Every finding on record at Comfort Care Hospice, LLC

It is required that the hospice has a written Patient Bill of Rights and Responsibilities (Bill of Rights). The patient has the right to be informed of his or her rights and responsibilities, and the hospice defines, protects, and promotes the exercise of these rights. This standard was not met as evidenced by a review of clinical records, document review and interview. Agency policy number 17.12, titled "Hospice Discharge from Care" with original policy date of 12/2/2021 with no revision or review dates, states in part under subtitle Process/Procedures "11) Patient can be discharged from services as follows...Patient revoked. To revoke the election of Hospice care, the patient or representative must file a statement with Hospice (Hospice Revocation form) that includes the following information: A signed statement that the patient or representative revokes the patient's election for Medicare coverage of Hospice Care for the remainder of the election period. The date that the revocation is to be effective. (A patient or representative may not designate an effective date earlier than the date that the revocation is made.) A verbal revocation of benefits is not acceptable." 1 of 2 (50%) records of patients who were live discharges for the reason of revocation revealed the agency did not obtain a signed written statement of revocation from the patient or representative. Clinical Record 7: The patient, with the election of hospice benefit dated 4/14/2022, had a primary diagnosis of pulmonary fibrosis and was relocating to an assisted living facility. The agency documented the patient's discharge from the agency as a revocation, effective 1/11/2023, to a residential care setting. The RN hospice discharge from agency note dated 1/11/2023 documented, "Pt will be moving to assisted living today. RN reinforced education to patient and caregiver on disease progression/management. Oxygen safety. No smoking/open flame/petroleum products near O2. Pt has made medical visits with the primary care physician on Monday and to specialists yesterday. No medication refills needed. No other needs/concerns". A written statement or a completed agency revocation form was not located in the record or provided by the agency. An interview with the Regional Vice President on 2/9/2023 confirmed the missing revocation documentation. In addition, it was stated that an expected electronic medical record enhancement to capture an electronic signature of the patient or representative to elect revocation of their hospice benefit was discovered to be not working during the time of the patient's discharge; however, as of 2/3/2023, the enhancement was working.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records, interview and observation on home visits. 2 of 4 (50%) observed home visits where medication reconciliations were completed, revealed the agency medication profiles were not updated accurately in comparison to the patient's current medication regimen. Home Visit 2 (Clinical Record 14): The patient with an election of hospice benefit dated 10/25/2022 was diagnosed with senile degeneration of the brain and lived with her daughter and son-in-law. During the observed home visit on 2/7/2023 the registered nurse conducted a medication reconciliation by comparing the agency medication profile dated 2/7/2023 to the medication bottles and items in the home. The medication profile listed "acetaminophen 500mg tablets, take 1-2 tablets every 4 hours as needed for pain or fever". However, the daughter stated that the patient takes children's liquid acetaminophen, 20mL orally every 4 hours, as needed for pain. Additionally, the medication profile listed "Dulcolax gummies 5mg as needed for constipation". However, the daughter stated the patient had not been taking the medication because it was not working. The daughter reported that the patient's current bowel regimen had been the stool softener Docusate Sodium 100mg, one (1) tablet by mouth every morning, and Fleets liquid glycerin suppository rectally daily as needed, both missing from the agency's medication profile and plan of care. Home Visit 1 (Clinical Record 13): The patient with an election of hospice benefit dated 1/13/2023 had a primary diagnosis of COPD and was oxygen-dependent. On 2/7/2023, an observed home visit was conducted. The registered nurse performed a medication reconciliation by comparing the agency medication profile dated 2/7/2023 to the medication bottles and inhalers in the patient's home. The medication profile documented Hydralazine 50 mg, one tablet orally twice daily for high blood pressure. However, the bottle label had an administration frequency of three times a day; the patient verbalized taking the medication once a day as needed. On the medication profile, Lactulose 10 gram/15mL was ordered for the patient to take 30 mL orally daily as needed for constipation if no bowel movement in four (4) days; however, the bottle's dosage was different at 15 mL. Lorazepam 2mg per mL concentrate was ordered 0.25mL to 1mL orally every 4 hours as needed for anxiety/shortness of breath/restlessness; however, the patient verbalized taking 0.25mL by mouth at bedtime scheduled. The medication profile documented Losartan 50 mg; take one tablet by mouth twice daily for high blood pressure. However, the medication bottle was labeled to take 100mg by mouth once daily. On the medication profile, Nystatin 100,000 unit/mL, take 5mL by mouth three times daily, dated 1/16/2023; however, the registered nurse stated that the medication was now "as needed" since the patient's thrush symptoms have resolved. On the medication profile as listed oxycodone-acetaminophen 10mg-325mg, take one tablet by mouth every 6 hours as needed for pain. However, the bottle was labeled to take one tablet by mouth every 8 hours as needed for pain. Pyridium, 100mg for bladder spasms, was documented on the medication profile to take one tablet by mouth three times per day. However, the patient and registered nurse stated that the medication had been completed and was not active. Two over-the-counter supplements were not listed on the medication profile; the patient verbalized taking them every day (fish oil Omega XL 300mg by mouth daily and Vitamin D 50 mcg by mouth daily). The registered nurse reported that the medications did not match the profile because the primary caregiver had taken some of the medications from the new bottles and poured them into the old prescription bottles. An interview with the Executive Director on 2/9/2023 confirmed the medication profiles were inaccurate after a review of the findings of the home visits was reported.

It is required that licensed professional services provided directly or under arrangement are supervised only by appropriately qualified health care professionals who meet the appropriate qualifications and who practice under the hospice’s policies and procedures. This standard was not met as evidenced by document reviews, interview and review of personnel records. Agency policy number 17.19, titled Hospice Employee Competency, with an original policy date of 12/1/2021 and no revised or reviewed dates states in relevant parts, under the subtitle Overview, "Hospice will provide for initial and ongoing discipline-specific competency assessments for all patient care staff by qualified individuals... Professional staff competency may only be assessed and determined by a qualified staff member using discipline-specific skills competency checklist." Under the subtitle Process/Procedure, the policy states in part, "(6), Hospice has established competency criteria for each job category. Qualified individuals will observe the employee during competency evaluation. The competency evaluation checklist will be completed and retained in the employee record." 1 of 14 (7%) personnel records reviewed revealed the agency did not complete a discipline-specific competency evaluation for the nurse practitioner by a qualified professional. Staff 11: A nurse practitioner employee with a hire date of 6/6/2022 was missing a discipline-specific nurse practitioner competency checklist. The agency's competency evaluation form titled Nursing Orientation Skills Checklist RN/LPN was completed and signed on 6/10/2022. Based on the agency's job description with an effective date of 5/2015, the nurse practitioner was not functioning within the scope of a registered nurse but instead within the scope of a nurse practitioner. The employee signed the job description form on 6/8/2022, which states in part, under the subtitle of General Purpose, "Perform hospice Face-to-Face (FTF) Encounter for recertification as required for hospice patients prior to the start of the third (3rd) benefit period and all subsequent recertifications. Assess, diagnose, and treat minor health problems. Conduct complete physicals, provide treatment, and counsel patients. May prescribe medication and practice as dictated in a collaboration agreement with a physician, which has been approved by the (state name) Board of Nursing and the (state name) Board of Medical Examiners." The agency form titled, Board of Medical Examiners Covering Physician Agreement, signed on 5/5/2022, states in part, "As a covering (backup) physician providing oversight for CRNP/CNM/PA, will be accountable for adequate collaborative/supervision regarding the medical care rendered pursuant to the protocols and additional skills, if applicable." During the interview with the Regional Vice President on 2/9/2023, it was reported the agency's interpretation of their policy met the regulation by having a registered nurse complete the competency for the nurse practitioner. NOTE: the Regional Vice President provided a competency evaluation form, number 1046, titled Nurse Practitioner Initial/Annual Competency and On-site Visit revised 1/10/2023 that will be used in the future for a nurse practitioner's initial and annual competency evaluation.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by a review of clinical records and document reviews. The agency's policy number 17.29 titled Hospice Bereavement Counseling Services states in part under the subtitle Overview, "Bereavement services reflect the needs to the bereaved and the plan of care notes the kind of bereavement services to be offered along with the frequency of services delivery to assist the patient and family in dealing with feelings of grief or loss". And under the subtitle Process/Procedures, "(4) The plan of care will reflect family needs, as well as a clear delineation of services to be provided and the frequency of service delivery and updated accordingly." 2 of 3 (67%) records reviewed where bereavement services were accepted, revealed the agency's bereavement plans of care lacked frequencies of the bereavement services or interventions. Clinical Record 10: The patient with an election of hospice benefit dated 9/9/2022 had a high-risk bereavement care plan dated and modified on 10/14/2022 for the identified bereaved. The following five (5) care plan bereavement services were missing documented frequencies: initial sympathy card/letter; development of bereavement plan of care; standard bereavement form letters; information/referral to community resources; and cards/newsletter. Clinical Record 12: The patient with an election of hospice benefit dated 8/26/2022 had a low-risk bereavement care plan dated 8/26/2022 and updated 12/1/2022 for the identified bereaved. The following five (5) care plan bereavement services were missing documented frequencies: initial sympathy card/letter; bereavement risk assessment in interdisciplinary group (IDG) review; standard bereavement form letters; information/referral to community resources; and card/newsletters.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by a review of clinical records and interviews. 5 of 11 (45%) records reviewed where hospice aide services were accepted, revealed a lack of specific written instructions on the hospice aide care plans, thus leaving the aides to make decisions outside the aides' scope of practice. Clinical Record 3: The patient with an election of hospice benefit dated 5/10/2022 had a primary diagnosis of senile degeneration of the brain and received hospice aide services three times weekly (3xW). The hospice aide care plan dated 5/10/2022 documented two different bath types that included a shower (1st bath choice per caregiver), and bed bath (2nd bath choice per caregiver). NOTE: The hospice aide care plan was updated on 2/7/2023, day 1 of the site visit, accurately with one bath type (bed bath). Clinical Record 8: The patient with an election of hospice benefit dated 10/14/2022 had a primary diagnosis of COPD and received hospice aide services twice weekly (2xW). The hospice aide care plan dated 10/17/2022 documented the following "as needed" assigned tasks: "transfer client from bed/chair every visit as needed, transfer client from chair/bed every visit as needed, assist bedside commode every visit as needed, shampoo every visit as needed, hair care every visit as needed, oral care every visit as needed, nail care weekly as needed, dressing every visit as needed, and apply deodorant every visit as needed. Clinical Record 10: The patient with an election of hospice benefit dated 9/9/2022 had diagnoses of myasthenia gravis and COPD and received hospice aide services three times weekly (3xW). The hospice aide care plan dated 9/9/2022 documented two different bath types that included a bed bath and a sponge bath (secondary with instructions). Clinical Record 13: The patient, with an election of hospice benefit dated 1/13/2023, had a primary diagnosis of COPD and received hospice aide services twice weekly. The hospice aide care plan dated 1/17/2023 documented two different bath types: a shower as the primary bath and a sponge bath as the secondary bath. Clinical Record 15: The patient with an election of hospice benefit dated 12/9/2022 had a primary diagnosis of Alzheimer's disease and received hospice aide service twice weekly (2xW). The hospice aide care plan dated 2/3/2023 documented a nonspecific bath type of a partial sponge bath. The hospice aide care plan was updated on 2/8/2023, day 2 of the site visit, after the home visit was conducted and was changed to a chair bath on a raised toilet seat. An interview with the Executive Director during the joint record review on 2/9/2023 confirmed the hospice aide care plans were not specific. Additionally, the Executive Director provided evidence of an educational in-service to clinical managers on 2/2/2023 on the topic of hospice aide care plans.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by a review of clinical records and interview. 1 of 10 (10%) records reviewed in which hospice aide services were accepted revealed the agency did not ensure the hospice aide reported to the registered nurse of the hospice aide's assigned tasks that were not completed in accordance with the plan of care. Clinical Record 10: The patient, with an election of hospice benefit dated 9/9/2022 and a hospice aide care plan dated 9/9/2022, had diagnoses of myasthenia gravis and COPD and received hospice aide services at a facility three times weekly (3xW). The hospice aide visit note dated 10/13/2022 documented patient refused a bed bath and sponge bath. There was no documentation the registered nurse was notified. An interview with the Executive Director during the joint record review on 2/9/2023 confirmed that there was no documentation or evidence of the hospice aide's notification to the registered nurse of the incomplete assigned tasks.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. All hospice care is provided in the facility in accordance with the hospice plan of care. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 1 (100%) records reviewed where the patient resided at a nursing facility and was receiving wound care treatment revealed the agency did not follow the plan of care for wound care. Clinical Record 12: The patient with the election of hospice benefit dated 8/26/2022 had a primary diagnosis of Alzheimer's and received hospice services at a nursing facility. The Plan of Care order dated 8/26/2022 for benefit period 8/26/2022-11/23/2022 documented the following wound care order: "Hospice nurse to perform wound care to Stage 2 pressure ulcer on the left coccyx. Utilizing clean technique - cleanse with wound cleanser, pat dry with gauze, apply Aquacel, cover with a non-adherent pad, and change every day and as needed. Instruct caregiver in wound care." The wound record report provided by the agency on 2/10/2023 revealed, for approximately a month, the wound was not assessed, nor was wound care provided by the hospice registered nurse. However, there was documentation that the facility nurse ("caregiver completed care") completed the wound care treatment: 08/27/2022; 8/28/2022, 8/29/2022, 8/31/2022, 9/5/2022, 9/7/2022, 9/12/2022, 9/19/2022, 9/21/2022, 9/23/2022, 9/25/2022, and 10/1/2022. The following hospice registered nursing visits documented the wound was assessed including measurements, however, the wound care treatment was completed by the facility nurse: 8/26/2022, 9/26/2022, 10/3/2022, 10/5/2022, and 10/7/2022. An interview with the Executive Director during the joint record review on 2/10/2023 confirmed the registered nurse did not follow the wound care order in accordance with the plan of care.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document reviews and interview. 5 of 6 (83%) contracts reviewed revealed the contracts were missing verbiage in the contracts to obtain criminal background checks for contracted employees who have direct patient contact or access to the patient records. Contract 1: The agency's contract for ambulance services, titled Transportation Services Agreement, with an effective date of March 14, 2018, was missing the criminal background check clause. Contract 2: The agency's contract for general inpatient and respite levels of care, titled Service Agreement Between Hospice and Hospital, with an effective date of 2/1/2017 was missing the criminal background check clause. Contract 3: The agency's contract for therapies and skilled nursing services, titled Therapy and Skilled Nursing Service Agreement, with an effective date of 11/1/2012, was missing the criminal background check clause. Contract 5: The agency's contract template numbered {W0973544.2} and titled Agreement for Hospice Care to Residents of a Skilled Nursing Facility, stated in part, under Section 2.10 subtitle Personnel, "Hospice shall also conduct criminal background checks of all personnel that it utilizes to perform Hospice Services at the Nursing Home and shall immediately advise the Nursing Home if any Hospice personnel have been convicted of a crime." The criminal background check clause for the skilled facility personnel was missing. Contract 4: The agency's contract for a skilled nursing facility, titled Agreement for Hospice Care to Residents of a Skilled Nursing Facility with an effective date of 6/14/2016 was missing the criminal background check clause for the facility staff. An interview with the Executive Director on 2/9/2023 confirmed the contracts were missing the criminal background check clause, and the corporate legal department was aware and updating all the contracts to include the regulatory clause. A review of the agency's contracts revealed multiple contracts were missing the criminal background clause of contracted employees who have direct patient contact or access to the patient records to obtain criminal background checks.

Based on observations, review of Medical Record (MR), agency policy and procedure, and interviews, it was determined the agency failed to ensure the staff maintained a current and accurate Client Medication Report (CMR) for each patient. This deficient practice affected one of five home visits (HV) including HV # 2 and had the potential to affect all patients admitted to this hospice agency. Findings include: Agency Policy: Medication/DME (Durable Medical Equipment) Review Policy Number: H701 Revised: 4/1/20 Policy: All medications and DME will be reviewed with the patient and/or family every fifteen (15) days and as necessary. Procedure: ...3. List all medications on the Hospice Medication Profile. 4. List any new and/or changes with medications on the Hospice Medication Profile upon occurrence. 1. HV # 2 was admitted to hospice on 3/11/21 and recertified for hospice care from 7/4/22 to 9/1/22 with diagnosis including Hypertensive Heart and Chronic Kidney Disease Without Heart Failure, With Stage 1-4 Unspecified Chronic Kidney Disease. Review of the Hospice Recertification Physician Orders dated 6/19/22 revealed orders for Skilled Nurse (SN) two times weekly for eight weeks and one time a week for one week. A HV was conducted at the patient's residence at a Skilled Nursing Facility (SNF) on 8/2/22 at 1:10 PM to observe care provided by Employee Identifier (EI) # 4, Chaplain. During the visit, the hospice CMR provided to the surveyor on 8/2/22 was compared to the facility physician orders. The following discrepancies were observed: a. Reglan 15 milligram (mg) tablet three times daily as needed was listed on the hospice CMR. The medication was not on the SNF medication orders. The SNF nurse reported the Reglan was discontinued on 9/18/21. b. Remeron 15 mg tablet, take one tablet at bedtime was listed on hospice the CMR and the facility orders were Remeron 15 mg take one half tablet at bedtime. The SNF nurse reported Remeron 15 mg, take one half tablet was the original medication order dated on 3/9/21 without changes. c. Senna Plus 8.6 mg - 50 mg tablet, take one tablet daily started on 7/13/22 was on the facility orders and not on the hospice CMR list. An interview conducted on 8/4/22 at 4:16 PM with EI # 1, Executive Director confirmed the hospice CMR had not been updated per the agency policy and procedure.

Based on medical record (MR) review, policy and procedure, and interview, it was determined the hospice agency failed to provide education to the patient/caregiver (CG) for new medications ordered. This affected one of twelve active records reviewed, including MR # 7, and had the potential to affect all patients served by the hospice agency. Findings include: Agency Policy: Medication/DME (Durable Medical Equipment) Review Policy Number: H701 Revision Date: 4/1/2020 Policy: All medications and DME will be reviewed with the patient and/or family every fifteen days and as necessary. Procedure: ...5. Provide medication teaching as necessary and document on the Skilled Visit Note. 1. MR # 7 was admitted to the agency on 2/15/22, and recertified for care on 6/30/22 for certification period 7/15/22 to 9/12/22 with diagnoses including Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris and Old Myocardial Infarction. Review of the Hospice Recertification Plan of Care Update dated 6/30/22 revealed a Skilled Nurse (SN) visit frequency of two times every two weeks for two weeks, then two times a week for seven weeks, with four additional PRN (as needed) visits effective 7/15/22. Review of the Hospice Physician Order dated 7/15/22 revealed an order for Restoril 15 milligrams (mg), one capsule at bedtime. Review of the Hospice Physician Order dated 7/19/22 revealed an order for Melatonin 10 mg, one tablet at bedtime. Review of the Hospice Physician Order dated 7/29/22 revealed orders for Haloperidol (Haldol) 0.5 mg, one tablet three times daily as needed for agitation, and Seroquel 25 mg, one tablet at bedtime. Review of the SN Visit Note Reports (VNR) dated 7/15/22, 7/16/22, 7/19/22, 7/21/22, 7/29/22, 7/30/22, and 8/2/22 revealed no documentation the patient/CG received education on any of the new medications ordered. In an interview conducted on 8/4/22 at 3:58 PM with Employee Identifier (EI) # 2, Executive Director, EI # 2 confirmed the patient/CG should have been educated on the new medications ordered, and there was no documentation the patient/CG received the education.

Based on review of medical records (MR), observations, policies and procedure, and interview, it was determined the agency failed to ensure an individualized Plan of Care (POC) was developed to include care and assessment of a gastrostomy tube (tube placed in the abdomen to assist with receiving nutrition, hydration and medications). This affected one of one records reviewed with a gastrostomy tube, including Home Visit (HV) # 5, and had the potential to negatively affect all patients with gastrostomy tubes. Findings include: Agency Policy: Plan of Care Policy Number: H402 Revision Date: 6/30/21 Policy: An individualized POC will be established for each hospice patient...The POC is developed and reviewed by the Interdisciplinary Team (IDT) every fifteen days... Agency Policy: Gastrostomy Tube (G-Tube) Policy Number: H605 Revision Date: 4/1/2020 Policy: A Registered Nurse (RN) or Licensed Practical Nurse (LPN) will perform care of a balloon retained G Tube... Procedure: ...7. Assess skin condition. Observe for any leakage, erythema (redness), edema (swelling), or tenderness. Notify physician for signs of infection. 1. HV # 5 was admitted to the agency on 7/21/21 and recertified for care 7/16/22 to 9/13/22 with diagnoses including Hemiplegia Following Cerebral Infarction Affecting Left Non-Dominant Side, and Dysarthria and Anarthria. Review of the Hospice Recertification Plan of Care (POC) Update dated 7/1/22 revealed a Skilled Nurse (SN) visit frequency of three times a week for eight weeks, one time a week for one week, effective 7/17/22. A HV was conducted on 8/2/22 at 3:08 PM to observe care provided by Employee Identifier (EI) # 7, Hospice Aide, which included a bed bath. During the HV, the patient was observed as having a G-Tube present. Review of the SN Visit Note Reports (VNR) dated 7/18/22, 7/22/22, 7/25/22, 7/29/22, and 8/1/22 revealed no documentation the G-Tube was assessed. Review of the IDT/POC dated 7/21/22 revealed no orders for care or asssessment of the G-Tube. In an interview conducted 8/4/22 at 4:00 PM with EI # 1, Executive Director, EI # 1 confirmed the G-Tube was present during the above noted SN visits, and was not assessed during the visits. EI # 1 also confirmed there was no physician order written for assessment of the G-Tube until 8/4/22.

Based on observations, Medical Record (MR) review, agency policy and procedure, and interviews, it was determined the agency failed to ensure the staff followed the agency policy and procedure for hand hygiene. This deficient practice affected one of five home visits including Home Visit (HV) # 1 and had the potential to affect all patients admitted to this hospice. Findings include: Agency Policy: Infection Control Guidelines Policy Number: 04.19.06 Revised: 6/2/2020 ...Handwashing 1. Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, wheather or not gloves are worn. Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated... 1. HV # 1 was admitted on 4/22/22 and recertified for hospice care from 7/21/22 through 10/18/22 with diagnoses including Hypertensive Heart and Chronic Kidney Disease and Chronic Diastolic (Congestive) Heart Failure. A HV was conducted on 8/2/22 at 12:50 PM to observe care provided by Employee Identifier (EI) # 6, Registered Nurse (RN). EI # 6 performed hand hygiene with soap and water, donned gloves, and removed the drainage soaked dressing from the right lower leg. EI # 6 then removed the dirty gloves and donned clean gloves. EI # 6 failed to perform hand hygiene after removing gloves. EI # 6 then removed the dressing from the left lower leg, removed dirty gloves, then donned clean gloves. EI # 6 failed to perform hand hygiene after removing gloves. EI # 6 then cleaned the wound to the left lower leg with a soap and water solution and patted dry. EI # 6 removed gloves and donned clean gloves without performing hand hygiene. EI # 6 applied xeroform gauze to right lower leg and applied a dressing. EI # 6 then removed the dirty gloves and donned cleaned gloves without performing hand hygiene. EI # 6 failed to perform hand hygiene after removing dirty gloves and before donning clean gloves at each opportunity. In an interview conducted on 8/2/22 at 1:45 PM, EI # 6 confirmed he/she did not perform hand hygiene between each glove change. In an interview conducted on 8/4/22 at 3:15 PM, EI # 1, Executive Director, confirmed the staff failed to follow the agency policy and procedure for hand hygiene.

Based on review of medical records (MR), policy and procedure, written oxygen safety education in the agency's patient admission folder, and staff interview, it was determined the agency failed to ensure the staff assessed oxygen cylinder storage and documented accurately in one of eleven active records reviewed with patients receiving home oxygen, including Home Visit (HV) # 5, and had the potential to affect all patients with home oxygen served by the agency. Findings include: Comfort Care New Patient Admission Folder, Oxygen Safety Date: None Oxygen Safety: ...Oxygen creates a high risk for fire ... ...Place oxygen cylinders in appropriate stand to prevent tipping, or secured to the wall or placed on their side on the floor. Agency Policy: Safety and Emergency Preparedness Policy Number: H1000 Revision Date: 4/1/2020 Purpose: ...4. Develop processes to: a. Prevent accidents and injuries to patients and staff. b. Promote a safe and secure environment. Policy/Procedure: ...2. The program addresses safety in patients' homes. a. The case manager conducts and documents a home safety assessment when a patient is admitted to service and during care when there are changes in the patient's environment,..equipment.. b. The home safety assessment includes: ...viii. Storage and handling of supplies, medical gases... ...6. The agency develops and implements fire safety policies and procedures for patient homes...The agency: ...f. Assesses fire safety in patient homes. ...ii. The assessment may address...use of oxygen... 1. HV # 5 was admitted to the agency on 7/21/21 and recertified for care 7/16/22 to 9/13/22 with diagnoses including Hemiplegia Following Cerebral Infarction Affecting Left Non-Dominant Side, and Dysarthria and Anarthria. Review of the 7/1/22 Hospice Recertification Plan of Care Update revealed a continued order for oxygen, initiated on 8/4/21, at 2-5 liters per minute as needed for shortness of breath. Review of the Skilled Nurse (SN) Visit Note Reports (VNR) dated 7/18/22, 7/22/22, 7/25/22, 7/29/22, and 8/1/22 revealed the SN documented oxygen was safely stored. A HV was conducted on 8/2/22 at 3:08 PM. During the HV, four cylinders of oxygen were observed upright, propped against a bedroom wall. They were not in a stand or laying flat on the floor. The patient's caregiver confirmed during the visit the cylinder's belonged to the patient, and that he/she routinely stored the cylinders propped against the wall. In an interview conducted on 8/4/22 at 4:00 PM, Employee Identifier (EI) # 1, Executive Director confirmed the agency policy states to store oxygen on it's side or in a stand, the oxygen was not being stored safely, and the SN documentation was not accurate.

Based on observation, review of medical records (MR) and interview with the agency administrative staff, it was determined the agency failed to ensure follow-ups and coordination of care with the facility were made to meet the patient's concerns and needs. This affected one of one home visits (HV) at a nursing facility including HV # 2 and had the potential to negatively affect all patients served by the agency residing in facilities. Findings include: Policy: Plan of Care Policy Number: H402 Revised date: 6/30/21 Policy: An individualized Plan of Care will be established for each Hospice patient... The Plan of Care (POC) is developed and reviewed by the Interdisciplinary Team (IDT) every fifteen (15) days and as the individual patient's needs arises. Persons participating in Hospice care as providers or receivers are informed of changes in the POC as it is reviewed and updated. Procedure: ...9. The POC for patients residing in facilities (nursing homes, hospital, etc)... The Hospice staff will continue to oversee... interventions and follow up with the facility to coordinate patient needs. 10. The IDT meets every fifteen days to maintain continuity of care for all patients, i.e. development, reviewing and revising of each POC. 14. The Registered Nurse (RN) will supervise each case... accomplished by record review, written or verbal instruction, care plan review... 1. HV # 2 was admitted to hospice on 3/11/21 and recertified for hospice care from 7/4/22 to 9/1/22 with diagnoses including Hypertensive Heart and Chronic Kidney Disease without Heart Failure, with Stage 1-4 Unspecified Chronic Kidney Disease. Review of Recertification Physician Orders dated 6/19/22 revealed orders for SN two times a week for eight weeks and one time a week for one week, Medical Social Worker (MSW) one time a month for two months, Hospice Aide (HA) two times a week for nine weeks and Chaplain one time a month for two months. A HV was conducted at the skilled nursing facility (SNF) on 8/2/22 at 1:10 PM to observe care provided by Employee Identifier (EI) # 4, Chaplain. During visit the surveyor reviewed the patient's hospice folder containing the hospice agency forms and documentation maintained at the SNF. The review revealed a face to face (F2F) visit note dated 4/6/22 and a nurse visit note report dated 6/7/22. The CMR in the hospice folder had a print date of 6/14/22. There was no documentation the hospice provided the current hospice plan of care to the facility and no documentation of care coordination. An interview conducted on 8/4/22 at 4:16 PM with EI # 1, Executive Director confirmed the agency failed to provide updated documentation for coordination of care to the facility per the agency's policy and procedure.