Every finding on record at County of Lewis

Based on a review of 10 patient records and interviews with the Administrator, Director of Patient Services, and Registered Nurse, it was determined in 1 of 10 records (patient #3), the plan of care failed to address the complications and risk factors that affect care planning. --- Home visit Patient #3 was admitted to the agency on 07/12/24 with a terminal diagnosis of lung cancer and additional diagnoses that included chronic obstructive pulmonary disease, chronic respiratory failure, and heart failure. On 07/01/24, the social worker visited the patient to review hospice services prior to admission and documented that the patient continued to smoke. On 07/12/24, the Registered Nurse (RN) visited to complete the start of care assessment and documented the patient was using oxygen 2 liters via nasal canula and had been for years. The RN also documented oxygen safety was reviewed with the patient and family, including proper ventilation, storage, no open flames, no smoking with oxygen, and smoke detectors were present in the home. There was no evidence RN assessed specifically how oxygen safety was maintained while the patient was smoking. The 07/23/24 IDT meeting did not address oxygen safety. The 10/29/24 IDT meeting reported ";patient has been educated on use of oxygen while smoking. Instructed to turn off and remove from area before smoking, [caregiver] reported the patient was now compliant with this after some teaching." On 02/19/25, the surveyor requested a copy of the agencys oxygen therapy policy, and this was provided by the Director of Patient Services at 11:15 a. m. The October 2024 policy titled ";Oxygen Therapy in the Home" stated: - ";as there is always the danger of fire when oxygen is in use, all patients on oxygen will be assessed for safety risks associated with home oxygen therapy use including home fires and evidence of observation of patient smoking tobacco products, electronic cigarettes, vaporizers at each home visit." - ";physician will be notified of any changes from baseline assess in the patients condition - ";physician will be notified of any patient/caregiver non-compliance with oxygen use. Specifics of non-compliance will be documented in the medical record." - ";observe positioning of equipment to allow free airflow around equipment, to be away from heat source or flame, and for standing oxygen cylinders to be in stands or otherwise secured." - ";identify, report and document any potential safety risks associated with oxygen therapy including home fires (especially related to smoking tobacco products, electronic cigarettes)." - ";if patient is known to have been smoking without removing oxygen, the following should be notified subsequent to each reported occurrence: agency supervisor, caregiver, MD, DME provider." - ";if a safety risk is identified, education and patient/caregiver response should be documented at every visit." On 02/20/24, the surveyor made a supervised home visit with the licensed practical nurse who assisted the patient with personal care. During the visit, the patient reported their memory was not good, did not remember if they took their meds that morning, and seemed to forget that the morphine and nebulizer were beside the chair and could have been self-administered prior to or during the visit. At the conclusion of the visit, when reminded that morphine was prepared next to the patients chair, the patient administered a dose of morphine. Throughout the visit, the surveyor observed the patient to be short of breath that worsened with activity and frequent moaning/vocalization with exhalation. The surveyor also observed multiple oxygen canisters laying on the couch approximately 3 feet from the patient. Additionally, the surveyor observed the oxygen concentrator was placed very close to patient with multiple blankets between patient and the concentrator, appearing to obstruct the airflow around the concentrator. After the visit, the surveyor interviewed the patient and caregiver. The caregiver reported the patient continued to smoke in the home, the RN provided oxygen safety a couple of months ago and resulted in the oxygen concentrator being moved closer to the patient's chair, which allowed the patient to turn off the concentrator prior to smoking. The caregiver reported that the patient was supposed to turn off the concentrator, place oxygen nasal canula at their feet, smoke the cigarette, then re-apply the canula, and turn the oxygen back on. However, the caregiver reported an occurrence the previous week in which the patient forgot to reapply the oxygen after smoking. The caregiver was unsure if the patient ever forgot to turn off the oxygen prior to smoking. On 01/20/24 at 1:20 p.m., the findings were reviewed with the Administrator and Director of Patient Services. The Administrator and Director of Patient Services reported that these findings were not consistent with their oxygen policy and follow-up would be necessary. On 01/21/25 at 9:20 a.m., the surveyor interviewed the RN who had been covering for the case manager. The RN reported that they identified patient safety concerns related to smoking with oxygen a couple of months prior and implemented teaching with patient and caregiver. The RN reported that the patient was rarely left home alone and would not be home alone for more than 2 hours. The RN also reported that the patient had been making decisions about what they wanted until recently when they had become more forgetful, causing the RN to question if patient no longer had the capacity to make decisions, including whether to take medication when experiencing pain or dyspnea. When the surveyor asked the RN about the impact the recent change in condition might have on the oxygen safety, the clinician expressed concern the patient would not remember to turn the oxygen off prior to smoking. The RN reported that the patients change in condition had been addressed with the physician and at the IDT meetings, the potential impact of the change in cognitive status on oxygen safety had not been addressed. At 11:20 a.m., the surveyor interviewed the Administrator and asked if any actions had been taken since yesterday to address the concerns about the patient smoking with oxygen. The Administrator was unsure if any actions were taken, and they would check. The surveyor informed the Administrator that the RN reported that the patient has had decline in their cognitive status that could place patient at risk for smoking with oxygen and that this had not been addressed with patient, caregiver, physician, durable medical equipment provider, or IDT. At 12:30, the Administrator informed the surveyor that an RN was en route to the patients home to assess and educate patient and caregiver on oxygen safety. Failure to factor complications and risk factors that affect care planning has the potential for unsafe patient situations and/or unmet patient needs.

Based on a review of 10 patient records and interviews with the Administrator and Director of Patient Services, it was determined in 4 records (patients #6, 7, 8, and 9), the plan of care failed to address all of the patient's needs. --- Home Visit1. Patient #1 was admitted to the hospice on 09/19/23 with a terminal diagnosis of rectal cancer and additional diagnoses of diabetes type 2, hypertension, and benign prostatic hyperplasia (BPH). Diabetes The 01/11/25-03/11/25 Plan of Care included a diagnosis of diabetes type 2. The following was documented by the registered nurse (RN), during visits, regarding blood glucose (BG):01/13/25 and 01/17/25: no documentation01/24/25: patient has not checked today but checked yesterday and it was 155 01/27/25: patient has not checked today01/31/25: patient has been testing BG in the morning with a range of 145-175 for the past week02/03/25: patient reports BG of 188 this morning02/06/25: patient reports BG of 144 this morning and states it has been in the 140s this week02/11/25: patient has not checked today02/13/25 and 02/17/25 (as needed visit): no documentation On 02/18/25 at 2:00 p.m. the surveyor conducted an observational home visit with the RN. During the visit, the patient told the RN they did not check their BG today but it was checked yesterday. The RN responded ";okay" and told the patient it was their decision if they wanted to check it or not. After the RN left, the surveyor asked the patient how often they checked their BG. The patient stated they usually check it every morning. The patient also stated the physician discontinued their diabetic medications. The Plan of Care failed to include an order for the patient to test their BG daily including when to notify the agency and/or physician if they obtained a high or low reading. Treatment OrderOn 11/18/24 the RN saw the patient for a routine visit and documented the patient had two perirectal abscesses that had ruptured and started draining. On 11/18/24 the RN obtained the following treatment order for the abscesses: cleanse perirectal abscess areas with mild soapy water and pat dry. Apply over the counter triple antibiotic ointment and cover with 4 X 4 gauze twice a day and as needed. On 11/21/24 the RN saw the patient for a routine visit and documented the patients rectal abscesses had resolved. The 11/26/24 IDT (interdisciplinary team) meeting notes included the patients rectal abscesses had resolved. On 01/09/25 the RN visited the patient. Documentation within the ";Integument" (skin) system only included the patient had some scratches to the right arm. The 01/11/25-03/11/205 Plan of Care continued to include the 11/18/24 treatment order for the patients rectal abscesses, which had since resolved. The RN failed to update the Plan of Care by discontinuing treatment orders no longer being used. On 02/20/25 at 1:20 p.m. the record was reviewed and the Administrator and Director of Patient Services were interviewed. The findings were acknowledged. The Director of Patient Services stated the treatment order should have been discontinued. 2. Patient #2 was admitted to the hospice on 02/05/25 with a terminal diagnosis of bladder cancer and additional diagnoses of diabetes type 2, atrial fibrillation, and chronic kidney disease. The 02/05/25-05/05/25 Plan of Care included:- diagnosis: diabetes type 2- diabetic medication: metformin 1,000 mg twice a day with meals On 02/05/25 the registered nurse (RN) saw the patient for an initial visit and documented the patient does not check their blood glucose (BG). The Plan of Care failed to include an order that the patient did not need to check their BG and/or interventions for signs and symptoms of hypo/hyperglycemia if the patient was not using a monitoring system for their BG. On 02/20/25 at 1:20 p.m. the record was reviewed and the Administrator and Director of Patient Services were interviewed. The findings were acknowledged. Neither the Administrator nor Director could provide any additional information. 3. Patient #8 was admitted to the hospice with a terminal diagnosis of Parkinsons disease and additional diagnoses of dementia, hypertensive heart disease with heart failure, and atrial fibrillation. SwallowingThe 02/14/24-05/13/24 Plan of Care included:- aspiration precautions- pureed diet On 02/14/24 the registered nurse (RN) visited the patient for an initial visit and documented the patient had choking/difficulty swallowing. The Plan of Care failed to include an order on how liquids should/could be consumed due to swallowing difficulties (i.e. thin vs thickened). Fluid RetentionThe 02/14/24-05/13/24 Plan of Care included:- diagnosis: hypertensive heart disease with heart failure- medication: Lasix (diuretic) 40 mg daily At the following visits the RN documented the patient had edema: - 02/14/24: + 1 edema bilateral lower extremities (BLE)- 02/21/24: + 2 pitting edema- 02/28/24: + 2 pitting edema to BLE The Plan of Care failed to include an order for monitoring fluid retention (i.e. weight monitoring, edema measurements) and/or interventions for signs and symptoms of fluid retention if the patient was not going to be monitored through weights and edema measurements. On 02/20/25 at 1:20 p.m. the record was reviewed and the Administrator and Director of Patient Services were interviewed. The findings were acknowledged. Neither the Administrator nor Director could provide any additional information. 4. Patient #7 was admitted to the hospice on 11/20/23 with a terminal diagnosis of pulmonary fibrosis and additional diagnoses of asthma, diabetes type 2, and pulmonary hypertension. Diagnosis/AllergiesThe hospice referral included a physician note dated 11/02/23 documenting:- diagnosis: diabetes type 2- allergies: nitrofurantoin, cefaclor, chlorpheniramine, diphenhydramine, and aspirin. The 11/20/23-02/17/24 Plan of Care included the following:- diabetic medications: glipizide 20 mg daily, Jardiance 10 mg daily, metformin 1,000 mg twice a day, Trulicity 0.75 mg/0.5 mL injection weekly- allergies: Macrodantin (nitrofurantoin), Ceclor (cefaclor), Chlor-Trimenton (chlorpheniramine), and Benadryl (diphenhydramine). The Plan of Care failed to include:- diabetes type 2 as a pertinent diagnosis- aspirin as an allergy Medication/PrecautionsThe 11/2023-02/17/24 Plan of Care included the following medications:- lorazepam 0.5 mg every 4 hours as needed for anxiety. 1 tablet for mild to moderate anxiety or 2 tablets for moderate to severe anxiety- warfarin (anticoagulant/blood thinner) 7 mg daily The Plan of Care failed to include:- a maximum daily dose safely allowed for a 24-hour time period for the Ativan- bleeding precautions secondary to taking a anticoagulant/blood thinning medication DiabetesThe 11/20/23-02/17/24 Plan of Care included the following diabetic medications: glipizide, Jardiance, metformin, and Trulicity. On 11/20/23 the RN saw the patient for an initial visit and documented the patient would like to continue checking their blood glucose (BG) daily even though they were instructed by the physician they did not need to. The Plan of Care failed to include an order the patient could test their BG daily including when to notify the agency and/or physician if they obtained a high or low reading. On 02/20/25 at 1:20 p.m. the record was reviewed and the Administrator and Director of Patient Services were interviewed. The findings were acknowledged. Neither the Administrator nor Director could provide any additional information. X. Patient #9 was admitted to the hospice on 10/17/24 with a terminal diagnosis of protein-calorie malnutrition with additional diagnoses that included dysphagia (difficulty swallowing) and history of stroke. The 10/17/24 plan of care included the order for ";caregiver performs gastrostomy tube feeding: Nestle fiber source HN as tolerated via infinity pump daily. May hold for nausea, vomiting, diarrhea. Flush prior to a d after feedings/medications with 35 ml tap water. Elevate head of bed 30 degrees at all times while feeding is running/with flushes." The plan of care failed to include: - rate, volume, or duration of the tube feeding infusion - order for oral intake On 10/17/24, the Registered Nurse (RN) visited the patient for the start of care visit and documented the patient ";drinks water well, is not able to take foods or other liquids orally" and that patient has not tolerated more than 2 containers of tube feeding a day. On 10/30/24, the RN visited the patient and documented the patient was ";nibbling on foods." On 11/08/24, the RN visited the patient and documented the patient ";had not had tube feeding at all this week. Decrease in fluid intake reported. Patient is taking 1-2 20-ounce tumblers a day. [Patient] reports [they] are not thirsty but drinks some. [Spouse] reports no foods yet today, taking in maybe an ounce of food total daily for the past few days. Yesterday, had a very small bowl of Special K cereal, ½ English muffin, picked at French fries at dinner last night." On 01/20/25 at 1:20 p.m., the record was reviewed, and the Administrator and Director of Patient Services were interviewed. The findings were acknowledged. The Director of Patient Services that the plan of care should have included complete tube feedings orders and a diet order. X. Patient #6 was admitted to the hospice on 12/20/24 with a terminal diagnosis of chronic obstructed pulmonary disease and additional diagnoses that included, chronic bronchitis, heart failure, and type 2 diabetes. The 12/20/24 Plan of Care included: - diagnoses of heart failure and type 2 diabetes - furosemide (diuretic) 20 mg orally twice a day - metformin 500 mg orally twice a day The 12/20/24 plan of care failed to include orders related to the management of heart failure or diabetes. On 01/20/25 at 1:20 p.m., the record was reviewed with the Administrator and the Director of Patient Services. The findings were acknowledged, and the Director of Patient Services reported that the plan of care should have reflected the management for diabetes and heart failure.

Based on a review of the hospices Professional Advisory Committee and Quality Council meeting minutes, Performance Improvement meeting minutes, and interviews with the Administrator and Director of Quality, the hospice failed to measure, analyze, and track quality indicators. --- On 02/18/25 at 11 a.m., during the entrance conference, the surveyor requested the hospices QAPI Plan and minutes for the past 12 months and this information was given to the surveyors later that day at 1:20 p.m. The 03/19/24 and 10/08/24 Professional Advisory Committee meeting minutes and the 12/16/24 Quality Council meeting minutes reflected the reporting of CMS quality metrics and family experience scores. The meeting minutes did not address adverse event tracking, analysis, or preventative actions that were implemented. The undated Quality Assurance/Performance Improvement Plan included: - The hospice must measure, analyze, and track quality indicators, including adverse patient events and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations. - Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice On 02/21/25 at 1:25 p.m., the surveyor interviewed the Administrator regarding the hospices quality program. The Administrator was not able to answer questions about the agencys adverse event tracking or analysis tasks. The Director of Quality was unable to attend the interview, and the Administrator reported that they would ask them to send this information to the surveyor on the next business day, 02/24/25. On 02/24/25, no information was received from the hospice via email or secure file transfer. On 02/25/25 at 10:15 a.m., the surveyor received PAC meeting minutes for 2023 and Quality Council meeting minutes for 2024. The Quality Council meeting minutes had already been provided to the surveyor and did not contain any new information on adverse event tracking. On 02/25/25 at 11:07 a.m., the surveyor interviewed the Director of Quality who reported that the hospice tracks all adverse events, including falls, medication errors, and patient safety issues. The Director of Quality reported that the hospice reviews the patient record when there is an adverse event to analyze their cases and implements preventative actions. Additionally, the agency had a performance improvement plan (PIP) for falls for the years 2023 and 2024. A PIP for diabetes was implemented in December for 2025 and included staff education regarding orders related to diabetes as this was an identified need in the certified home care agency and the PIPs are usually implemented in both agencies. When asked about how the PIP reflected the management of diabetes in the hospice patient population, the Director of Quality reported that they will need to revisit the implementation of PIPs. The surveyor requested documentation to support the tracking and analysis of adverse events and performance improvement information for 2024. On 02/25/25 at 12 p.m., the surveyor received performance improvement meeting minutes from 01/25/23 through 11/08/23 and a fall report from 2024. The fall report contained information documented by clinicians about the circumstances of a patient fall and did not include any documentation to support the record was reviewed by the hospice, causes were analyzed, or preventative actions were implemented. On 02/26/25 at 11:24 a. m., the Director of Quality reported via email that there were no performance improvement meeting minutes for 2024 and that the fall report was the only tool the hospice has at that time. The Director of Quality also reported that this is something they will need to be working back into the QAPI program. Although the Director of Quality reported that the hospice tracks, analyzes, and implements preventative measures for adverse events, the hospice failed to produce supporting documentation. Failure to implement a QAPI program that tracks, analyzes, and implements preventative measures for adverse events has the potential to place patients and the patient population at risk.

Based on a review of 11 patient records and interviews with the Chief Nursing Officer (CNO), Director of Patient Services (DPS), and Nursing Supervisor, it was determined in 3 records (patients # 1, 4, and 9), the comprehensive assessments failed to identify all of the patient's needs. Evidence as follows: 1. Patient # 1 was admitted to the hospice on 03/07/22 with diagnoses of chronic obstructive pulmonary disease, heart failure, type 2 diabetes, gastroesophageal reflux disorder, recurrent pneumonia and dependence on supplemental oxygen. On 03/07/22 the hospice nurse (HN) visited the patient and documented the patient had bilateral lower extremity edema and was wearing Tubigrip compression. On 03/16 and 03/17/22 the HN visited the patient and failed to document any assessment of edema. On 03/23/22 the HN documented the patient had edema and was using compression to bilateral lower extremities on a daily basis with benefit noted but failed to assess the extent of edema. On 03/30/22 and 04/06/22 the HN visited and failed to document any assessment of edema. The surveyor reviewed the agency's policy titled "Congestive Heart Failure Standard of Care" dated 09/2021 which stated "The presence or absence of edema must be assessed/documented at admission and at each visit. Document bilateral lower extremity measurement in centimeters as follows: - At the calf: 6 inches below the center of the patella - At the ankle: directly above the lateral malleolus - At the foot: at the midpoint of the dorsum" On 04/14/22 at 3:15 p.m. the record was reviewed with the DPS and CNO. They acknowledged the findings. 2. Patient # 4 was admitted to the hospice on 01/20/22 with diagnoses of amyotrophic lateral sclerosis (ALS / Lou Gehrig's disease), hyperlipidemia, hypertension, disc degeneration and right foot drop. The 01/20/22 Certification and Plan of Care included "liquids thickened with Thick It to nectar consistency." On 01/20/22 the hospice nurse (HN) completed the initial comprehensive assessment and failed to assess the patient's use of thickened liquids, including the patient or caregivers' ability to thicken to the proper consistency. On 04/14/22 at 3:15 p.m. the record was reviewed with the DPS and CNO. They acknowledged the findings and provided no additional information. 3. Patient # 9 was admitted to the hospice on 10/14/21 with diagnoses of chronic obstructive pulmonary disease, chronic kidney disease and congestive heart failure. On 10/14/21 the hospice nurse (HN) completed an initial comprehensive assessment and documented the patient had a skin tear on left lower arm, and a "venous right lower leg." The HN failed to assess the wounds but rather documented both had "clean and dry dressing." The 10/14/21 plan of care included: - Apply Mepilex dressing to left arm every three days and as needed; hospice nurse to assess weekly on Wednesdays, nursing home staff to do days without hospice visit. No measurements required. - Wound care right shin: cleanse with saline and pat dry. Apply Xeroform. Cover with sterile gauze. Hold in place with leg wraps if patient allows. Apply Kerlix loosely to keep gauze in place when wraps are removed at night. To be changed every 3 days and as needed; hospice nurse will change on Wednesdays, nursing home staff to change on days without hospice visit. No measurements required. On Wednesday, 10/20/21, the HN visited the patient and documented weeping edema to right lower leg and that the patient declined having his lower extremities wrapped. There was no evidence the HN assessed and/or dressed either wound. On Wednesday, 10/27/21, the HN documented nursing home staff noted the patient consistently refused the application of leg wraps and the patient did not have any wraps on during the visit. The HN delivered supplies including foam dressing, gauze, saline bullet for dressing change to left forearm; however, there was no evidence the hospice nurse completed dressing changes or assessed the arm and leg wounds. On 11/03/21 the HN documented the skin tear to his lower right arm (rather than left arm as previously noted), and lower left leg (rather than right leg as previously noted), had resolved. On 04/20/22 at 2:40 p.m. the record was reviewed with the DPS and Supervising Nurse. They acknowledged the findings, and no further information was provided. Failure to conduct a comprehensive assessment of the patient has the potential for the development of an incomplete plan of care and unmet patient needs.

Based on review of 11 patient records and interviews with Director of Patient Services (DPS), Chief Nursing Officer (CNO) and Nursing Supervisor, it was determined in 5 of 11 records (patients # 1, 4, 6, 8 and 11), the agency failed to ensure the interdisciplinary group (IDG) reviewed and revised the plan of care to meet the patient's needs. Evidence as follows: HV 1. Patient # 1 was admitted to the hospice on 03/07/22 with diagnosis of chronic obstructive pulmonary disease (COPD), heart failure, type 2 diabetes, gastroesophageal reflux disorder, recurrent pneumonia and dependence on supplemental oxygen. The 03/07/22 Plan of Care included oxygen 8 liters via nasal cannula (NC) continuous. On 03/07/22 the hospice nurse (HN) completed the initial comprehensive assessment and documented the patient reported that she missed being able to use her BiPAP (bi-level positive airway pressure machine), as she slept better with that than with the use of oxygen via NC. There was no evidence the HN collaborated with the IDG regarding whether the plan of care should include continued use of the BiPAP with oxygen connected. Review of activity notes revealed that on 03/17/22 at 11:30 a.m. the patient's caregiver called to report the patient did not sleep well due to dry cough. The HN discussed increasing humidification in the home, increasing use of Biotene, and adding a cough suppressant. The HN visited at 12:30 p.m. and documented the patient had a poor night's rest the previous night due to dry cough. On 03/23/22 the HN visited the patient and documented the patient had a non-productive cough, had coughing episodes which interrupted sleep, and was using morphine sulfate 0.25 ml prior to sleep for management of cough. IDG meeting minutes on 03/29/22 document "DME company is adding humidifier to oxygen to help with dry throat/cough." On 03/30/22 the HN visited and documented humidification to oxygen system was tremendously beneficial, and the patient was having fewer coughing spells during the night. On 04/13/22 at 10:30 a.m. the surveyor completed an observational home visit with the HN. Following the visit, the surveyor interviewed the patient and patient's caregiver regarding the patient's use of oxygen and BiPAP. They stated the patient had not used her BiPAP since admission to the agency and they never discussed whether oxygen could be attached to the BiPAP. The patient's caregiver reported that the patient was previously having difficulty with dry mouth and sore throat, and the HN provided Biotene, medications and a room humidifier. The caregiver stated it wasn't helping much and she recalled when her father was on oxygen it had a humidification bottle attached, so she contacted the oxygen company and they mailed one out, and that helped tremendously. The IDG failed to effectively review and revise the plan of care to determine the patient, on 8 liters of oxygen, would benefit from humidification attached to the oxygen concentrator. On 04/14/22 at 3:15 p.m. the record was reviewed with the DPS and CNO. They acknowledged the findings and provided no additional information. 2. Patient # 4 was admitted to the hospice on 01/20/22 with diagnoses of amyotrophic lateral sclerosis (ALS / Lou Gehrig's disease), hyperlipidemia, hypertension, disc degeneration and right foot drop. The 01/20/22 Plan of Care included "liquids thickened with Thick It to nectar consistency." On 02/07/22 the HN documented the patient "didn't like the consistency of the thickening agent that was brought for her to try. She and her daughter note that they have been adding a small amount of powder protein shake to her fluids with benefit noted." The HN failed to collaborate with the IDG concerning the ongoing need for thickened liquids and/or swallow evaluation. On 02/07/22 the physical therapist (PT) visited the patient and documented "daughter to look into getting AFO (ankle foot orthotic) again which therapist forwarded a link for her to check out. Therapist to get prescription for platform walker. Will follow up with patient/family as needed." On 02/07/22 the plan of care was updated with: "obtain platform walker for functional mobility in four weeks." On 02/09/22 a case conference note documented "limited upper extremity use but able to ambulate with caregivers assist to transfer sit to stand. Unable to safely use standard rolling walker due to hand and upper extremity strength. PT is getting a platform rolling walker for forearm support as patient does have fair shoulder strength." IDG meeting on 02/15/22 included "right foot continues to drop more. PT evaluation completed." There was no documentation in the medical record to indicate the AFO and platform walker were obtained; and no collaboration regarding revisions to the plan of care concerning AFO or platform walker in IDG meeting notes on 03/01, 03/15, 03/29 or 04/12/22. On 04/14/22 at 3:15 p.m. the record was reviewed with the DPS and CNO. They acknowledged the findings. During interview, the DPS stated that the patient had no choking episodes and was managing with regular thin liquids, and the patient's physical decline made the use of AFO and platform walker impractical. No further information was provided. 3. Patient # 6 was admitted to the hospice on 03/21/22 with diagnoses of protein calorie malnutrition, hypertension, coronary artery disease, and type 2 diabetes. On 04/01/22 at 10:05 a.m. the social worker documented the family decided to start giving the patient applesauce and juice instead of solids due to concerns about swallowing. On 04/01/22 at 2:50 p.m. the hospice nurse (HN) documented in an activity note the patient was having trouble swallowing metoprolol (medication to treat high blood pressure). The HN contacted the primary care physician who ordered to discontinue the metoprolol. On 04/05/22 the HN visited and documented medications were being crushed and given and applesauce. Active oral medications in tablet form included Plavix (a blood thinner), Lisinopril (for high blood pressure), Senna (for constipation), tramadol (pain reliever) and Tylenol as needed. The HN failed to coordinate with the primary care physician or IDG to determine whether or not the medications needed to continue and could be crushed; and failed to update the plan of care to include crushing medications. On 04/20/22 at 2:30 p.m. the record was reviewed with the DPS and Supervising Nurse. They acknowledged the findings, and no further information was provided. 4. Patient # 8 was admitted to the hospice on 11/03/21 with diagnoses of end-stage heart failure, type 2 diabetes and atrial fibrillation. On 11/03/21, during the initial comprehensive assessment, the hospice nurse (HN) visited the patient and documented scant, non-pitting, ankle and pedal edema. The 11/03/21 Plan of Care included edema: assess signs/symptoms, knowledge/skill deficit - teach identification/notification and source of edema. On 11/09 and 11/12/21 the HN documented trace edema to bilateral lower extremities, and soft bilateral pedal edema. On 11/19/21 the HN documented no lower extremity edema noted or reported. On 11/26/22 the HN visited and documented +3 pitting edema bilateral lower extremities from feet to knees with some weeping. The HN documented a telephone call to the primary care physician's office regarding other issues, but there was no evidence the nurse discussed the patient's increased edema. On 12/01/21 the HN documented "+3 pitting edema noted to bilateral lower extremities, feet to thigh, legs elevated during this visit". On 12/03/21 the HN documented "bilateral lower extremity edema noted, feet to thighs, feet resting on frame of Rollator walker during visit." The interdisciplinary group (IDG) met on 12/07/21 and failed to discuss the patient's significant increased edema to determine whether any changes to the plan of care were indicated. On 04/20/22 at 2:40 p.m. the record was reviewed with the DPS and Supervising Nurse. They acknowledged the findings, and no further information was provided. 5. Patient # 11 was admitted to the hospice on 02/11/22 with diagnoses of multiple myeloma, congestive heart failure, chronic kidney disease and type two diabetes. On 02/11/22 the hospice nurse (HN) documented in the initial comprehensive assessment the patient was told by his oncologist he no longer needed to check blood glucose. The HN informed the patient the primary care physician (PCP) would like blood glucose checked every morning. Present in the record was a message sent to the PCP on 02/11/22 at 12:26 p.m. inquiring whether the patient needed to check his blood glucose daily. On 02/11/22 at 12:38 p.m. a message was faxed to the hospice from the physician stating the patient did not need to check his blood sugars daily. The 02/11/22 plan of care included the patient was to check blood glucose daily and as needed for signs / symptoms of hypo or hyperglycemia, notify physician if less than 70 or greater than 300. On 02/15/22 the IDG met and failed to discuss the patient's plan of care for continued blood glucose testing. On 02/17, 02/21 and 02/24/22 the hospice nurse visited and continued to assess the patient's blood glucose readings which ranged 120-139. On 02/23/22 the nutritional therapist visited the patient and documented the patient was "not always monitoring daily as ordered however reports has been running in 120's." On 04/20/22 at 3 p.m. the record was reviewed with the DPS and Supervising Nurse. They acknowledged the findings, and no further information was provided. Failure to ensure that the IDG reviews and revises the plan of care has the potential for unmet patient needs and negative patient outcomes.

Based on a review of 4 records for patients receiving hospice aide services (patients # 2, 6, 9 and 10), and interviews with the Director of Patient Services (DPS), Chief Nursing Officer (CNO) and Supervising Nurse, it was determined in 1 record (patients # 10), the hospice aide care plan failed to include all information necessary for the aide to provide care. Evidence as follows: 1. Patient # 10 was admitted to the hospice 11/04/21 with diagnosis of metastatic breast cancer. Referral information, dated 11/02/21, included the patient had recurrent herpes simplex 2 (genital herpes). The 11/04/21 plan of care included a hospice aide twice weekly for personal care. The non-skilled care plan included a total sponge bath at every visit. On 11/16/21 the hospice aide/LPN visited and documented the patient had lesion/blister area to bilateral labial folds and perianal area, area bleeding scantly. The hospice nurse case manager and physician's office were notified. On 11/23/21 the interdisciplinary group discussed that the patient "currently has a break out of herpes." The hospice nurse failed to update the aide care plan with contact precautions, or any instructions related to bathing the area with active herpes blisters. On 04/20/22 at 2:50 p.m. the record was reviewed with the DPS and Supervising Nurse. They acknowledged the findings, and no further information was provided. Failure of the hospice nurse to individualize and provide complete instructions to the aide has the potential for unmet patient needs, and possible negative patient outcomes.