Every finding on record at Covenantcare at Home

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. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) home visits revealed the agency did not ensure the drug profile contained the patient's current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. Home Visit 1: The patient (clinical record 1) elected the hospice benefit on 02/20/2025 for a diagnosis of Parkinson's disease. The patient resided in a skilled nursing facility (SNF). The last nursing comprehensive assessment was dated 04/18/2025. During the home visit with the Hospice Aide (Personnel Record 6) on 04/22/2025, the hospice medication profile (printed on 04/21/2025) was compared to the SNF medication profile (printed on 04/22/2025). The hospice list documented the following medications that were not documented on the SNF list: Lorazepam 0.5 mg tablet. Take one by mouth every 4 hours as needed for anxiety (ordered 02/25/2025). The SNF list documented the following medications that were not documented on the hospice list: Glucerna oral liquid. Take one can twice daily (ordered 04/10/2025). Multivitamin. Take one tablet by mouth daily (ordered 11/15/2024). There was also a discrepancy with the hospice listing Tylenol 325 mg. Take 1 tablet every 6 hours as needed for mild pain. The SNF had to take 2 tablets. There was no documented evidence that a medication reconciliation occurred and the medication profile was updated during the last comprehensive assessment dated 04/18/2025. An interview and joint clinical record review was conducted with the Administrator/DPCS (Director of Patient Care Services) on 04/23/2025, in which she stated, "the case managers should be reconciling medications with every visit."

It is required that 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 clinical record review and interview. In 8 of 16 (50%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the registered nurse provided specific written instructions for the hospice aide. CLINICAL RECORD 1: The patient’s election of the hospice benefit was 02/20/2025 with diagnosis of Parkinson's disease. The hospice aide care plan dated 02/20/2025 included the following relevant tasks: "sponge bath, shampoo, shampoo tray disinfected, comb hair, lotion, assist with dressing and undressing, peri care, incontinence care, provide emotional support." The aide visit frequency was twice weekly. The nursing assessment dated 03/11/2025 noted the following: "wound care to coccyx, apply Calmoseptine and cover with bordered gauze." The aide's plan of care was not updated to provide the aide with notification of the wound, nor instructions for the dressing during tasks. CLINICAL RECORD 2: The patient’s election of benefit was 10/08/2024 with diagnosis of Malignant neoplasm of prostate. The hospice aide care plan dated 10/08/2024, updated 04/01/2025, and 4/10/2025 included the following relevant tasks: "sponge bath, shower, and assist with bathing." The aide visit frequency was three times weekly. The aide care plan did not have specific instructions for the aide on which bath type, nor the frequency for these tasks. CLINICAL RECORD 4: The patient’s election of benefit was 02/07/2025 with diagnosis of Heart failure. The hospice aide care plan dated 02/07/2025 included the following relevant tasks: "sponge bath, skin care-lotion and protective barrier, assist with dressing/undressing, peri care, incontinence care, change bed linens, remind patient to elevate legs." The aide visit frequency was twice weekly. The initial nursing assessment dated 02/07/2025 noted the patient to have bilateral Unna boots. The aide care plan did not notify the aide of the Unna boots, nor provide specific instructions for the care of the Unna boots during aide tasks. CLINICAL RECORD 5: The patient’s election of benefit was 01/04/2025 with diagnosis of Pneumonia, unspecified. The hospice aide care plan dated 01/04/2025 included the following relevant tasks: "shower, sponge bath, shampoo, shampoo tray disinfected, comb hair, lotion, assist with dressing and undressing, peri care, incontinence care, provide emotional support, remind patient to elevate legs." Aide visit frequency of twice weekly. A nursing assessment dated 02/27/2025 noted "Clean PEG tube site with N/S (normal saline), pat dry, apply lanolin to redness around site cover with bordered gauze." The aide's plan of care was not updated to provide the aide with notification of the PEG tube, nor instructions for the dressing during tasks. The aide care plan did not have specific instructions for the aide on which bath type, nor the frequency for these tasks. Aide visits dated 03/04/2025, 03/14/2025, and 04/08/2025 noted "shower given, but sponge bath not completed. RN (registered nurse) notified." CLINICAL RECORD 7: The patient’s election of benefit was 12/10/2024 with diagnosis of Malignant neoplasm of prostate. The hospice aide care plan dated 12/10/2024, updated 02/08/2025, and 04/03/2025 included the following relevant tasks: "Shower, assist with bathing (other specify), change bed linens, oral care, assist/perform ROM (range of motion) exercises, turn and position." The aide frequency was twice weekly. A nursing assessment dated 02/02/2025 noted "wound to left shin. Apply dry sterile dressing 3x week." The aide's plan of care was not updated to provide the aide with notification of the wound, nor instructions for the dressing during tasks. The aide's care plan also did not specify a bath type and listed two choices. Aide visit dated 04/08/2025 noted: "Patient had shower yesterday so he only wanted sponge bath today. Reported to RN 4/8/2025." CLINICAL RECORD 8: The patient’s election of benefit was 07/24/2025 with diagnosis of Alzheimer's disease. The hospice aide care plan dated 07/25/2024, updated 09/25/24 and 01/21/2025 included the following relevant tasks: "sponge bath, skin care-lotion, protective barrier, incontinence care." The aide frequency was twice weekly. A nursing assessment dated 01/13/2025 noted the following: "dressing to bilateral buttocks." The aide's plan of care was not updated to provide the aide with notification of the wound, nor instructions for the dressing during tasks. CLINICAL RECORD 15: The patient’s election of benefit was 08/19/2024 with diagnosis of Degenerative disease of nervous system. The hospice aide care plan dated 08/19/2024, updated 12/16/2024 and 02/03/2025 included the following relevant tasks: "sponge bath, shampoo, shave, peri care, incontinence care, skin care-lotion, change bed linens, turn and position." A nursing assessment dated 08/20/2024 noted the following: "surgical wound to lateral thigh with non-adherent dressing." The aide visit frequency was six times weekly. The aide's plan of care was not updated to provide the aide with notification of the wound, nor instructions for the dressing during tasks. CLINICAL RECORD 18: The patient’s election of benefit was 01/03/2025 with diagnosis of Aspiration pneumonia. The hospice aide care plan dated 01/03/2025 included the following relevant tasks: "sponge bath, skin care, turn and position." A nursing assessment dated 01/21/2025 noted the following:" Stage II right buttocks, covered with Calmoseptine and gauze." The aide visit frequency was twice weekly. The aide's plan of care was not updated to provide the aide with notification of the wound, nor instructions for the dressing during tasks. An interview and joint clinical record review was conducted with the

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 3 of 16 (19%) clinical records reviewed in which aides services were accepted revealed the agency did not ensure a registered nurse makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. CLINICAL RECORD 7: The hospice aide services were ordered for a frequency of twice weekly on 12/10/2024 . There was a registered nurse supervisory visit on 03/19/2025, and the next documented registered nurse supervisory visit was on 04/16/2025, 28 days. CLINICAL RECORD 8: The hospice aide services were ordered for a frequency of twice weekly on 07/25/2024. There was a registered nurse supervisory visit on 11/11/2024, and the next documented registered nurse supervisory visit was on 12/09/2024, 28 days. CLINICAL RECORD 12: The hospice aide services were ordered for a frequency of three times weekly on 06/21/2024 . There was a registered nurse supervisory visit on 07/31/2024, and the next documented registered nurse supervisory visit was on 08/22/2024, 22 days. There was a documented registered nurse supervisory visit on 10/21/2024 and the next documented registered nurse supervisory visit was 11/29/2024,39 days. There was a documented registered nurse supervisory visit on 12/11/2024 and the next documented registered nurse supervisory visit was 01/03/2025,23 days. There was a documented registered nurse supervisory visit on 02/17/2025 and the documented registered nurse supervisory visit was 03/12/2025, 23 days. An interview and joint clinical record review was conducted with the Administrator/DPCS (Director of Patient Care Services) on 04/24/2025, in which she stated, "there has been a performance plan in place to improve these missed supervisory visits."

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, interview, and personnel record review. In 6 of 9 (67%) personnel records reviewed revealed the agency did not ensure the hospice assessed the skills and competencies of all individuals providing care, including volunteers providing services. Agency policy titled "Competency Assessment Policy No 3-003 Dated 2003, Revised November 2024" stated in relevant part: "Policy: The competence of all organization clinical personnel (employed, contract or volunteer) will be assessed during orientation, during the probationary period, periodically throughout the course of the year and during the annual performance evaluation. Procedure: Competency assessments will be completed at least one (1) time per year; Using a competency skills performance checklist developed specifically for each clinical job category, the clinical supervisor will evaluate the competence in performing and rendering care." Agency policy titled "Annual Core Competence. Policy No 3-005. Dated 2003, Revised November 2024" stated in relevant part: "1. Hospice personnel will demonstrate proficiency in the performance criteria/skills during the orientation period and at least annually thereafter as part of the annual performance evaluation." Personnel Record 2: A review of the personnel record for the registered nurse with a hire date of 10/24/1994 did not have documentation of skills and competencies being assessed in 2023 or 2024 in accordance with agency policy. Personnel Record 3: A review of the personnel record for the licensed vocational nurse with a hire date of 07/26/2022 did not have documentation of skills and competencies being assessed in 2023 or 2024 in accordance with agency policy. . Personnel Record 4: A review of the personnel record for the social worker with a hire date of 01/11/2016 did not have documentation of skills and competencies being assessed since 2020 in accordance with agency policy. Personnel Record 6: A review of the personnel record for the hospice aide with a hire date of 10/21/2015 did not have documentation of skills and competencies being assessed in 2023 or 2024 in accordance with agency policy. Personnel Record 7: A review of the personnel record for the bereavement coordinator with a hire date of 08/25/2015 did not have documentation of skills and competencies being assessed since 2021 in accordance with agency policy. Personnel Record 8: A review of the personnel record for the volunteer coordinator with a hire date of 11/28/2016 did not have documentation of skills and competencies being assessed in 2023 or 2024 in accordance with agency policy. Personnel Record 9: A review of the personnel record for the volunteer with a hire date of 09/18/2024 did not have documentation of skills and competencies being assessed upon hire in accordance with agency policy. An interview and joint personnel record review was conducted with the Administrator/DPCS (Director of Patient Care Services) on 04/22/2025, in which she stated they "Switched processes and started doing in-services instead of competencies."

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The hospice EP training program includes the following for all new hospice employees and those providing services under arrangement: initial training in EP policies and procedures consistent with their expected roles and demonstration of staff knowledge of emergency procedures. Documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by a review personnel record review and interview. 1 of 2 (50%) personnel records reviewed revealed the hospice agency did not ensure emergency preparedness training of newly hired staff. Staff 11: there was no documented evidence of emergency preparedness training at time of hire on 4/4/2022 The agency Administrator/DPCS confirmed prior to exit that Emergency Preparedness training was verbally provided to the employee but was not documented. The agency Administrator/DPCS also confirmed that there was no documented evidence of demonstration of staff knowledge of agency-specific emergency procedures. The agency Administrator/DPCS confirmed prior to exit that Emergency Preparedness training was verbally provided to the employee but was not documented. The agency Administrator/DPCS also confirmed that there was no documented evidence of demonstration of staff knowledge of agency-specific emergency procedures such as an EP training post-test passed with a minimum of 80% proficiency.

It is required that each patient’s individualized written plan of care includes a detailed statement of the scope and frequency of services necessary meet specific patient and family needs. This standard was not met as evidenced by clinical records review and interview. 1 of 5 (20%) clinical records reviewed revealed the hospice did not ensure plans of care included services necessary to meet specific patient and family needs. Clinical Record 3: included the following protocols with corresponding orders: “DME protocol” which included alternating air pressure pad with pump, Hoyer lift, suction machine, trapeze." "Foley catheter protocol” which included 14-18Fr, 5-30ML balloon prn urinary retention and “Seizure protocol” which included dosage and direction for the frequency of administration of Ativan and Valium. The Supervising Nurse was interviewed and stated that none of this equipment was needed or provided to the patient; that the patient did not have or require a foley catheter and that the patient did not have a history of seizures. The Administrator/DPCS, was interviewed and stated Hospice Protocol Orders/Treatments were included on the initial plans of care for each new patient admitted to the agency. The Administrator/DPCS stated the initial plan of care includes a hospice protocol of “standing orders” for drugs, treatments, and services that are anticipated to be needed for care of most hospice patients during their course of care. The Administrator/DPCS confirmed that the orders were not specific to the patient but rather put in place to be used on an “as needed” basis. The Supervising Nurse stated that hospice protocol/ standing orders were intended to save time in executing orders in the event of a patient's change in condition or needs. Per the agency Administrator/DPCS, Hospice Protocol Orders/Treatments are included on the initial plans of care for each new patient admitted to the agency. The Administrator/DPCS stated the initial plan of care includes a hospice protocol of “standing orders” for drugs, treatments, and services that are anticipated to be needed for the effective care of most hospice patients during their course of care. The Administrator/DPCS confirmed that the orders are not specific to the patient but rather put in place to be used on an “as needed” basis. The Supervising Nurse stated that Hospice Protocol/ Standing Orders are intended to save time in executing orders in the event of a patient's change in condition or needs. The Administrator/DPCS stated that nurses are instructed to contact the Hospice Medical Director or hospice physician on-call if there is a change in patient condition to inform the physician of the changes and to request new drugs and/or treatments to meet the patient’s current needs.

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by personnel record review and interview. 2 of 11 (18%) personnel records revealed the hospice agency did not ensure infection control education was provided to staff. Staff 10: no documented evidence of infection control annual in-service education during 2019. Staff 4: no documented evidence of infection control annual in-service education during 2020. During interview, the agency Administrator/DPCS confirmed prior to the exit conference that she was unable to locate and provide evidence of infection control in-services. The agency Administrator/DPCS confirmed prior to the exit conference that she was unable to locate and provide evidence of infection control in-services received by two (2) employees for two (2) specific years.

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 clinical record review, document review and interview. 12 of 12 (100%) aide plans of care revealed the hospice agency did not ensure the Registered Nurse prepared specific patient care instructions of hospice aide assignments and duties. Clinical Record 0: Aide plan of care includes Shampoo (prn request), includes Skin Care powder, lotion, and applied barrier with only lotion marked as applied (no documented skin issues); oral care includes options for use of toothbrush, mouth rinse or self-care. Clinical Record 4: Aide plan of care includes Shampoo (prn request), change bed linens (prn request). Clinical Record 7: Aide plan of care includes Shampoo (prn request), includes Skin Care powder, lotion, and applied barrier with only lotion marked as applied by aide (no documented skin issues) Clinical Record 9: Aide plan of care includes Skin Care powder, lotion, and applied barrier with only lotion and skin barrier marked as applied; the location of the body where skin barrier is to be applied and how often is not specified. Oral care: Toothbrush, Toothette, Mouth Rinse, Self-Care all included as potential options for service for aide to choose from. Clinical Record 12: Aide plan of care includes both shower and sponge bath and Shampoo (prn request). Clinical Record 3: Aide plan of care indicates choice of shower or sponge bath (per patient request); Skin care: Apply Powder, Lotion, and Protective barrier (powder and protective barrier are not required or used by the patient). Shampoo (prn request). Clinical Record 6: Aide plan of care indicated choice of shower or sponge bath (aide plan of care updated by RN to include sponge bath only on 7/12/22); Shampoo (prn request); Change bed linens (prn request). Clinical Record 8: Aide plan of care indicates choice of shower or sponge bath (per patient request); Shampoo (prn request), change bed linens (prn request). Clinical Record 11: Aide plan of care includes Shampoo (prn request), change bed linens (prn request) Clinical Record 1: Aide plan of care includes Shampoo (prn request), includes Skin Care powder, lotion, and applied barrier with only lotion marked as applied (no documented skin issues); Shave (prn request), Linen change (prn request). Clinical Record 2: Aide plan of care includes Shampoo (prn request), change bed linens (prn request). Clinical Record 10: Aide plan of care includes Shampoo (prn request), change bed linens (prn request). During interview the Administrator/DPCS and the supervising nurse stated options were provided so that the aide could decide what type of bath may be most appropriate to perform according to the patient’s condition. Agency policy titled the plan of care states in part, "...The plan of care will identify the patient's needs and the services to meet those needs... It must state in detail, the scope and frequency of services needed to meet the patient's and family/caregiver's needs. ...any change in the patient's condition must result in a change in the plan of care, prior to the implementation of the new service. ..." Agency policy titled the plan of care states in part, "...The plan of care will identify the patient's needs and the services to meet those needs... It must state in detail, the scope and frequency of services needed to meet the patient's and family/caregiver's needs. ...any change in the patient's condition must result in a change in the plan of care, prior to the implementation of the new service. ..." The Administrator/DPCS and the Supervising Nurse stated during clinical record review that options are provided so that the aide and/or patient can decide what services are best to provide to the patient during each aide visit. The Administrator/DPCS stated on day 2 of 3 of the site visit that the RN Case Managers are updating aide plans of care to remove any care decisions to be made by the aide including any "prn" services. The Administrator/DPCS stated that aides are being instructed to contact a supervising nurse if services on the aide plan of care cannot safely be provided to the patient or if the patient refuses the service listed to be performed on the aide plan of care. For example, a shower cannot be provided because the patient that was ambulatory during the last aide visit is now confined to the bed and unable to safely shower.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency. This standard was not met as evidenced by a review personnel record review and interview. 1 of 11 (9%) of personnel records reviewed revealed the hospice agency did not ensure there was documented evidence of the assessment of the skills and competency of an individual providing care. Staff 10: no documented evidence of a skills/competency evaluation completed by a supervising physician in 2019, 2020, or 2021. The agency Administrator/DPCS confirmed prior to the exit conference that the hospice medical director or associate physician had not documented an annual assessment of the skills and competency of the nurse practitioner. The agency Administrator/DPCS confirmed prior to the exit conference that the hospice medical director or associate physician had not documented an annual assessment of the skills and competency of the nurse practitioner.