. Goals written were: “patient/caregiver will demonstrate understanding of infusion or injection line treatment plan,” and “patient's infusion line care will be managed within limits of disease.” Edema was also a problem identified on the plan of care. Goals written were: “patient/caregiver will demonstrate understanding of edema treatment plan,” and “patient's edema will be controlled within limits of disease.” The last problem identified was confusion. Goals written were: “patient/caregiver will demonstrate understanding of confusion treatment plan,” and “patient's confusion will be controlled within limits of disease.” There was no documented evidence in the written plan of care that the agency included measurable outcomes anticipated by implementing the plan of care. Clinical Record 2: The patient elected the hospice benefit on 11/24/2024 with a diagnosis of vascular dementia. The plan of care dated 11/24/2024 identified a problem of urinary catheter. Goals written included: “patient/caregiver will demonstrate understanding of urinary catheter treatment,” and “patient's urinary catheter will be maintained while in the IPU (Inpatient Unit).” A second problem identified was Dyspnea. Goals included: “patient/caregiver will demonstrate understanding of dyspnea treatment plan,” and “patient dyspnea will be controlled within 24 hours of admission.” There was also a problem of pain management identified, and goals written were: “patient/caregiver will demonstrate understanding of pain treatment plan,” and “patient’s pain will be controlled within 24hours of admission to IPU.” There was no documented evidence in the written plan of care that the agency included measurable outcomes anticipated by implementing the plan of care. Clinical Record 3: The patient elected the hospice benefit on 07/03/2024 with a diagnosis of amyotrophic lateral sclerosis. The plan of care dated, 10/31/2024 - 12/29/2024 identified a problem of respiratory: vent dependent. Respiratory goals written were: “comfort will be maintained,” and “respirations regular and unlabored.” Also, a problem of high risk for dermal wounds related to immobility and incontinence, stage I wound to coccyx, recurrence of perianal fungal infection was identified. Goals written were: “comfort maintain current integumentary status.” There was no documented evidence in the written plan of care that the agency included measurable outcomes anticipated by implementing the plan of care. Clinical Record 5: The patient elected the hospice benefit on 11/04/2024 with a diagnosis of squamous cell carcinoma of skin, scalp and neck. A problem of pain was identified in the initial assessment dated 11/04/2024. Goals that were written included: “Patient/Caregiver will verbalize pain relief measures including pharmacologic and non-pharmacologic measures by (blank)” and “Encouraged scheduling morphine three times a day and utilizing as needed if needed.” Problem identified: high risk for skin breakdown. High risk for bleeding related to fungating neck tumor. Goals: “dark towels available in the event patient bleeds heavily from fungating neck tumor,” and “Patient will exhibit pain related to wound care acceptable to patient.” There was no documented evidence in the written plan of care that the agency included measurable outcomes anticipated by implementing the plan of care. Clinical Record 6: The patient elected the hospice benefit on 11/01/2024 with a diagnosis of cerebral infarction. Problem identified in the initial RN assessment dated 11/01/2024 were, patient at risk for falls due to history of falls, weakness and paralysis from stroke. Goal written was: “patient will remain safe in environment.” Problem identified, patient at risk of skin breakdown due to incontinence of bowel and bladder and patient is bedbound. Goal written was: “patient/caregiver demonstrate understanding of skin breakdown prevention.” There was no documented evidence in the written plan of care that the agency included measurable outcomes anticipated by implementing the plan of care. In a joint clinical record reviews and interviews with the clinical directors (11/25/2024 and 11/26/2024) they confirmed and agreed that these plans of care included incomplete and non-measurable goals. This is a continued required action

It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code fire drills at varied times on all shifts. This standard was not met as evidenced by document review and interview. Document review revealed the hospice inpatient facility did not conduct Life Safety Code fire drills at the intervals specified in NFPA 101, 19.7.1.6. NFPA 101, 19.7.1.6 stated in part, "Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions." Observation 1: A review of the fire drill records for the inpatient unit (IPU) revealed that two fire drills were conducted, one per each shift, in September of 2024. There was no documented evidence of fire drills conducted in the first two quarters of 2024, and in all of 2023 and 2022. During an interview on 10/09/2024, the Facilities Manager confirmed there was no documented evidence that the IPU conducted quarterly fire drills for each shift. The Facilities Manager stated that a fire drill process and schedule were implemented on 08/19/2024. During an interview on10/09/2024, the Regional Executive Director confirmed there was no documented evidence that the IPU conducted quarterly fire drills for each shift. A review of the fire drill records of the agency's inpatient unity (IPU) revealed that the agency did not ensure that fire drills were done at least quarterly for each regularly scheduled work shifts.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review and interview. In 4 of 31 (13%) clinical records reviewed, revealed that the agency did not ensure all medications were documented on the medication profile. Clinical Record 3: The medication profile dated 01/03/2024 for a patient admitted for GIP (general in-patient care) did not include saline for the peripheral IV. The medications being delivered via peripheral line included: morphine (pain) 4mg/ml, as needed; lorazepam (anxiety) 2 mg, as needed; dexamethasone phosphate (pain), as needed; and pantoprazole (stomach upset) 40mg, as needed. During an interview, the In-patient Clinical Supervisor stated that saline-only flushes were used for peripheral catheters. The Clinical Supervisor confirmed that saline was not included on the medication profile. Clinical Record 4: The medication profile dated 02/17/2024 for a patient admitted for GIP did not include saline for the IV. The patient was receiving Dilaudid (paint) intravenous infusion every 6 hours. The peripheral catheter that was in place for the infusion required a saline flush before and after delivery. This was not on the medication profile as of the patient's death on 02/20/2024. Clinical Record 22: The patient was admitted to care on 08/27/2024 and was living at a skilled nursing facility (SNF). The updated medication profile did not include the following medications: Biotene (dry mouth) 5mg/ml every six hours; MiraLax (constipation) 1 packet every 24 hours; and Timolol Maleate Opthalmic solution 0.5%, 1 drop in right eye at bedtime. During a home visit on 10/07/2024, the SNF medication profile was observed to include these medications. Clinical Record 28: The patient was admitted to the hospice IPU (in-patient unit) on 10/03/2024 with the following intravenous medications: haloperidol (relax) prn; lorazepam (anxiety) prn; ondansetron (stomach upset) prn; glycopyrrolate, hydromorphone (pain), prn. The medication profile did not include saline to flush the intravenous line between medications. During a joint record review and interview, the clinical team confirmed the medication profiles did not include all of the patient's current medications.

The Condition of Participation requires that the hospice must designate an interdisciplinary group, in consultation with the patient's attending physician, to prepare a written plan of care for each patient. The plan of care must specify the hospice care and services necessary to meet the patient needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY This Condition of Participation was not met as evidenced by clinical record review, observation and interview. In 5 of 8 (63%) clinical records reviewed for patients receiving inpatient facility care, it was revealed that the hospice failed to ensure each patient's individualized written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments [L545/418.56(c)]. Clinical Record 3: The initial comprehensive assessment was dated 01/03/2024 and documented that the patient had a mediport and a peripherally inserted catheter. The documented interventions on the initial and updated plans of care included: mediport care assessed and provided every 7 days; assess and monitor the line. However, the intervention did not specify the care to be assessed and provided every 7 days. There was no intervention to assess and monitor the peripherally inserted catheter. Clinical Record 4: The initial comprehensive assessment was dated 02/17/2024 and documented that the patient had a peripherally inserted catheter. The initial and updated plans of care did not include interventions for the peripheral catheter. Clinical Record 28: The initial comprehensive assessment was dated 10/03/2024 for a patient admitted to the inpatient unit. The assessment identified a PICC (peripherally inserted central catheter) line and a peripheral line. The plan of care documented the following interventions: instruct patient/caregiver in the administration of IV solutions/medications, infusion site care, and precautions and complications of infusion care. The initial and updated plans of care did not include any other individualized interventions for the PICC line and peripheral IV. During a home visit, the staff was observed to flush the PICC and the peripheral catheter site was without any redness, swelling, or drainage. Clinical Record 29: The initial comprehensive assessment for a patient admitted to the in-patient unit on 10/07/2024 identified breast cancer and need for pain control with a PCA (patient-controlled anesthesia). The initial plan of care did not include specific interventions for care of the peripherally inserted catheter/PCA. The plan of care documented the following interventions: instruct patient/caregiver in the administration of IV solutions/medications, infusion site care, and precautions and complications of infusion care. There were no other interventions for the peripherally inserted catheter/PCA. Clinical Record 30: The initial comprehensive assessment for a patient admitted to the in-patient unit on 10/05/2024 identified a mediport. The inital plan of care included: a fentanyl PCA via the mediport. The plan of care documented the following interventions: providing instructions to the patient and caregiver regarding signs and symptoms of the line site and their line care treatment plan. There were no other interventions for the PCA/mediport. During an interview, the Compliance Director and the Clinical Supervisor confirmed the plans of care were missing complete individualized interventions for problems identified in the assessments. The cumulative effect of this deficiency has resulted in the hospice's inability to ensure the provision of quality care for the Condition of Participation CFR 418.56, Interdisciplinary group, care planning, and coordination of services. The collective deficient practice illustrated a systemic process failure that had the potential to affect all patients receiving care services.

It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, observation and interview. In 4 of 23 (29%) clinical records reviewed for patient's receiving routine hospice care, the agency did not ensure that each patient’s individualized written plan of care identified interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 12: The initial comprehensive assessment was dated 08/14/2024 and documented problems of heart failure and respiratory distress. The initial plan of care dated 08/14/2024 and all updated plans of care documented the following intervention, "Dyspnea will decrease by ____ achieved by 09/25/2024. The intervention was incomplete. Clinical Record 14: The initial comprehensive assessment was dated 08/15/2024 and documented problems of heart failure and respiratory distress. The initial plan of care was dated 08/15/2024 and documented the following interventions: "Dyspnea will decrease by ____ effective 08/15/2024; symptom management related to cardiac dyspnea/anxiety as evidenced by slower respiratory rate within -------; and patient will demonstrate energy conservation technique by ------. The updated plans of care dated every 2 weeks through 10/09/2024 documented the same incomplete interventions. Clinical Record 26: The initial comprehensive assessment was dated 05/13/2024 and documented that the patient had dementia and diabetes. The plan of care was updated every two weeks. The nursing assessment dated 07/16/2024 documented a Foley catheter. The plan of care documented the following interventions: flush with normal saline (missing frequency and amount); and change the Foley catheter every 14 to 21 days (missing catheter size). The interventions did not specify how to flush with normal saline including the frequency and amount, nor the size of the catheter. The plan of care included skin integrity interventions for the heels and right great toe. The nursing assessment was dated 10/04/2024 and documented moon boots at night and a blanket tent. However, the plan of care did not include these interventions. Clinical Record 27: The initial comprehensive assessment was dated 05/15/2024 and identified the problem of a Foley catheter. The initial and updated plans of care documented the following intervention: "Instruct catheter care." The intervention did not specify the type of catheter care, the frequency for care, and the size of catheter. The nursing assessments documented that the catheter was changed monthly. During an interview, the Compliance Director and the Clinical Supervisor confirmed the plans of care were missing complete individualized interventions for problems identified in the assessments.

It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 31 (3%) clinical records reviewed, the agency did not ensure the written plan of care included measurable outcomes. Clinical Record 22: The initial plan of care was dated 08/27/2024 and updated every two weeks. The following goals were documented on all plans of care: changes in cardiac status will be identified and managed; bowel/bladder incontinence will be managed; and the patient will remain safe in the environment. The goals were not measurable. During a joint record review and interview, the Clinical Manager confirmed the goals were not measurable.

It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 5 of 31 (16%) clinical records reviewed, the agency did not ensure that each individualized written plan of care included all drugs and treatment necessary to meet the needs of the patient. Clinical Record 3: The patient was admitted on 01/03/2024 with a peripheral catheter. Pain and anxiety medications were being administered via the peripheral catheter. The initial and updated plans of care did not include saline which would was required to flush the peripheral catheter before and after medication administration. Clinical Record 4: The patient was admitted on 02/18/2024 for GIP (general in-patient care) care with a peripheral IV catheter and Dilaudid (pain) every 6 hours prn (as needed). Normal saline was ordered, however was not included on the plan of care as of the patient's death on 02/20/204 Clinical Record 22: The patient was admitted to care on 08/27/2024 and was living at a skilled nursing facility (SNF). The updated plan of care dated 10/02/2024 did not include the following medications: Biotene (dry mouth) 5mg/ml every six hours; MiraLax (constipation) 1 packet every 24 hours; and Timolol Maleate Opthalmic solution 0.5%, 1 drop in right eye at bedtime. During a home visit on 10/07/2024, the SNF medication profile was observed to include these medications. Clinical Record 28: The patient was admitted to the hospice IPU (in-patient unit) on 10/03/2024 with the following intravenous medications: haloperidol (relax) prn; lorazepam (anxiety) prn; ondansetron (stomach upset) prn; glycopyrrolate, hydromorphone (pain), prn. The plan of care did not include saline to flush the intravenous line between medications. Clinical Record 29: The patient was admitted to care on 10/07/2024 to the hospice IPU with a peripheral catheter. The patient received the following medications via the peripheral catheter: diphenhydramine (itching); methadone (pain); dexamethasone (pain); lorazepam (distress); and fentanyl PCA. The plan of care did not include the saline required to flush the peripheral catheter during medication administration. During a joint record review and interview, the clinical supervisors confirmed the plans of care did not include all of patient's medications.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions, such as: safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids; safe handling of soiled items in the patient’s care environment; and other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, interview and observation. In 1 of 9 (11%) observed home visits, it was revealed that the hospice did not follow accepted standards of practice to prevent the transmission of infections and communicable diseases. Home Visit 4 / Personnel Record 11: During the home visit on 10/8/2024 with the registered nurse, the RN measured the MAC (mid-arm circumference) with a retractable tape measure. After the measurement, the RN retracted the tape measure without cleaning it. After the patient assessment was completed, the RN cleaned all the equipment with a Sani-Wipe. The tape measure was extended, wiped with a Sani-Wipe and immediately retracted. The stethoscope was wiped with a Sani-Wipe and immediately placed in the nurses' bag. The blood pressure cuff and pulse oximeter were wiped with a Sani-Wipe, allowed to air and returned to the bag. The Sani-Wipe manufacturer label stated in part, "Contact Time: Use a second germicidal cloth to thoroughly wet the surface. Allow to remain wet for three (3) minutes, let air dry." There was no evidence the RN followed the manufacturer guidelines to "Allow to remain wet for three minutes, let air dry." During an interview with the clinical team, it was confirmed that the RN did not adhere to the manufacturer's recommended contact time.

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 21 (10%) clinical records reviewed for hospice aide services, it was revealed that the agency did not ensure the hospice aide provided services included in the plan of care. Clinical Record 2: The patient had a diagnosis of Parkinson's disease and resided in a skilled nursing facility. The start of care was 11/08/2023. The aide plan of care dated 03/30/2024 directed the aide to give a tub bath every visit. However, the clinical record revealed that the patient was receiving a bed bath every visit. During an interview, the Clinical Manager confirmed that the patient received a bed bath, not a tub bath. During the joint clinical record review and interview, the Clinical Manager confirmed that the aide did not provide services included in the plan of care. Clinical Record 20: The hospice aide assignment sheet was dated 07/17/2024, and included the following tasks: shower on Mondays; and a complete bed bath on Wednesdays and Fridays. The hospice aide visit dated 08/06/2024 (Tuesday), 08/08/2024 (Thursday), and 08/13/2024 (Tuesday) documented that a shower and a complete bed bath were provided. There was no evidence the hospice aide provided services as ordered in the plan of care. During a joint record review and interview, the Clinical Supervisor confirmed that services were not provided as assigned on the plan of care.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: assess the quality of care and services provided by the hospice aide; and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review and interview. In 3 of 21 (14%) clinical records reviewed of hospice aide services, the agency did not ensure the aide was supervised every 14 days. Clinical Record 12: The hospice aide started to provide care to the patient on 08/14/2024 and visited the patient two times a week. There was no documented aide supervision until 09/19/2024, which would be 35 days and two missed 14-day supervisions. Clinical Record 16: The hospice aide started to provide care to the patient on 08/16/2024 and visited the patient two times a week. There was no documented aide supervision as of the last registered nurse visit dated 10/01/2024, which would be 55 days and 3 missed 14-day supervisions. Clinical Record 27: The hospice aide started to provide care to the patient on 05/21/2024 and visited the patient two times a week. Aide supervision was documented on 07/30/2024 and 08/20/2024, which was 21 days. During a joint record review and interview, the Clinical Supervisor confirmed that aide supervision was not documented every 14 days as required.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed for patients admitted to a skilled facility, the agency did not ensure the plan of care identified which provider was responsible for performing the functions included in the plan of care. Clinical Record 22: The initial plan of care was documented on 08/27/2024 for a patient in a skilled facility with senile degeneration, hypertension, kidney failure with problems of pain, cardiovascular, nutrition and musculoskeletal interventions and goals. The initial and updated plans of care did not specify the functions/interventions for which the facility was responsible. During a joint record review and interview with the clinical team, it was confirmed that the plan of care did not include what functions/interventions the facility was responsible to complete.

The Condition of Participation requires that a hospice that provides inpatient care directly in its own facility is responsible to ensure the level of intensity of services needed to ensure that the patient's plan of care outcomes are achieved and negative outcomes avoided. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This Condition of Participation was not met as evidenced by observation, document review and interview, which revealed the hospice's inability to ensure the avoidance of negative outcomes for patients in the inpatient care facility. The hospice failed to maintain a safe physical environment free of hazards for patients, staff and visitors [L824/418.110(c)]. The hospice failed to address real or potential threats to the health and safety of the patients, others and property [L825/418.110(c)(1)]. The cumulative effect of this deficiency has resulted in the hospice's inability to ensure the provision of quality care for the Condition of Participation CFR 418.110, Hospices that provide inpatient care directly. The collective deficient practice illustrated a systemic process failure that had the potential to affect all patients receiving hospice inpatient care.

It is required that the inpatient hospice facility physical environment maintains a safe environment free of hazards and addresses real or potential threats to the health and safety of patients, hospice staff, visitors, others, and property. This standard was not met as evidenced by observation, document review and interview. Observation and document review revealed the inpatient hospice facility did not maintain a safe environment free of hazards and did not address real or potential threats to the health and safety of patients, staff, visitors and others. NFPA 101, 19.7.1.6 stated in part, "Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions." Observation 1: A review of the fire drill records for the inpatient unit (IPU) revealed the facility did not conduct Life Safety Code fire drills at the intervals specified in NFPA 101, 19.7.1.6. Two fire drills were conducted, one per each shift, in September of 2024. There was no documented evidence of fire drills conducted in the first two quarters of 2024, and in all of 2023 and 2022. There was no evidence the facility conducted quarterly drills to familiarize facility personnel with the signals and emergency action required under varied conditions. During an interview on 10/09/2024, the Regional Executive Director and Facilities Manager confirmed there was no documented evidence that the IPU conducted quarterly fire drills for each shift. The Facilities Manager stated that a fire drill process and schedule were implemented on 08/19/2024. CFR 418.110(i) stated in part, "The intent of this regulation is that the temperature of water at fixtures and in showers and tubs used by patients shall be automatically regulated by control valves and delivered for use at the appropriate temperature. There is a risk that patients or staff may be scalded by excessively hot water discharged by plumbing fixtures. Water that is too hot may scald individuals who are exposed to it. This danger is particularly significant for patients who may have circulatory or other neurological deficits that prevent the instantaneous recoil from water that is too hot...The recommended water temperatures at the plumbing fixtures should be maintained at or below 110 degrees." Observation of the inpatient unit (IPU) on 10/09/2024 revealed that the agency did not regulate the temperature of the hot water used by patients. The water temperature was checked in the patient room farthest from the hot water source. The water temperature was 111.4 degrees Fahrenheit. This was 1.4 degrees above the recommended water temperature of 110 degrees Fahrenheit. There was no evidence the facility regulated the temperature of water at fixtures and in showers and tubs used by patients and delivered for use at the appropriate temperature. During an interview, the Facility Manager reported that the IPU required testing of the hot water every month. A review of the maintenance records revealed there was no documented evidence of monthly testing of hot water temperatures in the patient bathrooms prior to August of 2024. During an interview on 10/09/2024, the Facility Manager confirmed the elevated water temperature was 111.4 degrees Fahrenheit. The Facility Manager confirmed there was no documentation of hot water testing in the patient bathrooms prior to 08/19/2024, as required by organization policy. Observation 1: During observation of the Patient Nourishment Room on 10/09/2024, the following items were labeled as ready for patient use, however were expired: five (5) Hospitality Raisin Bran, 1 oz. containers, expired on 09/26/2024 (approximately 12 days); six (6) Hospitality Toasted Oats, 1 oz. containers expired on 08/14/2024 (approximately 55 days); one (1) Quaker Grits, quick 5-minute, 24 oz., expired on 08/13/2024 (approximately 56 days); one (1) Quaker Oats, quick 1-minute, 42 oz., expired 10/30/2020 (approximately 4 years); and 1 Fresh Finds Iodized Salt, 26 oz., expired 05/10/2020 (approximately 4 years). Additionally, several individual items were not labeled for individual use, not in the original containers, and expiration dates were not marked. There was no evidence the facility stored meals under sanitary conditions. During a joint observation and interview on 10/09/2024, the Regional Executive Director confirmed the food was expired and should not have been available for patient use. The cumulative effect of this deficiency has revealed that the hospice in-patient facility did not maintain a safe environment free of hazards and did not address real or potential threats to the health and safety of patients, hospice staff, visitors and others.

It is required that each patient in the hospice inpatient facility always has an adequate supply of hot water and has plumbing fixtures with control valves that automatically regulate the temperature of the hot water used by patients. This standard was not met as evidenced by observation, document review and interview. During observation of the inpatient unit (IPU) on 10/09/2024, it was revealed that the agency did not regulate the temperature of the hot water used by patients. 418.110(i) stated in part, "The intent of this regulation is that the temperature of water at fixtures and in showers and tubs used by patients shall be automatically regulated by control valves and delivered for use at the appropriate temperature. There is a risk that patients or staff may be scalded by excessively hot water discharged by plumbing fixtures. Water that is too hot may scald individuals who are exposed to it. This danger is particularly significant for patients who may have circulatory or other neurological deficits that prevent the instantaneous recoil from water that is too hot...The recommended water temperatures at the plumbing fixtures should be maintained at or below 110 degrees." Observation 1: During observation of the IPU, the water temperature was checked in the patient room farthest from the hot water source. The water temperature was 111.4 degrees Fahrenheit. This was 1.4 degrees above the recommended water temperature of 110 degrees Fahrenheit. A review of the maintenance records revealed there was no documented evidence of monthly testing of hot water temperatures in the patient bathrooms prior to August of 2024. During an interview, the Facility Manager reported that the IPU required testing of the hot water every month. During an interview on 10/09/2024, the Facility Manager confirmed the elevated water temperature was 111.4 degrees Fahrenheit. The Facility Manager confirmed there was no documentation of hot water testing in the patient bathrooms prior to 08/19/2024, as required by organization policy.

It is required that the hospice inpatient facility provides meals to each patient that are obtained, stored, prepared, distributed, and served under sanitary conditions. This standard was not met as evidenced by observation and interview. During observation, it was revealed that the hospice inpatient facility did not store meals under sanitary conditions. Observation 1: During a tour of the Patient Nourishment Room on 10/09/2024, the following items were labeled as ready for patient use, however were expired: five (5) Hospitality Raisin Bran, 1 oz. containers, expired on 09/26/2024 (approximately 12 days); six (6) Hospitality Toasted Oats, 1 oz. containers expired on 08/14/2024 (approximately 55 days); one (1) Quaker Grits, quick 5-minute, 24 oz., expired on 08/13/2024 (approximately 56 days); one (1) Quaker Oats, quick 1-minute, 42 oz., expired 10/30/2020 (approximately 4 years); and 1 Fresh Finds Iodized Salt, 26 oz., expired 05/10/2020 (approximately 4 years). Additionally, several individual items were not labeled for individual use, not in the original containers, and expiration dates were not marked. During a joint observation and interview on 10/09/2024, the Regional Executive Director confirmed the food was expired and should not have been available for patient use. During a tour of the agency's inpatient unit (IPU) on 10/09/2024, it was revealed that the agency did not ensure that all the food that was available for patient use was not expired.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: Prescription and over-the-counter (OTC) drugs; Supplements; Herbal remedies; and Other alternative treatments that could affect drug therapy. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by review of clinical records and policy review. In 3 of 20 (15%) records reviewed it was revealed that the drug profile did not contain all prescription and over the counter drugs; supplements, herbal remedies and other alternative treatments that could affect drug therapy. Agency Policy PC.M50 stated in part,"a medication profile is maintained for every patient and includes a listing of the current medication orders for each patient..." Record # 65549: The patient was admitted on 10/22/2021 with an order for Oxygen @ 3 liters per nasal cannula. Oxygen was not included on the drug profile as of the date of survey on 11/12/2021. Record # 65577: The patient was admitted on 10/20/2021 with an order for Oxygen @2 liters per nasal cannula. Oxygen was not included on the drug profile as of the date of survey on 11/12/2021. Record # 65439: The patient was admitted on 10/19/2021 with an order for Oxygen @ 2 liters per nasal cannula. Oxygen was not included on the drug profile as of the date of survey on 11/12/2021. The above evidence was confirmed in discussion with the Director of Compliance during record review.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by review of clinical records and discussion with the Compliance Director and the Regional Executive Director. In 3 of 20 (15%) clinical records reviewed it was revealed the records did not include an initial bereavement assessment. Record #52362: The patient was admitted on 10/15/2021. No bereavement assessment was done by the nurse, social worker or chaplain from time of admit through the date of survey . Record #56450: The patient was admitted on 10/23/2021. No bereavement assessment was done by the nurse, social worker or chaplain from time of admit through the date of survey. Record # 36746: The patient was admitted on 10/23/2021. No bereavement assessment was done by the nurse, social worker or chaplain from time of admit through the date of survey. The above evidence was reviewed and confirmed by the Compliance Director at the time of the record review.

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by review of clinical records. In 3 of 20 (15%) clinical records reviewed it was revealed the skilled nurse did not follow the visit frequency ordered on the plan of care. Record #65032: The patient was admitted on 10/13/2021 and the skilled nurse was ordered to visit 1x/week. There was a missed nursing visit the week of 10/24/2021. No documentation was found to support the missed visit. Record #836697: The patient was admitted on 2/2/2020. The skilled nurse frequency order on the recertification dated 9/24/2021 was skilled nurse to visit 1x/week. There was a missed visit on 10/13/2021. No documentation was found to support the missed visit. Record #36746: The patient was admitted on 10/23/2021. Upon admission the order for skilled nurse visits was 2x/week then changed to 3x/week on 10/31/2021. The nurse only visited 2 times the week of 10/31/2021 missing a visit on 11/5/2021. No documentation was found to support the missed visit. The above evidence was confirmed with the Compliance Director during the record review.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient's attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient's record includes, at a minimum: physician orders. This standard was not met as evidenced by review of clinical records and interview. In 2 of 20 (10%) clinical records reviewed it was revealed the records did not include all physician orders required for the care of the patient. Record #30716: The patient was admitted on 10/22/2021 with a diagnosis of senile degeneration of the brain. SN visit note dated 10/25/2021, the nurse documented that the patient has diminished breath sounds and was being treated with Oxygen @2liters. There was no order found in the clinical record for Oxygen. Record # 72072: The patient was admitted on 10/19/2021 with a diagnosis of Cancer of the Lung. The plan of care dated 10/19/2021 stated the patient is on Oxygen but it did not include the liters per minute or whether it is prn or continuous in duration. The above evidence was discussed and confirmed with the Director of Compliance during the clinical record review.