Every finding on record at Caring Hands Hospice Corporation

Upon patient record review, 3 of 14 (Patient #4, 7, 11) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #4: Medication profile 2/14/23: Acetaminophen 325 mg po 2 tabs po q 6 hrs prn, Tramadol 50 mg 1/2 tab q 12 hours po prn, Miralax 12gm po daily as need. No prn indication listed Patient #7:Medication profile 4/17/23: Acetaminophen 325 mg po 2 tabs po q 6 hrs prn,No prn indication listed Patient #11: Medication profile 11/7/22: Oxygen 2L via NC prn, No prn indication listed

Upon patient record review, 6 of 14 (Patient #1,2,5,6,7,8) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient#1: POC dated 5/8/23: Acetaminophen 325 mg 2 tabs q 6 hours prn. No prn indication listed Patient #2: POC dated 2/15/23: Acetaminophen 325 mg 2 tabs q 6 hours prn. O2 2Lpm via NC as needed. No prn indication listed Patient #5: POC dated 3/13/23: Acetaminophen 325 mg 2 tabs q 6 hours prn. No prn indication listed Patient #6: POC dated 4/7/23: Acetaminophen 325 mg 2 tabs q 6 hours prn. Biscodyl 10 mg sup daily prn. No prn indication listed Patient #7: POC dated 4/17/23: Acetaminophen 325 mg 2 tabs q 6 hours prn. No prn indication listed Patient #8: POC dated 4/18/23: Alprazolam 0.5 mg po 2 x days prn. No prn indication listed

Upon patient record review 1 of 14 (Patient #9) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #9: Aide care plan dated 11/30/22 assigns grocery shopping weekly. Grocery shopping documented as performed 11/28/22, 11/30, 12/2 and 12/3.

Based on medical record review, staff interview, family interview, and review of facility documentation, it was determined the facility failed to ensure all elements of its emergency preparedness program, is complete. --- Findings include: 1. The facility failed to ensure that a call down list of patients is maintained for contact in the event of an emergency. (Cross refer to Tag E0016) 2. The facility failed to ensure that emergency preparedness assessment plans are conducted, prepared, discussed with the patient and family, and documented. (Cross refer to Tag E0019) 3. The facility failed to ensure that policies and procedures to collaborate with emergency preparedness officials of all homebound patients are developed and implemented. (Cross Refer to Tag E0019)

Based on staff interview and review of facility documentation, it was determined that the facility failed to ensure that a call down list of patients is maintained for contact in the event of an emergency. --- Findings include: Facility policy titled, "Disaster Plan" (last reviewed 4/4/23) states, " ... Procedure: 1. The agency is responsible for establishing a functional disaster committee ... 4. The committee is charged with developing a responsive call down list for identified emergencies. ...6. The Agency will mobilize nurses and aides to assist in making calls (via the call down list) and visiting patients as needed. ... 9. The call down list will contain, at a minimum: a) Patient name, address, and telephone number. b) Patient classification level. c) Identification of patient dependent on electricity to sustain life. d) Emergency contact telephone numbers of family/caregivers. e) Other specific information that may be critical to first responders. ..." On 05/02/23 at 1:20 PM, an interview with Staff #2 (Administrative Director) revealed that he/she was the Director and Incident Commander in the event of an emergency. Upon request for the facility's call down list of patient names, addresses, phone numbers, classification level, identification of dependence on electricity, emergency contact of care givers, and critical first provider information, Staff #2 stated, "I keep all the intakes and I call them." On 05/03/23 at 2:25 PM, a request was made to view the intakes Staff #2 would utilize in the event of an emergency. Staff #2 stated that he/she "has to go into each patient's medical record on the computer and find their information on the intake." Staff #2 confirmed that he/she did not maintain a call down list.

Based on review of four of four medical records (#1, #3, #5, #11), staff interview, family interview, and review of facility documentation, it was determined the facility failed to ensure that: 1) emergency preparedness assessment plans are conducted, prepared, discussed with the patient and family, and documented; 2) policies and procedures to collaborate with emergency preparedness officials of all homebound patients are developed and implemented. --- On 5/3/23, during medical record review of the Initial Comprehensive Nursing Assessments, completed by the admitting nurse it was revealed that for two of four patient charts reviewed (#2 and #6), the admitting nurse did not select the check box under "Patient/Caregiver Teaching" to indicate that the "Emergency plan and escape route" were discussed with the patient and family/caregiver. Findings include: 1) Facility document titled, "Emergency Preparedness Plan" (undated) states, " ... Patient Care and Planning; On admission, the admitting nurse will assign each patient a priority code dictating that patient's emergency rating. The admitting nurse will obtain a list of contact numbers and discuss emergency planning options with the patient and family. All information will be kept in the patient's chart and shall be kept in paper as well as electronic format." On 5/2/23 at 12:31 PM, a review of Patient (P)1's medical record was conducted. There was no documentation found in the medical record of emergency planning options that were discussed with the patient and family. At 1:20 PM, during an interview, Staff (S)4, the admitting nurse and the Director of Nursing (DON), stated that for emergency preparedness, upon admission, he/she assigns the patients an acuity level to be used to triage patients in the event of an emergency. S4 confirmed that he/she does not document in the patients' charts that emergency planning options are discussed with the patient and family. At 3:41 PM, during a home visit of P3, S4 stated that the patient's son lives upstairs above the patient's home. A request was made for the folder provided to the family by the agency upon admission. The documented emergency preparedness packet included in the folder did not include a patient specific plan in the event of an emergency evacuation. During an interview, the patient's son stated that he "doesn't remember" an emergency plan being discussed by the hospice staff. On 5/3/23, during medical record review, Initial Comprehensive Nursing Assessments, completed upon admission by the admitting nurse, were reviewed. For four of four patient charts reviewed (#1, #3, #5, #11), S4, the admitting nurse, did not select the check box "Patient/Caregiver Teaching" to indicate that an "Emergency plan and escape route" were discussed. The above findings were confirmed with S1 and S2 on 5/4/23 during exit conference. 2) On 5/3/23 at 9:49 AM, during review of the medical records for P1, P2, P3, and P5, home location counties for the following patients were documented as listed below: P1 - Middlesex County, 56 miles from the agency P3 - Union County, 72 miles from the agency P5 - Essex County, 77 miles from the agency P11 - Bergan County, 96 miles from the agency At 10:40 AM, a review of the facility's Emergency Preparedness Plan was conducted with S2, (Administrative Director, Incident Commander.) The "Emergency Contact" list included names and telephone numbers for the following: Fire, EMS (Emergency Medical Services), Emergency Office, Hazmat, Department of Health, [named] hospital, and the County Highway Department. S2 confirmed that the telephone numbers were for the agency's county. Upon request, S2 was unable to provide a policy or procedure for collaboration with emergency preparedness officials in the patient's home counties if they were in need of evacuation from their residences due to an emergency situation, or for the reporting of patients who cannot be reached during an emergency situation living in other counties. The above findings were confirmed with S1 and S2 on 5/4/23 during exit conference.

Based on medical record review, staff interviews, and review of facility policies and procedures, it was determined the facility failed to ensure that comprehensive patient assessments are conducted to identify patient and caregiver's psychosocial, emotional, and spiritual care needs. --- Findings include: 1. The facility failed to ensure that social services assessment visits are completed within five days of admission, as indicated in facility policy. (Cross refer to Tag L0523) 2. The facility failed to ensure that spiritual counseling assessment visits are completed within five days of admission, as indicated in facility policy. (Cross refer to Tag L0523) 3. The facility failed to ensure that comprehensive assessments are complete and thorough and identify patient's emotional and spiritual needs. (Cross refer to Tag L0524)

Based on observation, review of seven of ten medical records (#2, #4, #6, #7, #8, #9, #10), staff interviews, and review of facility documents, it was determined the facility failed to ensure that: 1) social services assessment visits are completed within five days of admission, as indicated in facility policy; 2) spiritual counseling assessment visits are completed within five days of admission, as indicated in facility policy. --- Findings include: 2) Reference #1: Facility policy titled, "Assessment - Initial and Comprehensive" (last revised 04/04/23) states, " ... The Registered Nurse will gather patient information during the initial assessment, which identifies the reason for admission to the hospice. Spiritual Care and Social Work Services will be offered at admission. When accepted by the patient and ordered in the initial plan of care these services will contact the patient and arrange for their evaluation visit/assessments within 5 days." Reference #2: Facility policy titled, "Coordination of Services - Spiritual Counseling" (last revised 04/04/23) states, "Policy: The hospice will provide an assessment of the patient's and family's spiritual needs. ... Spiritual Care - Chaplain services by a qualified chaplain are provided in accordance with the patients' plan of care. Assessments will be completed within 5 days of patients' admission. ... Procedure: 1. The duties of the chaplain include the following: ... b) Participating in the development of the patient plan of care. c) Administer the spiritual assessment and development of the spiritual plan of care. ... ." Review of Patient #7 (P7)'s medical record on 05/03/23 revealed the patient was admitted to the hospice service on 10/14/22. There was no evidence of a spiritual care assessment completed by the chaplain within five days of the patient's admission. Review of Patient #8 (P8)'s medical record on 05/03/23 revealed the patient was admitted to the hospice service on 07/19/22. There was no evidence of a spiritual care assessment completed by the chaplain within five days of the patient's admission. Review of Patient #9 (P9)'s medical record on 05/03/23 revealed the patient was admitted to the hospice service on 11/15/22. There was no evidence of a spiritual care assessment completed by the chaplain within five days of the patient's admission. During a telephone interview on 05/03/23 at 10:58 AM, Staff #7 (Chaplain) stated, "When a patient comes on service, I make a call to them to set up an appointment for me to come out and do the initial assessment. I go in person to do the initial assessment. I try to go as soon as I can. I try to get out there within the week. It really depends because you know we all have other jobs. But I try to do the initial assessment and go out within seven days. I really just go to listen and see what their needs are. I offer prayer or support." Staff #7 was asked if the nurse completes the patient's spiritual assessment during the nurse's initial assessment. Staff #7 stated, "The nurses do their own assessment. I go out and speak to my patient and do the spiritual assessment." Staff #7 stated that the expectation is that he/she would complete a spiritual assessment for all patients, even if the nurse asks about the patient and family's spiritual needs during the nurse's initial assessment. Staff #7 was asked why he/she did not complete a spiritual assessment for P7, P8, and P9. Staff #7 stated, "I've been gone for a few years. I just started back in April. I was not the Chaplain at the time." Findings include: 1) Reference: Facility policy titled, "Coordination of Services - Medical Social Worker" (last revised 04/04/23) states, "... The social services assessment visit shall be completed within 5 days of admission or sooner if indicated. ... ." Review of Patient #2 (P2)'s medical record on 05/03/23 revealed the patient was admitted to hospice service on 04/07/23. During the review, it was revealed that the medical social worker assessment visit was not conducted until 05/02/23, 25 days after the patient was admitted to the hospice service. Review of Patient #4 (P4)'s medical record on 05/03/23 was conducted for the recertification period starting 03/10/23. There was no evidence of a medical social worker assessment visit conducted within five days of the patient's admission. Review of Patient #6 (P6)'s medical record on 05/04/23 was conducted for the re-admission period starting 02/15/23. There was no evidence of a medical social worker assessment visit conducted within five days of the patient's admission. Review of Patient #7 (P7)'s medical record on 05/03/23 revealed the patient was admitted to hospice service on 10/14/22. There was no evidence of a medical social worker assessment visit conducted within five days of the patient's admission. Review of Patient #8 (P8)'s medical record on 05/04/23 revealed the patient was admitted to hospice service on 07/19/22. There was no evidence of a medical social worker assessment visit conducted within five days of the patient's admission. Review of Patient #9 (P9)'s medical record on 05/04/23 revealed the patient was admitted to hospice service on 11/15/22. There was no evidence of a medical social worker assessment visit conducted within five days of the patient's admission. Review of Patient #10 (P10)'s medical record on 05/04/23 revealed the patient was admitted to hospice service on 04/18/23. There was no evidence of a medical social worker assessment visit conducted within five days of the patient's admission. Upon interview, Staff #2 (S2) stated that the social worker will call to schedule a visit and that the family/caregivers are refusing the visit. There was no evidence that comprehensive social services assessment visits were completed to identify patient/caregiver needs, prior to accepting the patient or caregivers' refusal of the service. The above findings were confirmed with S1 and S2 during the exit conference.

Based on review of three of three medical records, staff interviews, and review of facility policies and procedures, it was determined the facility failed to ensure that comprehensive assessments are complete and thorough, and identify patient's emotional and spiritual needs. --- Review of Patient #7 (P7)'s medical record on 05/03/23 revealed the patient was admitted to hospice service on 10/14/22. P7's initial comprehensive nursing assessment completed by Staff #4 (Director of Nursing) on 10/14/22, included a form labeled "Psychosocial/Spiritual Assessment." Review of the "Psychosocial/Spiritual Assessment" form indicated the following: In the section labeled "Psychosocial Assessment," the question "Does caregiver seem overwhelmed at the responsibility of caring for patient?" was marked "Yes." There was no additional information provided to indicate what assistance the caregiver required or what assistance the hospice planned to provide for the caregiver. There was no evidence that the Medical Social Worker conducted a social services visit to assess the needs of the caregiver. The question "Support Systems" which assesses the patient and caregiver's support system, was left blank. The question "Does the patient have spiritual support?" was left blank. The question "Does the caregiver/family have spiritual support?" was left blank. The question "Spiritual Affiliation?" and "Name of Church" was left blank. The name and phone number of the patient or caregiver's Spiritual Representative was left blank. The nurse's initial comprehensive assessment did not completely assess the patient's psychosocial status or spiritual needs. There was no evidence in the medical record that the Social Worker or Chaplain completed comprehensive assessments to identify patient and caregiver psychosocial or spiritual needs. Review of Patient #8 (P8)'s medical record on 05/04/23 revealed the patient was admitted to hospice service on 07/19/22. P8's initial comprehensive nursing assessment completed by Staff #4 on 07/19/22, included a form labeled "Psychosocial/Spiritual Assessment." Review of the "Psychosocial/Spiritual Assessment" form indicated the following: The question "Does the patient have spiritual support?" was left blank. The question "Does the caregiver/family have spiritual support?" was answered "No." The name and phone number of the patient or caregiver's Spiritual Representative was left blank. There was no evidence in the medical record that the Chaplain completed a comprehensive assessment to identify patient and caregiver spiritual needs. Review of Patient #9 (P9)'s medical record on 05/04/23 revealed the patient was admitted to hospice service on 11/15/22. P9's initial comprehensive nursing assessment completed by Staff #4 on 11/15/22, included a form labeled "Psychosocial/Spiritual Assessment." Review of the "Psychosocial/Spiritual Assessment" form indicated the following: In the section labeled "Psychosocial Assessment," the question "Is patient able to care for self? If not, why?" was left blank. The question, "Is caregiver able and willing to care for patient?" was answered "No." The question "Does caregiver seem overwhelmed at responsibility of caring for patient?" was answered "Yes." There was no evidence that the Social Worker conducted a social services visit to obtain additional information and to assess the needs of the patient and caregiver. The question "Support Systems" which assesses the patient and caregiver's support system, was left blank. The question "Does the patient have spiritual support?" was left blank. The question "Does the caregiver/family have spiritual support?" was left blank. The question "Spiritual Affiliation?" and "Name of Church" was left blank. The name and phone number of the patient or caregiver's Spiritual Representative was left blank. The nurse's initial comprehensive assessment did not completely assess the patient's psychosocial status or spiritual needs. There was no evidence in the medical record that the Social Worker or Chaplain completed comprehensive assessments to identify patient and caregiver psychosocial or spiritual needs. Upon interview on 05/04/23 at 10:00 AM, Staff #2 (Administrative Director) stated the Social Worker and Chaplain have five days to complete their initial assessments, which include assessments of the patient and caregiver's psychosocial and spiritual needs. Staff #2 confirmed that the psychosocial and spiritual assessments performed by Staff #4 for P7, P8, and P9 were incomplete. Staff #2 confirmed that the Social Worker did not complete a psychosocial assessment and the Chaplain did not complete a spiritual assessment for P7, P8, and P9. A review of Patient #2 (P2)'s medical record on 05/03/23 revealed the patient was admitted to hospice service on 4/7/23. P2's initial comprehensive nursing assessment completed by S4 on 4/7/23, included a form labeled "Psychosocial/Spiritual Assessment." A review of the "Psychosocial/Spiritual Assessment" form indicated the following: On the "Psychosocial/Spiritual Assessment" form completed by S4 (DON) dated 4/7/23, the following question under Psychosocial Assessment was left blank: Has the patient accepted diagnosis/prognosis? Does patient demonstrate effective coping? Is patient able to care for self? Is caregiver able and willing to care for patient? Does caregiver seem overwhelmed at responsibility of caring for patient? Does the caregiver seem overwhelmed at the responsibility of caring for patient? Has caregiver accepted diagnosis/prognosis? Does caregiver demonstrate effective coping? Needs identified: [blank]. The question "Patient has issued Advance Directive in form of: Living Will or Medical POA (power of attorney)" was left blank. The question "Patient/Caregiver wishes to discuss Advance Directives with a member of the Hospice Team" was left blank. The question "PCG understands patient's wishes" was left blank. On the "Psychosocial/Spiritual Assessment Patient/Caregiver Information" form completed by S4 dated 4/7/23, the following assessment areas were left blank: Caregiver capable of giving medications and participating in plan of care; Person responsible for patient's emergency plan; Support systems; Does the patient have spiritual support; Spiritual Affiliation; Spiritual Representative; The patient/family would desire: Hospice Chaplain to contact patient, Hospice Chaplain to contact family/caregiver, Hospice Chaplain to contact spiritual representative, No contact at this time. The nurse's initial comprehensive assessment did not completely assess the patient's psychosocial status or spiritual needs. There was no evidence in the medical record that the Social Worker or Chaplain completed comprehensive assessments to identify patient and caregiver psychosocial or spiritual needs. A review of P6's medical record on 05/03/23 revealed the patient was admitted to hospice service on 11/11/22. The certification period 2/15-5/15/23 was reviewed. P6's initial comprehensive nursing assessment completed by S4 on 2/15/23, included a form labeled "Psychosocial/Spiritual Assessment." A review of the "Psychosocial/Spiritual Assessment" form indicated the following: In the section labeled, "Advanced Directives," the statement "Patient expresses wish for No Resuscitation" answer "Yes." The statement, "Patient has issued Advanced Directive in form of: Living Will or Medical POA (Power of Attorney)" was left blank. The statement, "patient/Caregiver wishes to discuss Advance Directives with a member of the Hospice Team" was left blank. The question, "Funeral Arrangements made?" was left blank. the statement, "PCG understands patient's wishes" was left blank.. On the "Psychosocial/Spiritual Assessment Patient/Caregiver Information" form, the following assessment areas were left blank: Caregiver capable of giving medications and participating in plan of care; Person responsible for patient's emergency plan; Support systems; Does the patient have spiritual support; Spiritual Affiliation; Spiritual Representative. The nurse's initial comprehensive assessment did not completely assess the patient's psychosocial status or spiritual needs. There was no evidence in the medical record that the Social Worker or Chaplain completed comprehensive assessments to identify patient and caregiver psychosocial or spiritual needs. A review of P10's medical record on 5/4/23 revealed that the patient was admitted to hospice service on 4/18/23. P10's initial comprehensive nursing assessment completed by S4 on 4/18/23, included a form labeled "Psychosocial/Spiritual Assessment." A review of the "Psychosocial/Spiritual Assessment" form indicated the following: On the "Psychosocial/Spiritual Assessment" form completed by S4 dated 4/18/23, the question "Does the caregiver seem overwhelmed at the responsibility of caring for patient?" was answered "Yes." On the "Psychosocial/Spiritual Assessment Patient/Caregiver Information" form, the following assessment areas were left blank: Caregiver capable of giving medications and participating in plan of care; Person responsible for patient's emergency plan; Support systems; Does the patient have spiritual support; Spiritual Affiliation; Spiritual Representative. The nurse's initial comprehensive assessment did not completely assess the patient's psychosocial status or spiritual needs. There was no evidence in the medical record that the Social Worker or Chaplain completed comprehensive assessments to identify patient and caregiver psychosocial or spiritual needs. Findings include: Reference: Facility policy titled, "Assessment - Initial and Comprehensive" (last revised 04/04/23) states, " ... 3. The comprehensive assessment will identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that will be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. The comprehensive assessment will take into consideration the following factors: ... g) Bereavement: 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. ... i) Additional items will include as appropriate: ... 6. Patient and family spiritual orientation, including their desire for the involvement of a religious group. 7. Spiritual concerns or needs identified by the patient or family, such as despair, suffering, guilt, and forgiveness. 8. Patient and family involvement in a support group, if any. 9. Additionally information about the patient's psychosocial status, such as family relationships, social history, the source and adequacy of environmental and other resources, coping mechanisms, and the patient's and family's reactions to illness. ... ." On 5/4/23, during medical record review, the following was revealed: Patient (P)1's start of care date was 4/17/23. On 4/17/23, a "Psychosocial/Spiritual Assessment" document was completed for by Staff (S)4 (DON). The document was not completed in the areas for Psychosocial Assessment, Pre-Bereavement Interventions, Risk Assessment for Survivors, assessment of Support Systems, Spiritual Support (for patient and caregiver), Spiritual Affiliation, Spiritual Representative, if the patient would desire a hospice chaplain to contact the patient, family/caregiver, or spiritual representative. On 4/18/23, a Hospice Clinical Note was documented by a staff member with an illegible signature. The staff member signed a typewritten note stating "Patient/PCG [patient caregiver] declined SW [social work] visit at this time. Social Worker will follow up and Continue [sic] to offer social work services, as appropriate." There was no documentation included of a psychosocial assessment of the patient or caregiver. On 4/18/23, a Hospice Clinical Note was documented by S7 (Chaplain). S7 signed a typewritten note stating "Patient decline [sic] chaplain visit at this time will continue to offer." There was no documentation included of any assessment of the patient or caregiver's spiritual needs. P11's start of care date for his/her initial benefit period was 1/14/23. On 1/14/23, a "Psychosocial/Spiritual Assessment" document was completed for by Staff (S)4 (DON). The document was not completed in the area for Risk Assessment for Survivors, Support Systems, Spiritual Support (for patient and caregiver), Spiritual Affiliation, or Spiritual Representative. S4 documented that no contact was desired by a hospice chaplain, without completion of the assessment. On 1/16/23, a Hospice Clinical Note was documented by a staff member with an illegible signature. The staff member signed a typewritten note stating "Patient/PCG [patient caregiver] declined SW [social work] visit at this time. Social Worker will follow up and Continue [sic] to offer social work services, as appropriate." There was no documentation included of a psychosocial assessment of the patient or caregiver. On 1/17/23, a Hospice Clinical Note was documented (signature illegible). The staff member signed a typewritten note stating "Patient decline [sic] chaplain visit at this time will continue to offer." There was no documentation included of any assessment of the patient or caregiver's spiritual needs. The above findings were confirmed at exit by S1 and S2.

Based on medical record review, staff interviews, and review of facility policies and procedures, it was determined the facility failed to ensure that the interdisciplinary group provides care planning and the coordination of hospice services that meet the needs of patients and families. --- Findings include: 1. The facility failed to ensure that interdisciplinary group members provide volunteer, social work, and chaplain services, in accordance with facility policy. (Cross refer to Tag L0539) 2. The facility failed to ensure that home health aide services ordered in the patient's plan of care, are provided. (Cross refer to Tag L0543) 3. The facility failed to ensure that an individualized written plan of care is developed for each patient. (Cross refer to Tag L0545) 4. The facility failed to ensure that communication with members of the interdisciplinary group was maintained in accordance with the plan of care. (Cross refer to Tag L0554) 5. The facility failed to ensure that the need for social work services are based on a social services visit assessment completed within five days of admission. (Cross refer to Tag L0556) 6. The facility failed to ensure that the need for spiritual services are based on a spiritual care assessment completed within five days of admission. (Cross refer to Tag L0556) 7. The facility failed to ensure that nurses communicate ineffective pain management with physicians to ensure the patient's pain is properly managed. (Cross refer to Tag L0557)

Based on observation, staff interviews, review of three of ten medical records (#7, #8, #9), and review of facility policy and procedure, it was determined the facility failed to ensure that interdisciplinary group members provide volunteer, social work, and chaplain services, in accordance with facility policy. --- Findings include: Reference #1: Facility policy titled, "Interdisciplinary (IDT) Team Services" (last reviewed 04/04/23) states, " ... The hospice interdisciplinary team/group or groups, in consultation with the patient's attending physician and the patient/family, will prepare a written plan of care for each patient. The plan of care will specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions. ... 4. Volunteers are part of the interdisciplinary team ... 11. Interdisciplinary Team (IDT) Meeting ... b. It is the expectation that all members of the interdisciplinary team will be present. ... c. The IDT meeting will include: ... 4. Determining level of services required by the patient/family based on Hospice Team assessments." Reference #2: Facility policy titled, "Interdisciplinary (IDT) Conferences" (last reviewed 04/04/23) states, " ... 3. Each staff member will be responsible for discussing appropriate issues/concerns with other disciplines involved in the patient's care and planning for future care and services, including: patient progress, patient education, care/treatment changes, scheduling needs." Reference #3: Facility policy titled, "Coordination of Services - Volunteer Coordinator" (last reviewed 04/04/23) states, " ... 6. Supervision activities will include: ... c) Observations of communications and involvement with the interdisciplinary team ... ." Observation of an IDT meeting on 05/02/23 at 1:36 PM revealed the following: Staff #2 (Administrative Director), Staff #4 (Director of Nursing [DON]), Staff #5 (Social Worker), and Staff #9 (Medical Director) were present during the IDT meeting. Staff #9 joined the meeting via telephone. Staff #1 (Volunteer Coordinator) and Staff #7 (Chaplain) were not present. During the IDT meeting, Patient #1 (P1), Patient #2 (P2), Patient #3 (P3), Patient #4 (P4), Patient #5 (P5), Patient #6 (P6), and Patient #10 (P10) were discussed. During the discussion of (P1), Staff #4 stated, "[P1] has a history of Alzheimer's disease and depression. [He/She] has had decreased mobility and was positive for falls. I reinforced with the family that if [P1] falls to call us." There was no further discussion regarding the patient's potential for falls. There was no discussion regarding falls prevention activities or education for the family. There was no discussion of the patient's need for a physical therapy referral. During a discussion of Patient #2 (P2), Staff #5 stated, "There have been recent deaths in the family. The son is going to need support. He seems sad." There were no further discussions during the IDT of how the facility planned to support the family and ensure their needs were met. During a discussion of Patient #5 (P5), Staff #4 stated, "[P5] has a problem with [his/her] eye. It got better, but I feel its an ongoing problem. [He/She] also has shoulder pain and warm compresses work. There is Tramadol ordered, but the patient tries to avoid pain meds. There's an increase in naps. There's a small wound." There was no further discussion regarding the patient's problem with his/her eye. Staff #9 (Medical Director) did not offer any insight or possible treatments or therapies for the patient's eye problem. There was no further discussion regarding the patient's avoidance of pain medications. Staff #4 did not indicate the location of the patient's wound, the size of the wound, whether the patient was being treated for his/her wound, and if so, if treatments were effective. There was no discussion about the need for volunteer services for P1, P2, P3, P4, P5, P6, or P10. Upon interview on 1:58 PM, Staff #1 was asked why as the Volunteer Coordinator, he/she did not join the IDT meeting. Staff #1 stated, "I usually do, but you guys were asking me to make copies." There was no evidence on the IDT meetings for P7, P8, and P9 that Staff #1 attended any of the IDT meetings. Upon interview on 05/04/23 at 10:03 AM, Staff #2 stated, "It's not required for the Volunteer Coordinator to be present at the IDT meeting." The facility failed to ensure that interdisciplinary group members collaborate and ensure the needs of the patients and families are met.

Based on review of one of three medical records (#8), staff interviews, and review of facility policy and procedure, it was determined the facility failed to ensure that home health aide services ordered in the patient's plan of care, are provided. --- Findings include: Reference: Facility policy titled, "Plan of Care" (last reviewed 04/04/23) states, "It is the policy of Hospice that a written individualized interdisciplinary team care plan be established and maintained for each individual admitted to hospice and the care provided to the individual will be in accordance with the care plan." Review of P8's medical record on 05/04/23 revealed the following: P8 was admitted to hospice service on 07/19/22 and expired on 08/22/22. On the "Initial Plan of Care/Physician Order" form dated 07/19/22, the anticipated frequency of home health aide (HHA) services states, "3-5 d/w (3 to 5 days per week)." There was no evidence in the medical record that the patient received any HHA visits from 07/19/22 to 08/22/22. Staff #1 (Executive Director) and Staff #2 (Administrative Director) confirmed the above finding during the exit conference.

Based on review of three of ten medical records (#7, #8, #9), staff interview, and review of facility policy and procedure, it was determined the facility failed to ensure that an individualized written plan of care is developed for each patient. --- Findings include: Reference: Facility policy titled, "Plan of Care" states, "It is the policy of Hospice that a written individualized interdisciplinary team care plan be established and maintained for each individual admitted to hospice ... ." Review of the medical records for P7, P8, and P9 on 05/04/23 revealed the following: On the "Initial Plan of Care/Physician Order" form, in the section labeled "Anticipated Frequency," the frequency of nursing visits were preprinted and states, "1-2 X WK [one to two times per week] + [plus] 3 PRN [as needed] for symptom management." The frequency of nursing visits for P7, P8, and P9 were the same and were not individualized and ordered based on the patient's needs. Staff #2 (Administrative Director) confirmed the above finding on 05/04/23 at 3:00 PM.

Based on review of one of four medical records (#5) and staff interview, it was determined that the facility failed to ensure communication with the members of the interdisciplinary group was maintained in accordance with the plan of care. --- Findings include: On 05/04/23 at 10:05 AM, a review of Patient(P) 5's medical record revealed the following: On 02/14/23, an order for Social Work 1-2 times a month was documented on the "Initial Plan of Care/Physician's Order." On 02/15/23 and on 03/15/23, Staff(S) 5 (Social Worker) documented patient visits. On 04/14/23, Staff #5 (MSW) signed his/her name to a typewritten "Hospice Clinical Note," stating, "Patient/PCG [patient care giver] declined SW [social worker] visit at this time. Social Worker will follow up and continue to offer social work support service, as appropriate." On 05/04/23 at 10:29 AM, an interview with Staff #2 (Administrative Director) was conducted. Staff #2 stated that if a discipline was refused, it would be documented in the IDT (interdisciplinary team) meeting minutes. Review of the medical record revealed that the next IDT meeting after the refusal of social work services was four days later on 04/18/23. Documented in the "IDT/POC Update" meeting minutes, the social work area was left blank. Staff #2 confirmed that patient refusal of social work services would be documented in that area. Staff #2 stated that when social work is ordered, "we call and offer it once a month." There was no documentation in the social worker note of whether the refusal of services was for the month period or for a scheduled visit. There was no documentation found in the medical record that the refusal of social worker services was communicated to the interdisciplinary committee.

Based on review of seven of ten medical records (#2, #4, #6, #7, #8, #9, #10), staff interviews, and review of facility policies and procedures, it was determined the facility failed to ensure that: 1) the need for social work services are based on a social services visit assessment completed within five days of admission; 2) the need for spiritual services are based on a spiritual care assessment completed within five days of admission. --- Findings include: 1) Reference: Facility policy titled, "Coordination of Services - Medical Social Worker" (last reviewed 04/04/23) states, "... The social services assessment visit shall be completed within 5 days of admission or sooner if indicated. ... ." Reference: Facility policy titled, "Assessment - Initial and Comprehensive" (last reviewed 04/04/23) states, " ... The Registered Nurse will gather patient information during the initial assessment, which identifies the reason for admission to the hospice. Spiritual Care and Social Work Services will be offered at admission. When accepted by the patient and ordered in the initial plan of care these services will contact the patient and arrange for their evaluation visit/assessments within 5 days." Review of Patient #2 (P2)'s medical record on 05/03/23 revealed the patient was admitted to hospice service on 04/07/23. During the review, it was revealed that the medical social worker assessment visit was not conducted until 05/02/23, 25 days after the patient was admitted to the hospice service. Review of Patient #4 (P4)'s medical record on 05/03/23 was conducted for the recertification period starting 03/10/23. There was no evidence of a medical social worker assessment visit conducted within five days of the patient's admission. Review of Patient #6 (P6)'s medical record on 05/04/23 was conducted for the re-admission period starting 02/15/23. There was no evidence of a medical social worker assessment visit conducted within five days of the patient's admission. Review of Patient #7 (P7)'s medical record on 05/03/23 revealed the patient was admitted to hospice service on 10/14/22. There was no evidence of a medical social worker assessment visit conducted within five days of the patient's admission. Review of Patient #8 (P8)'s medical record on 05/04/23 revealed the patient was admitted to hospice service on 07/19/22. There was no evidence of a medical social worker assessment visit conducted within five days of the patient's admission. Review of Patient #9 (P9)'s medical record on 05/04/23 revealed the patient was admitted to hospice service on 11/15/22. There was no evidence of a medical social worker assessment visit conducted within five days of the patient's admission. Review of Patient #10 (P10)'s medical record on 05/04/23 revealed the patient was admitted to hospice service on 04/18/23. There was no evidence of a medical social worker assessment visit conducted within five days of the patient's admission. Upon interview, Staff #2 (Administrative Director) stated that the social worker will call to schedule a visit and that the family/caregivers are refusing the visit. There was no evidence that comprehensive social services assessment visits were completed to identify patient/caregiver needs, prior to accepting the patient or caregivers' refusal of the service. 2) Reference: Facility policy titled, "Coordination of Services - Spiritual Counseling" (last reviewed 04/04/23) states, "Policy: The hospice will provide an assessment of the patient's and family's spiritual needs. ... Spiritual Care - Chaplain services by a qualified chaplain are provided in accordance with the patients' plan of care. Assessments will be completed within 5 days of patients' admission. ... Procedure: 1. The duties of the chaplain include the following: ... b) Participating in the development of the patient plan of care. c) Administer the spiritual assessment and development of the spiritual plan of care. ... ." Review of Patient #7 (P7)'s medical record on 05/03/23 revealed the patient was admitted to the hospice service on 10/14/22. There was no evidence of a spiritual care assessment completed by the chaplain within five days of the patient's admission. Review of Patient #8 (P8)'s medical record on 05/03/23 revealed the patient was admitted to the hospice service on 07/19/22. There was no evidence of a spiritual care assessment completed by the chaplain within five days of the patient's admission. Review of Patient #9 (P9)'s medical record on 05/03/23 revealed the patient was admitted to the hospice service on 11/15/22. There was no evidence of a spiritual care assessment completed by the chaplain within five days of the patient's admission. Upon interview on 05/02/23 at 2:00 PM, Staff #2 stated that patients or family members "refuse" spiritual care services during the nurse's initial assessment, "so the Chaplain does not do a visit. The family refuses." During a telephone interview on 05/03/23 at 10:58 AM, Staff #7 (Chaplain) stated, "When a patient comes on service, I make a call to them to set up an appointment for me to come out and do the initial assessment. I go in person to do the initial assessment. I try to go as soon as I can. I try to get out there within the week. It really depends because you know we all have other jobs. But I try to do the initial assessment and go out within seven days. I really just go to listen and see what their needs are. I offer prayer or support." Staff #7 was asked if the nurse completes the patient's spiritual assessment during the nurse's initial assessment. Staff #7 stated, "The nurses do their own assessment. I go out and speak to my patient and do the spiritual assessment." Staff #7 stated that the expectation is that he/she would complete a spiritual assessment for all patients, even if the nurse asks about the patient and family's spiritual needs during the nurse's initial assessment. Staff #7 was asked why he/she did not complete a spiritual assessment for P7, P8, and P9. Staff #7 stated, "I've been gone for a few years. I just started back in April. I was not the Chaplain at the time." There was no evidence that spiritual care assessment visits were completed to identify patient and caregiver needs prior to accepting the patient or caregivers' refusal of the service. Staff #1 (Executive Director) and Staff #2 (Administrative Director) confirmed the above findings during the exit conference.

Based on review of one of three medical records (#7), staff interviews, and review of facility policies and procedures, it was determined the facility failed to ensure that nurses communicate ineffective pain management with physicians to ensure the patient's pain is properly managed. --- Findings include: Reference #1: Facility policy titled, "Coordination of Services - Nursing Services (last reviewed 04/04/23) states, " ... 3. Nursing services must ensure that the nursing needs of the patient are met as identified in the patient's initial assessment, comprehensive assessment, and updated assessments. ... o) Informs the attending physician, medical director and other personnel of changes in the patient's needs and outcomes of intervention. p) Makes referrals to other agencies or services, as needed. ... ." Reference #2: Facility policy titled, "Pain Management" (last reviewed 04/04/23) states, " ... 1. The skilled nurse will perform a pain assessment during each home visit. The pain assessment will be documented. ... 4. Pain assessment should include a thorough history of the pain and pain relief methods due to date. A pain scale will be utilized. ... 5. The skilled nurse will contact the attending physician and/or Medical Director/designee to report unresolved pain issues including a new site, increase in pain or other symptoms. ... 7. The IDT (interdisciplinary team) will discuss pain issues to determine other causal factors and possible non-pharmacologic treatment measures to employ. ... ." Review of P7's medical record on 05/03/23 revealed the following: P7 was admitted to the hospice service on 10/14/22. The "Initial Comprehensive Nursing Assessment" dated 10/14/22 states, "Client was d/c [discharged] from the hospital after recent fall resulted in pelvic fx [fracture]. ... c/o [complaining of] r [right] leg 8/10 pain [8 out of 10 on a numeric pain scale]. Dr. ___ [name of doctor] contacted Fentanyl patch ordered." A wound assessment conducted on 10/14/22 indicates the patient had a right heel Stage 2 pressure injury measuring "0.5 X 0.4." Physician orders dated 10/14/22 state, "Clean with NASL [normal saline] r heel apply Medihoney to heel daily as needed." Skilled nursing (SN) visits were ordered for the patient "1-2 x WK + 3PRN [one to two times per week plus 3 as needed visits] for symptom management." The patient expired on 11/04/22. A "Nurse Visit Note" dated 10/18/22 states, "Current pain (0-10): 3/10 ... Worst in last 24 hrs [hours]: 7/10 ... Location(s): bilateral shoulders, knees ... constant ... Routine Pain Med: Fentanyl patch 12 mcg [micrograms] q [every] 72 hrs ... Is pain management effective for pt [patient]: No." There was no evidence the nurse notified the physician that the patient's current pain management was ineffective. A "Nurse Visit Note" dated 10/19/22 states, "Current pain (0-10): 8/10 ... Worst in last 24 hrs: 10/10 ... Location(s): bilateral shoulders, knees, right leg ... constant ... Routine Pain Med: Fentanyl patch 12 mcg/hr q 72 hrs ... Is pain management effective for pt?: No." Nurse's note states, "Home PRN [as needed] visit made due to PCG [patient caregiver] ___ [name of caregiver] request due to client's right leg severe pain and rupture of right heel wound. ... R heel wound performed by this RN and educated and instructed on the wound care utilizing medihoney niece [name of niece] [sic]. Measures to prevent skin breakdown including heels protector are reinforced. ... ." There was no additional information provided. There was no evidence in the medical record the nurse notified the physician of the patient's severe pain. There was no evidence in the medical record the nurse notified the physician of the patient's ruptured right heel wound. A "Nurse Visit Note" dated 10/22/22 states, "Current Pain (0-10): 3/10 ... Worst in last 24 hrs: 8/10 ... Location(s): bilateral shoulders, knees, right leg ... constant ... Routine Pain Med: Fentany Patch 12 mcg/hr q 72 hrs. .... Is pain management effective for pt?: No." Nurse's note states, "R heel wound performed by this RN and educated and instructed on the wound care utilizing medihoney. ... ." There was no evidence the nurse notified the physician that the patient's current pain management was ineffective. Staff #1 (Executive Director) and Staff #2 (Administrative Director) confirmed the above finding on 05/04/23 at 3:00 PM.

Based on staff interview and review of facility documents, it was determined the facility failed to develop, implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment and performance improvement program. --- Findings include: 1. The facility failed to ensure that the Quality Assessment and Performance Improvement (QAPI) program shows measurable improvement in quality indicators. (Cross refer to Tag L0561) 2. The facility failed to ensure that its QAPI program measures, analyzes and tracks quality indicators, including adverse patient events. (Cross refer to Tag L0562) 3. The facility failed to ensure that the facility uses data collection to evaluate and improve the quality of hospice services. (Cross refer to Tag L0563) 4. The facility failed to ensure that the QAPI program includes performance improvement activities focused on high risk, high volume, or problem-prone areas. (Cross refer to Tag L0566) 5. The facility failed to ensure that performance improvement projects, are developed and implemented. (Cross refer to Tag L0571) 6. The Governing Body failed to implement and maintain a QAPI program designed for quality improvement and patient safety and failed to evaluate the QAPI program annually. (Cross refer to Tag L0574)

Based on staff interview and review of facility documents, it was determined the facility failed to ensure that the Quality Assessment and Performance Improvement (QAPI) program shows measurable improvement in quality indicators. --- Findings include: Reference: Facility policy titled, "Quality Assessment and Performance Improvement (last revised 04/04/23) states, " ... 2. The hospice will maintain documentary evidence of its quality assessment and performance improvement program and be able to demonstrate its operation to CMS and the accreditation agency. 3. The QAPI program will show measurable improvement in indicators related to improved palliative outcomes and hospice services. The Hospice will measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations." Upon interview on 05/04/23 at 10:05 AM, Staff #2 (Administrative Director) identified him/herself and Staff #4 (Director of Nursing) as the staff responsible for the facility's QAPI program. Staff #2 was asked to name the quality indicators the facility tracks and analyzes. Staff #2 stated, "We monitor pain on admission, infection, falls, GI (gastrointestinal) and UTIs (urinary tract infections), and staff submitting documentation on time." Staff #2 was asked to provide evidence of data used to measure improvement in quality indicators. No data was provided. Staff #2 was asked how often QAPI meetings were held. Staff #2 stated, "At least quarterly, we have Governing Body meetings where we review QAPI data that happened during the quarters. We discuss any problems that happened." A request was made to Staff #2 for QAPI meeting minutes for 2021, 2022, and 2023. QAPI meeting minutes dated 04/04/23 were provided. The "QAPI report for Patient Safety and Quality Indicators Outcome Report" for the 1st quarter 2023 indicated the following: -Percentage of social work assessments within 5 days of admission was 100% -Percentage of pastoral care assessments within 5 days of admission was 100% -Percentage of patients with completed fall risk assessments on admission was 100% -Number of patient falls was 0 -Number of patients with pain on admission was 0 -Handwashing observations were 100% There were no measurable goals indicated in the QAPI report as all quality indicators were at 100%. Staff #2 was asked to provide the data to support the information on the report. There was no data provided. Staff #2 confirmed that there were no QAPI meeting minutes for 2021 or 2022.

Based on staff interview and review of facility documents, it was determined the facility failed to ensure that its QAPI (Quality Assessment and Performance Improvement) program measures, analyzes and tracks quality indicators, including adverse patient events. --- Findings include: Reference: Facility policy titled, "Quality Assessment and Performance Improvement (last revised 04/04/23) states, " ... 2. The hospice will maintain documentary evidence of its quality assessment and performance improvement program and be able to demonstrate its operation to CMS and the accreditation agency. 3. ... The Hospice will measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations." Upon interview on 05/04/23 at 10:05 AM, Staff #2 (Administrative Director) identified him/herself and Staff #4 (Director of Nursing) as the staff responsible for the facility's QAPI program. Staff #2 indicated QAPI meetings are held quarterly. A request was made to Staff #2 for QAPI meeting minutes for 2021, 2022, and 2023 and any supporting data used in the QAPI program. QAPI meeting minutes dated 04/04/23 were provided and contained a QAPI report for "Patient Safety and Quality Indicators" report for the 1st quarter of 2023. There were no other QAPI meeting minutes provided. Staff #2 was asked how he/she was able to measure, analyze, and track quality indicators or adverse patient events without data to review. Staff #2 was unable to answer the question.

Based on staff interview and review of facility documents, it was determined the facility failed to ensure that the facility uses data collection to evaluate and improve the quality of hospice services. --- Findings include: Reference: Facility policy titled, "Quality Assessment and Performance Improvement [QAPI] (last revised 04/04/23) states, " ... 2. The hospice will maintain documentary evidence of its quality assessment and performance improvement program and be able to demonstrate its operation to CMS and the accreditation agency. ... 4. Program Data: a) The program will use quality indicator data, including patient care, and other relevant data, in the design of its program. b) The hospice will use the data collected to do the following: i. Monitor the effectiveness and safety of services and quality of care. ii. Identify opportunities and priorities for improvement. c) The frequency and detail of the data collection will be quarterly as approved by the Hospice's governing body." Upon interview on 05/04/23 at 10:05 AM, Staff #2 (Administrative Director) identified him/herself and Staff #4 (Director of Nursing) as the staff responsible for the facility's QAPI program. Staff #2 indicated QAPI meetings are held quarterly. A request was made to Staff #2 for QAPI meeting minutes for 2021, 2022, and 2023 and any data collection used in the QAPI program. QAPI meeting minutes dated 04/04/23 were provided and contained a QAPI report for "Patient Safety and Quality Indicators" report for the 1st quarter of 2023. There was no evidence of data collection provided to support the quality indicator measurements indicated in the report. There were no other QAPI meeting minutes provided. Staff #2 was asked how he/she was able to measure, analyze, and track quality indicators or adverse patient events without data to review. Staff #2 was unable to answer the question.

Based on staff interview and review of facility documents, it was determined the facility failed to ensure that the QAPI (Quality Assessment and Performance Improvement) program includes performance improvement activities focused on high risk, high volume, or problem-prone areas. --- Findings include: Reference: Facility policy titled, "Quality Assessment and Performance Improvement" (last reviewed 04/04/23) states, " ... 5. Program activities: a) The hospice's performance improvement activities will: i. Focus on high risk, high volume, or problem-prone areas. (i) Consider incidence, prevalence, and severity of problems in those areas. (ii) Affect palliative outcomes, patient safety, and quality of care. b) Performance improvement activities will track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice." Upon interview on 05/04/23 at 10:05 AM, Staff #2 (Administrative Director) identified him/herself and Staff #4 (Director of Nursing) as the individuals responsible for the facility's QAPI program. Staff #2 indicated the QAPI program monitors the following quality indicators: pain on admission, infection, falls, GI/UTI, and submitting documentation on time. Staff #2 was asked to provide evidence of monitoring, analyzing, and measuring of data collected regarding the quality indicators. There was no data collection, or any other evidence provided. Upon interview at 10:10 AM, Staff #2 stated, "We monitor falls and implement fall prevention activities to make sure the patients are safe." Staff #2 was asked to describe the falls prevention activities that are currently being implemented. Staff #2 was unable to name any falls prevention activities. Staff #2 stated, "I would like to look at the policy." Staff #2 was unable to provide evidence the facility is conducting performance improvement activities designed to improve the hospice's performance.

Based on staff interview and review of facility documents, it was determined the facility failed to ensure that performance improvement projects, are developed and implemented. --- Findings include: Reference: Facility policy titled, "Quality Assessment and Performance Improvement [QAPI]" (last reviewed 04/04/23) states, " ... 6. Performance improvement projects. On or before February 2, 2009 the Hospice will develop, implement, and evaluate performance improvement projects. ... b) The hospice will document what performance improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects." Upon interview on 05/04/23 at 10:10 AM, Staff #2 (administrative Director) was asked what QAPI performance improvement projects the facility is currently conducting. Staff #2 stated, "We're doing a project to prevent falls. We chose this project because it is a safety measure and we have to make sure patients are safe. A lot of our patients are prone to falls." Staff #2 was asked how many patients falls the facility had in 2022 and 2023. Staff #2 stated, "We haven't had any falls." Staff #2 was asked to provide documentation related the project and evidence of measurable progress achieved from performance improvement activities. Staff #2 was unable to provide any documentation. Staff #2 was unable to provide evidence the facility was conducting a performance improvement project.

Based on staff interview and review of facility documents, it was determined the Governing Body failed to implement and maintain a QAPI (Quality Assessment and Performance Improvement) program designed for quality improvement and patient safety and failed to evaluate the QAPI program annually. --- Findings include: Reference: Facility policy titled, "Quality Assessment and Performance Improvement" (last reviewed 04/04/23) states, " ... 1. ... The hospice's governing body must ensure that the program reflects the complexity of its organization and services; involves all hospice services (including those services furnished under contract or arrangement); focuses on indicators related to improved palliative outcomes; and takes actions to demonstrate improvement in hospice performance. 2. The hospice will maintain documentary evidence of its quality assessment and performance improvement program and be able to demonstrate its operation to CMS and the accreditation agency." Upon interview on 05/04/23 at 9:30 AM, Staff #2 (Administrative Director) stated his/her role at the hospice was "the Administrator." Staff #2 stated, "I oversee the whole process. I make sure everything is compliant. I oversee the day-to-day operations of the hospice." Staff #2 confirmed that he/she is a member of the facility's Governing Body. Upon interview on 05/04/23 at 10:05 AM, Staff #2 identified him/herself and Staff #4 as the staff responsible for the facility's QAPI program. Staff #2 indicated QAPI meetings are held quarterly. A request was made to Staff #2 for QAPI meeting minutes for 2021, 2022, and 2023 and any supporting data used in the QAPI program. QAPI meeting minutes dated 04/04/23 were provided and contained a QAPI report for "Patient Safety and Quality Indicators" report for the 1st quarter of 2023. There were no other QAPI meeting minutes provided. Staff #2 was asked how he/she was able to measure, analyze, and track quality indicators or adverse patient events without data to review. Staff #2 was unable to answer the question. Staff #2 indicated the QAPI program monitors the following quality indicators: pain on admission, infection, falls, GI/UTI (gastrointestinal/urinary tract infection) and submitting documentation on time. Staff #2 was asked to provide evidence of monitoring, analyzing, and measuring of data collected regarding the quality indicators. There was no data collection, or any other evidence provided. Upon interview at 10:10 AM, Staff #2 stated, "We monitor falls and implement fall prevention activities to make sure the patients are safe." Staff #2 was asked to describe the falls prevention activities that are currently being implemented. Staff #2 was unable to name any falls prevention activities. Staff #2 stated, "I would like to look at the policy." Staff #2 was unable to provide evidence the facility is conducting performance improvement activities designed to improve the hospice's performance.

Based on staff interview and review of facility documents, it was determined the facility failed maintain and document an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases. --- Findings include: 1. The facility failed to ensure that policies and procedures for patients on isolation precautions are developed and implemented. (Cross refer to Tag L0579) 2. The facility failed to ensure that an agency approved list of disinfectants is developed and implemented. (Cross refer to Tag L0579) 3. The facility failed to ensure that an infection control program designed to monitor, identify, investigate, and control infectious disease, is maintained and is an integral part of the facility's QAPI (Quality Assessment and Performance Improvement) program. (Cross refer to Tag L0580) 4. The facility failed to ensure that employees receive annual infection control training. (Cross refer to Tag L0582)

Based on staff interview and review of facility documentation, it was determined that the facility failed to ensure that: 1) the development and implementation of policies and procedures for patients on isolation precautions; 2) the development and implementation of an agency approved list of disinfectants. --- Findings include: 1) Reference: CDC document "2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings," Last update: May 2022, states, " ...I.D.2. Non-acute healthcare settings. Healthcare is provided in various settings outside of hospitals including ... rehabilitation centers and hospices. ...I.D.2.c. Home care. Home care in the United States is delivered by over 20,000 provider agencies that include home health agencies, hospices, durable medical equipment providers, home infusion therapy services, and personal care and support services providers. ... The main transmission risks to home care patients are from an infectious healthcare provider or contaminated equipment; providers also can be exposed to an infectious patient during home visits. Since home care involves patient care by a limited number of personnel in settings without multiple patients or shared equipment, the potential reservoir of pathogens is reduced. Infections of home care providers, that could pose a risk to home care patients include infections transmitted by the airborne or droplet routes (e.g., chickenpox, tuberculosis, influenza), and skin infestations (e.g., scabies and lice) and infections (e.g. Impetigo) transmitted by direct or indirect contact. There are no published data on indirect transmission of MDROs from one home care patient to another, although this is theoretically possible if contaminated equipment is transported from an infected or colonized patient and used on another patient. ..." Agency policy "Infection Control," (last reviewed 4/4/23), states, "...Procedure: ...9. ...h) Transmission based precautions will be implemented as appropriate to the suspected infection. ..." On 05/03/23 at 10:18 AM, a request was made to Staff #1 (Executive Director) for the policy on the care of patients on contact, droplet, or respiratory isolation precautions, or patients with multi-drug resistant organism infections, including required personal protective equipment and equipment disinfection procedure. Staff #1 confirmed that the facility did not have a policy. 2) Reference: 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings" states: "... II.I. Environmental measures Cleaning and disinfecting non-critical surfaces in patient-care areas are part of Standard Precautions. ... Certain pathogens (e.g., rotavirus, noroviruses, C. difficile) may be resistant to some routinely used hospital disinfectants. The role of specific disinfectants in limiting transmission of rotavirus has been demonstrated experimentally. Also, since C. difficile may display increased levels of spore production when exposed to non-chlorine-based cleaning agents, and the spores are more resistant than vegetative cells to commonly used surface disinfectants, some investigators have recommended the use of a 1:10 dilution of 5.25% sodium hypochlorite (household bleach) and water for routine environmental disinfection of rooms of patients with C. difficile when there is continued transmission. In one study, the use of a hypochlorite solution was associated with a decrease in rates of C. difficile infections. The need to change disinfectants based on the presence of these organisms can be determined in consultation with the infection control committee. Detailed recommendations for disinfection and sterilization of surfaces and medical equipment that have been in contact with prion-containing tissue or high risk body fluids, and for cleaning of blood and body substance spills, are available in the Guidelines for Environmental Infection Control in Health-Care Facilities and in the Guideline for Disinfection and Sterilization. Agency policy titled "Standard Precautions," (last reviewed 4/4/23), states, "...Procedure: ...3. Blood/Other Potentially Infectious Material Spills: A. An approved disinfectant or bleach is carried into the home to be used for cleaning and disinfection after a blood spill. ...10. Standard Precaution Supplies: Appropriate supplies available to field staff to protect them from contact or airborne exposure to infectious materials include: ...D. Approved disinfectant ..." On 05/02/23 at 4:10 PM, following a home visit, an interview with Staff #4 (Director of Nursing) was conducted. Staff #4 stated that "alcohol wipes" are the only disinfectant used by the agency for cleaning patient care equipment shared between homes. When asked what type of disinfectant would be used on a patient with a multidrug resistant organism, such as MRSA (Methicillin-resistant Staphylococcus aureus), or any other communicable diseases, Staff #4 stated that "we have never had a patient like that." On 05/02/23 at 10:24 AM, a request was made to Staff #2 (Administrative Director) for a copy of the agency's approved list of disinfectants. At 3:05 PM, a second request was made for the approved disinfectant list. The agency failed to provide a copy of the list. The above findings were confirmed on 05/04/23 during exit conference with Staff #1 and Staff #2.

Based on staff interviews and review of facility documents, it was determined the facility failed to ensure that an infection control program designed to monitor, identify, investigate, and control infectious disease, is maintained and is an integral part of the facility's QAPI (Quality Assessment and Performance Improvement) program. --- Findings include: Reference: Facility document titled, "Infection Control Plan" (last reviewed 02/21/23) states, " ... The organization's infection control program should be part of the hospice's overall quality assessment and improvement efforts ... Surveillance: ... The basic elements of surveillance include defining categories of infection, systematically finding, and collecting, tabulating and interpreting data. ... Surveillance is conducted by review of medical record, inter-office reports, care plans, medication orders. [Initials of hospice] conducts targeted surveillance for the following HAI [healthcare associated infections]: Urinary Tract Infections both device and non-device related; Respiratory Illness; GI illness; Any illness determined to be reportable to state and local health department. ... Process surveillance is performed by random audits of hand hygiene compliance, bag technique, disinfection of equipment and compliance with employee flu vaccination. ... 18. Infection control activities will be reported at QAPI meeting. Hand Hygiene observation will be monitored quarterly. Medical Equipment, devices, and supplies (nurse bag) will be monitored quarterly." Upon interview on 05/02/23 at 11:25 AM, Staff #4 (Director of Nursing) identified him/herself as the day-to-day infection control professional for the facility. Staff #4 stated his/her duties as the infection control professional included "collecting infection control data from home visits and medical records, monitoring infections, antibiotic management, and annual hand hygiene audits." Staff #4 was asked to provide evidence of infection control data collected during his/her infection control surveillance. Staff #4 provided evidence of employee hand hygiene competencies for 2022. Upon interview, Staff #4 stated hand hygiene competencies are done in the office, and he/she does not observe the employees performing hand hygiene. Staff #4 stated the employees tell him/her how they would perform hand hygiene and he/she deems them competent. Staff #4 was asked if he/she performs hand hygiene observations for staff. Staff #4 stated, "No." Staff #4 was asked if he/she performs random audits of staff bag technique and staff disinfection of equipment. Staff #4 stated, "No." Staff #4 was asked to provide evidence of infection control activities reported at the quarterly QAPI meeting. No infection control activities were provided. Upon interview Staff #4 stated, "I help to create infection control policies." Staff #2 and Staff #4 were unable to provide the following infection control policies: Transmission-based precautions, mandatory vaccination policy, PPE [personal protective equipment) (related to COVID positive or PUI patients), or a wound care policy. Staff #1 and Staff #2 confirmed the above findings on 05/04/23 at 3:00 PM.

Based on staff interview, review staff personnel files, and review of facility documents, it was determined the facility failed to ensure that employees receive annual infection control training. --- Findings include: Reference: Facility document, "Infection Control Plan" (last reviewed 02/21/23) states, " ... 8. [Name of Hospice] will communicate the responsibilities for infection control and prevention in formal orientation and in-service programs and by periodic written materials as needed. ... 16. Annual in-service update on exposure and post-exposure, communicable disease and infection control will be provided to the direct care staff through in-service education." Upon interview on 05/02/23 at 11:35 PM, Staff #4 (Director of Nursing) identified him/herself as the facility's Day-to-Day infection control professional. Staff #4 stated, "I help to create infection control policies. I provide infection control training to staff when they are hired and when I do annual competencies and in-service training." Review of the personnel files for Staff #3, Staff #4, Staff #6, and Staff #7 lacked evidence of annual infection control education. A request was made to Staff #2 (Administrative Director) and Staff #4 for evidence of annual staff infection control education for 2021, 2022, and 2023. At 1:00 PM, a second request was made to Staff #2 and Staff #4 for evidence of annual staff infection control education for 2021, 2022, and 2023. Staff #2 provided a binder and stated it was staff infection control education. The binder contained an unlabeled sign-in sheet dated 03/11/23. Seven employee signatures were listed on the sign-in sheet. The sign-in sheet did not indicate what staff education was provided. Staff #2 stated, "That is our infection control in-service. We went over infection control training on that day." Staff #2 was asked to provide the content of the infection control education during the in-service. Staff #2 stated, "There are policies behind the sign-in sheet. They were educated on the policies that are in there." Staff #2 was referencing the following policies contained in the binder: Annual Mandatory Training, Medical Device Act, Fire Plan, Corporate Compliance Program, Quality Assessment and Performance Improvement, Tuberculosis Risk Assessment Worksheet, Tuberculosis Exposure Control Plan, Bloodborne Pathogens/Tuberculosis Control - Training Program and In-service Outline, and Recall of Supplements and Medication/Medical Devices. There were no other policies present in the binder. Upon interview at 1:05 PM, Staff #4 indicated he/she educated the staff during the in-service on 03/11/23. Staff #4 was asked to describe what infection control education was provided to staff during the in-service. Staff #4 stated, "I went over the policies. I also went over hand-washing and COVID stuff with them because COVID was more prevalent then." Staff #4 was asked why the policy for hand hygiene and COVID was not included with the policies contained in the binder. Staff #4 was unable to provide an answer. Staff #4 was asked to confirm that he/she reviewed all of the policies contained in the binder with the staff during the in-service. Staff #4 stated, "Yes." Staff #4 was asked to provide this surveyor with information on the Medical Device Act and to discuss the facility's policy on the recall of supplements and medication/medical devices. Staff #4 was unable to answer and stated, "I see what you mean." Staff #2 and Staff #4 was unable to provide evidence that staff received infection control training on the in-service date of 03/11/23. At 3:15 PM, Staff #2 and Staff #4 confirmed that there were no other dates annual staff infection control training was provided.

Based on medical record review, staff interviews, and review of facility policies and procedures, it was determined the facility failed to ensure that nursing services, medical social services, and counseling services are provided in accordance with acceptable standards of practice. --- Findings include: 1. The facility failed to ensure that nurses implement interventions to manage patient's pain. (Cross refer to Tag L0591) 2. The facility failed to ensure that nurses notify the physician when a patient's pain management interventions are not effective. (Cross refer to Tag L0591) 3. The facility failed to ensure that patient wounds are re-assessed by the nurse. (Cross refer to Tag L0591) 4. The facility failed to ensure that a policy and procedure for nursing care of patients with wounds is developed and implemented. (Cross refer to Tag L0591) 5. The facility failed to ensure that social work services are provided to patients in accordance with a completed psychosocial assessment that determines the patient and caregiver needs. (Cross refer to Tag L0594) 6. The facility failed to ensure that spiritual services are provided to patients in accordance with a completed spiritual assessment that determines the patient and caregiver's spiritual needs. (Cross refer to Tag L0598)

Based on review of three of three medical records of patients with wounds (#7, #9, #11), staff interviews, and review of facility policies and procedures, it was determined the facility failed to ensure that: 1) nurses assess and re-assess patient wounds, implement interventions to manage patient's pain from wounds, and notify the physician when a patient's pain management interventions are not effective; 2) a policy and procedure for nursing care of patients with wounds is developed and implemented. --- 2) Review of Patient #11 (P11)'s medical record on 05/04/23 at 10:40 AM revealed the following: For certification period 01/14/23 until 04/13/23, on the signed "Physician's Certification of Terminal Illness for Medicare Hospice Benefit ... Signed Statement for first 90-day period," the following was documented in the Brief Narrative Statement: " ... Stays in hospital bed most of the day. Sacrum wound treated with SSD [Silver Sulfadiazine)." For certification period 04/14/23 until 06/12/23, on the signed "Physician's Certification of Terminal Illness for Medicare Hospice Benefit Certification Statement for second 90-day period," the following was documented in the Brief Narrative Statement: " ... Spends most of the day on hospital bed ... Sacrum wound stage - 1." A review of P11's chart revealed "Wound Assessment and Care Tool With Braden Scale" forms filled out on the following dates: 01/14/23, 02/15/23, 03/14/23, and 04/12/23. The forms included areas to document the following where applicable: Wound Location, Size, Type, Stage, Wound Bed, Drainage, Color, Odor, Tunneling/Undermining, Surrounding Tissue, Edema, Stoma, Wound Status, Wound Care, Satisfactory Return Demo, and Patient Response as well as an area to document wound location on a diagram. Upon interview, Staff #2 was unable to answer how often patient wounds are assessed or how often the "Wound Assessment and Care Tool With Braden Scale" should be completed. A request was made for the policy and procedure on patient wound care, and it was not provided. The above findings were confirmed with S1 and S2 at exit conference. Findings include: Reference #1: Facility policy titled, "Coordination of Services - Nursing Services (last reviewed 04/04/23) states, " ... 3. Nursing services must ensure that the nursing needs of the patient are met as identified in the patient's initial assessment, comprehensive assessment, and updated assessments. ... 4. Duties of the Registered Nurse include: ... a) ... Has the responsibility for the observation, assessment, nursing diagnosis, counsel, care and health teaching of the hospice patient and family. ... f) Assesses the ability of the caregiver to meet the patient's immediate needs upon admission and throughout care. ... h) Evaluates the effects of the care given and regularly reevaluates the patient's nursing needs. ... o) Informs the attending physician, medical director and other personnel of changes in the patient's needs and outcomes of intervention. p) Makes referrals to other agencies or services, as needed. ... ." Reference #2: Facility policy titled, "Pain Management" (last reviewed 04/04/23) states, " ... 1. The skilled nurse will perform a pain assessment during each home visit. The pain assessment will be documented. ... 4. Pain assessment should include a thorough history of the pain and pain relief methods due to date. A pain scale will be utilized. ... 5. The skilled nurse will contact the attending physician and/or Medical Director/designee to report unresolved pain issues including a new site, increase in pain or other symptoms. ... 7. The IDT (interdisciplinary team) will discuss pain issues to determine other causal factors and possible non-pharmacologic treatment measures to employ. ... ." Review of P7's medical record on 05/03/23 revealed the following: P7 was admitted to the hospice service on 10/14/22. The "Initial Comprehensive Nursing Assessment" dated 10/14/22 states, "Client was d/c (discharged) from the hospital after recent fall resulted in pelvic fx (fracture). ... c/o (complaining of) r (right) leg 8/10 pain (8 out of 10 on pain scale). Dr. (name of doctor) contacted Fentanyl patch ordered." A wound assessment conducted on 10/14/22 indicates the patient had a right heel Stage 2 pressure injury measuring "0.5 X 0.4." Physician orders dated 10/14/22 states, "Clean with NASL (normal saline) r heel apply Medihoney to heel daily as needed." Skilled nursing (SN) visits were ordered for the patient "1-2 x WK + 3PRN (one to two times per week plus 3 as needed visits) for symptom management." The patient expired on 11/04/22. A "Nurse Visit Note" dated 10/18/22 states, "Current pain (0-10): 3/10 ... Worst in last 24 hrs (hours): 7/10 ... Location(s): bilateral shoulders, knees ... constant ... Routine Pain Med: Fentanyl patch 12 mcg (micrograms) q (every) 72 hrs ... Is pain management effective for pt (patient): No." There was no evidence the nurse notified the physician that the patient's current pain management was ineffective. A "Nurse Visit Note" dated 10/19/22 states, "Current pain (0-10): 8/10 ... Worst in last 24 hrs: 10/10 ... Location(s): bilateral shoulders, knees, right leg ... constant ... Routine Pain Med: Fentanyl patch 12 mcg/hr q 72 hrs ... Is pain management effective for pt?: No." Nurse's note states, "Home PRN (as needed) visit made due to PCG (patient caregiver) [name of caregiver] request due to client's right leg severe pain and rupture of right heel wound. ... R heel wound performed by this RN and educated and instructed on the wound care utilizing medihoney niece [name of niece] [sic]. Measures to prevent skin breakdown including heels protector are reinforced. ... ." There was no additional information provided. There was no documentation indicating what pain management interventions were performed by the nurse regarding the patient's severe pain rated eight out of 10 on the pain scale. There was no evidence in the medical record the nurse notified the physician of the patient's severe pain. The nurse's documentation did not include a wound assessment or specify how the nurse cared for the patient's ruptured right heel wound. There was no evidence in the medical record the nurse notified the physician of the patient's ruptured right heel wound. A "Nurse Visit Note" dated 10/22/22 states, "Current Pain (0-10): 3/10 ... Worst in last 24 hrs: 8/10 ... Location(s): bilateral shoulders, knees, right leg ... constant ... Routine Pain Med: Fentany Patch 12 mcg/hr q 72 hrs. .... Is pain management effective for pt?: No." Nurse's note states, "R heel wound performed by this RN and educated and instructed on the wound care utilizing medihoney. ... ." There was no evidence the nurse notified the physician that the patient's current pain management was ineffective. There was no evidence the nurse performed a wound assessment or wound measurements of the patient's right heel pressure injury. A "Nurse Visit Note" dated 10/28/22 indicates P7's Fentanyl patch was increased by the physician to "25 mcg/hr q 72 hrs" for pain relief. There was no evidence the nurse performed a wound assessment or wound measurements of the patient's right heel pressure injury. Review of P9's medical record on 05/04/23 revealed the following: P9 was admitted to the hospice service on 11/15/22. The "Initial Comprehensive Nursing Assessment" dated 11/15/22. A wound assessment conducted on 11/15/22 indicates the patient had a left heel stage 2 pressure injury measuring "1.5 X 2.1." Physician orders dated 11/15/22 states, "Clean with NASL apply Medihoney twice a day cover with dry sterile dressing." Skilled nursing (SN) visits were ordered for the patient "1-2 x WK + 3PRN (for symptom management)." The patient expired on 12/09/22. A "Nurse Visit Note" dated 11/20/22 states, "Skin ... location: left heel wound (see weekly wound sheet). ... The left leg heel wound care is performed by this RN including medihoney. ... ." There was no evidence of a weekly wound sheet in the medical record. There was no evidence of a wound assessment or measurement performed by the RN. A "Nurse Visit Note" dated 11/27/22 states, "Skin ... location: left heel wound (see weekly wound sheet). ... The left leg heel wound care is performed by this RN including medihoney. ... ." There was no evidence of a weekly wound sheet in the medical record. There was no evidence of a wound assessment or measurement performed by the RN. A "Nurse Visit Note" dated 12/04/22 states, "Skin ... location: left heel wound (see weekly wound sheet). ... The left leg heel wound care is performed by this RN including medihoney. ... ." There was no evidence of a weekly wound sheet in the medical record. There was no evidence of a wound assessment or measurement performed by the RN. On 05/03/23, a request was made to Staff #1 and Staff #2 for the facility's wound care policy indicating how often wound assessments performed by the nurse are required. No wound care policy was provided. Upon interview on 05/03/23 at 3:50 PM, Staff #2 confirmed the facility does not have a wound care policy. Staff #2 was asked how often wound assessments are required to be performed by the nurse. Staff #2 stated, "I'm not sure, I'll have to check."

Based on review of eight of ten medical records (#1, #2, #6, #7, #8, #9, #10, #11), staff interviews, and review of facility documents, it was determined that facility failed to ensure a psychosocial assessment is completed in order to determine patient and caregiver needs. --- Review of P7's medical record on 05/03/23 revealed the following: P7 was admitted to hospice service on 10/14/22. On the "Psychosocial/Spiritual Assessment" form completed by Staff #4 (DON) and dated 10/14/22, the question "Does the caregiver seem overwhelmed at the responsibility of caring for patient?" was answered "Yes." The question "Patient has issued Advance Directive in form of: Living Will or Medical POA (power of attorney)" was left blank. The question "Patient/Caregiver wishes to discuss Advance Directives with a member of the Hospice Team" was left blank. There was no evidence in the medical record of a social services assessment visit completed by the Social Worker within five days of the patient's admission. Review of the "Initial Plan of Care/Physician Order" form for benefit period 10/14/22 to 01/11/23, completed by Staff #4 on 10/14/22, indicated Social Worker visits were originally ordered "1-2 days per week." The order was then crossed out with a different color ink and the word "refused" was written across the original order in a different handwriting. There was no documentation in the medical record from the Social Worker, or any other staff member, that indicated the patient or family refused social work services. There was no evidence in the medical record that social work services were offered or provided to the patient and family. Upon interview on 05/04/03 at 10:30 AM, Staff #1 (Executive Director) and Staff #2 confirmed that staff should not be crossing out orders that are already written, and writing new orders over the crossed out order. Review of P8's medical record on 05/04/23 revealed the following: P8 was admitted to hospice service on 07/19/22. On the "Psychosocial/Spiritual Assessment" form completed by Staff #4 on 07/19/22, the question "Patient has issued Advance Directive in form of: Living Will or Medical POA (power of attorney)" was left blank. The question "Funeral Arrangements made?" was left blank. There was no evidence in the medical record of a social services assessment visit completed by the social worker within five days of the patient's admission. Review of the "Initial Plan of Care/Physician Order" form for benefit period 07/19/22 to 10/16/22, completed by Staff #4 on 07/19/22, indicated "refused" under the frequency of social work visits. There was no documentation in the medical record from the social worker, or any other staff member, that indicated why the patient or family refused social work services. There was no evidence in the medical record that social work services were offered or provided to the patient and family. Review of P9's medical record on 05/04/23 revealed the following: P9 was admitted to hospice service on 11/15/22. On the "Psychosocial/Spiritual Assessment" form completed by Staff #4 on 11/15/22, the question "Is patient able to care for self?" was left blank. The question "Is caregiver able and willing to care for patient?" was answered "No." The question "Does caregiver seem overwhelmed at responsibility of caring for patient?" was answered "Yes." The question "Funeral Arrangements made?" was answered "No." There was no evidence in the medical record of a social services assessment visit completed by the social worker within five days of the patient's admission. Review of the "Initial Plan of Care/Physician Order" form for benefit period 11/15/22 to 02/12/23, completed by Staff #4 on 11/15/22, indicated an initial order for social work visits "1-2." There was no indication of the frequency (i.e. per week, per month). A "Hospice Clinical Note" dated 11/16/22 at 10:00 AM, contained a preprinted statement that states, " TC (telephone call): Patient/PCG (patient caregiver) declined SW (social work) visit at this time. Social Worker will follow up and continue to offer social work support services, as appropriate." There was no additional information provided. There was no documentation indicating why the patient or caregiver declined the SW visit. There was no documentation indicating whether the SW spoke with the patient or caregiver to offer SW services prior to the patient or caregiver refusing SW services. Upon interview on 05/03/23 at 1:30 PM, Staff #4 stated, "I do my initial assessment within 24-48 hours. I do my nursing assessment and the Social Worker and Chaplain do their own assessment. When I mention the social worker and chaplain services, sometimes the patients may refuse, but I tell them they (social worker and chaplain) will reach out to them anyway. I try to tell them and encourage them to use the services." Upon interview on 05/04/23 at 10:00 AM, Staff #1 (Administrative Director) stated, "The social worker is required to do an initial assessment in five days. If the social worker is making a visit, then [he/she] does the psychosocial assessment." Staff #1 also stated that if the patient or caregiver refuses social work services to the nurse during his/her initial assessment, then the social worker does not conduct a social services assessment visit. Staff #1 was asked why so many of the patient's medical records indicate patients or caregivers are "refusing" social work services prior to the social worker performing his/her initial assessment. Staff #1 stated, "I don't know why they are refusing. This is what they are telling the nurse." Staff #1 was asked if he/she was aware that so many patients and caregivers were refusing services that would greatly benefit them, and if so, what interventions were put in place to prevent patients from refusing vital services. Staff #1 stated that he/she is aware that patients and caregivers are refusing social work services and stated that he/she has not implemented interventions to prevent patients from refusing social work services. A review of P2s medical record on 5/2/23 revealed the following: P2 was admitted to hospice service on 4/7/23. On the "Psychosocial/Spiritual Assessment" form completed by S4 (DON) dated 4/7/23, the following question under Psychosocial Assessment was left blank: "Has the patient accepted diagnosis/prognosis? Does patient demonstrate effective coping? Is patient able to care for self? Is caregiver able and willing to care for patient? Does caregiver seem overwhelmed at responsibility of caring for patient? Does the caregiver seem overwhelmed at the responsibility of caring for patient? Has caregiver accepted diagnosis/prognosis? Does caregiver demonstrate effective coping? Needs identified: [blank]" The question "Patient has issued Advance Directive in form of: Living Will or Medical POA (power of attorney)" was left blank. The question "Patient/Caregiver wishes to discuss Advance Directives with a member of the Hospice Team" was left blank. The question "PCG understands patient's wishes" was left blank. There was no evidence in the medical record of a social services assessment visit completed by the Social Worker within five days of the patient's admission. On the "Psychosocial/Spiritual Assessment Patient/Caregiver Information" form completed by S4 (DON) dated 4/7/23, the following assessment areas were left blank: Caregiver capable of giving medications and participating in plan of care; Person responsible for patient's emergency plan; Support systems; Does the patient have spiritual support; Spiritual Affiliation; Spiritual Representative; The patient/family would desire: Hospice Chaplain to contact patient, Hospice Chaplain to contact family/caregiver, Hospice Chaplain to contact spiritual representative, No contact at this time. A pre-printed Hospice Clinical Note dated 4/10 [no year] stated, "Patient/PCG declined SW visit at this time. Social Worker will follow up and Continue [sic] to offer social work support services, as appropriate." On 5/2/23 at 11:00 AM, a social services home visit was conducted for P2. Upon interview, S5 (Medical Social Work) confirmed that it was the first social work visit for the patient. During the visit, S5 went over the Social work comprehensive Assessment form and Psychosocial/Spiritual Assessment forms. A copy of P2's Power of Attorney was also requested by S5. During an interview with P2's family/caregiver, he/she stated, "I don't know what hospice does for [the patient] other than they come here to take vitals signs once a week." P2's family/caregiver then expressed that he/she purchase diapers, pads, and wipes for the patient. S5 told the family/caregiver that the hospice can supply those for the patient. A review of P6's medical record on 05/03/23 revealed the following: P6 was admitted to hospice service on 11/11/22. Review of the certification period 2/15-5/15/23, on the "Psychosocial/Spiritual Assessment Patient/Caregiver Information" form completed by S4 (DON) dated 2/15//22, the following assessment areas were left blank: Caregiver capable of giving medications and participating in plan of care; Person responsible for patient's emergency plan; Support systems; Does the patient have spiritual support; Spiritual Affiliation; Spiritual Representative. A pre-printed Hospice Clinical Note dated 2/16/23 stated, "Patient/PCG declined SW visit at this time. Social Worker will follow up and Continue [sic] to offer social work support services, as appropriate." A review of the "Initial Plan of Care/Physician Order" form for the benefit period 2/15-5/15/23, completed by Staff #4 on 10/14/22, indicated Social Worker visits were originally ordered "1-2 days per month + PRN." There was no evidence that an initial psychosocial assessment visit was completed by a social worker to determine the needs of the patient/caregiver within five days of the patient's admission. A review of P10's medical record on 05/04/23 revealed the following: P10 was admitted to hospice service on 4/18/23. On the "Psychosocial/Spiritual Assessment" form completed by S4 dated 4/18/23, the question "Does the caregiver seem overwhelmed at the responsibility of caring for patient?" was answered "Yes." on the "Psychosocial/Spiritual Assessment Patient/Caregiver Information" form completed by S4 dated 4/18/23, the following assessment areas were left blank: Caregiver capable of giving medications and participating in plan of care; Person responsible for patient's emergency plan; Support systems; Does the patient have spiritual support; Spiritual Affiliation; Spiritual Representative. A pre-printed Hospice Clinical Note dated 4/19/23 stated, "Patient/PCG declined SW visit at this time. Social Worker will follow up and Continue [sic] to offer social work support services, as appropriate." A review of the "Initial Plan of Care/Physician Order" form for the benefit period 4/18/23, completed by S4 on 4/18/23, indicated Social Worker visits were originally ordered "1-2 days per month." There was no evidence in the medical record of a social services assessment visit completed by the Social Worker within five days of the patient's admission to determine patient/caregiver needs. On 5/3/23 at 10:07 AM, upon interview, S2 (Administrator) confirmed that the facility keeps pre-printed Hospice Clinical Note with the blanket statement of refusal. Findings include: Reference: Facility policy titled, "Coordination of Services - Medical Social Worker" (last reviewed 04/04/23) states, " ... Social work services must be based on the patient's psychosocial assessment and the patient's and family's needs and acceptance of these services. ... The social services assessment visit shall be completed within 5 days of admission or sooner if indicated. The duties of the social worker include the following: a) Assessing emotional factors related to terminal illness. Assessing caregiver's ability to function adequately. ... b) Evaluating patient/family response to psychosocial interventions. ... d) Assessing the patient/family psychosocial status ... h) Providing social services, including short-term individual counseling, crisis intervention, assistance in providing information and preparation of advance directives and funeral planning issues ... ." On 5/4/23 at 12:10 PM, during medical record review, the following was revealed: Patient (P)1's start of care date was 4/17/23. On 4/17/23, a "Psychosocial/Spiritual Assessment" document was completed for by Staff (S)4 (DON). The document was not completed in the areas for Psychosocial Assessment, Pre-Bereavement Interventions, or Risk Assessment for Survivors. On 4/18/23, a Hospice Clinical Note was documented by a staff member with an illegible signature. The staff member signed a typewritten note stating "Patient/PCG [patient caregiver] declined SW [social work] visit at this time. Social Worker will follow up and Continue [sic] to offer social work services, as appropriate." There was no documentation included of a psychosocial assessment of the patient or caregiver. P11's start of care date for his/her initial benefit period was 1/14/23. On 1/14/23, a "Psychosocial/Spiritual Assessment" document was completed for by Staff (S)4 (DON). The document was not completed in the area for Risk Assessment for Survivors. On 1/16/23, a Hospice Clinical Note was documented by a staff member with an illegible signature. The staff member signed a typewritten note stating "Patient/PCG [patient caregiver] declined SW [social work] visit at this time. Social Worker will follow up and Continue [sic] to offer social work services, as appropriate." There was no documentation included of a psychosocial assessment of the patient or caregiver. The above findings were confirmed at exit by S1 and S2.

Based on a review of eight of ten medical records (#1, #2, #6, #7, #8, #9, #10, #11), staff interviews, and review of facility documents, it was determined that the facility failed to ensure all patients and families receive a full and timely spiritual assessment to determine the needs of the patient and family/caregiver. --- Review of Patient #7 (P7)'s medical record on 05/03/23 revealed the patient was admitted to hospice service on 10/14/22. P7's initial comprehensive nursing assessment completed by Staff #4 on 10/14/22, included a form labeled "Psychosocial/Spiritual Assessment." Review of the "Psychosocial/Spiritual Assessment" form indicated the following: The question "Does the patient have spiritual support?" was left blank. The question "Does the caregiver/family have spiritual support?" was left blank. The question "Spiritual Affiliation?" and "Name of Church" was left blank. The name and phone number of the patient or caregiver's Spiritual Representative was left blank. The nurse's initial comprehensive assessment did not completely assess the patient's spiritual needs. There was no evidence in the medical record that the chaplain completed a comprehensive spiritual assessment to identify the patient and caregiver's spiritual needs, within five days of the patient's admission. A "Hospice Clinical Note" dated 10/17/22 states, "Time: 1:14 ... TC (telephone call) ... Patient decline chaplain visit at this time will continue to offer." The note was preprinted on the form. There was no additional information provided. There was no documentation indicating why the patient or caregiver declined the chaplain visit. There was no documentation indicating whether the chaplain spoke with the patient or caregiver to offer spiritual services prior to the patient or caregiver refusing chaplain services. Review of Patient #8 (P8)'s medical record on 05/04/23 revealed the patient was admitted to hospice service on 07/19/22. P8's initial comprehensive nursing assessment completed by Staff #4 on 07/19/22, included a form labeled "Psychosocial/Spiritual Assessment." Review of the "Psychosocial/Spiritual Assessment" form indicated the following: The question "Does the patient have spiritual support?" was left blank. The question "Does the caregiver/family have spiritual support?" was answered "No." The name and phone number of the patient or caregiver's Spiritual Representative was left blank. The nurse's initial comprehensive assessment did not completely assess the patient's spiritual needs. There was no evidence in the medical record that the chaplain completed a comprehensive spiritual assessment to identify the patient and caregiver's spiritual needs, within five days of the patient's admission. On the "Initial Plan of Care/Physician Order" form completed by Staff #4 on 07/19/22, the word "Refused" is written in the section labeled "Chap/Counselor." There was no additional information provided. There was no documentation from the chaplain, or any other staff member, that indicated spiritual services were offered to the patient or caregiver, and was declined. Review of Patient #9 (P9)'s medical record on 05/04/23 revealed the patient was admitted to hospice service on 11/15/22. P9's initial comprehensive nursing assessment completed by Staff #4 on 11/15/22, included a form labeled "Psychosocial/Spiritual Assessment." Review of the "Psychosocial/Spiritual Assessment" form indicated the following: The question "Does the patient have spiritual support?" was left blank. The question "Does the caregiver/family have spiritual support?" was left blank. The question "Spiritual Affiliation?" and "Name of Church" was left blank. The name and phone number of the patient or caregiver's Spiritual Representative was left blank. The nurse's initial comprehensive assessment did not completely assess the patient's spiritual needs. Documentation on the "Psychosocial/Spiritual Assessment" form states "The patient/family would desire: Hospice Chaplain to contact family/caregiver." There was no evidence in the medical record that the chaplain completed a comprehensive spiritual assessment to identify the patient and caregiver's spiritual needs, within five days of the patient's admission. A "Hospice Clinical Note" dated 11/17/22 states, "Time: 1 PM ... TC (telephone call) ... Patient decline chaplain visit at this time will continue to offer." The note was preprinted on the form. There was no additional information provided. There was no documentation indicating why the patient or caregiver declined the chaplain visit. There was no documentation indicating whether the chaplain spoke with the patient or caregiver to offer spiritual services prior to the patient or caregiver refusing chaplain services. Upon interview on 05/04/23 at 10:00 AM, Staff #2 stated the chaplain has five days to complete his/her initial assessment, which includes an assessment of the patient and caregiver's spiritual needs. Staff #2 confirmed that the spiritual assessments performed by Staff #4 for P7, P8, and P9 were incomplete. Staff #2 confirmed that the chaplain did not complete a spiritual assessment for P7, P8, and P9. A review of P2's medical record conducted on 5/3/23 revealed the following: The patient's start of care date was 4/7/23. A review of the Psychosocial/Spiritual Assessment page lacked documentation under the patient's Psychosocial Assessment, Pre-Bereavement Interventions, and Advanced Directives. The Psychosocial/Spiritual Assessment - Patient/Caregiver Information page. lacked assessments of support systems, spiritual support, and spiritual affiliations. The Initial Plan of Care/Physician Orders form was blank for the anticipated frequency for the Chaplain/Counselor. A review of the Hospice Clinical Note dated "4/10" revealed a preprinted note that stated, "Patient declined chaplain visit at this time will continue to offer." The spiritual assessment was not completed until 5/2/23 on the second day of the survey when a social work visit was observed. A review of P6's medical record conducted on 5/4/23 revealed the following: The patient's start of care was 11/11/22. The re-certification period from 2/15-5/15/23 was reviewed. The Initial Plan of Care/Physician Order form was blank for the anticipated frequency for the Chaplain/Counselor. A review of the Psychosocial/Spiritual Assessment - Patient/Caregiver Information page lacked assessment of support system, spiritual affiliation, and spiritual support. A review of the Hospice Clinical Notes dated "2/17/23 and 3/7" revealed preprinted notes that stated, "Patient declined chaplain visit at this time will continue to offer." A Chaplain Comprehensive Spiritual Assessment was not performed until 4/10/23 when it was documented that the patient "would be interested in spiritual support from Chaplain" and that "it would be a great help to pt [patient]." A review of P10's medical record conducted on 5/4/23 revealed the following: A review of the Psychosocial/Spiritual Assessment - Patient/Caregiver information page, revealed that assessments of support systems, spiritual affiliations, and spiritual support were blank and not assessed. The initial plan of Care/Physician Orders indicated that Chaplain/Counselor service was documented as "refused." The above findings, the lack of a consistent and timely spiritual assessment for all patients was confirmed with S2 upon discovery and during the exit conference. Findings include: Findings include: Reference #1: Facility policy titled, "Coordination of Services - Spiritual Counseling (last reviewed 04/04/23) states, "The hospice will provide an assessment of the patient's and family's spiritual needs. ... The Hospice will advise the patient and family of this service. Spiritual Care - Chaplain services by a qualified chaplain are provided in accordance with the patient's plan of care. Assessments will be completed within 5 days of patients' admission. ... 1. The duties of the chaplain include the following: b) Participating in the development of the patient plan of care. c) Administer the spiritual assessment and development of the spiritual plan of care." Reference #2: Facility policy titled, "Assessment - Initial and Comprehensive" (last reviewed 04/04/23) states, " ... 3. The comprehensive assessment will identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that will be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. The comprehensive assessment will take into consideration the following factors: ... 6. Patient and family spiritual orientation, including their desire for the involvement of a religious group. 7. Spiritual concerns or needs identified by the patient or family, such as despair, suffering, guilt, and forgiveness. On 5/4/23 at 12:10 PM, during medical record review, the following was revealed: Patient (P)1's start of care date was 4/17/23. On 4/17/23, a "Psychosocial/Spiritual Assessment" document was completed for by Staff (S)4 (DON). The document was not completed in the areas for assessment of Support Systems, Spiritual Support (for patient and caregiver), Spiritual Affiliation, Spiritual Representative, if the patient would desire a hospice chaplain to contact the patient, family/caregiver, or spiritual representative. On 4/18/23, a Hospice Clinical Note was documented by S7 (Chaplain). S7 signed a typewritten note stating "Patient decline [sic] chaplain visit at this time will continue to offer." There was no documentation included of any assessment of the patient or caregiver's spiritual needs. P11's start of care date for his/her initial benefit period was 1/14/23. On 1/14/23, a "Psychosocial/Spiritual Assessment" document was completed for by Staff (S)4 (DON). The document was not completed in the areas for assessment of Support Systems, Spiritual Support (for patient and caregiver), Spiritual Affiliation, or Spiritual Representative. S4 documented that no contact was desired by a hospice chaplain, without completion of the assessment. On 1/17/23, a Hospice Clinical Note was documented (signature illegible. D Ricelno?). The staff member signed a typewritten note stating "Patient decline [sic] chaplain visit at this time will continue to offer." There was no documentation included of any assessment of the patient or caregiver's spiritual needs. The above findings were confirmed at exit by S1 and S2.

Based on medical record review, staff interviews, caregiver interview, and review of facility documents, it was determined the facility failed to ensure that volunteer services are utilized and offered to patients and families. --- Findings include: 1.The facility failed to ensure that volunteer services are utilized and offered to patients and families in the hospice program. (Cross refer to Tag L0644) 2. The facility failed to ensure that the Volunteer Coordinator makes ongoing attempts to recruit and retain volunteers. (Cross refer to Tag L0645) 3. The facility failed to ensure that documentation of all volunteer services and time worked, is maintained. (Cross refer to Tag L0647)

Based on observation, review of six of ten medical records (#1, #3, #6, #7, #9, #10), staff interviews, caregiver interviews, and review of facility documents, it was determined the facility failed to offer or utilize volunteer services to patients or families in the hospice program. --- Review of Patient #10 (P10)'s medical record on 05/04/23, revealed on the "Psychosocial/Spiritual Assessment" form dated 04/18/23, the question "The patient/family would desire a volunteer? ... Reason ..." was left blank. There was no evidence in the medical record the patient or family was offered volunteer services. There was no evidence in the medical record the patient or family refused volunteer services. Staff #1 and Staff #2 confirmed the above findings during the exit conference. Review of Patient #6 (P6)'s medical record on 05/04/23 revealed on the "Psychosocial/Spiritual Assessment" form dated 02/15/23, the question "The patient/family would desire a volunteer? ... Reason... " was left blank. There was no evidence in the medical record the patient or family was offered volunteer services. There was no evidence in the medical record the patient or family refused volunteer services. Review of P7's medical record on 05/03/23 revealed on the "Psychosocial/Spiritual Assessment" form dated 10/14/22, the question "The patient/family would desire a volunteer? ... Reason ... " was left blank. There was no evidence in the medical record the patient or family was offered volunteer services. There was no evidence in the medical record the patient or family refused volunteer services. Review of P9's medical record on 05/04/23 revealed on the "Psychosocial/Spiritual Assessment" form dated 11/15/22, the question "The patient/family would desire a volunteer? ... Reason ... " was left blank. There was no evidence in the medical record the patient or family was offered volunteer services. There was no evidence in the medical record the patient or family refused volunteer services. Findings include: Reference #1: Facility policy titled, "Assessment - Initial and Comprehensive" (last reviewed 04/04/23) states, " ... 3. The comprehensive assessment will identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that will be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. ... i) Additional items will include as appropriate: ... 10. the need for volunteer services to offer support or respite to the patient, family, or other caregivers. ... ." Reference #2: Facility policy titled, "Coordination of Services - Volunteers" (last reviewed 04/04/23) states, "Hospice utilizes volunteers as an integrated component of the Interdisciplinary Team. ... the hospice will maintain records on the use of volunteers for patient care and administrative services, including the type of services and time worked." Upon interview on 05/02/23 at 9:40 AM, Staff #1 (Executive Director) identified him/herself as the Volunteer Coordinator. Staff #1 stated the facility has one volunteer "because we are small." Staff #1 identified Staff #3 as the facility's sole volunteer and stated Staff #3 only performs administrative office duties. When asked why Staff #3 does not volunteer for patient care services, Staff #1 stated, "The patients don't want [him/her] in the home because of COVID." Staff #1 stated upon admission, patients and families are offered volunteer services, however, they refuse. Review of Patient #1 (P1)'s medical record on 05/02/23 revealed that on the "Psychosocial/Spiritual Assessment" form dated 04/17/23, the question "The patient/family would desire a volunteer? ... Reason ... " was left blank. There was no evidence in the medical record the patient or family was offered volunteer services. There was no evidence in the medical record the patient or family refused volunteer services. Review of Patient #3 (P3)'s medical record on 05/02/23 revealed that on the "Psychosocial/Spiritual Assessment" form dated 03/13/23, the question "The patient/family would desire a volunteer? ... Reason ..." was left blank. There was no evidence in the medical record the patient or family was offered volunteer services. There was no evidence in the medical record the patient or family refused volunteer services. At 3:41 PM, during a home visit for P3, Staff #4 (S4), Director of Nursing, stated the patient's son lives upstairs above the patient's home. Upon interview at 4:04 PM, when asked if the agency offered volunteer services to the patient or family, the patient's son stated, "Nobody asked."

Based on staff interview and review of facility documents, it was determined the facility failed to ensure the Volunteer Coordinator made ongoing attempts to recruit and retain volunteers. --- Findings include: Reference: Facility policy titled, "Coordination of Services - Volunteer Coordinator" (last reviewed 04/04/23) states, " ... The Volunteer Coordinator will: ... e) Document and demonstrate viable and ongoing efforts to recruit and retain volunteers. ... l) Facilitate community awareness and support of Hospice Agency volunteer program. ... 2. The Volunteer Coordinator will schedule and conduct regularly recruiting activities [sic] ... Recruiting activities will include: a) Church bulletins, b) Newspapers, c) Community and volunteer fairs. ... ." Upon interview on 05/02/23 at 9:40 AM, Staff #1 (Executive Director) identified him/herself as the Volunteer Coordinator. Staff #1 indicated the hospice agency has one volunteer. Staff #1 was asked how he/she coordinates volunteer recruitment activities. Staff #1 stated, "We try but it's hard. We call churches and home care agencies. We call community centers, libraries, and adult day care centers. Sometimes our volunteer will go out and give out brochures." Staff #1 was asked to show evidence of the agency's volunteer recruitment efforts. Staff #1 stated, "I don't have evidence to show you. We call places but we don't keep a log. I don't have anything to show you." Staff #1 was unable to provide evidence of any ongoing recruitment efforts.

Based on staff interview and review of facility documents, it was determined the facility failed to ensure that documentation of all volunteer services and time worked, is maintained. --- Findings include: Reference #1: Facility policy titled, "Coordination of Services - Volunteers" (last reviewed 04/04/23) states, " ... The hospice will maintain records on the use of volunteers for patient care and administrative services, including the type of services and time worked." Reference #2: Facility document titled, "Volunteer Documentation" states, "All volunteers are required to document each attempt and/or contact with the patient or family member(s). Every visit, phone call, mail, e-mail, etc. must be documented in quarter hour increments and includes travel time to and from. ... Volunteers are required to record all volunteer time and mileage driven in relationship to the needs of Hospice. Volunteer hours are maintained for the following services: ... 3. Office clerical support. ... 5. Public Relations (Presentations, Health fairs, State Fair, etc.). ... ." Upon interview on 05/02/23, Staff #1 (Executive Director) identified him/herself as the Volunteer Coordinator. Staff #1 identified Staff #3 as the hospice's sole volunteer. Staff #1 stated, "[Staff #3] is an administrative volunteer only. [He/She] does not go into homes." When asked why Staff #3 does not volunteer to perform patient care duties, Staff #1 stated, "Nobody wants anyone in their home now because of COVID." Staff #1 was asked when was the last time the volunteer provided patient care services in the home. Staff #1 stated, "There was maybe a few times the volunteer was in the home, but not recently." Staff #1 was unable to recall the name of any patients who were provided volunteer services in the home. Review of the "Volunteer Hours Log" for January 2023 indicated the following: On 01/03/23, 01/10/23, 01/17/23, and 01/26/23, the volunteer activity was listed as "delivery." Upon interview, Staff #1 stated the volunteer "will sometimes deliver supplies to patients if they need it." Staff #1 was unable to provide documentation of delivery visits including what was delivered, name and address of delivery recipient, or mileage driven for delivery. On 01/05/23, 01/06/23, 01/09/23, 01/11/23, 01/13/23, 01/16/23, 01/20/23, 01/24/23, 01/30/23, and 01/31/23, the volunteer activity was listed as "office." Upon interview, Staff #1 stated, "[Staff #3] comes to the office and does whatever we need [him/her] to do. It depends on what we need." Staff #1 was unable to provide documentation of volunteer activities including phone calls made or received, mailings, emails, telephone communication with patients or families, or any other activities he/she may have performed while working in the office. On 02/01/23, 02/09/23, 02/15/23, 02/20/23, 02/23/23, and 02/27/23, the volunteer activity was listed as "delivery." Staff #1 was unable to provide documentation of delivery visits including what was delivered, name and address of delivery recipient, or mileage driven for delivery. On 02/03/23, 02/07/23, 02/08/23, 02/13/23, 02/17/23, 02/22/23, 02/24/23, and 02/28/23, the volunteer activity was listed as "office." Staff #1 was unable to provide documentation of volunteer activities including phone calls made or received, mailings, emails, telephone communication with patients or families, or any other activities he/she may have performed while working in the office. In March 2023, the volunteer signed on the "Volunteer Hours Log" that he/she volunteered on the following dates: 03/01/23, 03/03/23, 03/06/23, 03/08/23, 03/10/23, 03/13/23, 03/15/23, 03/16/23, 03/17/23, 03/22/23, 03/27/23, and 03/30/23. There was no volunteer activity listed for any of the above referenced dates. There was no indication of what services the volunteer performed on those dates. On 04/07/23, 04/11/23, 04/18/23, and 04/20/23, the volunteer activity was listed as "delivery." Staff #1 was unable to provide documentation of delivery visits including what was delivered, name and address of delivery recipient, or mileage driven for delivery. On 04/03/23, 04/05/23, 04/10/23, 04/13/23, 04/17/23, 04/19/23, 04/24/23, 04/26/23, and 04/27/23, the volunteer activity was listed as "office." Staff #1 was unable to provide documentation of volunteer activities including phone calls made or received, mailings, emails, telephone communication with patients or families, or any other activities he/she may have performed while working in the office. Upon interview on 05/02/23 at 10:08 AM, Staff #1 stated, "I didn't know we needed to keep track of everything [he/she] does. I didn't write everything down." A telephone interview was conducted with Staff #3 on 05/02/23 at 10:35 AM. Staff #3 confirmed that he/she is the only volunteer in the facility. Staff #3 stated that he/she works full-time as an EMT (Emergency Medical Technician) in Pennsylvania, where he/she lives. Staff #3 stated, "I work full-time as an EMT. I work overnights three nights a week from 7:00 PM to 7:00 AM. My schedule varies - the first week I work Thursday, Friday, and Saturday and the second week I can work Monday, Tuesday, and Wednesday. I try to volunteer at the hospice about 3 to 4 days a week, depending on when I can do it." Staff #3 was asked to describe his/her volunteer duties. Staff #3 stated, "I do deliveries. I deliver packets of stuff to the aides (nurse's aides) when they need it. Most of my deliveries are in North Jersey. When I'm in the office I do office stuff like filing and stapling." This surveyor asked Staff #3 how he/she was able to work overnight until 7:00 AM in Pennsylvania, report to the hospice located in South Jersey by 10:00 AM as indicated on the "Volunteer Hours Log," then drive to North Jersey to deliver supplies, without any sleep. Staff #3 stated, "I don't do deliveries when I come from work. I stay in the office. I don't want to get in an accident." Staff #3 was asked when was the last time he/she volunteered at the hospice. Staff #3 stated, "I'm not sure. I don't have my schedule with me. I can call you back when I get home." Staff #3 was asked to give an estimate of the last time he/she volunteered (last week, two weeks ago, last month, etc.). Staff #3 again stated he/she could not recall and would need to look at his/her calendar. Review of the "Volunteer Hours Log" indicated Staff #3 last volunteered at the hospice on 04/27/23, five days prior to the telephone interview.

Based on medical record review, staff interviews, and review of facility documents, it was determined the facility failed to ensure that core and non-core services are provided to patients. --- Findings include: 1. The Governing Body failed to ensure that social work services, spiritual care services, and volunteer services, are offered and provided to patients and caregivers based on their needs. (Cross refer to Tag L0652). 2. The facility failed to ensure that administrative oversight over physical therapy (PT), occupational therapy (OT), speech language pathology (SLP), and dietician services, was maintained. (Cross refer to Tag L0655).

Based on review of nine of ten medical records (#1, #2, #3, #6, #7, #8, #9, #10, #11), staff interviews, and review of facility documents, it was determined the Governing Body failed to ensure that social work services, spiritual care services, and volunteer services, are offered and provided to patients and caregivers based on their needs. --- Findings include: Reference: Facility policy titled, "Governing Body" states, "The Governing Body assumes full legal authority and responsibility for the operation of this Hospice Agency. ... Governing Body Members: [Staff #2], [Staff #1], [Staff #4], [Staff #9] ... ." On 05/03/23 and 05/04/23, review of the medical records of P1, P2, P6, P7, P8, P9, P10, and P11 lacked evidence that comprehensive social services assessment visits were completed to identify the patient or caregiver's need for social work services. The patient's "Initial Plan of Care/Physician Orders" form has the frequency of social worker visits crossed out and the word "refused" written over the initial frequency order. Pre-printed notes found in some of the medical records state, "Patient/PCG [patient caregiver] declined SW [social work] visit at this time. Social Worker will follow up and continue to offer social work support services, as appropriate". The pre-printed notes do not indicate why the patient or caregiver is refusing social work services. There was no evidence that the social worker continued to offer support to the patient or caregiver. On 05/03/23 and 05/04/23, review of the medical records of P1, P2, P6, P7, P8, P9, P10, and P11 lacked evidence that spiritual care assessment visits were completed to identify the patient or caregiver's need for spiritual services. The patient's "Initial Plan of Care/Physician Orders" form has the frequency of chaplain visits crossed out and the word "refused" written over the initial frequency order. Pre-printed notes found in some of the medical records state, "Patient decline Chaplain visit at this time will continue to offer." The pre-printed notes do not indicate why the patient or caregiver is spiritual services. There was no evidence that the chaplain continued to offer support to the patient or caregiver. On 05/03/23 and 05/04/23, review of the medical records of P1, P3, P6, P7, P9, and P10 lacked evidence that volunteer services were offered or provided to the patients. Upon interview on 05/04/23 at 9:30 AM, Staff #1 (Executive Director) was asked his/her role at the agency. Staff #1 stated, "I am the Executive Director and I overlook the processes of the hospice. I report to [Staff #2]." Staff #2 (Administrative Director) was asked his/her role at the agency. Staff #2 stated, "I am the Administrator. I oversee the whole process. I make sure everything is in compliance. I oversee the day-to-day operations." Staff #1 and Staff #2 confirmed that they are both members of the Governing Body. At 10:00 AM, Staff #2 was asked if he/she was aware that the social worker and chaplain were not performing comprehensive assessments on admission, as indicated in facility policy. Staff #2 stated, "I oversee staff and I'm aware of what's happening with them." Staff #2 was asked if he/she was aware that patients were not receiving social work, spiritual care, or volunteer services. Staff #2 then stated that the patients and caregivers are "refusing" those services. Staff #2 was asked if the agency has provided education to patients and caregivers about the services they are refusing, to encourage them to utilize the services. Staff #2 stated, "No." Staff #2 was asked what steps were taken after the agency identified that a large number of patients were refusing vital services. Staff #2 stated that the agency has not taken any measures to ensure that patients receive social work, spiritual care, and volunteer services.

Based on staff interviews and review of facility documents, it was determined the facility failed to ensure that administrative oversight over physical therapy (PT), occupational therapy (OT), speech language pathology (SLP), and dietician services, is maintained. --- Findings include: Reference #1: Facility policy titled, "Coordination of Services - Core and Non-Core Services" (last reviewed 04/04/23) states, " ... Non-Core services may be provided directly by the hospice or under arrangements made by the hospice. ... 4. Non-Core services include: a) Physical therapy, occupational therapy, and speech-language pathology. ... ." Reference #2: Facility policy titled, "Coordination of Services - Dietary Counseling" (last reviewed 04/04/23) states, " ... The Hospice will provide dietary counseling when needed. Procedure: Dietary counseling, when identified in the plan of care, must be performed by a qualified individual, which include: a) Dietitians ... ." During the entrance conference on 05/01/23 at 9:30 AM, Staff #1 (Executive Director) and Staff #2 (Administrative Director) confirmed that the facility provides PT, OT, SLP, and dietary services to patients as needed. Staff #2 stated the facility has an arrangement with outside agencies to provide the services. At 12:30 PM, Staff #2 provided contracts for Physical Therapy services, Occupational Therapy services, and Speech Therapy services signed on 06/29/15 by Staff #2 and a representative of the contracted provider. All three contracts contained a clause that stated, "This Agreement shall commence on the effective date and shall be in full force and effect until terminated by either party by giving notice to the other party." Staff #2 provided a contract for Registered Dietician services signed on 06/16/15 by Staff #1 and a representative of the contracted provider. A clause in the Registered Dietician contract states, "This contract will continue and be binding upon both parties unless terminated as herein provided." Upon interview, Staff #2 stated the contract agreements for Physical Therapy services, Occupational Therapy services, Speech Therapy services, and Registered Dietician services were currently active. During an interview on 05/03/23 at 1:30 PM, Staff #4 was asked how he/she refers patients for core and non-core services within the hospice. Staff #4 stated that if the patient needed PT services, he/she would find community resources for the patient because "we don't have that here. We don't have PT." Upon interview on 05/03/23 at 1:50 PM, Staff #2 stated that Staff #4 was ";confused." Upon interview on 05/04/23 at 10:15 AM, Staff #2 again confirmed that the PT, OT, SLP, and dietician contracts were active. Staff #2 was asked the last time a patient was referred for PT, OT, SLP, or dietician services. Staff #2 stated, "It's been a while. Before COVID was the last time we referred patients to PT." Staff #2 was asked to contact the contracted PT, OT, Speech, and Dietary service providers identified in the contracts to initiate a ";mock" referral and confirm the contracts were still active. At 11:00 AM, in the presence of this surveyor, Staff #2 attempted to contact Staff #10 using his/her personal cellphone. Staff #2 stated this person was a Physical Therapist and the owner of the company contracted to provide PT services. When asked why he/she was calling Staff #10 on his/her personal cell phone and not using the contracted agency's business number listed on the contract, Staff #2 did not have an answer. At 11:01 AM, Staff #10 called Staff #2 on his/her cellphone, spoke to him/her, then hung up. Staff #2 stated Staff #10 ";was sick for a few days and will call me later when [he/she] gets in the office." When asked why Staff #2 did not allow Staff #10 to speak to this surveyor to verify that the facilitys PT contract was still active, Staff #2 stated, ";I cannot speak for [him/her]." Staff #2 was asked to call the business numbers listed on the PT, OT, Speech, and Dietary contracts to confirm the contracts were still active. Staff #2 refused and stated, ";Im not going to go against [him/her]." The facility was unable to provide evidence of any patients referred for PT, OT, SLP, or dietician services. The facility was unable to provide evidence that the contracts for PT, OT, SLP, and dietician services were active and that those services can be provided to patients requiring them under arrangement.

Observed in Record Review. In 2 of 2 patient records reviewed, the comprehensive care plan did not reflect the services and or interventions required based on the comprehensive assessment. The nursing assessment reflected that RR#1 had bilateral leg pain, edema and wore compression stockings. The comprehensive care plan (nor any updates to the care plan) did not reflect any interventions related to these identified problems. Similarly, the nursing assessment of RR#2 reflected that the patient had delusions, depression, and anxiety. The comprehensive care plan (nor any updates to the care plan) did not reflect any interventions associated with these identified problems. These observations were discussed with the administrator.

Observed in Individual Tracer. In 2 of 2 patient records reviewed, the Hospice Care Plan did not include goals that were measurable related to needs identified on the assessment. None of the goals listed on the care plans and updates to the care plans of RR#1 and RR#2 had target dates. For example, RR#1 had nausea, vomiting and respiratory distress identified as issues but there were no associated target dates for the goals. These same goals have been present since admission which occurred almost one year ago. This observation was discussed with the administrator.

Observed in Infection Control System Tracer. Based on a review of the 2022 infection control plan (which included the risk assessment), the corona virus was not listed as a priority although the DOH literature search performed by the organization, listed this virus as an issue. There were no measurable goals or strategies outlined on the IC Plan that addressed the Corona Virus. This observation was discussed with the administrator.

Observed in Leadership Session. No evidence that the governing body and leadership had established processes to support patient care treatment and services through sustained compliance as evidenced by a continued lack of the development of measurable goals for patient care plans 418.56.

Observed in Record Review. In 2 of 2 patient records reviewed, the Hospice did not maintain clinical information that was in useable formats for the hospice staff and or surveyor. For example, the clinical record was on paper and utilized templates for the care planning. The clinician would draw a squiggly line through multiple interventions but not check the section for identified problem. Additionally, the narrative sections were unable to be read by this surveyor or the hospice administrator. These illegible sections included orders, medications, and the clinical status of patients RR#1 and RR#2.

Observed in Individual Tracer. In 2 of 2 new patient records reviewed, RR1, RR2 during record review the surveyor noted the organization did not show evidence the plan of care was based on goals, time frames, services required to meet the goals. For example, the goals documented on the IDG/POC had the same time frame to achieve the goals at end of cert period or did not have a time frame identified. For example, Patient will remain free of respiratory distress; optimal quality of life, maintain personal care and ADL's. HHA will assist with personal needs 5 times/week. Client will remain free of skin breakdown and will be free of infection this cert. period. However, the patient had a wound on the left leg with a topical cream applied twice daily. In addition, it was noted the patient was not assessed for anticipatory grief during the initial comprehensive assessment nor were there any psychosocial or spiritual goals identified on the plan of care. RR2 the goals included patient and caregiver will have adequate sleep and rest. Skin will be free of infection and breakdown, left heel to promote healing this cert period. Will remain free of respiratory distress this cert period; the patient was admitted with severe protein malnutrition; however, the nutrition risk assessment was scored as low and goal under nausea and vomiting stated adequate nutrition within disease limitation and free from aspiration. On October 18, 2022, an in-service was conducted by the DPCS regarding individualized plan of care, comprehensive plan of care based upon patient assessment, problems and needs, developing goals and interventions based upon the problems/needs.

Observed in Individual Tracer. In 2 of 2 patient records with oxygen, RR2, during the record review, the surveyor noted the patient had severe protein malnutrition, however nutrition risk was scored as low, no BMI or MAC documented; interventions included cutting up food; RR1, RR2 during the record review the surveyor noted the organization failed to conduct an oxygen safety risk assessment when oxygen was initiated. For example, RR1, RR2 both patients were admitted without oxygen but subsequently had oxygen ordered and initiated. There was no evidence that the oxygen was added to the problem list or interventions updated/developed based upon the change in condition. There was no oxygen risk assessment re-evaluated for RR1 and RR2, when oxygen was initiated two weeks after admission or interventions related to oxygen use and safety.

Observed in Infection Control System Tracer. The goal associated with Improving and hygiene did not include an objective or measurable goal. The surveyor was provided a Hand Hygiene Handwashing Compliance 2022 report the reflected data tracked in 2022 for Q1, Q2, Q3. The Administrator stated the observations were conducted during the annual skills competency by the DPCS and were recorded on the competency skills form. The results were collated and retrospectively counted for each quarter. All results reflected 100% compliance however, no surveillance was conducted yet in Q4, following the in-service. There was no 2021 data provided. However, upon review of the tool used for data collection, the surveyor the tool was an undated teaching sheet that included pictures ad 14 hand washing steps which did not include hand hygiene/gloving. This document was signed but not dated by the individual employee, not the observer. There was no documentation in the Infection Control Plan or in a hand hygiene program plan that indicated a goal, frequency of monitoring compliance or ongoing surveillance. An in-service was conducted on November 16, 2022, by the Medical Director and the DPCS on the Infection Prevention and Control Program. According to the Administrator a full day of education included topics: hand hygiene, bag technique, information on influenza, COVID precautions, basic education on pathogen transmission, proper use and cleaning of equipment such as thermometers, blood pressure cuffs, pulse oximeter, PPE, Guide for Infection Prevention in Outpatient settings and the top infections in the geographic service area. No surveillance activities have occurred in Q4 or following the in-service. Observed in Infection Control System Tracer. Upon review of the Infection Control plans presented, the surveyor noted the organization had not shown evidence it had corrected/updated the 2021 plan. There was no goal identified/included in the new updated 2022 plan associated with limiting the spread of infections with the use of equipment and supplies. An in-service was conducted on November 16, 2022, by the Medical Director and the DPCS on the Infection Prevention and Control Program. According to the Administrator a full day of education included topics: hand hygiene, bag technique, information on influenza, COVID precautions, basic education on pathogen transmission, proper use of equipment such as thermometers, blood pressure cuffs, pulse oximeter, PPE, Guide for Infection Prevention in Outpatient settings and the top infections in the geographic service area. The Administrator stated patient specific infections are discussed at IDG, however no analysis or goal documented. No surveillance activities have occurred in Q4 or following the in-service. Observed in Infection Control System Tracer. Upon review of an undated plan (Administrator states it is 2022) the surveyor noted the written plan presented had not been updated/corrected to include a goal associated with the limiting of the spread of infections from pathogens. The plan stated: Limiting unprotected exposure to pathogens. There was no measurable goal documented.An in-service was conducted on November 16, 2022, by the Medical Director and the DPCS on the Infection Prevention and Control Program. According to the Administrator a full day of education included topics: hand hygiene, bag technique, information on influenza, COVID precautions, education on pathogen transmission, proper use of equipment such as thermometers, blood pressure cuffs, pulse oximeter, PPE, Guide for Infection Prevention in Outpatient settings the top infections in the geographic service area. No surveillance activities have occurred in Q4 or following the in-service. Observed in Infection Control System Tracer. The surveyor was provided a Hand Hygiene Handwashing Compliance 2022 report that reflected data tracked in 2022 for Q1, Q2, Q3. The Administrator stated the observations were conducted during the annual skills competency by the DPCS and were recorded on the competency skills form. The results were collated and retrospectively counted for each quarter. All results reflected 100% compliance. No surveillance activities were conducted in Q4, following the recent in-service. Upon review of the tool used for data collection, the surveyor noted the tool was an undated teaching sheet that included pictures and 14 hand washing steps which did not include hand hygiene/gloving. This document was signed but not dated by the individual employee, not the observer. There was no documentation in the Infection Control Plan or a Hand Hygiene Program Plan that indicated goals, frequency of monitoring compliance or ongoing surveillance. An in-service was conducted on November 16, 2022, by the Medical Director and the DPCS on the Infection Prevention and Control Program. According to the Administrator a full day of education included topics: hand hygiene, bag technique, information on influenza, COVID precautions, basic education on pathogen transmission, proper use and cleaning of equipment such as thermometers, blood pressure cuffs, pulse oximeter, PPE, Guide for Infection Prevention in Outpatient settings and the top infections in the geographic service area. No surveillance activities have occurred in Q4 or following the in-service. Observed in Infection Control System Tracer. The Infection Control Plan presented to the surveyor was undated. The 2021 Infection Prevention and Control Plan prioritized risks had not been updated/corrected to include an associated goal. The prioritized goals included in the undated new plan (Administrator stated was for 2022) were: UTI, URI, GI and any illness determined to be reportable to the state and local health departments, however, there were no Infection Prevention and Control goals documented that were associated with those prioritized risks. It was noted that 3 infections were recorded in 2022 however 2 of the 3 infections did not include the source only infection was listed as reason; there was one wound infection, however this was not listed as a prioritized risk. Observed in Infection Control System Tracer. Upon review of the plan presented to the surveyor, it was noted there was no evidence the plan had been corrected or updated to include an objective measurable goal associated with limiting the spread of infections associated with procedures. For example the plan did not include any goals related to Limiting the spread of infections associated with procedures.An in-service was conducted on November 16, 2022, by the Medical Director and the DPCS on the Infection Prevention and Control Program. According to the Administrator a full day of education included topics: hand hygiene, bag technique, information on influenza, COVID precautions, basic education on pathogen transmission, proper use of equipment such as thermometers, blood pressure cuffs, pulse oximeter, PPE, Guide for Infection Prevention in Outpatient settings the top infections in the geographic service area. No surveillance activities have occurred in Q4 or following the in-service.

Observed in Leadership Session. The Governing Body /leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation and staff interviews. 418.60, 418.56, 418.100.

Observed in Emergency Management Session. It was noted that the organization's emergency plan did not specifically state that the organization would contact state or local officials when the organization could not locate or communicate with any on-duty staff during an emergency. Observed in Emergency Management Session. It was noted that the organization's emergency plan did not specifically state that the organization would contact state or local officials when the organization could not locate or contact a patient or if a patient would need evacuation during an emergency.

Observed in Record Review. In 4 of 4 appropriate records reviewed, it was noted that for patients with pain who were cognitively impaired, there was no objective pain scale like FACES, or FLACC used to report pain without bias.

Observed in Patient Home. During one hospice home visit the medication reconciliation was not accurate. The medication of Restasis prescription eyedrops which the patient began using in August was not on the medication profile. Also the medication Xanax was listed on the medication profile to be taken once a day, however the patient was taking the Xanax as listed on the prescription bottle as twice a day for several months

Observed in Patient Home. There was no order obtained for Respite Care -- the family arranged the Respite Care through New Jersey Medicaid -- and the Hospice staff continues to visit the hospice patient in the Respite Care facility

Observed in Patient Home. In 11 of 11 patient records reviewed, it was noted that goals for IDT were not specific to the patients involved, updated or had time frames. For instance, when the patient's pain increased and a fentanyl patch was added, there was no update to the IDG notes. None of the IDG goals have time frames associated with the goals for the patients. All the patients had a similar goal for Safety/ Infection-: which stated verbatim as- -- Fall prevention, ambulation safety instructed, proper hand hygiene advised, remove clutter, to prevent falls, educated report any changes, COVID precautions.

Observed in Infection Control System Tracer. For the 2022 IC Plan the organization found that URI, UTI and Covid were prioritized risks, however there were no IC goals noted that discussed the goal associated with those prioritized risks . And there were no other Infection goals listed for the 2022 IC Plan. Observed in Infection Control System Tracer. It was noted that the organization had not set an infection prevention goal for limiting the spread of infection with hand hygiene. Observed in Infection Control Tracer. There was no written Infection Control Goal for limiting the spread of infections with the use of equipment and supplies. for the 2021 or the 2022 Infection Plans Observed in Infection Control System Tracer. There was no Infection Prevention Goal listed for limiting the spread of infection from pathogens for 2021 and 2022. Observed in Infection Control System Tracer. There was no surveillance , monitoring or analysis of any data for hand hygiene program during 2021 and 2022. Observed in Infection Control System Tracer. It was noted that the organization had not set an infection prevention goal for limiting the spread of infection with procedures.

Observed in Patient Home. It was noted on one hospice aide care plan, there was no instruction for the aide to remove the patient oxygen when the aide is assisting with the shower for the patient.

Observed in Record Review. The RN did not document that she administered the medication Bydureon-BCise 2 mg subcutaneously on a recertification visit in April.