Every finding on record at Clarity Health Services Sc, LLC

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The hospice EP training program includes the following: for all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles, demonstration of staff knowledge of emergency procedures, EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years, more frequent training occurs if there is a significant update of EP policies and procedures, a periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others, and documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by document review, interview, and personnel record review. In 9 of 10 (90%) personnel records reviewed of employees hired greater than two years ago revealed the agency did not ensure emergency preparedness training was provided and documented at least every two years. Annual Education RHC 2025, 2024, 2023: Annual education RHC 2025 provided to site visitors as evidence of annual in-services. The cover page of the packet included the names and signatures of each employee. The packet included attestations from each employee that read, "I__(Name), hereby state that I have read the Code of Conduct, including the conflict-of-interest policy dated August 2024. I agree to comply with all provisions of the Code of Conduct during my employment or tenure. If I become aware of an actual or potential conflict of interest, I will promptly notify and disclose the circumstances to the Administration/Compliance Officer. Employee Signature and Date." PERSONNEL RECORD 3: The Chaplain was hired 10/10/2012 and included Emergency Preparedness training upon hire. There was no documented evidence in the personnel record of Emergency Preparedness training every two years after the initial training at time of hire. PERSONNEL RECORD 4: The Licensed Medical Social Worker (LMSW) was hired 01/04/2023 and included Emergency Preparedness training upon hire. There was no documented evidence in the personnel record of Emergency Preparedness training every two years after the initial training at time of hire. PERSONNEL RECORD 5: The Chaplain was hired 01/07/2016 and included Emergency Preparedness training upon hire. There was no documented evidence in the personnel record of Emergency Preparedness training every two years after the initial training at time of hire. PERSONNEL RECORD 6: The Bereavement Coordinator/ Social Worker (LCSW) was hired 07/20/2009 and included Emergency Preparedness training upon hire. There was no documented evidence in the personnel record of Emergency Preparedness training every two years after the initial training at time of hire. PERSONNEL RECORD 7: The Volunteer Coordinator was hired 02/28/2024 and included Emergency Preparedness training upon hire. There was no documented evidence in the personnel record of Emergency Preparedness training every two years after the initial training at time of hire. PERSONNEL RECORD 8: The hospice aide was hired 06/18/2016 and included Emergency Preparedness training upon hire. There was no documented evidence in the personnel record of Emergency Preparedness training every two years after the initial training at time of hire. PERSONNEL RECORD 9: The Administrator was hired 08/21/2012 and included Emergency Preparedness training upon hire. There was no documented evidence in the personnel record of Emergency Preparedness training every two years after the initial training at time of hire. PERSONNEL RECORD 10: The Medical Director was hired 12/20/2010 and included Emergency Preparedness training upon hire. There was no documented evidence in the personnel record of Emergency Preparedness training every two years after the initial training at time of hire. PERSONNEL RECORD 12: The Registered Nurse (RN) was hired 10/02/2023 and included Emergency Preparedness training upon hire. There was no documented evidence in the personnel record of Emergency Preparedness training every two years after the initial training at time of hire. The Compliance Officer stated in an interview on 03/27/2026, "We review policies for emergency preparedness every year and it is included in our annual compliance education and staff sign an attestation." The Compliance Officer confirmed that there is no documentation that the specifies that emergency preparedness education was completed with all staff minimally every two years.

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by document review, personnel record review, and interview. In 10 of 10 (100%) personnel records reviewed of employees hired greater than a year revealed that the agency did not ensure that all employees had a record of annual infection control training documented in the personnel file, consistent with agency policy. Policy and Procedures: Agency policy no. C:2-040.1, titled "Infection Control Plan" stated in part, Procedure 3. Infection control in-services will be scheduled no less than annually. A. Attendance will be mandatory and will be documented. Records of in-service attendance will be maintained in the personnel file." Annual Education RHC 2025, 2024, 2023: Annual education RHC 2025 provided to site visitors as evidence of annual in-services. The cover page of the packet included the names and signatures of each employee. The packet included attestations from each employee that read, "I__(Name), hereby state that I have read the Code of Conduct, including the conflict-of-interest policy dated August 2024. I agree to comply with all provisions of the Code of Conduct during my employment or tenure. If I become aware of an actual or potential conflict of interest, I will promptly notify and disclose the circumstances to the Administration/Compliance Officer. Employee Signature and Date." PERSONNEL RECORD 2: The Licensed Practical Nurse was hired on 04/08/2015. The orientation checklist included infection control training, however, there was no further documented evidence in the personnel record to demonstrate annual training related to infection control in-services or training. PERSONNEL RECORD 3: The Chaplain was hired 10/10/2012. The orientation checklist included infection control training, however, there was no further documented evidence in the personnel record to demonstrate annual training related to infection control in-services or training. PERSONNEL RECORD 4: The Licensed Medical Social Worker was hired 01/04/2023. The orientation checklist included infection control training, however, there was no further documented evidence in the personnel record to demonstrate annual training related to infection control in-services or training. PERSONNEL RECORD 5: The Chaplain was hired 01/07/2016. The orientation checklist included infection control training, however, there was no further documented evidence in the personnel record to demonstrate annual training related to infection control in-services or training. PERSONNEL RECORD 6: The Bereavement Coordinator/ Social Worker (LCSW) was hired 07/20/2009. The orientation checklist included infection control training, however, there was no further documented evidence in the personnel record to demonstrate annual training related to infection control in-services or training. PERSONNEL RECORD 7: The Volunteer Coordinator was hired 02/28/2024. The orientation checklist included infection control training, however, there was no further documented evidence in the personnel record to demonstrate annual training related to infection control in-services or training. PERSONNEL RECORD 8: The Hospice Aide was hired 06/18/2016. The orientation checklist included infection control training, however, there was no further documented evidence in the personnel record to demonstrate annual training related to infection control in-services or training. PERSONNEL RECORD 9: The Director of Nursing/Administrator was hired 08/21/2012. The orientation checklist included infection control training, however, there was no further documented evidence in the personnel record to demonstrate annual training related to infection control in-services or training. PERSONNEL RECORD 10: The Medical Director was hired 12/20/2010. The orientation checklist included infection control training, however, there was no further documented evidence in the personnel record to demonstrate annual training related to infection control in-services or training. PERSONNEL RECORD 12: The Registered Nurse (RN) was hired 10/02/2023. The orientation checklist included infection control training, however, there was no further documented evidence in the personnel record to demonstrate annual training related to infection control in-services or training. The Compliance Officer reported on 03/27/2026, that all in-services were completed in the form of policy review during the compliance review and all staff sign an attestation of understanding. The Compliance Officer confirmed that there was no document that confirmed annual education specifically related to infection control.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. The agency did not ensure that viable and ongoing efforts to recruit volunteers were completed and documented to recruit and retain volunteers. Review of the agency's QAPI (Quality Assurance Performance Improvement) program revealed the agency identified the number of volunteers as a performance improvement area within the QAPI plan, the plan did not include any actionable items or any specific efforts in to recruit volunteers. The Volunteer Coordinator was interviewed on 03/24/2026 and reported that she attempts to recruit volunteers at nearby colleges and does try to recruit at church. There was no documentation to demonstrate efforts to recruit. The agency did not ensure that viable and ongoing efforts to recruit volunteers were completed and documented to recruit and retain volunteers.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of the volunteer activity records revealed that the agency did not ensure that 5% of total services were provided by volunteers. Interviews with the Volunteer Coordinator on 03/25/2026 and Administrator/Director of Nursing on 03/26/2026 revealed that Volunteer hours for 2025 averaged 2.4%, for 2024 averaged 3.8%, and for 2023 averaged 1.2%. The Administrator additionally stated that the percentages have not reached the 5% requirement in the past 3 years. The Volunteer Coordinator stated that there are challenges associated with primarily using students as volunteers. They explained, there is also a Performance Improvement Plan in place with the Quality Assurance team. A review of the volunteer activity records revealed that the Agency did not ensure that 5% of total services were provided by volunteers. Interviews with the Volunteer Coordinator on 3/25/2026 and Administrator/DON on 3/26/2026 revealed that Volunteer hours for 2025 averaged 2.4%, for 2024 averaged 3.8%, and for 2023 averaged 1.2%. Administrator additionally stated that the percentages have not reached the 5% requirement in the past 3 years. Volunteer Coordinator stated that there are challenges associated with primarily using students as volunteers; we discussed the possibility of expanding recruitment efforts to bring in older adults, as well as different areas that they might provide support. There is also a Performance Improvement Plan in place with the Quality Assurance team.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I; This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed in which the patient was transferred to a Medicare facility revealed that the agency did not ensure the receiving facility received a discharge summary. Clinical Record 15: The patient was discharged on 11/21/2025 and transferred to a skilled nursing facility. The clinical record contained a discharge summary, but there was no evidence that the discharge summary was sent to the receiving facility. The Compliance officer confirmed that a discharge summary should have been provided to the facility, but there was no evidence that it was provided to the facility. The compliance officer stated in an interview on 03/26/2026, "We identified that discharge summaries were an issue a couple of weeks ago and created a performance improvement plan."

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed with patient discharge revealed that the agency did not ensure the discharge summaries were sent to the physician when a patient was discharged. CLINICAL RECORD 14: The patient was discharged from hospice services on 09/16/2025. The clinical record contained a discharge summary but there was no evidence that the discharge summary was sent to the physician. Clinical Record 15: The patient was discharged on 11/21/2025. The clinical record contained no evidence that a discharge summary was provided to the physician. Reviewed clinical records with Compliance Officer on 03/26/2026. The Compliance Officer stated, "There should be documentation in a note or the discharge summary that it was sent, if it was, but there is no documentation. We recently found that this was a problem."

It is required that each patient in the hospice inpatient facility always has an adequate supply of hot water and has plumbing fixtures with control valves that automatically regulate the temperature of the hot water used by patients. This standard was not met as evidenced by interview and observation. The hospice inpatient facility (IPU) did not ensure that plumbing fixtures included control valves that automatically regulated the temperature of the hot water used by patients. During the tour of the IPU on 03/26/2026 with the Assistant Director of Nursing (DON) and the Hospice Chief Executive Officer (CEO), the water temperature in patient room #104 was measured at 117 degrees, and in patient room #105 at 119 degrees. During an interview on 03/26/2026, the Assistant DON and the Hospice CEO agreed with the observed water temperature and asked the staff present to turn down the water heater temperature, which was immediately done. During tour of IPU on 3/26/2026 with the Assistant DON and the hospice CEO, revealed that the agency did not ensure compliance with safe water temperatures.

Based on interviews and record review, the Hospice agency’s inpatient facility failed to have a system in place to ensure a patient’s clinical record included accurate documentation of all inpatient services provided.  This deficient practice was evidenced by failure to maintain an accurate Medication Administration Record (MAR) reflective of medications administered during respite care for 1 (#1) of 3 (#1, #2, and #3) patients reviewed in the sample.  This deficient practice had the potential to affect a current inpatient census of 11 patients. --- Findings: Review of the American Nursing Association’s publication titled “Principles for Nursing Documentation”, published Spring 2010, revealed, in part, the following: Summary: Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice.Timely documentation of the following types of information should be made and maintained in a patient’s Electronic Health Record to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: MAR.Principle 5. Documentation Entries - Entries into the MAR must be:Accurate, valid, and complete; andDated and time-stamped by the persons who created the entry.Review of the Hospice agency’s policy number H:2-057.1, titled, “Administration and Documentation of Medications”, revised April 2013, revealed, in part, the following: Policy:Licensed nursing personnel will administer and document medications.  Review of Patient #1’s Clinical Record revealed she was admitted to the inpatient facility for respite care from 08/21/2025 through 08/22/2025.  Further review revealed, in part, a current Certification Period of 08/21/2025 through 11/18/2025 with a terminal diagnosis of Heart Failure and Comorbidities including Acute and Chronic Respiratory Failure with Hypoxia.  Review of Patient #1’s Physician’s Orders, dated 08/21/2025 through 08/22/2025, revealed, in part, the following active Physician’s Orders during her respite stay: 08/21/2025 - Alprazolam Tablet 0.5 mg.  Give 1/2 tablet every 4 hours as needed (PRN) for anxiety/dyspnea;08/21/2025 - Ipratropium Bromide/Albuterol Sulfate 2.5 mg/3 mL Ampule.  Give 1 nebulizer treatment via inhalation 4 times a day PRN for dyspnea/wheezing; and08/22/2025 - Morphine Sulfate Oral Solution 100 milligrams (mg)/5 milliliters (mL).  Give 10mg every 2 hours PRN for shortness of breath/pain.  Review of Patient #1’s Nurse Service Notes, dated 08/21/2025 through 08/22/2025, revealed, in part, the following:08/21/2025 at 7:15 p.m. by S2RN - Administered Ipratropium Bromide/Albuterol Sulfate Nebulizer treatment;08/22/2025 at 7:00 a.m. by S3LPN – Administered Ipratropium Bromide/Albuterol Sulfate Nebulizer treatment;08/22/2025 at 7:45 a.m. by S3LPN - Administered Alprazolam Tablet and Morphine Sulfate Oral Solution; and 08/22/2025 at 10:30 a.m. by S3LPN - Administered Ipratropium Bromide/Albuterol Sulfate Nebulizer treatment.Review of Patient #1’s MAR, dated 08/21/2025 through 08/22/2025, as of 09/18/2025, revealed, in part, no documented evidence to indicate the following medications were administered:08/21/2025 at 7:15 p.m. – Ipratropium Bromide/Albuterol Sulfate Nebulizer;08/22/2025 at 7:00 a.m. – Ipratropium Bromide/Albuterol Sulfate Nebulizer;08/22/2025 at 7:45 a.m. – Morphine Sulfate Oral Solution;08/22/2025 at 7:45 a.m. – Alprazolam Tablet; and 08/22/2025 at 10:30 a.m. – Ipratropium Bromide/Albuterol Sulfate Nebulizer.An interview was conducted on 09/18/2025 at 2:15 p.m. with S3LPN.  S3LPN confirmed Patient #1 received a nebulizer treatment on 08/22/2025 around 7:00 a.m.  S3LPN confirmed Patient #1 received a dose of Morphine Sulfate Oral Solution and Alprazolam on 08/22/2025 at 7:45 a.m.  S3LPN confirmed Patient #1 received a nebulizer treatment on 08/22/2025 at 10:30 a.m.  S3LPN confirmed the aforementioned medication administrations were not documented on Patient #1’s MAR and should have been.   An interview was conducted on 09/18/2025 at 2:00 p.m. with S1ADM.  S1ADM confirmed she expected a patient’s MAR to accurately reflect all medications administered while in the agency’s facility.  S1ADM reviewed Patient #1’s Clinical Record and confirmed the aforementioned medication administrations were not documented on Patient #1’s MAR and should have been.

Based on record reviews and interviews, the agency failed to ensure a patients Plan of Care (POC) was individualized with treatments and goals necessary for problems identified during assessment for 1 (#1) of 3 (#1, #2, and #3) patients reviewed in the sample. --- Review of the facilitys Policy Number H:2-030.1, ";The Plan of Care", revised April 2013, revealed, in part, the following: Purpose: To ensure an individualized plan of care is completed that complies with accepted standards of care and regulatory issues. Policy: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The POC will meet the documentation requirements of the physician-directed medical orders and the care planning process. The POC will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members or the interdisciplinary group (IDG) and will be reviewed on a regular basis but no less than every fourteen days. This plan will focus on identified problems, goals and interventions. The patient and family/caregiver will be encouraged to participate in the development of care and continued updating of the POC. Procedure: 4. The POC will identify the patients needs and services to meet those needs, including the management of pain and discomfort and symptom relief. ...9. The POC will be reviewed and revised as frequently as deemed necessary, but not less often than every 14 days, by the IDG, with input from the attending physician, the patient and the family/caregiver, based on ongoing comprehensive assessments of the patient and family/caregiver. Review of the POC will be documented in the clinical record. Revision dates will be noted on the POC. 10. Any changes in the patients condition must result in a change in the POC, prior to the implementation of the new service. Patient #1Review of Patient #1s Clinical Record revealed he was admitted to the agency on 03/23/2023 with a terminal diagnosis of Malignant Neoplasm of Unspecified Part of Left Bronchus or Lung. Review of Patient #1s handwritten Verbal Physicians Order received from S3MD on 08/21/2024 at 12:31 p.m. by S5RN, revealed, in part, the following: Cephalexin 250 milligrams. One capsule by mouth. Every morning for 14 days. Prednisone 20 milligrams. One tablet by mouth. Twice daily for 7 days. Problem/Note: Plan of Care Updated – Unchecked. Review of the agencys handwritten ";Avoidable Events Action Boards – Patient Infection Form" for Patient #1, revealed, in part, the following: Date of Infection: 08/21/2024; Type of Event: Urinary Tract Infection (UTI); Orders received: Yes; Order received on 08/21/2024 for Cephalexin 250mg. x14 days. Review of Patient #1s POC for the Hospice Certification Period of 07/14/2024 through 09/11/2024 revealed no documentation of the UTI and cough identified during assessment on 08/21/2024. Further review revealed no documented goals and interventions to include the verbal orders received for Cephalexin and Prednisone. An interview was conducted on 10/29/2024 at 11:28 a.m. with S5RN. S5RN confirmed she assessed Patient #1 on 08/21/2024 and received verbal orders for cephalexin and prednisone. S5RN stated the cephalexin was ordered to treat a newly identified urinary tract infection and the prednisone was to manage a new cough that was causing him discomfort. S5RN stated if the newly identified infection, cough, and new medications were not reflected in the POC, she had not remembered to enter them. An interview was conducted on 10/29/2024 at 9:42 a.m. with S7RN. S7RN confirmed she was Patient #1s routine nurse and he did receive the Cephalexin and Prednisone as ordered even though neither the medications or problems were documented in his EHR. An interview was conducted on 10/29/2024 at 12:05 p.m. with S1ADM. S1ADM reviewed Patient #1s POC and confirmed it was not updated to include the treatments and goals necessary for the newly identified problems from his assessment on 08/01/2024 and should have been. An interview was conducted on 10/29/2024 at 10:35 a.m. with S4MD. S4MD confirmed a patients POC should accurately reflect their medical status at all times.

Based on record reviews and interviews, the agency failed to ensure a patients Plan of Care (POC) included all drugs and treatment necessary to meet the needs of the patient for 1 (#1) of 3 (#1, #2, and #3) patients reviewed in the sample. --- Review of the facilitys Policy Number H:2-030.1, ";The Plan of Care", revised April 2013, revealed, in part, the following: Purpose: To ensure an individualized plan of care is completed that complies with accepted standards of care and regulatory issues. Policy: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The POC will meet the documentation requirements of the physician-directed medical orders and the care planning process. The POC will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members or the interdisciplinary group (IDG) and will be reviewed on a regular basis but no less than every fourteen days. This plan will focus on identified problems, goals and interventions. The patient and family/caregiver will be encouraged to participate in the development of care and continued updating of the POC. Procedure: 4. The POC will identify the patients needs and services to meet those needs, including the management of pain and discomfort and symptom relief. ...9. The POC will be reviewed and revised as frequently as deemed necessary, but not less often than every 14 days, by the IDG, with input from the attending physician, the patient and the family/caregiver, based on ongoing comprehensive assessments of the patient and family/caregiver. Review of the POC will be documented in the clinical record. Revision dates will be noted on the POC. 10. Any changes in the patients condition must result in a change in the POC, prior to the implementation of the new service. 12. The written POC will contain, but will not be limited to, the following: A. Diagnosis.L. Individualized interventions to assist with end of life care. P. Pain and symptom management interventions. Q. Drugs and treatments.S. Physician Orders. Patient #1Review of Patient #1s Clinical Record revealed he was admitted to the agency on 03/23/2023 with a terminal diagnosis of Malignant Neoplasm of Unspecified Part of Left Bronchus or Lung. Review of Patient #1s handwritten Verbal Physicians Order received from S3MD on 08/21/2024 at 12:31 p.m. by S5RN, revealed, in part, the following: Cephalexin 250mg. One capsule by mouth. Every morning for 14 days. Prednisone 20mg. One tablet by mouth. Twice daily for 7 days. Problem/Note: Plan of Care Updated – Unchecked. Review of Patient #1s POC for the Hospice Certification Period of 07/14/2024 through 09/11/2024 revealed no documentation of drugs and treatment to reflect the verbal orders received for Cephalexin and Prednisone on 08/21/2024. Review of Patient #1s EHR Physicians Orders for the Hospice Certification Period of 07/14/2024 through 09/11/2024 revealed, in part, no electronic orders for Cephalexin and Prednisone on 08/21/2024. Review of Patient #1s Medication and Treatment Profile, both active and inactive, for the Hospice Certification Period of 07/14/2024 through 09/11/2024 revealed, in part, no documentation of Cephalexin and Prednisone initiated on 08/21/2024. An interview was conducted on 10/29/2024 at 11:28 a.m. with S5RN. S5RN confirmed she assessed Patient #1 on 08/21/2024 and received verbal orders for cephalexin and prednisone. S5RN stated the cephalexin was to treat a newly identified urinary tract infection and the prednisone was to treat a new cough he developed. S5RN stated if the medications were not reflected in the POC, she had not remembered to enter them. An interview was conducted on 10/29/2024 at 9:42 a.m. with S7RN. S7RN confirmed she was Patient #1s routine nurse and he did receive the Cephalexin and Prednisone as ordered even though neither medication was documented in his EHR. An interview was conducted on 10/29/2024 at 12:05 p.m. with S1ADM. S1ADM reviewed Patient #1s POC and confirmed there was no documentation of drugs and treatment to reflect the verbal orders received for Cephalexin and Prednisone on 08/21/2024. S1ADM confirmed a patients POC should be accurate and up to date at all times. An interview was conducted on 10/29/2024 at 10:35 a.m. with S4MD. S4MD confirmed a patients POC should accurately reflect their medical status at all times.

Based on record reviews and interviews, the hospice agency failed to ensure licensed professionals actively participated in all aspects of the patients hospice care in accordance with current professional standards. The agency failed to ensure a patients medical pronouncement of death by a coroner was based on personal observation or information and statements obtained from a qualified professional for 1 (#2) bereavement records reviewed. --- Review of Louisiana Revised Statute 9.111 revealed, in part, the following: A. A person will be considered dead if in the announced opinion of a physician, duly licensed in the state of Louisiana based on ordinary standards of approved medical practice, the person has experienced an irreversible cessation of spontaneous respiratory and circulatory functions....B. The medical pronouncement of death by a coroner may also be based on personal observation, information, or statements obtained from coroner investigators, Registered Nurses (RN), physician assistants, or emergency medical technicians at the scene who are reporting from firsthand observation of the physical condition of the deceased. ... Patient #2Review of Patient #2s Clinical Record revealed a Start of Care Date of 09/12/2024 with a Certification Period of 09/12/2024-11/10/2024, and a date of death of 09/24/2024. Review of Patient #2s On Call Visit Assessment in the Electronic Health Record (EHR) dated 09/24/2024 and written by S6LPN revealed, in part, the following: Time of Death: 7:32 p.m.Pronounced by: S6LPN. Review of Patient #2s handwritten Death Note dated 09/24/2024 by S6LPN revealed, in part, the following: Time of Death: 7:32 p.m.Pronounced by: S6LPN. Review of Patient #2s Service Note, dated 09/24/2024, revealed no documentation indicating an RN or other qualified professional was present and performed Patient #2s death assessment. An interview was conducted on 10/29/2024 at 11:20 a.m. with S6LPN. S6LPN confirmed on 09/24/2024 she performed the death assessment and pronouncement of death on Patient #2. An interview was conducted on 10/29/2024 at 11:24 a.m. with S1ADM. S1ADM confirmed the agencys process upon death was for a nurse, either Licensed Practical Nurse (LPN) or RN, to perform a death assessment to ensure the absence of vital signs then contact the coroner by phone to receive pronouncement of death and release of the body. S1ADM confirmed S6LPN had signed Patient #2s death notice which noted Patient #2s pronouncement of death was performed by S6LPN. S1ADM confirmed S6LPN had performed Patient #2s death assessment, and should not have.

Based on record reviews and interviews, the agency failed to have complete Electronic Health Records (EHR) which included responses to medications, symptom management, treatments and services for 1 (#1) of 3 (#1, #2, and #3) patients reviewed in the sample. --- Review of the agencys Policy Number H:2-030.1 titled ";The Plan of Care", revised April 2013 and reviewed on 10/29/2024, revealed, in part, the following: Purpose: To ensure an individualized plan of care is completed that complies with accepted standards of care and regulatory issues. Policy: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members or the Interdisciplinary Group (IDG) and will be reviewed on a regular basis but no less than every fourteen days. This plan will focus on identified problems, goals and interventions. Review of Patient #1s Clinical Record revealed he was admitted to the agency on 03/23/2023 with a terminal diagnosis of Malignant Neoplasm of Unspecified Part of Left Bronchus or Lung. Review of Patient #1s handwritten Physicians Order dated 08/21/2024 by S5RN, revealed, in part, the following: Cephalexin 250 milligrams. One capsule by mouth. Every morning for 14 days. Prednisone 20 milligrams. One tablet by mouth. Twice daily for 7 days. Review of Patient #1s EHR Physician Orders, dated 08/21/2024 through 09/14/2024, revealed no electronic orders for Cephalexin or Prednisone on 08/21/2024. Review of Patient #1s ";Hospice RN Routine Visit", dated 08/21/2024, revealed, in part, no documented evidence which indicated Patient #1 had an infection or S5RN contacted the patients physician to obtain orders for Cephalexin and Prednisone. Review of Patient #1s Medication and Treatment Profile with Active and Inactive Orders, dated 08/21/2024 through 09/14/2024, revealed no documentation of Cephalexin and Prednisone initiated on 08/21/2024. Review of Patient #1s Plan of Care (POC), dated 08/21/2024 through 09/14/2024, revealed no documented evidence of Patient #1s infection or the orders received for Cephalexin or Prednisone on 08/21/2024. Further review revealed no documented evidence of the patients response to the new medications, symptom management, treatment or services. Review of Patient #1s Notes, dated 08/21/2024 through 09/14/2024, revealed no documented evidence of Patient #1s infection or the orders received for Cephalexin or Prednisone on 08/21/2024. Further review revealed no documented evidence of the patients response to the new medications, symptom management, treatment or services. An interview was conducted on 10/29/2024 at 11:28 a.m. with S5RN. S5RN confirmed she was the nurse who saw Patient #1 on 08/21/2024 and received the verbal orders for Cephalexin and Prednisone then submitted them to the pharmacy to be filled. An interview was conducted on 10/29/2024 at 9:42 a.m. with S7RN. S7RN confirmed she was Patient #1s routine nurse. S7RN confirmed Patient #1 did receive the Cephalexin and Prednisone as ordered even though neither medication was documented anywhere in his EHR. An interview was conducted on 10/29/2024 at 12:05 p.m. with S1ADM. S1ADM reviewed Patient #1s EHR and confirmed it was not updated to reflect the new orders received on 08/21/2024 for Cephalexin or Prednisone and should have been. S1ADM confirmed if Patient #1s infection and new medications were not added into the EHR, there would not be any documented evidence of the patients response to the new medications, symptom management, treatment or services. An interview was conducted on 10/29/2024 at 10:35 a.m. with S4MD. S4MD confirmed a patients plan of care should accurately reflect their medical status at all times; including their response to new medications, symptom management, treatment or services.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview and observation. In 1 of 9 (11%) home visit observations it was revealed that the agency did not ensure the staff adhered to standards of practice to prevent the transmission of infections and communicable disease in regard to proper hand hygiene. Document 2: #3 A: Stated in part that hand decontamination using an alcohol-based hand rub should be performed "before having direct contact with patients." #3 D: Further stated in part that hand decontamination will be utilized after contact with "non-intact skin and wound dressings". Home Visit 2: During the home visit, on 5/23/23, the patient asked the chaplain (staff 6) to help her elevate her legs from the floor to the stool and stated that "brings me comfort". The patient's legs revealed multiple wounds that were covered by bandaged pads. The chaplain was not observed to sanitize hands prior to assisting the patient to physically lift her legs to a stool nor sanitizing after the completion of the task. During interview at the end of the visit, the Chaplain confirmed that proper hand hygiene was not followed before or after giving assistance to the patient. Personnel Record 3: The administrator confirmed during an interview on 5/23/23 that the hand hygiene policy was not followed.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 2 (50%) clinical records, in which a patient was discharged from hospice services, it was revealed that the agency did not ensure the discharge summary information was provided to the attending physician. Document 3: Stated in relevant part "2. The case manager will facilitate the patient's revocation and assist with a smooth transition to another setting" and "3. The case manager will notify the attending physician about the revocation...and a discharge summary will be sent." Clinical Record 22: The Election of Benefit was dated 3/16/23. The revocation statement, dated 3/22/23, stated in relevant part, "Nephrostomy tube fell out. Family revoked to seek aggressive treatment at (name of hospital)." The discharge note did not include any communication with the attending physician (nephrologist) or the receiving hospital nor was there documentation that the discharge summary was forwarded. Personnel Record 3: On 5/25/23, the administrator/director of nursing confirmed that the record did not contain any documentation that the discharge summary information was provided to the physician or the hospital.