Every finding on record at Community Health Center of Branch County Hospice

Observed in Leadership Session. During review of the hospice contracts, the written agreement with the durable medical equipment companies that were providing contracted services for the hospice did not include a stipulation that the durable medical companies would complete criminal background checks on employees who would provide direct patient care or have access to hospice patient records. This was discussed with the agency Director of Patient Care Services.

Based on document review and interview, the Agency failed to provide documentation of field staff attendance for any trainings designated towards the testing and training of the Agency's Emergency Preparedness program, resulting in the potential to adversely affect all 14 hospice patients currently receiving services in the event of an actual emergency. Findings include: Agency policy: "Emergency Preparedness Plan" (dated 12/2019) pg. 40 stated, "Agencies must perform the following: Emergency Preparedness training is completed biennially (every 2 years), and documentation of the training is maintained." During the review of the Agency's Emergency Preparedness trainings on 7/12/22, no evidence of individual field staff names or field staff attendance was found. Review of the trainings for the last 2 years found attendance was categorized by clinical discipline only. The above finding was reviewed with and acknowledged by the Agency's Administrator during an interview on 7/13/22 at 11:04 AM.

Based on document review and interview, the hospice Agency failed to provide documentation for the required community-based full-scale exercises and failed to provide evidence that a community-based exercise was not available to participate in, resulting in the potential for staff being ill-prepared in the event of an actual emergency and the potential for poor patient outcomes. This deficient practice could negatively affect all staff employed, and the 14 active patients currently serviced by this Agency. Findings include: Agency Policy: "Emergency and Disaster Preparedness Plan (revised 9/2017) stated, "In the event the disaster extends beyond the limits of hospice and/or involves multiple entities, hospice will coordinate services with the internal command center in closest proximity or follow direction from local and state authorities leading the response." During review of the Agency's Emergency Preparedness binder on 7/12/2022 at 12:10 PM., no evidence was found concerning the Agency's participation in the full-scale exercise that is community-based every two years. The Administrator (Adm.#1) was then queried for documentation showing the Agency's participation and if not, documented efforts made to communicate with Region 5's Healthcare Preparedness Coordinator to determine the feasibility of the Agency's participation in the next community-based exercise. At the survey's conclusion, the above findings were reviewed with and confirmed by Adm.#1 that the Agency failed to provide documentation of efforts made to participate in the required full-scale community-based exercise during an interview on 7/14/22 at 0910 AM.

Based on document review and interview, the Agency failed to ensure all members of the interdisciplinary group had completed the comprehensive assessment within 5 days in 1 (MR #4) of 11 records, from a total of 11 records reviewed, resulting in the potential for unidentified and unmet care needs for all 14 patients currently receiving services. Findings include: Agency Policy: "Hospice Social Services" (updated 9/2015) stated, "A psychosocial assessment is completed on initial contact with patient/caregiver(s) or as soon as possible." MR #4: The patient was admitted to hospice on 1/4/22 with terminal diagnoses of Malignant Neoplasm (cancer) of prostrate and bone. During review of the patient's Plan of Care (POC), it was noted that MSW (Master of Social Work) services were ordered to evaluate the patient effective 1/16/22. However, MSW services did not evaluate this patient until 27 days (1/31/22) after being admitted. Review of the clinical record found no refusal of services by the patient/caregiver(s) or any notification to the physician concerning the delay in services. Review of documentation noted attempts by MSW services under coordination notes to contact the patient with "no answer" noted on 1/6/22 with an attempt to reschedule on 1/24/22. However, additional record review noted three of three other disciplines (skilled nursing, aide services and spiritual counseling) all provided services (15 of 15 opportunities) as ordered at the start of care with no missed visits. During an interview with the Administrator (Adm. #1) on 7/13/22 at 2:15 PM., Adm. #1 was queried as to the Agency expectation when Social Work services would perform an initial evaluation. Adm.#1 replied, "Within five business days." Adm.#1 acknowledged the findings above and noted this had failed to meet Agency expectations.

Based on document review and interview, the hospice failed to ensure the initial Bereavement Risk Assessment was comprehensive and included patient family members/significant individuals identified during a home visit interview and record reviews to determine factors that may impact grieving individuals' ability to cope with the patient's impending death for 7 (MR#'s 1, 2, 3, 6, 7, 8, 11) of 11 records reviewed from a total sample of 11 records. This deficient practice has the potential to negatively affect the loss/grief issues for all 77 patients/family members serviced within the past 12 months. Findings include: Agency Policy: "Bereavement Program" (undated) stated, "A bereavement assessment will be completed with those individuals identified during the Initial Social Work Assessment and/or by the IDG (inter-disciplinary group) meeting." Agency Policy: "Bereavement Coordinator Guidebook" (dated 9/2021) stated, "The bereavement risk assessment is... not a single event, but rather a continuous process throughout contacts with the bereaved individual (NHPCO, 2018). Review the admissions report daily and identify recently admitted patients. Utilizing the report, verify those patients and their bereavement contacts are showing up in the bereavement activity console in the EMR (electronic medical record). Verify the risk assessment was performed." MR #6: The patient was admitted to hospice on 6/20/22 with terminal diagnoses of Parkinson's Disease and Dementia. On 7/12/22, review of the patient's contacts listed only the patient's wife. However, during a scheduled hospice home visit with aide services, the patient was queried who would be impacted and would substantially grieve upon his passing. The patient replied, "My wife, my three children and my closest friend (co-worker of many years). I also have three step-children." The initial Bereavement Risk Assessment performed by Skilled Nursing (SN) services (6/20/22) only acknowledged the patient's spouse and failed to include the other family members and friend noted above. No further entries or updates were noted in the patient's ongoing Bereavement Risk Assessment since being admitted on 6/20/22. MR #7: The patient was admitted to hospice on 6/1/22 with terminal diagnoses of Liver Failure and Chronic Kidney Disease. On 7/12/22, review of the patient's family contact list noted a sister, two daughters, and a son-in-law who is the patient's financial and medical DPOA (Durable Power of Attorney). The initial Bereavement Risk Assessment performed by SN services (6/1/22) only acknowledged the patient's sister and failed to include the other family members noted above. No further entries or updates were noted in the patient's Bereavement Risk Assessments since admission to hospice. These findings were reviewed with and acknowledged by the Administrator and the Director of Patient Services during an interview on 7/13/22 at 3:15 PM. MR #1: The patient was admitted to Hospice on 1/14/22 with terminal diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Pneumonia and Bilateral Lung Nodule. On 7/12/22 at 10:53 a.m., during a review of the clinical record, the patient's "Family contact Information" sheet identified the patient's son and stepchild. The patient's "Bereavement Risk Assessment Report" dated 1/14/22 completed by the Registered Nurse, and 1/31/22 completed by the Medical Social Worker (MSW) both identified the patient's son. The patient's stepchild had not been included in the Initial Bereavement Assessments as a person who would experience anticipatory grieving and be affected by the patient's death. MR #2: The patient was admitted to Hospice on 6/17/22 with terminal diagnoses of Breast Cancer and Congestive Heart Failure. On 7/11/22 at 3:15 p.m., during the clinical record review, it was noted that the patient's contacts listed 2 daughters and 1 son-in-law. The patient's Bereavement Risk Assessment report, dated 6/17/22, failed to include the patient's son-in-law as a person who would experience anticipatory grieving and be affected by the patient's death. MR #3: The patient was admitted to Hospice on 6/10/22 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD). On 7/12/22 at 9:00 a.m., during the clinical record review, it was noted that the patient's contacts listed 3 daughters, 1 son and 1 in-law. The patient's Bereavement Risk Assessment reports dated 6/10/22 and 6/15/22, failed to include the patient's son and in-law as persons who would experience anticipatory grieving and be affected by the patient's death. The findings in the above-mentioned records were reviewed with and acknowledged by the Administrator (Adm #1) and the Director of Patient Services (DPS #1) during an interview on 7/13/22 and again during the exit conference on 7/14/22. MR#8: The Start of Care (SOC) was dated 12/17/21. The Plan of Care (POC) identified terminal diagnosis of Chronic Obstructive Pulmonary Disease. During record review on 7/11/22, it was noted that the bereavement risk assessment was completed by the Skilled Nurse (SN) at the time of death for the patient's husband. The SN that completed the discharge documented, "Comments Related to Bereavement: Dtrs (Daughters) siting on bed with mom ..." The bereavement risk assessment failed to include the patient's mother and two daughters. MR#11: The Start of Care (SOC) was dated 1/29/22. The Plan of Care (POC) identified terminal diagnoses of Chronic Kidney Disease and Congestive Heart Failure. During record review on 7/13/22, it was noted that the bereavement risk assessment was completed by the SN at the time of death for one of the patient's two sons. The SN that completed the discharge documented, "Indicate name and relationship(s) of bereaved to the deceased: Daughter." The bereavement risk assessment failed to include the patient's daughter and the other son. These findings were reviewed with and acknowledged by the Administrator (Adm#1) and Director of Professional Services (DPS#1) during an interview on 7/14/22 at 10:45 am.

Based on record review and interview, the Hospice Agency failed to ensure the Plans of Care were clear, accurate and addressed the individualized needs of the patients for 11 (MR' #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11) of 11 records, from a total of 11 sampled records reviewed, resulting the potential for unidentified, untreated health concerns, unmet care needs and poor patient outcomes (L545); failed to develop a patient specific plan of care that included specific interventions for pain and symptom management for 3 (MR's #1, 3, 7) of 11 records, from a total of 11 sampled records reviewed, resulting in unrelieved pain and symptom management (L546); failed to ensure the plan of care included patient specific measurable goals for 11 (MR' #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11) of 11 records, from a total of 11 sampled records reviewed, resulting in the potential for unmet patient care needs and goals (L548); failed to establish a system of communication to ensure that 1 (MR #2) of 1 patient received supplemental Oxygen to relieve shortness of breath, in accordance with the plan of care, from a total of 11 sampled patients reviewed, resulting in unrelieved episodes of Hypoxia and unmet care needs (L555); and, failed to ensure the ongoing sharing of information between the Physician, and all disciplines providing care for 1 (MR #2) of 1 patient who was not provided with supplement oxygen to relieve shortness of breath; 1 (MR #10) of 1 patient with acute exacerbation of symptoms; and 1 (MR #4) of 1 patient who experienced a significant change in condition, from a total of 11 sampled records reviewed, resulting in lack in continuity of care and the patients not receiving the required care and services specific to their individualized needs during the end of life (L557). The cumulative effect of these systemic problems resulted in the Hospice Agency's inability to ensure the provision of quality Hospice care at the end of life, in a safe environment for the Condition of Participation: 42 CFR §418.56 Interdisciplinary Group, Care Planning, and Coordination of Services.

Based on record review and interview, the Hospice Agency failed to ensure the Plans of Care were clear, accurate and addressed the individualized needs of the patients for 11 (MR' #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11) of 11 records, from a total of 11 sampled records reviewed, resulting the potential for unidentified, untreated health concerns, unmet care needs and poor patient outcomes. Findings include: MR's #1-11: During a review of the identified records, it was noted that all the patients had several admitting diagnoses. It was further noted that all the listed diagnoses had the same date of exacerbation, which was the date of admission to this Hospice Agency. The plans of Care were non-specific and void of any reportable parameters and failed to address the individualized needs of the patients. Upon review, it was unclear as to which, of all the listed diagnoses, was the actual treating diagnosis/diagnoses that the patients were admitted to the Hospice Agency for. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Director of Patient Services (DPS #1) during an interview on 7/13/22 and again during the exit conference on 7/14/22 at 2:00 p.m.

Based on document review and interview, it was determined the Hospice failed to develop a patient specific plan of care that included specific interventions for pain and symptom management for 3 (MR's #1, 3, 7) of 11 records, from a total of 11 sampled records reviewed, resulting in unrelieved pain and symptom management. Findings include: Agency Policy: "Pain Management" (updated 12/2016) stated, "Each patient will be informed of his or her right to receive appropriate pain management... The pain assessment tool includes the following: Intensity scale (self-reported 1-10); Pain goal... and monitor for adequacy of pain relief." MR #7: The patient was admitted to hospice on 6/1/22 with terminal diagnoses of Liver Failure and Chronic Kidney Disease. On 7/13/22, review of the patient's Plan of Care (POC) ordered Skilled Nursing (SN) services on 6/1/22. The visit frequency was twice a week for 13 weeks, along with three as needed visits for symptom management. Under the POC's "Orders and Treatments", pain management was addressed by using a pain scale (1-10; 10 being the highest pain) along with the administration and side effects of pain medications. The POC goals for pain were "Patient/Caregiver(s) verbalize understanding of pain medication administration and side effects as evidenced by demonstrated patient comfort." Review of SN's visit note on 6/8/22 documented the patient's "Upper Limit" concerning adequate pain relief was a 3 out of 10 and was at a 5 when SN made the home visit. SN documented under "PAIN" that an initial dose of oral Dilaudid (pain medication) was given but failed to answer the question "Indicate their effectiveness." The following day on 6/9/22, SN had to make another visit to help manage the patient's pain as it was at a 5 out of 10. SN documented under "PAIN" that the patient was experiencing sharp abdominal pain along with generalized aches. Under the question, "How many PRN (as needed) medications were taken and indicate their effectiveness" SN documented 3 and the effectiveness section was left blank. The following represents SN's documentation concerning the patient's pain along with level and effectiveness on the corresponding dates: 6/16/22; generalized-abdominal and coccyx with no pain level reported and pain medication effectiveness was left blank, 6/18/22; generalized with no pain level reported and pain medication effectiveness was left blank, and 6/20/22; Patient had become confused, agitated, and unable to verbalize pain issues with "Occasional moan/groan. Low level speech with a negative or disapproving quality." Concerning the question, "How many PRN medications were taken and indicate their effectiveness" SN documented "4, effective when she doesn't spit it out." Review of the patient's POC noted no other alternative or modes of delivery (pain patch or shot) to facilitate pain relief for the patient. Further, no other use of alternative therapies (massage, music) was found on the patient's POC when medications alone were not effective due to the patient spitting them out. These findings were reviewed with and acknowledged by the Administrator and the Director of Professional Services during an interview on 7/13/22 at 3:15 PM. The Agency failed to ensure the patient's POC was individualized to help meet the patient's specific palliative care needs concerning pain. MR #1: The patient was admitted to Hospice on 1/14/22 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and additional diagnoses which included Solitary Pulmonary Nodule and Low Back Pain, Protein Malnutrition and Generalized Anxiety disorder. During review of the clinical record on 7/12/22 at 10:53 a.m., it was noted that the Plan of Care (POC) was void of any interventions to to treat/monitor/manage pain and failed to include interventions to manage any of the other identified diagnoses or symptoms. During the record review, it was noted that the patient complained of 8/10 and 9/10 throughout the course of care. No additional interventions were put into place to manage the patient's pain. These findings were reviewed with the Administrator (Adm #1) and Director of Patient Services (DPS #1) during an interview on 7/13/22 at 8:46 a.m. who acknowledged the absence of interventions and reported, "We should have added more Nursing visits to address the patient's needs. We could have even rotated the staff to make sure eyes were on him (patient) at all times." MR #3: The patient was admitted to Hospice on 6/10/22 with a terminal diagnosis of COPD and additional diagnoses which included Congestive Heart Failure (CHF) and Diabetes Mellitus. Upon review of the clinical record on 7/12/22, it was noted that the POC was void of interventions to monitor/treat/manage pain and associated symptoms. These findings were reviewed with and acknowledged by Adm #1 and DPS #1 during an interview on 7/13/22 at 1:50 p.m.

Based on record review and interview, the Hospice Agency failed to ensure the plan of care included patient specific measurable goals for 11 (MR' #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11) of 11 records, from a total of 11 sampled records reviewed, resulting in the potential for unmet patient care needs and goals. Findings include: Agency Policy: "Interdisciplinary Group Plan of Care" 104.1 (undated) stated, "The POC (Plan of Care) must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: Measurable outcomes anticipated from implementing and coordinating the plan of care." MR's #1-11: During the 7/11/22 through 7/14/22 review of the preceding records, it was noted that the Plans of Care (POC) were generic, not individualized and were not quantitative. All 11 patient POC's were not stated in measurable terms that would enable the staff to accurately perform an objective evaluation of the patient's progress toward their goals and outcomes. For example, the POC's included goals such as, "Patient will maintain optimal cardiac function within constraints of disease process; Patient/Caregiver will verbalize understanding of effects of urinary incontinence; Patient will remain safe within home environment." On 7/13/22 at 3:15 PM., the findings were reviewed with the Administrator and Director of Professional Services, and it was acknowledged the Plans of Care did not include measurable goals.

Based on record review and interview, the Hospice failed to establish a system of communication to ensure that 1 (MR #2) of 1 patient received supplemental Oxygen to relieve shortness of breath, in accordance with the plan of care, from a total of 11 sampled patients reviewed, resulting in unrelieved episodes of Hypoxia and unmet care needs. Findings include: MR #2: The patient was admitted to Hospice on 6/17/22 with a terminal diagnosis of Breast Cancer and additional diagnoses which included Congestive Heart Failure and Hypoxemia with Hypoxic (shortness of breath) episodes and periods of dyspnea (difficulty breathing) and required supplemental Oxygen. During the record review on 7/11/22, it was noted that the Plan of Care ordered the patient to receive Nursing services at a frequency of 2 x/wk. x 9 wks., 1x/wk. x 1 wk., 4 as needed visits for symptom management, and was ordered to have an Oxygen Concentrator and Oxygen supplies. On 7/11/22 at 1:00 p.m., during a scheduled home visit with the Registered Nurse (RN #1), the patient complained of shortness of breath, difficulty breathing and chest discomfort and pressure. It was further reported that the patient had not received her Oxygen equipment as ordered and had no Oxygen support since admission on 6/17/22. RN #1 confirmed that she was unable to locate the needed Oxygen equipment. During the continued review of the clinical record, there was no communication between disciplines regarding the missing equipment. The Agency failed to maintain a system of communication and integration to ensure the needs of the patient were met. These findings were reviewed with the Administrator and Director of Patient Services during an interview on 7/11/22 an gain during the Exit Conference on 7/14/22 at 2:00 p.m.

Based on record review and interview, the Agency failed to ensure the ongoing sharing of information between the Physician, and all disciplines providing care for 1 (MR #2) of 1 patient who was not provided with supplement oxygen to relieve shortness of breath; 1 (MR #10) of 1 patient with acute exacerbation of symptoms; and 1 (MR #4) of 1 patient who experienced a significant change in condition, from a total of 11 sampled records reviewed, resulting in lack in continuity of care and the patients not receiving the required care and services specific to their individualized needs during the end of life. Findings include: Policy: Interdisciplinary Group (IDG) Plan of Care: PC 9/17 stated, "The IDG is responsible for: Ensure ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. MR #2: The patient was admitted to Hospice on 6/17/22 with diagnoses that included Breast Cancer, Hypertensive Heart Disease and Congestive Heart Failure. A "History of Present Illness" dated 3/8/22 documented, "Hypoxemia (low blood oxygen level) requiring supplemental Oxygen (O2)." A "Client Supplies Report" dated 6/17/22 documented, "Oxygen Concentrator, Oxygen Supplies..." The Plan of Care (POC) ordered, "DME (durable medical equipment) Oxygen concentrator; Oxygen Supplies..." During the clinical record review on 7/11/22 at 3:15 p.m., a review of the Skilled Nurses (SN) visit notes documented the patient complained of shortness of breath (SOB) on 6/23/22 and 6/27/22. On 7/11/22 at 1:00 p.m., a scheduled home visit was conducted with the Registered Nurse (RN #1). Prior to entering the facility (Patient resided in an Assisted Living Facility), RN #1 reported, "They (facility staff) reported that the patient was experiencing SOB this past weekend and that her oxygen levels were in the low 80's." Upon entering, the patient was seated in a recliner and exhibiting facial grimaces. The patient then reported that she was experiencing shortness of breath and chest discomfort and pressure and pain to her right shoulder. RN #1 assessed the patient's oxygen saturation using her right hand and revealed a reading of 92%. The patient's left hand had a reading of 90%. The patient was leaning forward in an orthopneic position (position assumed when experiencing SOB) and stated, "I don't have as much air as I think I should have." During the visit, RN #1 inquired as to whether the patient used her supplement oxygen as ordered to which the patient responded, "I don't have any. I would use it if I had it." RN #1 began to search the patient's room for the O2 concentrator and was unable to locate it. RN #1 then called the supply company, who stated that the equipment had been delivered. The patient had not received her O2 concentrator to assist with episodes of SOB as ordered. Upon further review of the clinical record, the patient was to receive an Oxygen Concentrator and supplies at the beginning of care (6/17/22). There was no documentation in the clinical record that the patient had received the required equipment. Further, there was documented evidence of the sharing of this information between the assigned disciplines and the Physician to ensure the required O2 concentrator was provided. Coordination Notes throughout the course of stay were reviewed. There was no documented discussions amongst disciplines concerning the patient's missing O2 concentrator that was to be received 6/17/22. On 7/14/22 at 12:30 p.m., the Agency conducted their scheduled IDG meeting. There was no discussion or mention of the patient's complaints of chest discomfort, complaints of SOB or that the patient had not received her O2 concentrator that was ordered on admission. After completion of the Agency's IDG meeting, the Administrator (Adm #1) was queried as to why the above information had not been shared or discussed with the team and Physician during the meeting to which she responded, "RN #1 went on leave. We told the doctor that day but we didn't discuss it in IDG. We should have mentioned it, but we didn't." The Agency failed to ensure the ongoing sharing of information regarding the patient's needs to all disciplines providing care in order to ensure the patient's needs were adequately met. MR#10: The Start of Care (SOC) was dated 1/29/22. The Plan of Care (POC) identified terminal diagnoses of Chronic Respiratory Failure and Congestive Heart Failure. During record review on 7/13/22, the Registered Nurse (RN) documented, "Pt (Patient) had a hard night last night, said her stomach hurt and had twitchy legs (contacted Dr yesterday about options for this and again today, awaiting orders)." On 6/11/22, the on-call RN documented, "Details of the call: Daughter states her mother's restless legs are bothering her ..." On 6/12/22, the Medical Social Worker (MSW) documented, " ...Patient reporting restless legs at night causing difficulty sleeping. Writer spoke to RN who will follow-up with Dr regarding concern and then follow-up with patient." On 6/13/22, the RN documented, " ...Night time she has issues with her "twitchy" legs ...Pt had been on Requip, bottle empty at admission, now in home, discussed and added it to med profile after verifying any reaction wit Ativan ..." On 6/21/22, the RN documented, " ...Pt still has "twitchy" legs, taking Ativan. In a conversation pt states she would rather take more Ativan than also take Morphine. Pt does have Requip but has not taken that. Discussed the need to take medications correctly and not more that it is needed. Pt states understanding." The agency failed to follow-up and coordinate communication between services to resolve the patient's ongoing issue. These findings were reviewed with and acknowledged by the Administrator (Adm#1) and Director of Professional Services (DPS#1) during an interview on 7/14/22 at 10:50 am. MR #4: The patient was admitted to hospice on 1/4/22 with terminal diagnoses of Malignant Neoplasm (cancer) of prostrate and bone. On 7/11/22, review of the clinical record noted an order dated 3/1/22 stating, "Stop all supplements as patient is choking." A subsequent physician order dated 3/8/22 stated, "Head of bed up 45% (degree of angle) with any intake" minus fluids. Further review of the clinical record found no Plan of Care (POC) updates concerning this significant change in condition on either the 485 (main POC incorporating all disciplines ordered) or the aide POC. Further, evidence of this lack of coordination of care regarding the orders noted above were found on the aide visit notes dated 3/3/22, 3/8/22, 3/10/22, and 3/14/22 (4 of 4 visits before patient's death on 3/14/22). Each aide visit documented under services performed the following: "Service: Offer fluids - Completed Y (Yes). Additionally, Skilled Nursing performed an "RN Aide Care Plan Review" on 3/8/22. The review documented updates were made to the aide care plan and reviewed with the aide. However, no evidence was found on the update which pertained to the physician orders concerning the patient's choking and the intervention to have the head of the bed inclined to 45 degrees to help minimize the risk of further choking. These findings were reviewed with and confirmed by the Administrator and Director of Professional Services during an interview on 7/13/22 at 2:15 PM. The Agency failed to ensure communication and care was coordinated among team members concerning a significant change in the patient's condition and potentially subjecting the patient to a poor outcome.

Based on record review and interview, the Hospice failed to ensure the patient's nursing needs were met for 2 (MR's #2, 7) of 2 patients who required supplemental oxygen and continued wound assessments, from a total of 11 sampled records reviewed, resulting in (MR #2) experienced unrelieved shortness of breath and the potential for worsening of wound for (MR #3). Findings include: MR #2: The patient was admitted to Hospice on 6/17/22 with a terminal diagnosis of Breast Cancer and additional diagnoses which included Congestive Heart Failure and Hypoxemia with Hypoxic (shortness of breath) episodes and periods of dyspnea (difficulty breathing) and required supplemental Oxygen. During the record review on 7/11/22, it was noted that the Plan of Care ordered the patient to receive Nursing services at a frequency of 2 x/wk. x 9 wks., 1x/wk. x 1 wk., 4 as needed visits for symptom management, and was ordered to have an Oxygen Concentrator and Oxygen supplies. On 7/11/22 at 1:00 p.m., during a scheduled home visit with the Registered Nurse (RN #1), the patient complained of shortness of breath, difficulty breathing and chest discomfort and pressure. It was further noted that the patient had not received her Oxygen equipment as ordered and had no Oxygen support since admission on 6/17/22. RN #1 confirmed that she was unable to locate the needed Oxygen equipment. During the visit, it was further noted that the patient had significant swelling to bilateral lower extremities to which RN #1 replied, "They do look bigger than before." RN #1 did not take measurements of the patient's edema to track increases or decreases in swelling. The Hospice failed to ensure the patient's Nursing needs were adequately met. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Director of Patient Services (DPS #1) during an interview on 7/11/22 at 2:39 p.m. Adm #1 reported, "I would expect the O2 Concentrator to be provided and edema should be measured." MR #7: The patient was admitted to hospice on 6/1/22 with terminal diagnoses of Liver Failure and Chronic Kidney Disease. On 7/13/22, review of the clinical record noted a patient fall on 7/2/22. The Skilled Nursing (SN) visit note documented the following: "Nurse visit made after a call from family stating that pt (patient) had fallen off her commode while self-transferring. EMS (emergency medical services) had been called to help her off the floor. EMS had bandaged skin tears to the bilateral forearms and anterior neck. She also has a laceration to her scalp which is clotted and already scabbing... She had no c/o (complaints) of pain and appeared comfortable." Wound assessments (objective measurements) or narrative documentation concerning the head laceration and skin tears to the neck and forearms were not found within the visit note. The next SN visit on 7/5/22 documented the patient's integumentary (skin) status was deteriorating due to increased skin tears and scabs. Two of four documented areas that were injured during the fall on 7/2/22 were assessed and treated per "Wound Assessment" documentation. They were: 1) anterior neck with an area of 4 (length) x 2 (width) x 0.1 (depth) cm. and 2) left forearm with an area of 3 x 1 x 0.1 cm. Both were treated without complication. However, documentation which ascertained the status of the other two wounds (head laceration and right forearm) noted on 7/2/22 were not found. The following SN visit on 7/8/22 documented treatments furnished to the neck and left forearm with no other wound documentation noted. That same visit, SN and the aide together changed the patient's "sheets as they were blood-stained from patient picking." Documentation that ruled out the source(s) of the bleeding and final status of the head laceration and right forearm were not found in the clinical record. These findings were reviewed with and acknowledged by the Administrator and the Director of Professional Services during an interview on 7/13/22 at 3:15 PM. The Agency failed to ensure SN had appropriately assessed all documented injuries sustained during the fall on 7/2/22 and failed to document the extent (if any) of wound progression that resulted from the fall in subsequent visit notes.

Based on record review and interview, it was determined the Hospice Agency failed to provide Medical Social Work services that addressed the patient and family's needs and concerns in 2 (MR #1 and 8) of 2 records of a patient who required assistance with meals and a patient with family dynamics, from a total of 11 sampled records reviewed, resulting in the potential for further decline in nutritional status, psychological decline, and unmet care needs. Findings include: Policy: Hospice social Services, PC.114, 9/2017 stated, "The services of a qualified social worker are necessary to address social, emotional and environmental concerns which are expected to be an integral part of the patient/family's adjustment to illness. Interventions will be directed to address these concerns identified by the patient, family, primary caregiver and/or social worker." MR #1: The patient was admitted to Hospice on 1/14/22 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD). During the record review on 7/12/22 at 10:53 a.m., it was noted that the Medical social Work (MSW) Evaluation dated 1/21/22 documented, "Indicate whether Meals on Wheels is available or needed - Needed..., Patient would benefit from Medicaid, meals on Wheels, as well as pursuing Area Agency on Aging Programs." A Skilled Nurse (SN) visit note dated 2/1/22 documented, "Emailed MSW for follow up on Life Alert and Meals on Wheels..." An MSW note dated 2/1/22 documented, "Referred to Meals on Wheels." A SN visit note dated 2/14/22 documented, "...unable to shop or cook..." An MSW visit noted dated 2/14/22 documented, "Encouraged patient to seek assistance from family and friends." Further review of the clinical record revealed that the patient lived with his son (only child) who was not active in caring for the patient. It was further noted that the patient had a glass eye with visual disturbances. The MSW failed to provide adequate assistance in meeting the nutritional needs of the patient. These findings were reviewed with and acknowledged by Adm #1 and the Director of Patient Services (DPS #1) during an interview on 7/13/22 at 8:46 a.m. MR#8: The Start of Care (SOC) was dated 12/17/21. The Plan of Care (POC) identified terminal diagnosis of Chronic Obstructive Pulmonary Disease. During record review on 7/11/22, it was noted that the Medical Social Worker (MSW) completed an evaluation on 12/21/21. On 1/7/21, the MSW documented a communication note stating, "1/6/22 1140am RN (Registered Nurse) reported 1/5/22 that patient showing signs of depressed mood and wanting MSW to follow-up on 1/6/22, MSW called and left message for patient this day requesting callback. 1/7/22 140pm Writer (MSW) left message for patient to callback if she would like additional support or if any MSW needs. Email to RN with update as unable to reach patient." On 1/10/22, the RN documented, "1/10/22 Patient laying in bed when nurse arrived. Patient was flat affect depressed today. Asked if MSW had followed up and she did not know. Nurse encouraged patient to check voicemail and follow-up with MSW ...Patients daughters are really giving her a hard time and patient knows that she is declining." On 1/12/22, the RN documented, " ...Patient still reports depressed mood, is having lots of family dynamics with children. MSW to follow-up when she returns." On 1/17/22, the RN documented, " ...Patient stated mood still depressed, will follow-up with MSW tomorrow when she returns." On 1/19/22, the RN documented, "Patient still quite a bit of distress over relationship with daughter. Reached out to MSW who is covering for follow-up." On 1/20/22, the RN documented, " ...Both daughters at bedside tearful as there has been a tremendous amount of disconnect and family dynamics with daughters and patient. Have been encouraging patient to make amends. Reached out to MSW and spoke with spouse several times about relationship. Patients seeking forgiveness and acceptance from daughters who are guarded. 91-year-old mother at bedside comforting patient. On 1/21/22, MSW documented a phone call stating, "Writer contacted patient's spouse, regarding patient's condition ...Patient is no longer able to express her wants or needs. Patient's spouse is her main caregiver, and he anticipates her wants and needs. Discussion regarding patient's 2 daughters who recently have been "back in the picture" and are visiting patient in her home. Spouse expressed he is supporting this even though patient's daughters have not been in the picture. Spouse expressed, "I do what I have to do. If her daughters want to visit her that is ok. It would have been better if they would have visited sooner. But they can visit her now."" The MSW failed to facilitate coordination of the family dynamics in a timely manner while the patient was able to express themselves, thus not meeting the patient's needs. This finding was reviewed with and acknowledged by the Administrator (Adm#1) and Director of Professional Services (DPS#1) during an interview on 7/14/22 at 10:55 am.

Based on record review and interview, the Hospice Nurse failed to provide clear patient care instructions for the Hospice Aide and failed to ensure the Aide care plan had been updated as appropriate to meet the needs of the patient in 2 (MR's #3, 4) records with Aide services ordered, resulting in the potential for the provision of unsafe care and services, unmet care needs and poor patient outcomes. Findings include: Policy: Home Health Aide PC.120 9/17 stated, "The patient's Care Plan for HHA (Hospice Aide) services shall be developed by the RN..., An RN will review the HHA care plan with the HHA..., The HHA will provide care as written on the care plan..." MR #3: The patient was admitted to Hospice on 6/10/22 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and additional diagnoses which included Stage II Pressure Ulcers to buttocks, Congestive Heart Failure (CHF) and Diabetes Mellitus. During the record review on 7/12/22 at 9:30 a.m., it was noted that the "Aide Care Plan Report" was void of any instructions for the Aide to follow in the event the wound dressing became soiled or removed. These findings were reviewed with and confirmed by the Administrator (Adm #1) and Director of Patient Services (DPS #1) during an interview on 7/13/22 at 1:50 p.m. MR #4: The patient was admitted to hospice on 1/4/22 with terminal diagnoses of Malignant Neoplasm (cancer) of prostrate and bone. The Plan of Care (POC) ordered on 1/4/22, aide services with a visit frequency of once-a-week times 13 weeks with additional visits (twice weekly) effective 2/6/22. On 7/11/22, review of the clinical record noted an order dated 3/1/22 stating, "Stop all supplements as patient is choking." A subsequent physician order dated 3/8/22 stated, "Head of bed up 45% (degree of angle) with any intake" minus fluids. Review of the aide POC performed by Skilled Nursing (SN) found no updates to the aide POC concerning this significant change in the patient's condition. In addition, the failure to update the aide POC is reflected within the aide visits dated 3/3/22, 3/8/22, 3/10/22, and 3/14/22 (4 of 4 visits before patient's death on 3/14/22). Each aide visit documented under services performed the following: "Service: Offer fluids - Completed Y (Yes). Further, Skilled Nursing performed an "RN Aide Care Plan Review" on 3/8/22. The review documented updates were made to the aide care plan and reviewed with the aide. However, no evidence was found on the update which pertained to the physician orders concerning the patient's choking and the intervention to have the head of the bed inclined to 45 degrees to help minimize the risk of further choking. These findings were reviewed with and confirmed by the Administrator and Director of Professional Services during an interview on 7/13/22 at 2:15 PM. The Agency failed to ensure SN updated the aide POC to reflect changes in the patient's condition and facilitate meeting the patient's needs safely.

Based on record review and interview, the Medical Director failed to assume overall responsibility of the Hospice's patient care program to ensure that Skilled Nursing and Medical Social Work services were provided in order to meet the patient and family's need in 2 (MR's #2, 3) records who required the services, resulting in unmet Nursing and Medical Social Work needs. Findings include: MR #1: The patient was admitted to Hospice on 1/14/22 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD). During the record review on 7/12/22 at 10:53 a.m., it was noted that the Medical social Work (MSW) Evaluation dated 1/21/22 documented, "Indicate whether Meals on Wheels is available or needed - Needed..., Patient would benefit from Medicaid, meals on Wheels, as well as pursuing Area Agency on Aging Programs." A Skilled Nurse (SN) visit note dated 2/1/22 documented, "Emailed MSW for follow up on Life Alert and Meals on Wheels..." An MSW note dated 2/1/22 documented, "Referred to Meals on Wheels." A SN visit note dated 2/14/22 documented, "...unable to shop or cook..." An MSW visit noted dated 2/14/22 documented, "Encouraged patient to seek assistance from family and friends." Further review of the clinical record revealed that the patient lived with his son (only child) who was not active in caring for the patient. It was further noted that the patient had a glass eye with visual disturbances. The MSW failed to provide adequate assistance in meeting the nutritional needs of the patient. Additionally, there was no documented evidence that the Physician provided overall oversight of the patient's care to ensure that his MSW needs were adequately met. These findings were reviewed with and acknowledged by Adm #1 and the Director of Patient Services (DPS #1) during an interview on 7/13/22 at 8:46 a.m. and again during the Exit conference. MR #2: The patient was admitted to Hospice on 6/17/22 with diagnoses that included Breast Cancer, Hypertensive Heart Disease and Congestive Heart Failure. A "History of Present Illness" dated 3/8/22 documented, "Hypoxemia (low blood oxygen level) requiring supplemental Oxygen (O2)." A "Client Supplies Report" dated 6/17/22 documented, "Oxygen Concentrator, Oxygen Supplies..." The Plan of Care (POC) ordered, "DME (durable medical equipment) Oxygen concentrator; Oxygen Supplies..." During the clinical record review on 7/11/22 at 3:15 p.m., a review of the Skilled Nurses (SN) visit notes documented the patient complained of shortness of breath (SOB) on 6/23/22 and 6/27/22. On 7/11/22 at 1:00 p.m., a scheduled home visit was conducted with the Registered Nurse (RN #1). Prior to entering the facility (Patient resided in an Assisted Living Facility), RN #1 reported, "They (facility staff) reported that the patient was experiencing SOB this past weekend and that her oxygen levels were in the low 80's." Upon entering, the patient was seated in a recliner and exhibiting facial grimaces. The patient then reported that she was experiencing shortness of breath and chest discomfort and pressure and pain to her right shoulder. RN #1 assessed the patient's oxygen saturation using her right hand and revealed a reading of 92%. The patient's left hand had a reading of 90%. The patient was leaning forward in an orthopneic position (position assumed when experiencing SOB) and stated, "I don't have as much air as I think I should have." During the visit, RN #1 inquired as to whether the patient used her supplement oxygen as ordered to which the patient responded, "I don't have any. I would use it if I had it." RN #1 began to search the patient's room for the O2 concentrator and was unable to locate it. RN #1 then called the supply company, who stated that the equipment had been delivered. The patient had not received her O2 concentrator to assist with episodes of SOB as ordered. Upon further review of the clinical record, the patient was to receive an Oxygen Concentrator and supplies at the beginning of care (6/17/22). There was no documentation in the clinical record that the patient had received the required equipment. Further, there was no documented evidence that the Physician provided any oversight of the Skilled Nurses to ensure orders were followed and the patient's O2 needs were met. On 7/14/22 at 12:30 p.m., the Agency conducted their scheduled IDG meeting. There was no discussion or mention of the patient's complaints of chest discomfort, complaints of SOB or that the patient had not received her O2 concentrator that was ordered on admission. At the time of this review, the patient had been without her needed supplemental Oxygen for 24 days. The Medical Director, who was in attendance, posed no questions regarding the health status of the patient and no inquiries as to whether the patient's oxygen concentrator had been delivered in order to meet the patient's comfort and oxygen needs at the end of life. These findings were reviewed during the Exit Conference on 7/14/22 at 2:00 p.m.

Based on record review and interview, it was determined that the Hospice failed to ensure a Discharge Summary was completed, detailed the course of care provided, including symptom and pain management, Physician's orders and the patient's health status at the time of discharge for 1 (MR #1) of 1 record review of a patient who was discharged, from a total of 11 sampled records reviewed, resulting in the potential for unmet care needs and interruption in post-discharge continuity of care. Findings include: MR #1: The patient was admitted to Hospice on 1/14/22 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease. During the clinical record review on 7/12/22 at 10:53 a.m., it was noted that the Plan of Care (POC) ordered Skilled Nursing (SN), Aide services and Medical Social Work (MSW) and Spiritual Care (SC) services to be provided. The patient was discharged from the Hospice's services on 2/15/22. Upon review, the "Discharge-Transfer Summary Report" was void of a summary that had been completed by any of the above ordered disciplines. The record review revealed the patient had additional diagnoses which included Pneumonia, Severe Malnutrition and had elevated pain levels and required assistance with meals. At the time of this review, no discharge summary of care had been completed by the SN or MSW which documented the patient's health status at the time of discharge or any MSW needs. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Director of patient Services (DPS #1) during an interview on 7/13/22 at 8:46 a.m.

Based on record review and interview, it was determined that the Agency failed to ensure all staff were fully vaccinated for the Covid-19 virus prior to granting them clinical privileges, and failed to ensure that those who were not vaccinated had a medical/religious waiver, resulting in the potential for the development and spread of the Covid-19 infection to staff and all patients currently serviced by this Agency. Findings include: On 7/11/22 at 9:27 a.m., during the Entrance Conference, the Administrator (Adm #1) was asked for permission to review the Agency's Vaccine policy along with any medical or religious waivers, as appropriate. At 9:45 a.m., during the review, it was noted that of the Agency's 23 staff, there was no evidence of vaccination status for 3 staff members (Medical Social Worker/ MSW #1, MSW #2) and a Dietician (RD #1). On 7/11/22 at 11:45 a.m., Adm #1 was queried about the vaccination status for the 3 above-mentioned staff members and reported, "We don't have anything on them because they're from a different office. I can call the corporate office and try to get it (vaccination status) for you if you like. The Dietician doesn't make visits, just phone consults only." There was no documented evidence that all staff had been vaccinated against the Covid-19 virus. Adm #1 later provided a vaccine card printout for MSW #1 and stated, "I don't have anything on MSW #2. The Agency had no knowledge of MSW #1's vaccination status prior to this date of review, yet granted clinical privileges. The Agency failed to ensure that all staff were fully vaccinated as required in January of 2022 or had an acceptable waiver prior to the granting of clinical privileges. These findings were reviewed with and acknowledged by Adm #1 at the time of discovery.