Every finding on record at Comfort Care Hospice, LLC

Based on review of agency policies, hospice volunteer file documentation and staff interview, it was determined the agency failed to follow its own policy and provide training on the Emergency Preparedness (EP) Plan for all staff including the hospice direct and indirect volunteers. This did affect 2 of 3 volunteers files reviewed including Volunteer Identifier (Vol) # 8, Volunteer (Vol), and EI # 7, Vol. This had the potential to negatively affect all patients served by this agency. Findings include: Agency Policy: Emergency Preparedness Plan Initiated: 1/4/2018 Policy: It is the policy... to have an emergency preparedness program that is designed to adequately prepare to meet the health, safety and security needs of our patients, staff and community during disasters and emergency situations... Training and Testing ...Reviewed and updated annually ...Training - provide education and instruction to staff, contractors and volunteers to ensure all individuals are aware of EP program... Initial training in EP policies and procedures to all new and existing staff, individual providing services under arrangement and volunteers consistent with their expectant role... Provide EP training annually... Maintain documentation of all EP training... Demonstrate staff knowledge of EP... Policy: Emergency Preparedness Plan Policy Number: H1005 Revised: April 1, 2020 Policy It is the policy...to have an emergency preparedness program...designed to...meet the health, safety and security needs of our patients, staff and community during disasters and emergency situations... ...8. Training and Testing a. Develop and maintain an EP training and testing program b... ii. Training-provide education and instruction to staff, contractors, and volunteers to ensure all individuals are aware of EP program 1. Initial training in EP policies and procedures to all new and existing staff, individual providing services...and volunteers consistent with their expected role 2. Maintain documentation of all EP training ...4. Demonstrate staff knowledge of EP... 1. Review of two of three Vol personnel files conducted on 7/12/22 at 1:00 PM revealed the following: a. Vol # 8, Date of Hire 4/1/19 revealed a document titled "New Employee Orientation Activities Agenda - Volunteer". There was no documentation Vol # 8 was trained during his/her initial training in the hospice EP Plan as directed per the agency policy. Further review of Vol # 8's personnel file revealed there was no documentation Vol # 8 was trained in the hospice EP Plan in 2020 and 2021 as directed per the agency policy. b. Vol # 7, Date of Hire 10/26/21 revealed a document titled, "New Employee Orientation Activities Agenda - Volunteer". There was no documentation Vol # 7 was trained during his/her initial training in the hospice EP Plan as directed per the agency policy. An interview was conducted on 7/13/22 at 12:40 PM with EI # 5, Vol Coordinator, who verified there was no documentation the hospice volunteers received training for the agency EP Plan which included EP Plan policies and procedures.

Based on observations, review of medical records (MR), agency policy and procedure and interviews with staff, it was determined the hospice staff failed to ensure all Client Medication Report's (CMR) were current and accurate. This affected one of three home visits (HV) conducted including HV # 2 and had the potential to negatively affect all patients served by the agency. Agency Policy: Medication...Review Policy Number: H701 Revised: 4/1/2020 Policy: All medications...will be reviewed with the patient and/or family every fifteen days and as necessary. Procedure: ...3. List all medication on the Hospice Medication Profile... Findings include: 1. HV # 2 was admitted to the agency on 6/29/22 with diagnoses including, Hypertensive Heart Disease with Heart Failure and Heart Failure, Unspecified. Review of the Hospice Certification and Plan Of Care dated 6/29/22 to 9/25/22 revealed a Skilled Nurse frequency of twice a week for 13 weeks. A HV was conducted on 7/12/22 at 10:33 AM with Employee Identifier (EI) # 3, Hospice Aide, to observe care provided during a bed bath. During the HV, the caregiver and the surveyor compared the home medications with the agency CMR, printed by the agency on 7/12/22 at 9:31 AM. The following discrepancies were found: Levemir insulin 20 Units twice daily was found in the home with prescription bottle dated 4/7/22. The caregiver verbalized the patient had been on Levemir "a long time, at least 12 years." There was no documentation of the Levemir on the agency CMR. An interview was conducted on 7/13/22 at 3:28 PM with EI # 1, Administrator, who confirmed there was no documentation of the Levemir insulin on the patient's CMR.

Based on review of agency policies and procedures, medical records (MR) and interview with staff it was determined the agency Medical Social Worker (SW) failed to update the IDG (Interdiscliplinary Group) and patient plan of care (POC) with changes related to patient needs and home environment. This deficient practice affected one of ten current MR's reviewed, including MR # 6 and had the potential to negatively affect all patients with SW services provided by the agency. Findings include: Agency Policy: Interdisciplinary Team (IDT) Policy Number: H403 Revised: 4/1/2020 Policy: The IDT supervises the care and services provided... The core IDT is composed of: Medical Director/Associate Hospice Physician(s)...Registered Nurse...SW...Spiritual Coordinator/Counselor... Procedure: ...5. In regard to direct patient care, the IDT has the responsibility of: ...c. Reviewing and updating each Care Plan every 15 (fifteen) days... ...f. Justifying changes of treatement setting as they revise, monitor, and/or change plans that are deemed necessary... Agency Policy: POC Policy Number: H402 Revised: 6/30/21 ...The POC is developed and reviewed by the IDT every fifteen (15) days and as the individual patient's need arises. Persons participating in Hospice care as providers...are informed of changes in the POC as it is reviewed and updated... Procedure: ...10. The IDT meets every 15 days to maintain continuity of care for all patients, i.e. development, reviewing, and revising of each individual POC. ...13. As the patient's condition deteriorates, needs are addressed to determine adjustments of visits...to meet the needs of the patient and family... Agency Policy: Social Work Services Policy Number: H505 Revised: 1/1/22 ...Procedure ...g. Participate in IDT meetings and provide updates to the team every 15 days at a minimum for all patients receiving social work services... 1. MR # 6 was admitted to the agency on 5/11/22 with a diagnosis including Malignant Neoplasm of Upper Lobe, Right Bronchus or Lung. Review of the IDT Meeting dated 5/19/22 revealed a SW frequency of twice a month. Review of the SW Note dated 5/20/22 revealed documentation of "...Patient reported that the family is taking her/his medication.... says that it is the medication that helps...with sleep and the pain medication...Patient also reported that her/his money is being used for most of the household items and is used by family members without her/his permission... SW will increase...visit frequency to 3 (three) time a month..." Review of the Hospice IDG Comprehensive Assessment and POC Update dated 6/2/22 revealed a SW frequency of twice a month. There was no documentation the SW notified the IDG of the patient's report his/her family was taking medication and using money without her/his permission and recommended increase in SW visit frequency. Review of the SW Note dated 6/13/22 revealed documentation of "patient complains to SW that her/his money is being stolen... SW will...visit 3 X Month (three times a month)..." Review of the Hospice IDG Comprehensive Assessment and POC Update dated 6/16/22 revealed a SW frequency of once a month for one month then twice a month for one month starting on 6/1/22. There was no documentation the SW notified the IDG of the patient's report his/her money was being stolen and recommended increase in SW visit frequency. An interview was conducted on 7/13/22 at 3:15 PM with EI # 1, Administrator, who confirmed there was no documentation the SW notified the IDG of patient report of family taking medication and using money without permission on 5/20/22 and money being stolen on 6/13/22. EI # 1 confirmed there was no documentation the SW discussed a frequency increase per recommendations on 5/20/22 and 6/13/22.

Based on review of agency policy, medical records (MR) and interviews, it was determined the agency failed to ensure the patient /caregiver (pt/cg) were provided education and completed a return demonstration for wound care to ensure competency. This affected 1 of 2 MR's reviewed with wounds, including HV (Home Visit) # 2 and had the potential to negatively affect all patients admitted to the hospice with wounds. Findings include: Agency Policy: Wound Care Policy Number: H613 Revised: 4/1/2020 Policy: ...The skilled nurse (SN) is to provide education on wound care procedures... The SN is to observe pt/cg perform return demonstration and document competency... Findings include: 1. HV # 2 was admitted to the agency on 6/29/22 with diagnoses including, Hypertensive Heart Disease with Heart Failure and Heart Failure, Unspecified. Review of the Hospice Certification and Plan Of Care (POC) dated 6/29/22 to 9/25/22 revealed a SN frequency of twice a week for thirteen weeks. Review of the Physician Order dated 7/6/22 revealed an order to "cleanse stage II (two) wound located to the coccyx with wound cleanser, pat dry with gauze, apply skin prep (to the) periwound and apply duoderm. Cg to perform once return demonstration obtained. Change dressing every 3-5 (three to five) days or if soiled" . Review of the SN Visit Note Report (VNR) dated 7/6/22 revealed no documentation the SN provided education to the pt/cg on wound care. Review of the SN VNR dated 7/8/22 and 7/12/22 revealed documentation the cg had provided wound care to the coccyx wound prior to the SN visit and no documentation the pt/cg was provided education and completed a return demonstration of the wound care to the coccyx to ensure competency. An interview was conducted on 7/13/22 at 3:28 PM with Employee Identifier # 1, Administrator, who confirmed there was no documentation the pt/cg was provided education and completed a return demonstration of the wound care to the coccyx.

4. HV # 1 was admitted to the agency on 6/23/22 with diagnoses including Chronic Obstructive Pulmonary Disease, Unspecified and Dependence on Supplemental Oxygen. Review of the Verbal Order dated 6/27/22 at 8:11 AM revealed, "Home Health Aide (Hopsice Aide) service for assistance with personal care, hygiene and activities of daily living... three x wk (week) x one wk, two x wk x one wk, three x wk x ten wks..." Review of the Hospice Aide (HA) VNR's for the week of 7/3/22 to 7/9/22 revealed only one HA visit was completed, which was on 7/6/22 and not two visits as ordered. Review of the HA Client Coordination Note Report dated 7/7 /22 revealed, "missed visit notification, visit date 7/7/22 attempt to reschedule details: No". There was no documentation the HA attempted to reschedule the missed visit per agency policy. The HA failed to provide two visits the week of 7/3/22 to 7/9/22 as ordered. In an interview conducted on 7/13/22 at 1:58 PM EI # 1, confirmed the two HA visits for the week of 7/3/22 to 7/9/22 were not completed as ordered. Based on review of Medical Records (MR), agency policy and procedure, and interviews, it was determined the agency failed to ensure the Plan of Care (POC) ordered frequencies were followed for all disciplines. This deficient practice affected 5 of 13 MR reviewed including MR # 7, MR # 1, HV # 3, HV # 1, MR # 6, and had the potential to affect all patients admitted to this hospice. Findings include: Agency Policy: Missed Visits Policy Number: H405 Revised: April 1, 2020 ...Procedure: 1. The Patient Care Coordinator ... is notified immediately of any potential missed visit. 2. The Patient Care Coordinator ... will attempt to reschedule visit. 3. The field staff ... will attempt to reschedule an unmade visit during the Medicare week of Sunday to Saturday... 4. ... A Missed Visits will be reviewed in IDT (Interdisciplinary Team). 1. MR # 7 was admitted to the agency on 4/29/22 with diagnoses including Hypertensive Heart and Chronic Kidney Disease and Heart Failure. Review of the Hospice Certification and POC dated 4/29/22 revealed orders for MSW (Masters Social Worker) one visit per month x (times) one month, nine visits per month x one month, then seven visits x one month and SN (Skilled Nurse) two visits per week x fourteen weeks. Review of the Visit Note Report (VNR)s for the month of May 2022 revealed only five of the nine ordered MSW visits were completed. There was no documentation of missed visits and no documentation of attempts to reschedule the visits. Review of the VNR for the week of 5/29/22 to 6/4/22 revealed only one of the two ordered SN visits were completed. There was no documentation of a missed visit and no documentation of attempt to reschedule the visit. Review of the Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and POC Report dated 6/16/22 revealed no documentation the IDT was notified of the missed visit. In an interview conducted on 7/13/22 at 2:45 PM, Employee Identifier (EI) # 1, Executive Director, confirmed the visit frequency was not followed as ordered for the MSW and SN. 2. MR # 1 was admitted to the agency on 6/8/22 with diagnoses including Secondary Malignant Neoplasm of the Brain, Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung, and Other Generalized Epilepsy. Review of the Hospice Certification and POC dated 6/8/22 revealed orders for Hospice Aide one visit x one week, three visits x twelve weeks, then one visit x one week. Review of the Hospice Aide Visit Note Reports for the week of 7/3/22 through 7/9/22 revealed only two of the three ordered Aide visits were completed. In an interview conducted on 7/13/22 at 2:55 PM, EI # 1 confirmed the staff failed to follow the Hospice Aide visit frequency as ordered. 3. HV # 3 was admitted to the agency on 6/14/22 with diagnoses including Malignant Neoplasm of Left Kidney and Malignant Neoplasm of Colon. Review of the Aide Care Plan Report dated 6/14/22 revealed orders for Hospice Aide one x a week x one week then two x a week x eight weeks. Review of the Aide Visit Note Reports revealed no Hospice Aide visits were completed for the week of 6/26/22 to 7/2/22. Review of the Client Coordination Note Report dated 6/28/22 revealed "...patient refused hygiene care for today, visit rescheduled..." Review of the Client Coordination Note Report dated 6/29/22 revealed "...patient did not answer door/phone. Visit rescheduled..." In an interview conducted on 7/13/22 at 2:25 PM, EI # 1 confirmed the two Aide visits for week of 6/26/22 to 7/2/22 were not completed as ordered. 5. MR # 6 was admitted to the agency on 5/11/22 with a diagnosis including Malignant Neoplasm of Upper Lobe, Right Bronchus or Lung. Review of the Hospice IDG Comprehensive Assessment and POC Update dated 6/2/22 revealed a HA frequency of twice a week. Review of the HA VNR's dated 6/19/22 to 6/25/22 revealed documentation one of two HA visits were completed. There was no documentation of a second HA visit for the week. An interview was conducted on 7/13/22 at 3:15 PM with EI # 1, who confirmed there was no documentation of a second HA visit for the week of 6/19/22 to 6/25/22.

Based on review of medical records (MR), agency policy and procedure, and interview with agency staff, it was determined the agency failed to ensure the physician was notified regarding patient's change in condition and development of wounds. This deficient practice affected one of two records reviewed with wounds, including MR # 3 and had the potential to negatively affect all patients served by this agency. Findings include: Agency Policy: Interdisciplinary Team (IDT) Policy Number: H403 Revision Date: April 1, 2020 Policy: The IDT supervises the care and services provided by Comfort Care Hospice. The IDT is composed of: Medical Director/Associate Hospice Physician(s)... Procedure: ...3. The IDT will communicate daily when necessary regarding changes in the patient/family needs and related changes in the Care Plan. The Attending Physician will be notified as a part of this process and will be kept apprised of any changes in the patient's condition... 1. MR # 3 was admitted to the agency on 6/8/22 with diagnoses including, Multiple Sclerosis, Encounter For Fitting and Adjustment of Urinary Device and Body Mass Index (BMI) 19.9 or Less, Adult. Review of the Hospice Certification and Plan Of Care dated 6/8/22 to 9/5/22 revealed a Skilled Nurse (SN) frequency of twice a week for thirteen weeks. Review of the SN Visit Note Report (VNR) dated 6/15/22 revealed the following in the Integumentary Assessment: "Number of Pressure Ulcers - Stage 1: Two" and in the Narrative note, the SN documented, "Pt (Patient) left lateral heel to show discoloration, suspected DTI (Deep Tissue Injury)". There was no documentation the physician was notified of the development of the Pressure Ulcers to the left lateral heel. An interview was conducted on 7/13/22 at 2:05 PM with Employee Identifier # 1, Administrator, who confirmed there was no documentation the staff notified the physician of the change in the patient's condition and the development of the Pressure Ulcers.

2. HV # 2 was admitted to the agency on 6/29/22 with diagnoses including, Hypertensive Heart Disease with Heart Failure and Heart Failure, Unspecified. A HV was conducted on 7/12/22 at 10:33 AM with EI # 3, Hospice Aide, to observe care provided during a bed bath. EI # 3 entered home and placed the agency Electronic MR (EMR) tablet on the armrest of the patient's couch, next to the patient's bed, and the agency bag on a couch cushion without a barrier. EI # 3 picked up the agency bag then placed a barrier on the couch cushion then placed the agency bag on top of the barrier. The EMR tablet remained on the armrest of the couch without a barrier. EI # 3 performed hand hygiene, donned gloves then documented on the EMR tablet. EI # 3 obtained clean towels and wash cloths, without glove removal and hand hygiene after contact with the EMR tablet, then documented on the EMR tablet. EI # 3 obtained clean linen and patient clothing then proceeded to fill bath basins, remove used bed linen and start bed bath procedure by washing HV # 2's face, without glove removal and hand hygiene after contact with an the EMR tablet. After cleaning HV # 2's face, EI # 3 washed patient bilateral arms, chest, bilateral front of legs, and bilateral feet. EI # 3 failed to wash under skin folds of bilateral breast and back of bilateral legs. EI # 3 rolled the patient onto the left side and washed the right side of the back then proceeded to roll the patient onto back and empty wash basins. EI # 3 failed to wash the patient left side of the back. EI # 3 removed front cover of patient diaper and washed bilateral side of the groin then proceeded to turn the patient to the left side. EI # 3 failed to spread the patient's legs, open labia and wash vaginal area. With the patient on the left side, EI # 3 removed the diaper from buttock which contained bowel movement, obtained wipe and cleaned bowel movement. EI # 3 removed gloves, performed hand hygiene, donned gloves and obtained additional wipes. EI # 3 cleaned the remaining bowel movement from the patient's skin, placed the wipes in the trash then preceeded to wash the outside of the buttocks, without removing gloves and performing hand hygiene. EI # 3 removed trash, used laundry and wash basins then lifted the agency bag from the couch, removed barrier under the bag, placed barrier in the trash and obtained EMR tablet from couch armrest. The patient's caregiver at this point mentioned brushing HV # 2's hair to which EI # 3 set the agency bag back on the couch cushion and the EMR tablet on the patient's coffee table, both without a barrier. EI # 3 brushed the patient's hair then removed gloves and performed hand hygiene. EI # 3 obtained agency bag and EMR tablet, documented on the EMR tablet and then asked the patient caregiver to sign EMR tablet. EI # 3 obtained EMR tablet from the caregiver after the caregiver signature was obtained and exited the home. EI # 3 failed to disinfect the EMR tablet before, during or after the visit. An interview was conducted on 7/13/22 at 3:28 PM with EI # 1, who confirmed EI # 3 failed to perform hand hygiene, bag technique, cleaning of re-usable equipment and bed bath per the agency policy. Based on observations, agency policies and procedures, and interviews, it was determined the agency failed to ensure the staff followed agency policy for hand hygiene, cleaning of re-usable equipment, bag technique, and bed bath. This deficient practice affected 2 of 3 home visits (HV) including HV # 3, HV # 2, and had the potential to affect all patients admitted to this hospice. Findings include: Agency Policy: Hand Hygiene Policy Number: H906 Revised: 4/1/2020 Policy: To prevent the transmission of microorganisms from patient to patient and from inanimate surfaces to patients by the hands of all healthcare providers... Procedure: Hand washing ...3. Handwashing may also be used for routinely decontaminating hands in the following clinical situations: a. Before having direct contact with patients. ...d. After contact with body fluids or excretions...even if hands are not visibly soiled. ...f. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient... Agency Policy: Infection Control Guidelines Policy Number: 04.19.06 Revised: 6/2/2020 ...Procedures ...Gloves: Wear gloves ... when touching blood, body fluids, secretions, excretions, and contaminated items. Put on clean gloves just before touching mucous membranes and nonintact skin. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another patient... Agency Policy: Infection Control Plan/Program Policy Number: 04.19.05 Revised: 6/2/2020 ...Items which touch only intact skin (i.e., blood pressure cuff, stethoscopes) ... These items will be cleaned with alcohol after each use... Agency Policy: Bag Technique Policy Number: H907 Revised: April 1, 2020 ...Procedure: 1. Locate a clean area for supplies near the patient. Place the bag on a disposable apron or bag barrier... ...8. Clean all equipment used with alcohol prep or germicidal cleanser... Agency Policy: Bathing-Complete or Partial Bed Bath Policy Number: 4.18.02 Reviewed: 3/18/22 Overview: To safely bathe the patient who is unable to use the shower or tub. ...Procedure: ...10. Wash trunk and upper extremities... Pay special attention to skin folds... Special Considerations: ...Assure folds of skin have been washed and thoroughly dried... Agency Procedure: Perineal Care Procedure Number: Not documented Date: Not documented Perineal care, which includes care of the external genitalia and the anal area, should be performed during the daily bath and , if the patient is incontinent...after...bowel movements. The procedure promotes cleanliness and prevents infection... ...For a female patient ...bend...knees slightly and...spread...legs. ...Separate the patient's labia with one hand and wash with the other... ...rinse thoroughly...pat the area dry with a bath towel... 1. HV # 3 was admitted to the agency on 6/14/22 with diagnoses including Malignant Neoplasm of Left Kidney and Malignant Neoplasm of Colon. A HV was conducted on 7/11/22 at 1:25 PM to observe ostomy care provided by Employee Identifier (EI) # 2, Registered Nurse (RN) Case Manager. EI # 2 performed hand hygiene, donned gloves and prepped the area around the ostomy site with disposable pads. EI # 2 then turned to reach for the ostomy supplies and knocked over the trash receptacle, spilling soiled gloves onto the floor. With his/her gloved right hand, EI # 2 picked up the soiled gloves, moved the trash receptacle closer to the bed and discarded the soiled gloves into the trash. Then, without removing gloves or performing hand hygiene, EI # 2 reached for the clean ostomy bag and placed it on a clean barrier beside HV # 3. EI # 2 then continued to remove the ostomy bag and cleaned the surrounding area with wipes. EI # 2 failed to remove gloves and perform hand hygiene after touching contaminated objects and surfaces before proceeding with ostomy care. In an interview conducted on 7/13/22 at 2:25 PM, EI # 1, RN, Administrator, confirmed the staff failed to observe agency policy for hand hygiene.

Based on review of the agency policy and procedure, Aide job description, observation, medical records (MR) and interviews it was determined the agency failed to ensure the Hospice Aide (HA) Care Plan was individualized to the patient and ability of the HA to safely care for the patient. This affected one of one Home Visit (HV) observations with HA services, including HV # 2. This deficient practice had the potential to affect all patients receiving aide services. Findings include: Agency Policy: HA...Services Policy Number: H504 Revised: 2/1/22 Policy: ...HA...work under the supervision of a Registered Nurse (RN)...for all patient assignments. Procedure: ...4. HA...Responsibilities: ...d. The RN assigns the HA...duties based on identified patient needs and creates the Plan of Care (POC) for the HA... Agency Job Description: Aide Effective Date: 10/15 ...General Purpose; The aide is a paraprofessional member of the hospice team who works under the supervision of a RN and performs various personal care services as necessary to meet the patient's needs...will be assigned in a manner that promotes...safety of a patient's care. ...Essential Job Functions: ...Meeting safety needs of patients and using equipment safely and properly... 1. HV # 2 was admitted to the agency on 6/29/22 with diagnoses including, Hypertensive Heart Disease with Heart Failure and Heart Failure, Unspecified. Review of the Hospice Certification and POC dated 6/29/22 to 9/25/22 revealed a HA frequency of once a week for one week, three times a week for twelve weeks then once a week for one week. Review of the RN admission Visit Note Report (VNR) dated 6/29/22 revealed documentation the patient had a "...unclean/cluttered living area" was bedbound, "...total care with ADLs (Activities of Daily Living) and personal care, non ambulatory and unable to reposition self in bed..." Review of the HA Care Plan effective 6/29/22 revealed documentation the RN assigned the HA to transfer the patient from the bed to a chair and from the chair to the bed every visit. There was no documentation of how, with a lift or manual transfer, the HA was to perform the transfer. A HV was conducted on 7/12/22 at 10:33 AM with Employee Identifier (EI) # 3, HA, to observe care provided during a bed bath. During the visit the surveyor observed HV # 2 who was bed bound, unable to reposition self and when rolled from side to side by EI # 3 had a rigid position. There was no patient lift observed in the home to aid in a transfer. An interview was conducted on 7/13/22 at 8:05 AM with EI # 3 who verbalized the patient did not have a lift in the home to aid in a transfer and due to the patient's health status and home environment he/she would not be able to safely transfer the patient from the bed to a chair and from a chair to the bed as directed in the HA POC. A second interview was conducted on 7/13/22 at 3:28 PM with EI # 1, Administrator, who confirmed there was no lift to aid in a transfer in HV # 2's home and the HA would be unable to safely perform a transfer of the patient without using a hoyer lift.

Based on review of medical records (MR), agency policy, Hospice Aide (HA) job description and staff interviews, it was determined the hospice failed to ensure the HA followed the tasks assigned in the HA Plan of Care (POC) and documented care provided accurately. This affected 2 of 8 MRs reviewed with HA services, including Home Visit (HV) # 2 and MR # 1, and had the potential to negatively affect all patients with HA services. Agency Policy: HA...services Policy Number H504 Revised: 2/1/22 Policy ...HA's...will follow the plan of care for all patient assignments... Agency Job Description: Aide Effective Date: 10/15 ...General Purpose; The aide is a paraprofessional member of the hospice team who works under the supervision of a Registered Nurse (RN) and performs various personal care services as necessary to meet the patient's needs. The HA is responsible for...documenting...care performed. 1. HV # 2 was admitted to the agency on 6/29/22 with diagnoses including, Hypertensive Heart Disease with Heart Failure and Heart Failure, Unspecified. Review of the Hospice Certification and POC dated 6/29/22 to 9/25/22 revealed a HA frequency of once a week for one week, three times a week for twelve weeks then once a week for one week. Review of the HA Care Plan effective 6/29/22 revealed documentation the RN assigned the following service task to the HA: Transfer the patient from the bed to a chair every visit Transfer the patient from the chair to the bed every visit. Perform oral care every visit. Apply deodorant every visit. Review of the HA Visit Note Reports (VNR) dated 7/1/22, 7/6/22, 7/8/22, and 7/11/22 revealed documentation the HA completed the transfer from the bed to a chair and transfer from the chair to the bed. A HV was conducted on 7/12/22 at 10:33 AM with Employee Identifier (EI) # 3, HA, to observe care provided during a bed bath. During the observation, EI # 3 did not offer and/or provide transfer from the bed to a chair, transfer from the chair to the bed, oral care and deodorant application. Review of the HA VNR dated 7/12/22 revealed documentation the HA completed the transfer from the bed to a chair and transfer from the chair to the bed, oral care and deodorant application. An interview was conducted on 7/13/22 at 8:05 AM with EI # 3. EI # 3 was asked when was the last time you transferred HV # 2 from the bed to a chair or from a chair to the bed. EI # 3 verbalized she/he had never transferred the patient. EI # 3 verbalized HV # 2 did not have a lift in the home and she/he would not be able to safely transfer HV # 2. EI # 3 confirmed she/he did not offer nor provide oral care and deodorant application during the HV on 7/12/22. A second interview was conducted on 7/13/22 at 3:28 PM with EI # 1, Administrator, who confirmed EI # 3 should have performed the service task assigned by the RN and/or notified the RN of the inability to perform the service task safely. EI # 1 confirmed the patient did not have a lift in the home and the patient would not be able to be transferred safely without the use of a lift. 2. MR # 1 was admitted to the agency on 6/8/22 with diagnoses including Secondary Malignant Neoplasm of the Brain, Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung, and Other Generalized Epilepsy. Review of the Aide Care Plan Reports dated 6/8/22, 6/14/22, and 7/6/22 revealed orders for HHA to record the urine output every visit. Review of the Aide Visit Note Reports dated 6/10/22, 6/15/22, 6/17/22, 6/20/22, 6/24/22, 6/27/22, 7/5/22, and 7/11/22 revealed the Aide documented under the section Service: Output - urine "Completed: N (no) ... not required this visit". In an interview conducted on 7/13/22 at 2:55 PM, EI # 1 confirmed the staff failed to follow the Aide Plan of Care and document the urine output.

Based on review of medical records (MR), agency policy and procedure, Hospice Aide (HA) job description and staff interviews, it was determined the hospice failed to ensure the HA: 1. Notified the Registered Nurse (RN) regarding inability to safely complete tasks asigned. 2. Notified the RN regarding tasks not completed per ordered Plan of Care (POC). 3. Notified the RN regarding the patient's date of last bowel movement (BM). This affected three of eight MRs reviewed with HA services, including Home Visit (HV) # 2, MR # 3, MR # 1 and had the potential to negatively affect all patients with HA services. Agency Policy: HA...services Policy Number H504 Revised: 2/1/22 Policy ...HA's...will follow the plan of care for all patient assignments... Procedure ...4. HA...Responsibilities: ...c. The HA...will communicate abnormal signs...to the RN and will document communication on the HA...Visit Note. d. ...Any deviation from the POC from the HA will be communicated to the RN... Agency Job Description: Aide Effective Date: 10/15 ...General Purpose; The aide is a paraprofessional member of the hospice team who works under the supervision of a RN and performs various personal care services as necessary to meet the patient's needs. The HA is responsible for...documenting...care performed. ...Essential Job Functions: Patient Care Function: ...Reporting on patient's...changes to the assigned nurse. 1. HV # 2 was admitted to the agency on 6/29/22 with diagnoses including, Hypertensive Heart Disease with Heart Failure and Heart Failure, Unspecified. Review of the HA Care Plan effective 6/29/22 revealed documentation the RN assigned the following service task to the HA: Transfer the patient from the bed to a chair every visit Transfer the patient from the chair to the bed every visit. Perform oral care every visit. Apply deoderant every visit. Review of the HA Visit Note Reports (VNR) dated 7/1/22, 7/6/22, 7/8/22, and 7/11/22 revealed documentation the HA completed the transfer from the bed to a chair and transfer from the chair to the bed. A HV was conducted on 7/12/22 at 10:33 AM with Employee Identifier (EI) # 3, HA, to observe care provided during a bed bath. During the observation, EI # 3 did not offer and/or provide transfer from the bed to a chair, transfer from the chair to the bed, oral care and deoderant application. Review of the HA VNR dated 7/12/22 revealed documentation the HA completed the transfer from the bed to a chair and transfer from the chair to the bed, oral care and deoderant application. There was no documentation the HA notified the RN the transfers, oral care and deoderant application was not performed. An interview was conducted on 7/13/22 at 8:05 AM with EI # 3. EI # 3 was asked when was the last time you transfered HV # 2 from the bed to a chair or from a chair to the bed. EI # 3 verbalized she/he had never transfered the patient. EI # 3 verbalized HV # 2 did not have a lift in the home and she/he would not be able to safely transfer HV # 2. EI # 3 verbalized she/he had not reported the inability to safely transfer HV # 2 per the POC to the RN. A second interview was conducted on 7/13/22 at 3:28 PM with EI # 1, Administrator, who confirmed EI # 3 should have notified the RN of the inability to perform the service task safely. 3. MR # 1 was admitted to the agency on 6/8/22 with diagnoses including Secondary Malignant Neoplasm of the Brain, Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung, and Other Generalized Epilepsy. Review of the the Aide Care Plan Report dated 6/23/22 revealed orders for the Aide to record the date of the last BM every visit and notify the RN if no BM in greater than three days. Review of the Aide Visit Note Report dated 6/27/22 revealed the Aide documented the date of the last BM was on 6/23/22 which was four days since the last BM. There was no documentation the Aide notified the RN of MR # 1 not having a BM for greater than three days. In an interview conducted on 7/13/22 at 2:55 PM, EI # 1 confirmed the staff failed to follow the Aide Plan of Care and notify the RN of no BM of greater than three days. 2. MR # 3 was admitted to the agency on 6/8/22 with diagnoses including, Multiple Sclerosis, Encounter For Fitting and Adjustment of Urinary Device and Body Mass Index (BMI) 19.9 or Less, Adult. Review of the Hospice Certification and POC dated 6/8/22 to 9/5/22 revealed a HA frequency of once a week for one week, three times a week for twelve weeks then once a week for one week. Review of the HA Care Plan effective 6/8/22 and 6/22/22 revealed documentation the RN assigned the following service task to the HA: Date of the last BM every visit. Review of the HA VNR dated 6/13/22 revealed, "Date of last BM: 6/7/22", which was six days. There was no documentation the HA notified the RN of the patient's last BM. Review of the HA VNR dated 6/15/22 revealed, "Date of last BM: 6/7/22", which was eight days. There was no documentation the HA notified the RN of the patient's last BM. Review of the HA VNR dated 6/17/22 revealed, "Date of last BM: 6/7/22", which was ten days. There was no documentation the HA notified the RN of the patient's last BM. An interview was conducted on 7/13/22 at 2:05 PM with EI # 1, who stated the HA should have notified the RN regarding the patient's date of the last BM on 6/13/22, 6/15/22 and 6/17/22.

Based on review of medical records (MR), agency policies and procedures, and interview with agency staff, it was determined the agency failed to ensure the staff completed and documented accurate assessments of wounds. This deficient practice affected one of two patients reviewed with wounds, including MR # 3 and had the potential to negatively affect all patients with wounds at this agency. Findings include: Agency Policy: Documentation Policy Number: H202 Revised: April 1, 2020 Policy: Documentation will be maintained...that is a true and accurate account of the patient's status and the care provided. Agency Policy: Wound Care Policy Number: H613 Revised: April 1, 2020 Policy: The Wound Form is to be utilized anytime the documentation of a wound is required and/or treatment is provided to evaluate the progress or decline of wound(s)...Wounds are to be measured at a minimum of one time a week. The following is a list of wound types which require documentation in the Wound Form: ...Pressure ulcers The Wound Form (Wound Assessment) is to be used in addition to the SN (Skilled Nurse) Regular Visit, SN Regular visit with a Recertification...and is to be maintained in the medical record for review. Agency Policy: Nursing Services Policy Number: H503 Revised: February 1, 2022 Procedure: 5. Nursing Staff: ...e. Nursing staff will document timely and accurately. 1. MR # 3 was admitted to the agency on 6/8/22 with diagnoses including, Multiple Sclerosis, Encounter For Fitting and Adjustment of Urinary Device and Body Mass Index (BMI) 19.9 or Less, Adult. Review of the Hospice Certification and Plan Of Care dated 6/8/22 to 9/5/22 revealed a SN frequency of twice a week for thirteen weeks. Review of the SN Visit Note Report (VNR) dated 6/15/22 revealed the SN documented the following in the Integumentary Assessment: "Number of Pressure Ulcers-Stage (Stg) 1: Two" and in the Narrative note, the SN documented, "Pt (Patient) left lateral heel to show discoloration, suspected DTI (Deep Tissue Injury)". The SN documented the wound was both a Stg 1 Pressure Ulcer (PU) and a suspected DTI. There was no documentation of the location of the second Stg 1 PU. The SN failed to document a wound assessment as directed per the agency policy. Review of the next SN VNR's dated 6/17/22, 6/20/22, and 6/22/22 revealed there was no documentation of the "Two- Stg 1 PU and discoloration to the left lateral heel. Review of the next SN VNR dated 6/27/22 revealed the SN documented the following in the Integumentary Assessment: "Number of PU - Stg 1: Zero, Number of PU - Stg 2: One", in the Narrative note, "There is a Stg 2 noted to Lt (left) heel", and the Wound Assessment, "# 1 Lt Heel Lt, PU Stg 1...Suspect DTI...Skin Color: DK (dark) red". The SN documented the wound was both a Stg 2 PU and a suspected DTI. There was no documentation of a wound assessment, or the location of the second Stg 1 PU documented by the SN on 6/15/22. Review of the next SN VNR dated 6/29/22 revealed the SN documented in the Wound Assessment, "# 1 Lt Heel Lt, PU Stg 1...Suspect DTI...Skin Color: DK red", and in the Narrative note, "There is a Stg 2 wound to her bilateral heel that measures 3 x (by) 2 cm (centimeters)". The SN documented the wound was both a Stg 2 PU and a suspected DTI. The SN failed to document a wound assessment on the right heel as indicated by "bilateral heel". The surveyor was unable to determine the number, type, and stage of wounds present. Review of the next SN VNR dated 7/5/22 revealed the SN documented the following in the Integumentary Assessment: "Number of PU - Stg 1: Two, Number of PU - Stg 2: Zero", and the wound assessment, "# 1 Lt Heel Lt, PU Stg 1...Suspect DTI...Skin Color: DK red, # 2 Lat (Lateral) Rt (right) - Heel, Rt, PU Stg II (2)... Suspect DTI...Skin Color: DK red", and in the Narrative note, " Pt has a new Stg 2 wound to her right heel...left heel Stg 2..." The SN documented the wounds were both a Stg 1, Stg 2, and a suspected DTI. An interview was conducted on 7/13/22 at 2:05 PM with Employee Identifier # 1, Administrator, who confirmed the staff failed to complete and document accurate assessment of wounds.

Based on observation, review of Hospice Admission Booklet, and interview, it was determined the agency failed to ensure oxygen was secured safely in one of one home visits (HV) conducted with patients receiving Oxygen (O2) therapy. This had the potential to affect all patients receiving O2 therapy and did affect HV # 1. Findings Include: Hospice Admission Packet Section 7: Home Safety Oxygen Safety ... Place the oxygen cylinders in appropriate stand to prevent tipping, or secured to the wall or placed on their side on the floor ... 1. HV # 1 was admitted to the agency on 6/23/22 with diagnose including Chronic Obstructive Pulmonary Disease, Unspecified and Dependence on Supplemental Oxygen. Review of the Hospice Certification and Plan of Care dated 6/23/22/ to 9/20/22 revealed a Skilled Nurse frequency of two times a week. A HV was conducted on 7/11/22 at 1:00 PM to observe care provided by Employee Identifier (EI) # 4, Medical Social Worker. Prior to the HV, the surveyor was provided a current Client Medication Report printed 7/11/22 at 11:46 AM, which included O2 at 2 - 5 Liters per Nasal Cannula prn (as needed), start date of 6/23/22. During the HV, the surveyor observed an O2 tank standing upright in the bedroom. The tank was unsecured to prevent tipping as directed per the agency home safety policy. An interview was conducted on 7/13/22 at 1:58 PM with Employee Identifier # 1, Administrator, who confirmed staff failed to ensure the safe storage of the O2 tank.

Based on review of the COVID-19 Staff Vaccination Status for Providers, personnel files, agency policy, and interviews, it was determined the agency failed to ensure all staff were fully vaccinated or had an approved exemption. This deficient practice affected 1 of 3 hospice volunteer (Vol) files reviewed including Vol # 7 and had the potential to affect all employees. Findings include: Agency Policy: Covid-19 Vaccination Policy Policy Number: 5.12.22 Policy date: January 1, 2022 ...All Aveanna employees covered by this policy are required to be fully vaccinated or have an approved exemption, as provided in this policy or under applicable law, as a term and condition of employment... This includes all Aveanna corporate and location staff; employees who provide care, treatment, or other services for the location and/or it's patients, whether the employee holds a license or certification or not; students, and volunteers; and contingent and contract workers... 1. Review of the updated agency Covid-19 tracking data revealed Vol # 7, Volunteer, had not been vaccinated or been granted an exemption. Review of Vol # 7's volunteer file on 7/12/22 at 1:00 PM revealed no documentation of Covid-19 vaccination or documentation of granted exemption. In an interview conduction on 7/13/22 at 1:45 PM, EI # 6, Regional Vice President of Operations, confirmed Vol # 7 had not been vaccinated for Covid-19 and had not been granted an exeption per agency policy.