Every finding on record at Crossroads Hospice of St. Louis, LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy #299-29-A, "Medication Reconciliation" (revised 8/30/2023), stated in part, "Staff will ensure accurate medication lists and reconciliation for patients. Therefore, it is important to establish accurate and complete medication lists for each patient as well as sending accurate medication lists to attending physician for review and processing." Agency policy #223-A "IDG Hospice Plan of Care-Content, Plan, Goals, Interventions, and Outcomes" (revised 5/23/2022) stated in part, "Authorized Prescriber Orders (standing orders) and as application emergency symptom kits must be individualized to address the specific patient's needs and must be signed by that patient's physician." In 4 of 4 (100%) home visits observed, the hospice agency did not ensure that the comprehensive assessment included a medication profile that contained the patient's current medications. Home Visit 1/Clinical Record 2: The patient elected hospice care on 11/5/2022 and resided in an assisted living facility (ALF). During the home visit on 1/24/2024, medication reconciliation was performed by comparing the hospice medication profile dated 1/14/2024 to the patient's current medication regimen. The patient's caregiver confirmed the patient took Promethazine, 25 mg, take one (1) tablet per oral or rectal every four (4) hours as needed (PRN) for nausea. The medication bottle was dated with a fill date of 8/1/2023. The hospice medication profile did not include documentation of Promethazine. There was no evidence Promethazine was reviewed during the review of the patient's medication regimen. Home Visit 2/Clinical Record 3: The patient elected hospice care on 8/15/2023. During the home visit on 1/24/2024, medication reconciliation was performed by comparing the hospice medication profile dated 1/14/2024 to the patient's current medication regimen. The hospice medication profile documented, "Mirtazapine 7.5 mg, give one (1) tablet every evening at bedtime." The patient's caregiver/spouse stated the patient was not taking Mirtazapine because of the side effects. The caregiver reported the patient had not taken the medication for "two or three weeks." Home Visit 3/Clinical Record 1: The patient elected hospice care on 9/14/2023 and resided at a skilled nursing facility (SNF). During the home visit on 1/24/2024, medication reconciliation was performed by comparing the hospice medication profile dated 1/14/2024 to the patient's medication administration record/medication list (MAR) provided by the SNF dated 1/24/2024. The SNF MAR documented, "Doxycycline Hyclate oral tablet 100 mg, give one (1) tablet by mouth two (2) times a day for congestion." The SNF physician's order for Doxycycline Hyclate Oral Tablet was dated 12/31/2023. The hospice medication profile did not document Doxycycline Hyclate. There was no evidence that Doxycycline Hyclate was reviewed during the patient's medication regimen review. The SNF MAR documented, "Hydromorphone oral tablet 8 mg, take one (1) tablet every eight (8) hours as needed (PRN) for pain." The physician's order for Hydromorphone oral tablet was dated 1/11/2024. The agency medication profile documented, "Hydromorphone oral tablet 8 mg, take one (1) tablet every four (4) hours as needed (PRN) for pain." The physician order start date was 1/11/2024. Home Visit 4/Clinical Record 4: The patient elected hospice care on 7/12/2023. During the home visit on 1/24/2024, medication reconciliation was performed by comparing the hospice medication profile dated 1/14/2024 to the patient's current medication regimen. The hospice medication profile documented, "Haldol 2 mg/ml, give one (1) (ml) milliliter every four (4) hours as needed (PRN) for agitation." The order date for the Haldol was 7/20/2023. The patient and caregiver confirmed the patient had never taken Haldol, and Haldol was not available in the home. In addition, the patient and caregiver confirmed the patient was taking "Oxycodone/Acetaminophen 10 mg/325 mg, take two (2) tablets every four (4) hours as needed (PRN) for pain (as of 1/16/2024)." Oxycodone/Acetaminophen was not documented on the patient's medication profile. There was no evidence Oxycodone/Acetaminophen was reviewed during the review of the patient's medication regimen. During a joint record review and interview on 1/26/2024, the Interim Clinical Director, who was present for the home visits, confirmed the Registered Nurse (RN) completed assessments on 1/16/2024 and 1/23/2024. Additionally, the Interim Clinical Director confirmed the patient did not take Haldol, stating, "I bet that order was from admission and is part of the e-kit." During joint record reviews and interviews, the Interim Clinical Director, who was present for the home visits, confirmed the agency's medication profiles did not match the patient's current medication regimen.

It is required that each patient’s individualized written plan of care includes all drugs and treatments necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy #223-A "IDG Hospice Plan of Care-Content, Plan, Goals, Interventions, and Outcomes" (revised 5/23/2022) stated in part, "The plan of care must include all services necessary for the palliation of the patient, including the following: Name, dosage, route, frequency, and indication of medication/treatments ordered." In 3 of 19 (16%) clinical records, the hospice agency did not ensure the written plan of care contained all drugs and treatments necessary for the palliation of the patient. Clinical Record 1/Home Visit 3: The patient elected hospice care on 9/14/2023 and resided at a skilled nursing facility (SNF). During the home visit on 1/24/2024, medication reconciliation was performed by comparing the hospice medication profile dated 1/14/2024 to the patient's medication administration record/medication list (MAR) provided by the SNF dated 1/24/2024. The SNF MAR documented, "Doxycycline Hyclate oral tablet 100 mg, give one (1) tablet by mouth two (2) times a day for congestion." The SNF physician's order for Doxycycline Hyclate Oral Tablet was dated 12/31/2023. The hospice POC did not document Doxycycline Hyclate. During the joint record review and interview on 1/24/2024, the Interim Clinical Director confirmed that Doxycycline was not on the POC. Clinical Record 2/Home Visit 1: The patient elected hospice care on 11/5/2022 and resided in an assisted living facility (ALF). During the home visit on 1/24/2024, the patient's caregiver confirmed the patient took Promethazine, 25 mg, take one (1) tablet per oral or rectal every four (4) hours as needed (PRN) for nausea. The medication bottle was dated with a fill date of 8/1/2023. The hospice plan of care did not include documentation of Promethazine. During the joint record review and interview on 1/24/2024, the Interim Clinical Director confirmed that Promethazine was not on the plan of care. Clinical Record 4/Home Visit 4: The patient elected hospice care on 7/12/2023. During the home visit on 1/24/2024, the patient and caregiver confirmed the patient was taking "Oxycodone/Acetaminophen 10 mg/325 mg, take two (2) tablets every four (4) hours as needed (PRN) for pain (as of 1/16/2024)." The hospice plan of care did not include documentation of oxycodone/acetaminophen was not documented on the patient's medication profile. During a joint record review and interview on 1/26/2024, the Interim Clinical Director, who was present for the home visits, confirmed that the Oxycodone/Acetaminophen was not on the Plan of Care. The POC dated 11/9/2023 through 1/7/2024 ordered: "Educate the patient/caregiver to monitor for residual and, if greater than 30 ml, to hold and contact hospice. Flush with 30 ml of normal saline before and after medication administration. The nurse will monitor the G-tube for patency and the surrounding skin for infection or complication—intervention: Jevity per order. Monitor PEG insertion for signs and symptoms of infection." The POC orders did not include documentation of the type of Jevity to be administered, the amount of Jevity to be administered, or how often the Jevity should be administered. During a joint record review and interview on 1/23/2023, the Interim Clinical Director confirmed the record did not contain orders for the type of Jevity to be used, the amount to be given, the frequency to be given, and the way it was to be administered (bolus vs pump). The Interim Clinical Director confirmed the tube feed should be administered via bolus, and the agency was not providing a tube feeding pump. The Initial Plan of care dated 7/12/2023 stated, "Jevity 1.2." The Interim Director of Clinical Services stated the Hospice medical director will clarify the patient orders.

It is required that each patient’s individualized written plan of care includes: medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 19 (11%) clinical records reviewed, the hospice agency did not ensure the written plan of care included the medical supplies and appliances necessary to meet the needs of the patient. Clinical Record 2/Home Visit 1: The patient elected hospice care on 11/5/2022 and resided in an assisted living facility (ALF). During the home visit with the Licensed Practical Nurse (LPN) [Personnel Record 1] on 1/24/2024, a review of the patient's supplies and durable medical equipment (DME) with the LPN revealed the hospice provided: hospital bed, low air loss pressure relief mattress, briefs, wipes, underpads, and gloves. The hospice plan of care dated 1/24/2024 did not include documentation of the hospital bed, low air loss pressure relief mattress, briefs, wipes, underpads, and gloves. During a joint record review and interview on 1/24/2024, the Interim Clinical Director confirmed the plan of care did not contain all DME and supplies needed to meet the patient's needs. Clinical Record 4: The patient elected hospice care on 7/12/2023. The comprehensive assessments completed by the Registered Nurse (RN) on 1/2/2024, 1/9/2024, and 1/16/2024 documented the assessment of the PureWick urine drainage system. The plans of care dated 11/9/2023 through 1/7/2023 and 1/8/2024 through 3/7/2024 did not include documentation of the PureWick urinary drainage system as a supply or appliance needed to meet the patient's needs. The interventions listed under the sub-section "urinary incontinence" on the plan of care dated 1/8/2024 through 3/7/2024 documented that the hospice provided incontinence supplies. During a joint record review and interview on 1/23/2024, the Interim Clinical Director confirmed the plan of care did not contain did not include documentation of the PureWick urinary drainage system.

It is required that a revised plan of care includes: information from the patient’s updated comprehensive assessment; [and] record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 19 (11%) clinical records reviewed, the hospice agency did not ensure that the revised plan of care (POC) included information from the patient’s updated comprehensive assessment. Clinical Record 2/Home Visit 1: The patient elected hospice care on 11/5/2022 and resided in an assisted living facility (ALF). The POC dated 1/23/2024 documented "Wound: Right heel pressure Ulcer." The POC problem and intervention were identified as active as entered initially by the Registered Nurse (RN) on the POC dated 9/28/2023. The RN documented on 10/6/2023 that the skin on the right heel was intact and "Wound to right heel healed. Skin intact." During the joint record review, interview, and home visit on 1/24/2024, the Interim Clinical Director, who was present at the home visit, confirmed the wound to the right heel was healed, and the plan of care was not updated to reflect the healed status. Clinical Record 11: The patient elected hospice care on 1/31/2023 and resided in a skilled nursing facility (SNF). On 8/7/2023, a wound was identified, and a wound care order was obtained that read, "Cleanse wound with wound cleanser. Apply TAO and dry dressing change daily and as needed (PRN). The POC dated 8/7/2023 through no end date ordered skilled nursing (SN) one (1) time weekly. On 9/1/2023, the RN documented the left knee wound was healed. The plan of care dated 1/17/2023 through no end date identified the left knee wound as active on 8/7/2023 with a problem and intervention that stated, "Problem: left knee skin tear. Intervention: Educated daughter and caregiver regarding cleansing and dressing skin tear." In addition, a skin tear on the right knee was identified on 11/21/2023. A wound care order was obtained on 11/21/2023: "Apply transparent dressing to right knee skin tear. Change three (3) to five (5) days, and as needed (PRN). The right knee skin tear wound was identified as healed on 12/18/2023. The plan of care dated 1/17/2023 through no end date identified the right knee wound as active on 11/21/2023 with a problem and intervention that stated, "Problem: right knee skin tear. Intervention: Educated daughter and caregiver regarding cleansing and dressing skin tear." During the joint record review and interview on 1/25/2024, the Interim Clinical Director confirmed the written care plan was not being updated to reflect current information obtained from comprehensive assessments.

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group; included in the plan of care; permitted to be performed under state law and regulation; [and] consistent with the hospice aide training. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy # 223-A "IDG Hospice Plan of Care-Content, Plan, Goals, Interventions, and Outcomes" (revised 5/23/2022) stated in part, "The hospice will develop and maintain a system of communication and integration, in accordance with policies and procedures, to ensure that the care and services are provided in accordance with the plan of care." In 1 of 16 (6%) clinical records reviewed of patients that accepted Hospice Aide services, the hospice agency did not ensure the Hospice Aide provided all services ordered by the Interdisciplinary Group included in the plan of care. Clinical Record 3: The patient elected hospice care on 8/15/2023. The Hospice Aide (HA) care plan dated 11/13/2023 through 2/10/2024 ordered Hospice Aide services two (2) times weekly. During the week of 12/24/2023 through 12/30/2023, the patient received one (1) Hospice Aide visit on 12/27/2023. A clinical record review revealed no documented missed HA visit or agency "Visit Care/Task Refusal" order signed by the physician. During a joint record review and interview on 1/23/2024, the Interim Director of Clinical Services confirmed the patient's electronic and paper medical records did not contain documented evidence of a HA missed visit for the week of 12/24/2023 through 12/30/2023.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy # 223-A "IDG Hospice Plan of Care-Content, Plan, Goals, Interventions, and Outcomes" (revised 5/23/2022) stated in part, "The hospice will develop and maintain a system of communication and integration, in accordance with policies and procedures, to ensure that the care and services are provided in accordance with the plan of care...The hospice will ensure systems are in place to facilitate the exchange of information and coordination of services among staff...The hospice will ensure that the documentation within the clinical record is geared and reflects the sharing of information between all disciplines providing care." In 1 of 16 (6%) clinical records reviewed of patients that accepted Hospice Aide services, the hospice agency did not ensure the Hospice Aide reported changes in the patient's needs to the Registered Nurse (RN). Clinical Record 3: The patient elected hospice care on 8/15/2023. The Hospice Aide (HA) care plan dated 11/13/2023 through 2/10/2024 ordered Hospice Aide services two (2) times weekly. During the week of 12/24/2023 through 12/30/2023, the patient received one (1) Hospice Aide visit on 12/27/2023. A clinical record review revealed no documented missed HA visit, agency "Visit Care/Task Refusal" order signed by the physician, or documented evidence that the HA updated the RN about the missed hospice aide visit. During a joint record review and interview on 1/23/2024, the Interim Director of Clinical Services confirmed the patient's electronic and paper medical records did not contain documented evidence that the HA reported the missed visit to the RN.

It is required that each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #SOP199-33, "Contents of the Medical Record" (revised 11/1/2023), stated in part, "Contents include anything related to the patient care, consents, legal documents related to the patient. The contents may include: Physician/Verbal Orders/Telephone orders." In 4 of 19 (21%) clinical records reviewed, the hospice agency did not ensure the patient's clinical record included all physician orders. Clinical Record 2: The patient elected hospice care on 11/5/2022 and resided in an assisted living facility (ALF). The comprehensive assessment completed by the Registered Nurse (RN) on 9/19/2023 documented, "Found a pressure ulcer on 9/17/2023 on the right heel. The caregiver applied Vaseline gauze and a bandage to the area. The hospice RN inspected the wound to find a stage two (2) pressure ulcer." On 9/19/2023, the physician ordered: "Keep the wound clean with soap and water. Keep the cushion heel pad on. Keep heel elevated as much as possible. OK, to bandage with gauze and dressing change daily." The RN visit frequency ordered was one (1) time weekly. The RN documented that wound care was performed on 9/28/2023. The RN documented the wound was resolved on 10/6/2023. The physician's order did not specify who would complete the daily wound care. During a joint record review and interview on 1/23/2023, the Interim Clinical Director confirmed that the physician order did not specify who would complete the daily wound care. Clinical Record 5: The patient elected hospice care on 9/5/2023 and lived in an assisted living facility (ALF). On 12/1/2023, the physician ordered: "Cleanse wound with alcohol pad, pat dry, apply triple antibiotic ointment with non-adherent pad. Bordered gauze every other day to right ankle." The RN documented coordinated wound care with the caregiver in the comment sub-section of the visit note dated 12/1/2023. The plan of care dated 11/29/2023 through 12/13/2023 ordered skilled nursing (SN) visits two (2) times a week. During the week of 12/3/2023 through 12/9/2023, the RN completed the wound care on 12/5/2023. The week of 12/10/2023 through 12/16/2023, the RN completed wound care on 12/11/2023. On 12/11/2023, the wound was documented as resolved on the wound assessment tool. The wound care order did not specify if the hospice RN or the caregivers would provide wound care. Clinical Record 10: The patient elected hospice care on 7/4/2023. The comprehensive RN assessment dated 12/8/2023 stated in part, "Facility putting iodine on it daily (right toe wound) and is open to the air." The RN was assessing the wound. The wound was assessed on 12/15/2023, 12/22/2023, and every week after. The comprehensive RN assessment dated 1/12/2024 stated in part, "Facility putting iodine on the brown spot daily. It is not open and looks like a blister but not raised. The spot is flat and dark brown in color. Only sore when touched." A clinical record review revealed no evidence of a physician's order for wound care. Clinical Record 11: The patient elected hospice care on 1/31/2023 and resided in a skilled nursing facility (SNF). On 8/7/2023, a wound was identified, and a wound care order was obtained that read, "Cleanse wound with wound cleanser. Apply TAO and dry dressing change daily and as needed (PRN). The POC dated 8/7/2023 through no end date ordered skilled nursing (SN) one (1) time weekly. During a joint record review and interview on 1/26/2024, the Interim Clinical Director confirmed the physician order was incomplete as it did not specify if the hospice or the SNF would be performing the wound care.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident the most recent hospice plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 1 (100%) home visit observed of a patient that resided in a skilled nursing facility (SNF), the hospice agency did not provide the SNF with the most recent hospice plan of care. Home Visit 3/Clinical Record 1: The patient elected hospice care on 9/14/2023 and resided at a SNF. During the home visit on 1/24/2024, a review of the patient's SNF clinical record revealed no evidence of an updated hospice plan of care. The plan of care in the patient's SNF clinical record was dated 9/13/2023. During a joint record review and interview on 1/24/2024, the Interim Clinical Director who was present for the home visit confirmed the patient's SNF clinical record did not contain the updated hospice plans of care and stated that there should be updated plans of care following the interdisciplinary group (IDG) meetings dated 9/27/2023, 10/11/2023, 10/25/2023, 11/8/2023, 11/22/2023, 12/6/2023, 12/20/2023, 1/3/2024, and 1/17/2024.

Based on policy review, employee personnel file review, and interview the hospice provider failed to ensure that one employee of eleven employees reviewed received bi-annual Emergency Preparedness training (Employee #8). This deficient practice has the potential to affect all patients served by the hospice provider. --- Findings included: Review of the providers policy titled, ";Initial and Ongoing Orientation, Education, Staff Meetings, and Staff Development," renewed date 05/08/2022, showed in part that: - Each employee and volunteer will receive and successfully complete all state and federal mandated educational training, as dictated by regulation upon hire, annually and as deemed necessary; - Initial orientation and ongoing annual training for employees, students, trainees and volunteers shall include but not limited to federal and state required topics; - Topics included Emergency Preparedness/Disaster Plan; and - Any and all staff development, completed modules, skills checklists and other educational in-services are to be documented in the employee personnel file. Employee #8: Review of the personnel file showed that the employee was hired on 02/18/2015. The personnel file failed to include any Emergency Preparedness training since hire. During an interview on 06/02/2023 beginning at 10:45 AM, the administrator stated that he/she would expect Emergency Preparedness training to be completed on hire and annually.

Based on policy review, record review, and interview the hospice provider failed to promote the patients right to choose his/her attending physician in one of 11 records reviewed (Record/Patient #11). This deficient practice has the potential to affect all patients served by the hospice provider. --- Findings included: Review of the providers policy titled, ";Patient and Family Rights and Responsibilities," revised 05/06/2022, showed in part that the patient/family has the right to choose care providers and attending physician, and the right to communicate with those providers, including their attending physician, as long as the physician agrees to abide by the policies and procedures of the agency. RECORD/PATIENT #11: Review of a fax from the patients attending physician to the hospice provider dated 08/22/2022 showed diagnoses included interstitial lung disease and weight loss. The patients prognosis was one to three months. Review of the record showed the patient elected hospice care on 08/24/2022. Review of the patients consent information dated 08/24/2022 showed the patient elected his/her attending physician as his/her choice for attending physician. Review of a physician order dated 08/24/2022 showed an order from the medical director to admit the patient to hospice routine level of care. Review of a form titled, ";Order for Admission to (named hospice provider) and Palliative Care Program," dated 08/24/2022 showed an order from the hospice medical director to evaluate and admit to the appropriate program as eligible of either hospice or palliative care. Notify the physician/primary care provider upon determination. A box was checked on the form that I am and will remain this patients attending physician. The medical director signed the form on 09/01/2022. Review of an email from the hospice admission nurse to the all hospice nurses dated 08/24/2022 showed he/she reviewed the patient with the hospice medical director and had a call out to the patients attending physician who the patient wished to have follow him/her while on hospice care. Awaiting return call. Review of the record showed no further documentation of attempts to contact the patients attending physician. Review of the physicians initial certification for Medicare hospice benefit showed the medical director signed as the patients attending physician on 09/01/2022. There was no documentation that this was discussed with the patient before 09/01/2022. Review of a form titled, ";Election/Change of Attending Authorization and Acknowledgement," showed the patient and nurse signed the form on 09/06/2022 (six days after the medical director signed that he/she was and would remain the patients attending physician). During an interview on 05/23/2023 beginning at 2:20 PM, the administrator stated that he/she would expect there to be further attempts to contact the patients attending physician and would expect it to be documented. If they could not get ahold of the patients attending, he/she would expect there to be documentation of discussion with the patient regarding what he/she wanted to do. He/she did not see this information in the record at this time but would look for it. Review of an email from the administrator sent 05/25/2023 at 1:43 PM, showed the administrator verified there was no documentation of discussion with the patient regarding changing attending physicians.

Based on record review and interview the hospice provider failed to ensure the patients physician order for oxygen was provided in a timely manner and covered by the hospice provider in one of 11 records reviewed (Record/Patient #11). This deficient practice has the potential to affect all patients served by the agency. --- Findings included: RECORD/PATIENT #11: Review of a physician order dated 08/24/2022 showed an order from the medical director to admit the patient to hospice routine level of care. The order included oxygen at 2-4 liters per minute as needed for dyspnea (difficulty breathing). Review of an email from the admission nurse to STL (St. Louis) nurses dated 08/24/2022 showed in part he/she reviewed the patient with the medical director and had a call out to the patients attending physician who the patient wished to follow him/her while on hospice care. Awaiting return call. The nurse failed to include any information regarding the patients oxygen order or whether the oxygen had been ordered for the patient. Review of the initial plan of care (POC) dated 08/24/2022 showed under the section for equipment to order/deliver showed oxygen concentrator four liters. Review of the nursing visit note dated 08/25/2022 showed an embedded note dated 12/28/2022 that the patient has an oxygen concentrator in the home. Awaiting for equipment to be switched out from admission. Message sent to the administrator regarding the portable oxygen concentrator the patient has in his/her home to determine if hospice was covering or what was discussed regarding oxygen at admission. Review of the record showed no further information regarding coverage of the patient's oxygen concentrator. Review of a nursing visit note dated 08/30/2022 (six days after admission) showed the nurse placed an oxygen order with (named company). Once received the patient will contact the DME (durable medical equipment) company to pick up his/her DME. Ongoing education regarding oxygen provided and instructed the patient to use his/her oxygen concentrator at home and use portable tanks when out. During an interview on 05/23/2023 beginning at 2:20 PM, the administrator stated that the date of 12/28/2022 showed the nurse entered the note very late. The clinical director stated that they typically do not put DME (durable medical equipment) on the list of items covered, just the medications. They discuss at the visit what is covered and not covered. We cover all DME. The administrator stated that he/she would look for a bill that shows they covered the patients oxygen. The administrator would expect the oxygen to have been ordered when they received the order on admission. Review of an invoice emailed from the hospice provider on 05/24/2022 showed the DME company listed the patients oxygen concentrator starting on 09/01/2022 (seven days after the order was received on admission).

Based on policy review, record review, home visit observation, and interview, the hospice provider failed to perform a review of all the patients prescription and over-the-counter drugs, herbal remedies, and other alternative treatments that could affect drug therapy in four of four home visit observations conducted (Records/Patients #21, #22, #23, and #24). This deficient practice has the potential to affect all patients served by the hospice provider. Findings included: Review of the hospice providers policy titled, ";Medication Reconciliation, Review, Coverage Determination, and Pharmacist Review," dated/renewed 05/23/2022, showed in part: - All medications will be carefully reviewed upon admission and with each and every medication change; - Staff will ensure accurate medication lists and reconciliation for patients; - It is important to establish accurate and complete medication lists for each patient as well as sending accurate medication lists to the attending physician, the home office pharmacist, and to ";PDC" (undefined abbreviation) for analysis, review, and processing; - The home office pharmacist will review all medication profiles and will notify the site with urgent issues along with routine advisements on admission and with any and all medication changes; - The nursing staff has the capability of generating a pharmacist medication profile review at any time throughout the hospice admission; - Upon admission/assessment, the Registered Nurse (RN), along with the medical director and attending physician will perform a thorough review of the patients medication profile; - The medical director/hospice physician will review the medication profile on admission and with each and every medication change; - The pharmacist medication profile review will be reviewed by the hospice medical director/hospice physician before and/or during the Interdisciplinary Group (IDG) meetings; - Nursing staff will review nursing home and facility patients medication administration records (MARs) during each visit and will print off any new medication orders and monthly MAR or physicians order sheets (POS) and will ensure that the patients medication profiles are reviewed and reconciled; and - Medication profiles will include all pertinent information, must be complete, concise, up to date, and accurate, detailed, and must include drug allergies. --- RECORD/PATIENT #21: Review of the hospice providers patient medication profile showed the following discrepancies with the assisted living facilitys (ALFs) medication profile: - The hospice providers medication profile showed the patient taking alprazolam (used to treat anxiety/agitation) 0.25 milligrams (mg) by mouth (PO) every six hours as needed (Pro re nata, PRN); - Alprazolam was not on the ALFs medication profile; - The hospice providers medication profile showed the patient taking quetiapine fumarate (used to treat schizophrenia, bipolar disorder, and depression) 25 mg PO twice daily (BID); - The ALF medication profile showed quetiapine fumarate 25 mg BID (at 8:00 AM and 4:00 PM) and also 50 mg BID with meals (the hospice medication profile did not have the 50 mg dosage listed); - The ALF medication profile showed acetaminophen ER (extended release) (a non-narcotic pain reliever used for mild to moderate pain) two tablets PO twice daily and 325 mg, take two tablets PO every six hours PRN; - Acetaminophen was not listed on the hospice providers medication profile; - The ALF medication profile showed aspirin EC (enteric coated) (used for heart health) 81 mg, one tablet PO daily; - Aspirin was not listed on the hospice providers medication profile; - The ALF medication profile showed haloperidol lactate (a short-acting solution used to treat mental/mood disorders) 2 mg/milliliter (ml) concentrate, take 0.25 ml (0.5 mg) sublingually (SL, under the tongue) every four hours PRN; - Haloperidol lactate was not listed on the hospice providers medication profile; - The ALF medication profile showed prochlorperazine (used to treat nausea/vomiting) 10 mg take one PO every six hours PRN; and - Prochlorperazine was not listed on the hospice providers medication profile. During an interview on 06/01/2023 at 4:20 PM, the RN coordinator stated that he/she would expect the nurse to compare the facility medication list to their medication list and reconcile it so it matches. This should be done on each visit to the facility then it is reviewed during the IDG meetings. Findings were reviewed with the administrator and RN coordinator on 06/02/2023 at 10:45 AM. Per an interview conducted during the review, the RN coordinator stated that the nurse should be reviewing medications at each visit and make sure they match what the facility has on their profile. They should ask the facility nurses if there are any changes to the patients medications during the visits. The medications are also reviewed during IDG meetings. RECORD/PATIENT #22: Review of the hospice providers patient medication profile showed the following discrepancies with the long-term care facilitys (LTCF) medication profile: - The hospice medication profile showed the patient took acetaminophen 325 mg two tablets at bedtime (HS); - The LTCF medication profile showed the patient took two 325 mg acetaminophen tablets three times a day (TID); - The hospice profile showed Align (brand) (a dietary probiotic supplement to improve gut health) one tablet daily; - Align was not listed on the LTCF medication profile; - The hospice profile showed aspirin (for heart health) 81 mg daily; - Aspirin was not on the LTCFs medication profile; - The hospice medication profile showed Effexor XR (an antidepressant) 150 mg BID; - The LTCF medication profile showed the Effexor XR dose was 75 mg BID; - The hospice medication profile showed that the methotrexate (a chemotherapy and immunosuppressive medication) 2.5 mg two tablets every week on Monday was discontinued on 07/01/2022; - The LTCF medication profile showed the methotrexate is still a current medication; - The hospice medication profile showed metoprolol tartrate (an immediate release tablet used to treat people with high blood pressure, arrhythmias, angina and heart attacks) 50 mg BID; - The LTC medication profile showed the patient took metoprolol succinate ER (a long- acting tablet) 50 mg BID; - The hospice medication profile showed trazodone hydrochloride (an antidepressant/sedative) 12.5 mg BID; - The LTCF medication profile showed the trazodone dose was 25 mg at HS; - The hospice medication profile showed vitamin D3 1000 international units (IU) daily; - Vitamin D3 was not on the LTCF medication profile; - The following medications were found on the LTCFs medication profile but were not listed on the hospice medication profile; * Cranberry 500 mg once daily (used for urinary health); * Loperamide 2 mg BID (used for diarrhea); * Polyethylene glycol 0.25% eye drops one drop in both eyes BID (used for dry eyes); * Hydrocodone-acetaminophen 5-325 mg ½ tablet one time daily 30 minutes before dressing changes for pain; * Ensure Enlive (a nutritional supplement) 0.08 gram (gm) - 1.5 kilocalorie/milliliter (kcal/ml), one carton BID; and * PRO-STAT AWC (advanced wound care) 17gm – 100 kcal/ml, 1 ounce BID. During an interview on 06/01/2023 at 4:20 PM, the RN coordinator stated that he/she would expect the nurse to compare the facility medication list to their medication list and reconcile it so it matches. This should be done on each visit to the facility then it is reviewed during the IDG meetings. Findings were reviewed with the administrator and RN coordinator on 06/02/2023 at 10:45 AM. Per an interview conducted during the review, the RN coordinator stated that the nurse should be reviewing medications at each visit and make sure they match what the facility has on their profile. They should ask the facility nurses if there are any changes to the patients medications during the visits. The medications are also reviewed during IDG meetings. RECORD/PATIENT #23: Review of the clinical record showed the patient was admitted to hospice services on 02/14/2023. The patient medication list provided on 05/30/2023 showed that the patient received the following medications: - Bactrim ointment (an antibiotic ointment for infection) apply once to the lesions on the abdomen daily as needed; and - Dilaudid (a narcotic medication used to control pain) one milligram (mg) per milliliter (mL) every two hours as needed for pain. Observation on 05/31/2023 beginning at 10:10 AM, during the patients home visit, showed that the patient reported the following medications: - Dilaudid one mg per mL every four hours as needed for pain; - Levothyroxine (a medication for the thyroid) 112 micrograms (mcg) one tablet daily; - Aspercreme (a topical medication used for minor pain relief) spray and ointment to the buttocks as needed; - Dressing changes with Betadine (an antiseptic used to cleanse the wound) and Calcium Alginate (a medication used for wound healing) daily; and - Anbesol (an anesthetic that is used to numb a painful area) to his/her mouth as needed. The hospice provider failed to update the medication list to include the current medications of the patient. During an interview on 06/01/2023 at 4:20 PM, the clinical manager stated that he/she would expect the nurse to compare the facility medication list to their medication list and reconcile it so it matches. This should be done on each visit to the facility then it is reviewed during the IDG meetings. RECORD/PATIENT #24: Review of the clinical record showed the patient was admitted to hospice services on 12/20/2022. The patient medication list provided on 05/30/2023 showed that the patient received the following medications: - MS Contin (a narcotic medication used for severe pain) 30 mg every eight hours; and - Olanzapine (a medication used to treat psychosis, schizophrenia, and/or bipolar disorder) 5 mg every day at bedtime. Observation on 05/31/2023 beginning at 3:40 PM, during the patients long-term care home visit, showed that the current medication orders from the facility included the following: - MS Contin 30 mg every 12 hours; - Ondansetron (a medication used for nausea and vomiting) four mg every 6 hours as needed; and - Polyethylene glycol (a medication used for constipation) 17 grams per dose- use one scoop once per day. The hospice provider failed to update the medication list to include the current medications of the patient. During an interview on 06/01/2023 at 4:20 PM, the clinical manager stated that he/she would expect the nurse to compare the facility medication list to their medication list and reconcile it so it matches. This should be done on each visit to the facility then it is reviewed during the IDG meetings.

Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure: - That each patient and the primary caregiver(s) receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care (L0544); - Develop an individualized plan of care for each patient reflecting goals and interventions identified in initial and comprehensive assessments (L0545); - A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs (L0547); - Measurable outcomes anticipated from implementing and coordinating the plan of care (L0548); - Medical supplies and appliances necessary to meet the needs of the patient were available (L0550 - This specific problem was identified as an immediate jeopardy during complaint #98251); and - That the care and services are provided to hospice patients was in accordance with the written plan of care (L0555). The cumulative effect of these deficient practices has the potential to affect the provision of safe care for all patients served by the provider. --- .

Based on policy review, record review, observation, and interview the hospice provider failed to ensure that education was provided to one of five full records reviewed (Record/Patient #23). This deficient practice has the potential to affect all patients served by the hospice provider. --- Findings included: Review of the hospice providers policy titled, ";Patient and Family Rights and Responsibilities," revised 05/06/2022, showed in part, that the patient and family have the right to participate in the planning of their care, the right to appropriate instructions and education regarding the plan, and to be involved with the development of the plan of care. RECORD/PATIENT #23: Review of the clinical record showed that on 05/17/2023 the providers registered nurse (RN) received an order from the physician to apply Bactrim (an antibiotic ointment for infection), Calcium Alginate (a medication used for wound healing), and an abdominal pad (a dressing used to cover an open area) to skin cancer lesions on the abdomen as needed. Review of the Registered Nurse (RN) Comprehensive Assessment Report dated 05/17/2023, showed that the patient was educated on the new order for Betadine (an antiseptic used to cleanse the wound), Calcium Alginate, and abdominal pad to avoid drainage going through to stain his/her shirt. The RN failed to document if a demonstration was provided to the patient or caregiver. Review of the RN Comprehensive Assessment Report dated 05/22/2023, showed that the skin cancer lesion on the abdomen remained 5 centimeters (cm) red bed and was no longer draining. The patient was to continue Betadine, Calcium Alginate, and cover with the abdominal pad. Review of the RN Comprehensive Assessment Report dated 05/26/2023, showed that the drainage was controlled on the lesion midline abdomen with current regimen of Betadine, Calcium Alginate, and abdominal pad. Review of the RN Comprehensive Assessment Report dated 05/31/2023, showed that the patient reported that the two skin cancer lesions on the abdomen were draining and had pus (a thick yellowish or greenish opaque liquid produced in infected tissue) on them. The patient reported the dressing had just been changed. The RN looked at the lesions, the wound bed had yellow wound bed on midline and small yellow spots on left upper quadrant. Patient was educated on use of Calcium Alginate when changing dressings, verbalized understanding and agreement. The patient reported he/she has not been using the Calcium Alginate. The hospice aide was to come today (05/31/2023) and aide with shower and will have him/her walk the patient through the proper order again. The RN failed to document if a demonstration of the dressing change was given to the patient or caregiver. Observation on 05/31/2023 beginning at 10:10 AM, during the patients home visit, showed that the providers RN assessed the patients wound by pulling back the dressing. The RN reminded the patient about using the Betadine and the Calcium Alginate. The patient reported that he/she was only covering the area with the bandage and had forgotten that he/she was supposed to be using the ";other stuff." The RN reapplied the bandage and stated that he/she would have the hospice aide that was coming in later in the day to redress the area and walk the patient through the dressing change. The RN failed to change the dressing and failed to provide a demonstration to the patient of proper dressing change. During an interview on 06/02/2023 beginning at 10:45 AM, the clinical manager stated that he/she would expect the RN to have changed the dressing and given a demonstration of how to properly change the dressing to the patient. He/she stated that the RN is responsible for changing the dressing and doing the demonstration and not the hospice aide.

Based on policy review, record review, and interview the hospice provider failed to develop an individualized plan of care (POC) in four of five full records reviewed (Records/Patients #21, #22, #23, and #24). This deficient practice has the potential to affect all patients served by the provider. --- Record/Patient #23: Review of the clinical record showed that the patient was admitted to hospice services on 02/14/2023. Review of the Care Plan Report and the Plan of Care History, both dated 05/30/2023, showed the following: - On 02/14/2023 an issue was identified that the patient was a do not resuscitate (DNR). The goal stated that the patient will experience a peaceful death and the intervention was that a signed DNR will be on file. The patient had a signed DNR from a previous admission to the hospice provider dated 06/17/2022. The provider failed to update the care plan to show that the DNR had been obtained and added to the patients medical record; - On 02/27/2023 an issue was identified that the patient had pneumonia (an inflammation of the lung caused by a bacterial or viral infection). The goal stated that the patient was continuing on antibiotic treatment previously started for a pneumonia diagnosis. The last antibiotic order found in the medical record for an upper respiratory infection was dated 01/18/2023 prior to the patients admission to hospice services. The provider failed to ensure that the issues identified for the patient were accurate. The issue was resolved on 05/31/2023 showing that the provider failed to update the care plan in a timely manner; - Review of a face-to-face visit dated 03/21/2023, showed that the patient had a history of Atrial Fibrillation (an irregular rapid heart rate). The provider failed to add this diagnosis to the care plan for the patient. On 05/11/2023 the patient received new orders for Dexamethasone (a medication used to treat inflammation and pain) two milligrams (mg) every morning and Metoprolol (a medication used to treat hypertension) 25 mg one hour after Dexamethasone to control rapid heart rate. The provider failed to add the medications to the care plan; and - On 05/17/2023 the provider obtained new orders for dressing changes including to apply Bactrim (an antibiotic ointment for infection), Calcium Alginate (a medication used for wound healing), and an abdominal pad (a dressing used to cover an open area) to skin cancer lesions on the abdomen as needed. The provider failed to update the care plan to include the dressing orders. During an interview on 06/02/2023 beginning at 10:45 AM, the clinical manager stated that he/she would expect the goals on the care plan to be specific to the patient and individualized. He/she also stated that the expectation was that care plans would be updated as needed. RECORD/PATIENT #24: Review of the clinical record showed that the patient was admitted to hospice services on 12/20/2022. Review of the Care Plan Report and the Plan of Care History showed the following: - On 12/20/2022 an issue was identified that the patient was a full code status. The goal stated that the patient will experience a peaceful death and the intervention was that a signed DNR will be on file. The patient had a signed do not resuscitate (DNR) dated 12/20/2022 and the long-term care facility showed an order from the physician showing DNR on 12/21/2022. The provider failed to update the care plan to show that the DNR had been obtained and added to the patients medical record until 01/04/2023; - The patient was admitted to hospice services with a diagnosis of congestive heart failure (a chronic condition in which the heart doesnt pump blood adequately). The provider failed to include any goals or interventions on the care plan to address symptom control for congestive heart failure; - The patient was admitted with a history of falls, including a fall prior to hospice admission that required a hospital stay, and the provider failed to include any goals or interventions related to falls or safety on the care plan; and - The patient was a cigarette smoker and the provider failed to include any goals or interventions related to smoking or safety on the care plan. During an interview on 06/02/2023 beginning at 10:45 AM, the clinical manager stated that he/she would expect the goals on the care plan to be specific to the patient and individualized. He/she also stated that the expectation was that care plans would be updated as needed. RECORD/PATIENT #21: The patient was admitted to hospice services on 12/06/2022 with a terminal diagnosis of Alzheimers disease (progressive mental deterioration due to generalized degeneration of the brain). The patient had a history of venous stasis ulcers (wounds on the legs or ankles caused by abnormal or damaged veins), pressure ulcers, and had multiple skin tears (wounds that happen when layers of skin separate or peel back). He/she lived in an assisted living facility (ALF). Review of the comprehensive/recertification assessment, dated 02/23/2023, showed the patient: - Was oriented to self only and disoriented to place, time, and situation; - Had a bowel regimen ordered on 12/06/2022 and the intervention was to increase fiber; - Was a fall risk and safety concerns were discussed with the family and facility staff; - Had impaired skin integrity and the intervention showed staff will replace soiled pull-ups immediately with good perineal care, apply barrier cream, and change position every two to three hours; - Was at risk for infection and the intervention was to monitor all wounds for signs and symptoms of infection; - Had the following wounds documented; * A ";healed" skin tear on the left arm (labeled as wound #1); * A skin tear on the right arm (labeled as wound #2) that measured width - 4.5, L – 7, D – 0.03 (does not specify the unit of measurement) and the treatment was to wash skin tear area with wound cleanser, dry thoroughly, apply ";Mucuprin ATB" (antibiotic) ointment, cover with non-adherent gauze then wrap arm with gauze/tape daily until healed; * A ";healed" arterial ulcer to the right leg/foot (labeled as wound #3); * A venous stasis ulcer on the left leg/foot (labeled as wound #4) that was ";unable to measure" (note does not indicate why the nurse was unable to measure) and the treatment was to wash feet/legs with soap and water, dry thoroughly, apply lotion to dry feet/legs, monitor bruises, small scabs, and bunion on large toes for signs and symptoms of infection, record/report changes; * ";Healed" redness to buttock (does not specify which buttock) (labeled as wound #5); * A ";healed" pressure ulcer to left upper buttocks at sacral area (labeled as wound #6); * A ";healed" pressure ulcer to left upper buttocks at sacral area (labeled as wound #7); * A skin tear on the right hand (labeled as wound #8) that was ";unable to measure" (note does not indicate why the nurse was unable to measure) and the treatment was to cleanse, apply TAO (triple antibiotic ointment) and bordered dressing; * A skin tear on the left ankle (labeled as wound #9) that was unable to measure (note does not indicate why the nurse was unable to measure) and the intervention was to cleanse, apply TAO, and a bordered dressing; and - Required an increase in skilled nursing (SN) visits to three times a week for wound care because the ALF does not do wound care. Review of the SN notes with dates ranging from 03/06/2023 to 05/30/2023, showed the patient wears protective sleeves on bilateral arms and legs due to repeated skin tear injuries to arms and legs. Review of the document titled, ";Care Plan Report," dated 05/30/2023, showed the plan of care (POC): - Failed to contain information about the patients orientation status; - Failed to include the prescribed bowel regimen or the intervention of increasing fiber; - Failed to include that the patient was a fall risk or indicate the safety interventions that were implemented; - Identified the redness to the unspecified buttock dated 01/11/2023 (wound #5 which was marked as ";healed" on the comprehensive assessment); - Identified the pressure ulcer to the left upper buttocks at sacral level dated 01/20/2023 (Wound #6 or #7 both were marked ";healed" on the comprehensive assessment); - Failed to include the patient had a risk for impaired skin integrity or any interventions to prevent pressure ulcers; - Failed to include specific orders for dressing changes/treatments to treat the current wounds and skin tears identified on the comprehensive assessment (wounds #2, #4, and #8); - Identified a right elbow skin tear on 05/26/2023 and the intervention was ";document wound care" but does not include the specific order for the wound care; - Failed to contain the need for the protective sleeves on bilateral arms/legs to prevent skin tears; - Failed to include the patients risk for infection or that the patients wounds should be monitored for signs and symptoms of infection; and - Failed to include the order for the increased SN visit frequency to three times weekly for wound care. During an interview on 06/01/2023 at 09:15 AM, the registered nurse coordinator (RN) stated that the ";Care Plan Report" is what the hospice provider uses as a current POC. During an interview on 06/01/2023 at 4:20 PM, the RN coordinator stated that he/she tells the staff they should be able to pick up a care plan and know exactly how to take care of that patient. He/she agreed the care plans need to be more individualized and he/she is working on educating the staff. Findings were reviewed with the administrator and RN coordinator on 06/02/2023 at 10:45 AM. Per an interview conducted during the review, the RN coordinator stated that he/she expects the POC to be individualized for each patient and there should have been an order for the change in visit frequency and the wound treatment/dressings. RECORD/PATIENT #22: The patient was admitted to hospice services on 07/01/2022 with a terminal diagnosis of cerebrovascular infarction (stroke). He/she was dysphasic (an impairment of language processing in which the patient has difficulty speaking or using words properly) and received treatment by a wound specialist for multiple open wounds. The patient has a history of peripheral vascular disease (PVD, a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and lived in a long-term care facility (LTCF). Review of the wound center visit note, dated 05/22/2023, showed the patient: - Had wound related pain, treated with tramadol and acetaminophen; - Had a skin tear on the right proximal calf (wound #2) with dressing changes every three days; - Had a full thickness arterial ulcer on the right Achilles (the tendon directly above the heel) area (wound #3); - Had a skin tear on the right lower posterior leg that has closed (wound #5); - Had a full thickness arterial ulcer on the left Achilles area that was debrided at this visit (wound #8); - All wounds had a treatment order to cleanse with wound cleanser, apply Aquacel Ag (an antimicrobial dressing used in acute and hard-to-heal wounds that are infected or at risk of infection with varying drainage levels), and cover with a dry dressing; - Dressings were to be changed three times a week and as needed; and - Had orders for an offloading boot (does not specify on which foot boot should be worn). Review of the document titled ";Care Plan Report," dated 05/30/2023, showed the POC: - Identified four areas described as a ";wound;" * A left lower extremity skin tear (added to POC on 08/19/2022); * A wound to ankle (does not specify which ankle) (added to POC on 02/22/2023); * A skin tear to the posterior left thigh (added to POC on 02/22/2023); * A bruise to forehead (added to POC on 02/22/2023); - Contained the same goal for all wounds, ";patient will maintain optimal level of skin integrity for disease;" - Contained the same intervention for all wounds, to ";document wound care;" - Failed to contain information that the patient has been treated by the wound center since 08/18/2022; - Failed to include any interventions to assess for signs and symptoms of infection related to the presence of skin tears and ulcers; - Failed to include information regarding who is responsible for dressing changes to wounds (LTCF or hospice); - Failed to show that the wounds listed were no longer active and the patient had current/active wounds in new locations (right calf, right Achilles, left Achilles); - Identified a problem of non-pitting edema (swelling) to bilateral lower extremities; - Contained the goal ";patient should exhibit minimal signs and symptoms of edema;" - Contained the intervention to ";assess for edema and record findings;" - Failed to contain individualized interventions to manage the discomfort or symptoms associated with edema; - Identified a problem of impaired mobility; - Contained the goal that ";patient will remain comfortable and safe;" - Contained the intervention to ";provide assistive devices;" and - Failed to contain individualized information on what assistive devices were required/provided. Review of the document titled, ";Plan of Care History," showed the following updates to the POC were made on 05/31/2023 (One day after the start of survey): - Issue - Chair-bound (patient was identified as using a Broda (brand) chair in SN notes dated 04/26/2023, 05/02/2023, and 05/17/2023); - Goal – Patient will have optimal skin integrity despite wheelchair/broda chair being primary transport/transfer source; - Intervention – Patient will have skin assessed by hospice nurse and facility staff. Hospice aides to report any skin changes with patient to hospice case manager and facility nurse. Facility aide will report skin changes to facility charge nurse; Facility nurses and hospice nurse will coordinate skin changes and treatment plans with one another; - Issue – Wound – Right Achilles ";hill" (heel), bilateral Achilles heel (patient has been seeing wound specialist at wound center since 08/18/2022); - Goal – Patient will maintain optimal level of skin integrity for disease; and - Intervention – Document wound care. Facility wound care nurse completes wound care every Monday and Thursday. Cleanse with wound cleanser, pat dry, apply ";aquacell" (Aquacel Ag, a type of dressing with antimicrobial properties) and cover with kerlix (a rolled bulky gauze). During an interview on 06/01/2023 at 09:15 AM, the RN coordinator stated that the ";Care Plan Report" is what the hospice provider uses as a current POC. During an interview on 06/01/2023 at 4:20 PM, the RN coordinator stated that he/she tells the staff they should be able to pick up a care plan and know exactly how to take care of that patient. He/she agreed the care plans need to be more individualized and he/she is working on educating the staff. Findings were reviewed with the administrator and RN coordinator on 06/02/2023 at 10:45 AM. Per an interview conducted during the review, the RN coordinator stated that he/she expects the POC to be individualized for each patient.

Based on policy review, clinical record review, and interview, the hospice provider failed to ensure a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs when it implemented standing physician orders without individualizing the orders to meet the specific needs of the patient in one of five full records reviewed (Record/Patient #21). This deficient practice has the potential to affect all patients served by the hospice provider. Findings included: Review of the hospice providers policy titled, ";Authorized Prescribers Orders (Hospice Standing Orders)," dated/renewed 05/23/2022, showed in part: - The purpose of the policy is to provide guidance regarding the use of authorized prescribers orders (standing orders); - Standing orders may be used only as a part of the plan of care; - Standing orders must be medication, procedural, and treatment specific, individualized, and not allow for non-prescribers choice; - Standing orders do not replace the necessity to contact the patients primary care physician or hospice medical director or to coordinate care with the primary care physician and hospice medical director, but will be utilized for emergent conditions to ensure the palliative needs of the patient are met within a timely manner; - The standing order will be individualized by eliminating contraindicated medications, treatments, and/or procedures, addressing the patients allergy history, and addressing any specific indications unique to said patient; - When implementing an order from the standing order form, the treatment, medication, or procedure shall be immediately reduced to writing, utilizing a physicians verbal order form. The order shall include the phrase ";per signed authorized prescribers orders;" and - The order shall be signed and dated by the person implementing the order. --- RECORD/PATIENT #21: Review of the document titled, ";Authorized Admission Prescriber Orders for Hospice Patients (Standing Orders)," dated/signed by physician 12/18/2022, showed the following: - Abrasions – Topical antibiotic ointment (TAO), apply topically PRN (Pro re nata – commonly used to mean as needed) for skin tears or minor abrasions. Apply dry bandage/band-aid (brand – but also a term used to describe any brand of adhesive bandage); - Physician will be notified within 72 hours upon implementation of any order; and - All orders will be transcribed upon implementation. Review of the skilled nurse (SN) notes showed the SN documented the following wound care interventions: - 03/06/2023, a dressing change to the right hand, left upper shin, left mid shin, left ankle, right shin, and right ankle (does not specify what was used). Dressings wrapped in Kerlix (a rolled bulky gauze); - 03/10/2023, a dressing change to right hand, right shin, right ankle, left upper shin, left shin, and left ankle (does not specify what was used); - 03/13/2023, a foam bordered dressing to the right hand; - 3/17/2023, a dressing change to right hand, left shin, right shin, and left ankle (does not specify what was used); - 03/20/2023, a dressing change to right hand, left upper shin, and left shin (does not specify what was used); - 03/22/2023, cleaned with wound cleanser, patted dry, applied TAO, covered with foam dressing; - 03/24/2023, cleansed and bordered dressing applied to new skin tear on right forearm and right hand; - 03/27/2023, a new skin tear on upper right forearm with steri-strips noted (wound closure strips used to close small wounds and lacerations), cleansed area and dry dressing applied, dressing to right forearm also changed (does not specify what was used for the dressing change); - 03/29/2023, a dressing change to right forearm (does not specify what was used); - 03/31/2023, a dressing change to the right forearm (does not specify what was used); - 04/03/2023, a new skin tear to the right shin was cleansed, TAO and bordered dressing applied; - 04/11/2023, a dressing change to the right forearm and right upper forearm and a dressing was applied prophylactically (preventatively) to the right shin (does not specify what was used); - 04/13/2023, a dressing change to the right forearm, right upper forearm and right shin (does not specify what was used); - 04/17/2023, a dressing change to right upper forearm (does not specify what was used) and a new skin tear was noted to right shin. SN cleansed with wound cleanser, bordered dressing applied; - 04/19/2023, foam ";4X4" dressing (a four inch square dressing) applied to a healing skin tear on the right shin; - 05/08/2023, a new skin tear on the right elbow was cleansed with wound cleanser, the wound was approximated (the edges were brought together), steri-strips, TAO, and dry dressing applied; - 05/11/2023, dressing change to right elbow (does not specify what dressing supplies were used); - 05/24/2023, right elbow cleansed with dermal cleanser, steri-stripped, wide band-aid applied; - 05/26/2023, right elbow and left shin cleansed with wound cleanser, patted dry, TAO applied, covered with foam dressing; and - 05/30/2023, a dressing change to the right elbow (does not specify what was used for the dressing change). Review of the clinical record showed the record failed to contain: - Individualized written orders for the treatment of the skin tears when the standing orders were initiated; - Specific instructions in each order on the type of dressing to be used for the treatment of the skin tears; and - Specific instructions in the order on the frequency of each dressing change. Findings were reviewed with the administrator and RN coordinator on 06/02/2023 at 10:45 AM. Per an interview conducted during the review, the RN coordinator stated that they use a standing order list that the physician signs and they have 72 hours after implementation to get the order from the physician. The standing orders are really only to be used in an emergency if they were not able to reach the physician but they still are expected to get the order and the order should specify the type of dressing and the frequency of the dressing change.

Based on policy review, clinical record review, and interview the hospice provider failed to ensure the individualized plan of care (POC) included measurable outcomes anticipated from implementing and coordinating the plan of care in four of five full records reviewed (Records/Patients #21, #22, #23, and #24). This deficient practice has the potential to affect all patients served by the hospice provider. Findings included: Review of the hospice providers policy titled, ";IDG (Interdisciplinary Group) Hospice Plan of Care – Content, Plan, Goals, Interventions and Outcomes," dated/renewed 05/23/2022, showed in part: - The hospice will ensure that the outcomes are a measurable result of the implementation of the plan of care (POC); - The hospice will use, as appropriate, data elements as a part of the assessment and the POC to ensure that goals of care are being met; - These will be documented within the hospice POC and hospice documentation; - The hospice will determine if the care goals are being met by assessing and determining if the goals are not met, progressing or met/resolved; - If these outcomes are not being met, then changes will be implemented; and - Ongoing assessments will be made to ensure that expected outcomes are met or, if not, that revisions in the POC are made. --- RECORD/PATIENT #23: Review of the clinical record showed: The Care Plan Report dated 05/30/2023, showed the following: - The patient was identified as having issues with back pain and generalized pain, the pain scales used included numeric and verbal scores (score range is 0 for no pain to 10 for the worst possible pain); * The patients back pain was rated a ";4" on the numeric pain scale and the generalized pain was rated a ";6" on the verbal scale; * The goals for pain included patient will exhibit minimal signs and symptoms from medications (no signs or symptoms of medication effects were given); and * The interventions for pain included assess effectiveness of medications and teach the patient and caregiver about pain medications (no specific areas of teaching needs were identified). - The patient was identified as having issues with shortness of breath; * The goal for shortness of breath was the patient should exhibit minimal signs and symptoms of dyspnea or shortness of breath (no signs or symptoms of dyspnea were given); and * The intervention for shortness of breath was teach normal changes of respirations with dying process and previous education regarding disease process and proper use of prescribed medications reinforced to patient for symptom management - The patient was identified as having issues with anxiety; * The goal for anxiety was patient should exhibit decreased signs and symptoms of anxiety (no signs or symptoms of anxiety were given); and * The intervention for anxiety was to assess signs and symptoms of anxiety as needed (no signs or symptoms of anxiety were given). - The POC failed to contain measurable goals for the identified problems; and - The POC failed to contain measurable outcomes resulting from the implementation of the interventions. During an interview on 06/02/2023 beginning at 10:45 AM, the clinical manager stated that the POC goals should be individualized and the outcomes should be measurable. RECORD/PATIENT #24: Review of the clinical record showed: The Care Plan Report dated 05/30/2023, showed the following: - The patient was identified as having issues with intake by mouth; * The goal for intake was the patient should maintain optimal intake within the disease process (no explanation for what would be considered optimal intake); and * The intervention for intake was monitor and document weight. - The patient was identified as a suicide risk level 1; * The goal for suicide risk was to ensure patient remains safe from self-harm (no indication of signs or symptoms of suicide that should be monitored); * The intervention for suicide risk was to assess patient monthly for suicidal thoughts (no plan noted for if patient became suicidal). - The POC failed to contain measurable goals for the identified problems; and - The POC failed to contain measurable outcomes resulting from the implementation of the interventions. During an interview on 06/02/2023 beginning at 10:45 AM, the clinical manager stated that the POC goals should be individualized and the outcomes should be measurable. RECORD/PATIENT #21: Review of the POC, dated 05/30/2023, showed the following: - Patient identified as having two wound sites that were active issues. Both wounds had the same goal and intervention; * Goal - Patient will maintain optimal level of skin integrity for disease; * Intervention – Document wound care; - An active issue of pain is identified using the FLACC pain scoring tool (F- face, L- legs, A - arms, C - crying, C- consolability, a behavioral pain assessment scale used for nonverbal patients who are unable to self-report their level of pain, score range is 0 - no pain to 10 - worst possible pain); - The FLACC pain score was a ";2;" - The goal was that patient should exhibit decreased signs and symptoms (does not specify what signs and symptoms); - The intervention was to teach patient care givers signs and symptoms of increased pain as verbalized/indicated by patient (does not specify what signs and symptoms); - The POC failed to contain measurable goals for the identified problems; and - The POC failed to contain measurable outcomes resulting from the implementation of the interventions. Findings were reviewed with the administrator and RN coordinator on 06/02/2023 at 10:45 AM. Per an interview conducted during the review, the RN coordinator stated that POC goals should be individualized and the outcomes should be measurable. RECORD/PATIENT #22: Review of the POC, dated 05/30/2021, showed the following: - On 07/01/2022, an active issue was identified as pain, generalized, FLACC score - ";1;" - Goal – Patient will exhibit minimal signs and symptoms from medications; - Intervention – Assess effectiveness of medications (does not specify what ";effectiveness" looked like for this patient); - On 03/18/2023, an active issue was identified as pain, left heel, FLACC score ";3;" - Goal – Patient should exhibit decreased signs and symptoms (does not specify what the signs and symptoms were); - Intervention – Assess effectiveness of meds (medications) (does not specify what ";effectiveness" looked like for this patient; - Active issues of feeding/meals, toileting/elimination, and housekeeping duties have the same goal and intervention; * Goal- patient should receive personal care safely and effectively and maintain patient dignity; * Intervention- Encourage patient to participate in ADLs (activities of daily living); - Active issues of five wounds identified on the POC and all have the same goal and intervention; * Goal- Patient will maintain optimal level of skin integrity for disease (does not specify what ";optimal" was for this patient); * Intervention – Document wound care (does not specify what wound care was); - The POC failed to contain measurable goals for the identified problems; and - The POC failed to contain measurable outcomes resulting from the implementation of the interventions. Findings were reviewed with the administrator and RN coordinator on 06/02/2023 at 10:45 AM. Per an interview conducted during the review, the RN coordinator stated that POC goals should be individualized and the outcomes should be measurable.

Based on policy review, record review, and interviews the hospice provider failed to ensure that a patient had medical supplies and appliances to meet the needs of a patient in one of 21 records reviewed (Record/Patient #12). It should be noted that this example was identified as an immediate jeopardy. This deficient practice has the potential to affect the provision of medical supplies and equipment for all of the agencys patients. Findings included: --- Review of the agency policy titled, ";IDG (Interdisciplinary Group) Hospice Plan of Care (POC), Coordination and Continuity of Care," and dated 05/22/2022 showed that: - Each patients individualized written plan of care includes all services necessary for the palliation and management of the terminal illness including medical supplies and appliances necessary to meet the needs of the patient. Review of the agency policy titled, ";Safe Use of Medical Equipment," and dated 05/23/2022 showed that the agency provides for the safe and effective use of medical equipment, including set-up, delivery, maintenance, and training of patients, family members, contracted facility staff, caregivers, and hospice staff and volunteers. The procedure included: - The agency will ensure that all DME (durable medical equipment), provided to patients has an implemented system to assure the quality of the medical equipment and related services; - The agency will ensure that all DME provided to patients has an implemented system to assure effective selection, timely delivery, set-up, maintenance, and patient teaching; and - The agency will ensure that emergency maintenance, replacement or backup for patient required medical equipment is available 24-hours a day, seven days per week, and 365 days per year. RECORD/PATIENT #12: Review of the clinical record showed the patient was admitted to hospice services with a terminal diagnosis of a cerebral infarction (stroke). The patient required total care with activities of daily living, was bedbound, received all nutrition and fluids via a gastric (stomach) feeding tube, had a tracheostomy (an artificial in the trachea to facilitate breathing) and required suctioning to maintain a patent airway. The patient resided in their own home with the assistance of family and paid caregivers. Review of the clinical record showed that on: - 05/06/2023 at 11:30 PM, the family called the hospice provider reporting that the suction machine for the patient's airway was not working, the hospice registered nurse (RN) notified the family that a replacement machine would be arranged, and educated the caller to reposition the patient on their side to remove secretions. The registered nurse failed to make a visit to assess the patient; - 05/07/2023 at 06:45 AM, an emergent RN visit was made due to the suction machine not working and the patient was short of breath. The hospice RN notified the equipment company that the suction machine was not working. The RN failed to ensure the patient had a working suction machine in the home and/or arrange for the equipment, or care to be provided in an alternative setting; and - 05/07/2023 at 09:30 AM, a licensed practical nurse (LPN) called the patients home to make arrangements for a nursing visit. Family reported that unless the nurse had a suction machine there was no point in a visit, and the family called an ambulance. Review of the hospital admission documentation showed that the patient was: - Admitted to the hospital on 05/07/2023 with sepsis secondary to pneumonia; and - The patient died at the hospital on 05/10/2023 at 03:24 PM. During an interview on 05/16/2023 at 3:06 PM the clinical director stated that: - It was not reasonable for a patient to be left in the home greater than three hours without a suction machine; - The nurse should have made a visit on 05/06/2023 at 11:30 PM to assess the patient; - The nurse should have remained with the patient until a working suction machine was in the home, or arrangements were made for alternative patient placement to an environment where the suction machine was available; and - The hospice clinical director provided staff education on 05/08/2023 regarding the emergency management of equipment.

Based on policy review, record review, observation, and interview the hospice provider failed to ensure that the plan of care was followed in two of five full records reviewed (Records/Patients #21 and #23). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the hospice providers policy titled, ";Hospice Aide Job Description," dated/renewed on 05/16/2022, showed the hospice aide: - Must exhibit the ability to provide safe care; - Perform as dictated by the plan of care (POC) and as assigned by the registered nurse (RN) direct and indirect patient care duties which includes personal care, including bathing; - Execute and follow the hospice aide assignment sheet and the patient hospice aide plan of care as established by the RN; - Comply with all standards of practice and any and all professional standards; - Operate within his or her scope of practice and ensuring that all services are provided consistent with best practices for hospice and palliative care; and - Demonstrate understanding and comply with all standards of practice(s) (SOPs) including all new, updated and revised SOPs as applicable. Review of the hospice providers policy titled, ";IDG Hospice Plan of Care- Content, Plan, Goals, Interventions, and Outcomes," renewed on 05/23/2022, showed in part that the hospice will develop and maintain a system of communication and integration, in accordance with policies and procedures, to ensure that the care and services are provided in accordance with the plan of care. --- Review of the POC, dated 05/30/2023, showed: - The patients admitting diagnosis is Alzheimers disease; and - The bathing goal showed the patient should receive personal care safely and effectively and maintain patient dignity. Observation on 05/31/2023 at 9:30 AM, during a home visit at an assisted living facility, showed: - C.N.A. – B helped sit the patient on the side of the bed; - The facility staff administered the patients morning medication which included quetiapine fumarate (an antipsychotic medication that has the common side effect of fatigue and dizziness); - C.N.A. – B transferred the patient into a wheelchair and took the patient to the shower; - C.N.A. – B assisted the patient into the shower chair and assisted to undress; - The patient was oriented to self and displayed signs of mild agitation (speaking harshly to the aide, asking aide if he/she wants to be punched in the stomach); - C.N.A. – B began shower and explained what he/she was doing to avoid further upsetting the patient; - During the shower, C.N.A. – B left the shower/bathroom and walked over to the patients dresser to look for an item in the drawer (the shower was not visible from the dresser, a wall separated the area); - The patient was sitting in the running shower on the shower chair, unsupervised by C.N.A. – B; - The patient was observed leaning over trying to touch his/her toes, out of the visual oversight of the C.N.A.; - This surveyor informed C.N.A. – B that the patient was leaning over in the shower chair, trying to touch his/her feet; - C.N.A. – B rushed back into the bathroom and finished the patients shower; and - C.N.A. – B failed to provide personal care safely as ordered in the POC. Findings were reviewed with the administrator and registered nurse coordinator on 06/02/2023 at 10:45 AM. Per an interview conducted during the review, the registered nurse coordinator stated that he/she would expect the POC to be followed and would not expect the hospice aide to leave a confused patient unattended in the shower chair. RECORD/PATIENT #23: Review of the clinical record showed that on 05/17/2023 the providers registered nurse (RN) received an order from the physician to apply Bactrim (an antibiotic ointment for infection), Calcium Alginate (a medication used for wound healing), and an abdominal pad (a dressing used to cover an open area) to skin cancer lesions on the abdomen as needed. Observation on 05/31/2023 beginning at 10:10 AM, during the patients home visit, showed that the supplies in place for the dressing change were Betadine (an antiseptic used to cleanse the wound), Calcium Alginate, and an abdominal pad. During a medication reconciliation no Bactrim was available for use during a dressing change. During an interview on 06/02/2023 beginning at 10:45 AM, the clinical manager stated that he/she expected that physicians orders would be correct and that the plan of care should be followed.

Based on nationally-recognized standards, policy review, home visit observation, and interview, the hospice provider failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases including the use of standard precautions in two of four home visit observations conducted (Records/Patients #22 and #23). This deficient practice has the potential to affect all patients served by the hospice provider. Findings included: Review of the Centers for Disease Control (CDC) policy titled, "Hand Hygiene Guidance," dated 01/30/2022, showed healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: - Immediately before touching a patient; - Before performing an aseptic task; - Before moving from work on a soiled body site to a clean body site on the same patient; - After touching a patient or the patient's immediate environment; - After contact with blood, body fluids, or contaminated surfaces; and - Immediately after glove use. Review of the hospice providers policy titled, ";Universal – Standard Infection Control Precautions – Equipment Bag Technique," renewed on 05/23/2022, showed in part: - Hospice personnel must ensure that all contents of the equipment bag will be clean and handled in a medically aseptic manner at all times; - Only those articles which can be sterilized, disinfected, properly washed, or discarded, are to be carried in the bag; - Clinical direct care staff will; * Place unopened bag on paper towels or newspaper; * Wash and thoroughly dry hands; * Remove any equipment needed to provide care and place on paper towels; * Close bag; * Provide care; * Maintain universal precautions and follow all infection control protective measures; and * Clean permanent items before returning them to the equipment bag. --- RECORD/PATIENT #23: Observation on 05/31/2023 beginning at 10:10 AM, during the patients home visit, showed that: - The registered nurse (RN) donned gloves prior to obtaining the patients vital signs; - After obtaining the patients vital signs the RN then pulled a dressing located on the patients abdomen down to assess the patients wounds; - The RN touched the patients wounds then picked up the soiled vital signs equipment and cleaned it with a disinfecting wipe and placed the equipment in his/her bag; - The RN then removed the gloves and failed to do hand hygiene; - The RN then touched the patients medication bottles, the tablet used for documentation, and the RNs phone; and - The RN then completed hand hygiene. During an interview on 06/02/2023 beginning at 10:45 AM, the clinical manager stated that he/she would expect the nurse to complete hand hygiene after removing his/her gloves and to remove soiled gloves before cleaning his/her equipment. RECORD/PATIENT #22: Observation on 05/31/2023 at 11:25 AM, during the patients home visit, showed RN – A: - Donned gloves and obtained vital signs; - Removed laptop from his/her bag and entered vital signs while wearing same soiled gloves; - Laid laptop on a table in the patients room without a barrier underneath; - Removed soiled gloves, performed hand hygiene and donned clean gloves; - Performed patient assessment; - Typed on laptop wearing soiled gloves; - Laid laptop on the patients dresser without a barrier underneath; - Removed gloves, performed hand hygiene; - Donned gloves, cleaned vital signs equipment and placed it back into bag; - Removed barriers used for bag and vital signs equipment and discarded barriers and gloves in the trash; - Performed hand hygiene; - Closed laptop and placed it back into bag without disinfecting it. During an interview immediately following the visit, RN – A stated that he/she realized he/she forgot to wipe down the laptop. Findings were reviewed with the administrator and RN coordinator on 06/02/2023 at 10:45 AM. Per an interview conducted during the review, the RN coordinator stated that the nurse should set up a clean area and use a barrier before placing the laptop down on a surface. The nurse should also clean their laptop before and after use before placing it in their bag.

Based on policy review, record review, and interview the hospice provider failed to ensure that a coordinated provider-wide program for infection control was in place, in but not limited to, one of five full records reviewed (Record/Patient #23). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the providers policy titled, ";Exposure Control Plan/Infection Control Plan and Reporting of Communicable and Contagious Diseases," renewed on 05/23/2022 showed in part that: - The provider will track, record, and monitor all contagious infections for both employees and patients; - The provider will maintain a tracking system of contagious infections found in patients and employees; and - When an infection is present, appropriate action will be taken to control its spread between staff and patients. This may include, but not limited to, providing written and verbal instructions on infection control, providing teaching sheets or safety booklets. RECORD/PATIENT #23: Review of the clinical record showed: - On 01/18/2023 the Physician Order Sheet showed that the physician ordered a Z-pack (an medication used to treat bacterial infections) and Mucinex (a medication used for cough) 1200 milligrams (mg) daily for 10 days; - On 02/14/2023 the Nurse Practitioner Initial Patient Assessment showed that the patient was readmitted to hospice services from a hospital stay for pneumonia (a lung inflammation caused by bacterial or viral infection) requiring intravenous antibiotic treatment for five days; - On 02/27/2023 the Care Plan Report showed that the patient had an issue of Pneumonia with a goal of ";patient is continuing antibiotic treatment previously started for pneumonia,"; - On 04/05/2023 the Physician Order Sheet showed that the physician ordered Valtrex (a medication used for viral infections) 1000 mg twice per day for 7 days; and - The hospice provider failed to complete an infection tracking log for the patient and to ensure that patient, caregiver, and staff teaching were completed to decrease the spread of bacterial and viral infections. During an interview on 06/01/2023 beginning at 1:20 PM, the administrator stated that he/she would expect the antibiotics and the anti-viral to be on the infection control log.

Based on policy review, clinical record review, and interview the hospice provider failed to provide care and services in a manner consistent with acceptable standards of practice that met the requirements for the Condition of participation: Core services. The hospice provider failed to provide nursing care and services by or under the supervision of a registered nurse to ensure the nursing needs of the patient were met as identified in the patients initial assessment, comprehensive assessment, and updated assessments (L591). The effect of this singular deficient practice has the potential to result in the inability to meet the ongoing nursing care needs of all patients served by the hospice provider and has elevated the deficiency under the Condition of participation: Core Services to the condition level. --- .

Based on policy review, record review, and interview the hospice provider failed to provide nursing care and services by or under the supervision of a registered nurse to ensure the nursing needs of the patient were met as identified in the patients initial assessment, comprehensive assessment, and updated assessments in two of five full records reviewed (Records/Patients #23 and #25) and one of six partial records reviewed (Record/Patient #30) . This deficient practice has the potential to affect all patients served by the hospice provider. Findings included: Review of the hospice providers policy titled, ";Interdisciplinary Group (IDG) – Purpose, Membership, Role, & Team Conference Meetings," renewed on 05/23/2022, showed in part: - Plan of care (POC) changes are discussed and revised as deemed necessary and the patients current level of care are reviewed for appropriateness; - The IDG discusses the active and potential problems for each patient; - The IDG discusses the goals for each problem identified; - The IDG reviews, discusses, and revises the POC as necessary to address active problems; - The IDG coordinates hospice services with those of the patients attending physician; - The IDG maintains responsibility for directing, coordinating, and supervising the care of the patient and family; - The IDG will review and discuss current frequencies for each discipline. If changes are warranted, IDG will discuss and make recommendations; and - The IDG members will establish, review, revise and update the hospice POC, and the information will be based on the comprehensive assessment and will progress toward achieving specific patient/family centered outcomes and goals. Review of the hospice providers policy titled, ";Wound Care Protocol in End-Of-Life Care," renewed on 05/23/2022, showed in part: - Assess for wounds/impaired skin integrity on admission and document on initial/comprehensive assessment or document within the electronic medical record (EMR); - Contact physician and review findings and wound care protocol with physician and obtain appropriate orders; - Document physician orders and submit per policy to obtain signature; - A skilled nurse (SN) will perform required wound care, as ordered by the physician; - If the patient resides in a nursing facility, coordinate the wound care treatment(s) with the facility to ensure coordination of care and to avoid duplication of services; - If the patient resides in an assisted living facility (ALF), or home setting, teach and coordinate with ALF personnel and family; - Document individuals that will be performing such treatments and dressing changes; - If or when hospice personnel is performing wound care but coordinating with the facility staff, hospice must visualize the wound at least weekly and document and must complete wound care at a minimum of biweekly; - The hospice must also document the frequency ordered, the actual treatment as ordered and as performed; - If or when facility staff are performing wound care, the hospice nurse must obtain report of the wound from the facility staff each visit and hospice staff are required to visualize the wound, at least weekly and document findings; - The hospice nurse must document all wound care, using approved staging procedures and must be very detailed in description; - Review wound care protocol with ordering physician and determine if protocol is acceptable to physician; and - Obtain physician order, document physician order. Review of the hospice providers policy titled, ";Standardized Pressure Injuries (Wounds) Staging and Documentation," renewed on 05/23/2022, showed in part: - A physician order is required for wound care treatments; - Skin integrity and/or conditions affecting the patients skin must be documented according to established procedures; - The presence of skin breakdown/abnormal skin appearance, i.e. (an abbreviation for the Latin expression, id est, meaning ";that is") abrasion, blister, bruising – due to pressure, burn, denuded, erythema (redness), hematoma (a pool of mostly clotted blood usually caused by a broken blood vessel that was damaged by surgery or an injury), laceration, rash, skin tear, and wound, will be documented upon admission, with each wound care treatment performed, as dictated by the wound care order and/or the coordination with facility personnel (as applicable); - If/when wound care is being mandated by facility management to be performed by the facility staff, hospice staff will document the coordination of care with the facility and ensure that the facility staff and team coordinate wound care treatment; and - Upon identification of a wound, a full wound assessment, including its location, size, and description of the tissue involved, will be completed. Review of the hospice providers policy titled, ";Authorized Prescribers Orders (Hospice Standing Orders)," renewed on 05/23/2022, showed in part: - The purpose of the policy is to provide guidance regarding the use of authorized prescribers orders (standing orders); - Standing orders may be used only as a part of the plan of care; - Standing orders must be medication, procedural, and treatment specific, individualized, and not allow for non-prescribers choice; - Standing orders do not replace the necessity to contact the patients primary care physician or hospice medical director or to coordinate care with the primary care physician and hospice medical director, but will be utilized for emergent conditions to ensure the palliative needs of the patient are met within a timely manner; - The standing order will be individualized by eliminating contraindicated medications, treatments, and/or procedures, addressing the patients allergy history, and addressing any specific indications unique to said patient; - When implementing an order from the standing order form, the treatment, medication, or procedure shall be immediately reduced to writing, utilizing a physicians verbal order form. The order shall include the phrase ";per signed authorized prescribers orders;" and - The order shall be signed and dated by the person implementing the order. --- RECORD/PATIENT #23: Review of the clinical record showed: - The patient was admitted to hospice services on 02/14/2023; - The Nurse Practitioner Initial Patient Assessment dated 02/14/2023, showed under skin condition pale, warm, dry, and other issues skin cancer; - The Nurse Practitioner Face-to-Face Patient Assessment Report dated 03/21/2023, showed skin cancer lesions noted to head and abdomen; - The Registered Nurse (RN) Comprehensive Patient Assessment Report dated 04/25/2023, showed patient had multiple cancerous skin lesions on the head and abdomen; - The RN Comprehensive Patient Assessment Report dated 04/28/2023, showed the patient reports seven cancerous skin lesions on various parts of his/her body, mainly on the trunk and scalp; - The RN Comprehensive Patient Assessment Report dated 05/02/2023, showed the patient reports no new cancerous skin lesions in the last few days. The lesion on the back side of the neck has been draining, since he/she has been picking pieces off of it. Patient reports the area will drain and he/she will place a warm compress on the area and it will stop draining for a few days; - The RN Comprehensive Patient Assessment Report dated 05/05/2023, showed the lesions on the head and abdomen remain the same size and the areas do not have any redness, drainage, or foul odor; - The RN Comprehensive Patient Assessment Report dated 05/10/2023, showed that the patient had six skin cancer lesions on the head and continued to pull off sections as they grow. Patient has two areas on the left side of the abdomen with no drainage, purple/reddish in color. On area starting on the right side under the breast that is the size of a Brazil nut and is still under the skin; - The Case Manager Comprehensive Patient Assessment Report dated 05/15/2023, showed that the patient continues with multiple skin cancer lesions; - The RN Comprehensive Patient Assessment dated 05/17/2023, showed that the patient had multiple skin cancer lesions on the head, abdomen, and groin and the Physician Order Sheet dated 05/17/2023, showed that the physician ordered Bactrim (an antibiotic ointment for infection), Calcium Alginate (a medication used for wound healing), and an abdominal pad (a dressing used to cover an open area) to skin cancer lesions on the abdomen as needed; - The RN Comprehensive Patient Assessment dated 05/22/2023, showed that the skin cancer lesion on the abdomen remains 5 centimeters (cm) with red bed and no longer draining per patient report. Patient is to continue Betadine, Calcium Alginate, and cover with abdominal dressing; - The RN Comprehensive Patient Assessment dated 05/26/2023, showed that the patient had new skin cancer lesions, the drainage was controlled on the lesion mid line abdomen with current regiment of Betadine, Calcium Alginate, and abdominal dressing; - The RN Comprehensive Patient Assessment dated 05/31/2023, showed that the patient reported the two skin cancer lesions on the abdomen have been draining and have puss on them. The RN looked at the lesions and the wound bed has yellow wound bed on midline and small yellow spots on the left upper quadrant; and - The provider failed to adequately measure and assess the patients multiple skin cancer lesions. During an interview on 06/01/2023 at 3:35 PM, the clinical manager stated that the areas had started as clusters and when the areas burst they were measured then. The clinical manager stated that he/she would expect wounds to be measured on comprehensive visits. During an interview on 06/02/2023 beginning at 10:45 AM, the clinical manager stated that he/she would expect the wounds to be measured on comprehensive visits and that he/she would expect a wound assessment to include how the area looked, odor, drainage, tunneling, depth, change in size, how the surrounding tissue looked, redness, signs of infection, and staff or family teaching that was completed, and/or any demonstrations that were done for a dressing change. RECORD/PATIENT #25: Review of the clinical record showed the patient was admitted to hospice on 05/24/2022 with a terminal diagnosis of senile degeneration (dementia, characterized by a decrease in cognitive abilities or mental decline) of the brain. The patient had a co-morbidity of severe protein-calorie malnutrition. The patient lived in a long term care facility. Review of plan of care (POC) dated 05/24/2022 to 12/31/2022, showed the following: - Issue: Non-ambulatory created 05/24/2022; - Issue: Wound, bilateral inner knees, blisters, monitor effectiveness of treatment created 05/25/2022; - Issue: Wound, excoriation, monitor for effectiveness of wound treatment created 05/25/2022; - Issue: Bed-bound, assess skin each visit created 06/02/2022; - Issue: Risk of pressure sores, assess skin and reposition each visit created 06/02/2022; - Issue: Wound, right hip, abrasion, document wound care created 07/01/2022; - Issue: Wound, bottom, pressure ulcer, document wound care created 09/14/2022; - Issue: Urinary incontinence, teach perineal care risk for skin breakdown created 11/21/2022; and - Issue: Wound, left lateral side, shingles, document wound care created 12/30/2022. Review of comprehensive assessment, dated 11/21/2022, showed the following: - No full visual skin assessment; - Wound site: * Site 1 - excoriation, healed; * Type - excoriation; * Size - unable to measure; * Wound care treatment - healed, protective ointment being used; * Site 2 - bilateral inner knees - active; * Type - blisters; * Size - unable to measure; * Wound care treatment - clean with wound cleanser then dry gently. Foam dressing over blisters. Record any changes; monitor for infection. Keep knees separated with pillows; * Site 3 - right hip - active; * Type - abrasion; * Size - unable to measure; * Wound care treatment - clean with wound cleanser daily, dry thoroughly, foam padded dressing to site; * Site 4 - bottom, active; * Type - pressure ulcer; * Size - unable to measure; * Wound care treatment - facility is cleaning wound and applying calmoseptine (multipurpose moisture barrier that protects and helps heal skin irritations); and - Narrative: Patient up in wheelchair at visiting waiting for lunch. Moved to hallway for assessment (unable to fully visualize skin). In no distress, no complaint of pain. Staff report no new changes or concerns at this time. Review of comprehensive assessment, dated 11/29/2022, showed the following: - Wound site: * Site 1 - excoriation, healed; * Type - excoriation; * Size - unable to measure; * Wound care treatment - healed, protective ointment being used; * Site 2 - bilateral inner knees - active; * Type - blisters; * Size - unable to measure; * Wound care treatment - clean with wound cleanser then dry gently. Foam dressing over blisters. Record any changes; monitor for infection. Keep knees separated with pillows; * Site 3 - right hip - active; * Type - abrasion; * Size - unable to measure; * Wound care treatment - clean with wound cleanser daily, dry thoroughly, foam padded dressing to site; * Site 4 - bottom, active; * Type - pressure ulcer; * Size - unable to measure; * Wound care treatment - facility is cleaning wound and applying calmoseptine; and - Narrative: Comprehensive visit completed. Dependent 6/6 ADLs (activities of daily living). Incontinent of bowel and bladder. Sleepy during visit with nonsensical speech. Brief removed during visit related to urine incontinence. Discussed care with facility staff. Review of comprehensive assessment, dated 12/14/2022, showed the following: - Wound site: * Site 1 - excoriation, healed; * Type - excoriation; * Size - unable to measure; * Wound care treatment - healed, protective ointment being used; * Site 2 - bilateral inner knees - active; * Type - blisters; * Size - unable to measure; * Wound care treatment - clean with wound cleanser then dry gently. Foam dressing over blisters. Record any changes; monitor for infection. Keep knees separated with pillows; * Site 3 - right hip - active; * Type - abrasion; * Size - unable to measure; * Wound care treatment - clean with wound cleanser daily, dry thoroughly, foam padded dressing to site; * Site 4 - bottom, active; * Type - pressure ulcer; * Size - unable to measure; * Wound care treatment - facility is cleaning wound and applying calmoseptine; and - Narrative: Found patient in room in wheelchair with eyes closed when name is called will open eyes. No signs or symptoms (s/s) of any distress noted. No issues noted at this time. Review of registered nurse emergent patient assessment, dated 12/17/2022, showed call received for emergent visit due to possible shingles. Arrived to facility with patient received lying in bed asleep. Displays no s/s of pain or discomfort. No distress or shortness of breath noted. Easy to arouse. Fluid filled vesicles noted wrapped around lower back and chest. Spoke with physician to coordinate plan of care with new order received for Acyclovir (antibiotic). Educated staff on shingles, new orders received and side effects. Review of comprehensive assessment, dated 12/28/2022, showed the following: - Wound site: * Site 1 - excoriation, healed; * Type - excoriation; * Size - unable to measure; * Wound care treatment - healed, protective ointment being used; * Site 2 - bilateral inner knees - active; * Type - blisters; * Size - unable to measure; * Wound care treatment - clean with wound cleanser then dry gently. Foam dressing over blisters. Record any changes; monitor for infection. Keep knees separated with pillows; * Site 3 - right hip - active; * Type - abrasion; * Size - unable to measure; * Wound care treatment - clean with wound cleanser daily, dry thoroughly, foam padded dressing to site; * Site 4 - bottom, active; * Type - pressure ulcer; * Size - unable to measure; * Wound care treatment - facility is cleaning wound and applying calmoseptine; * Site 5 - left lateral side - active; * Type - shingles; * Size - unable to measure; * Wound care treatment - Valtrex (treats virus infections) and cream; and - Narrative: He/she was received lying in bed with her eyes closed. He/she requires total assistance with care. He/she has shingles to his/her left lateral side that extends to his/her back. The shingles are currently being treated orally and topically. (The patient had multiple comprehensive assessments with no measurements of wounds). RECORD/PATIENT #30: Review of the clinical record showed the patient was admitted to hospice on 03/10/2022 with a primary diagnosis of sepsis (bodys extreme response to an infection) and secondary diagnosis of mycosis (disease caused by infection). The patient had co-morbidities of acute posthemorrhagic anemia (low amount of red blood cells), enterocolitis (inflammation in intestines) due to clostridium difficile (germ that causes an inflammation of the colon) as recurrent, quadriplegia (paralysis of all four limbs), pressure ulcer with unspecified stage, septic pulmonary embolism (uncommon disorder in which a microorganism-containing thrombus causes an inflammatory reaction and a mechanical obstruction in the pulmonary vasculature) with acute cor pulmonale (condition that causes the right side of the heart to fail), severe protein-calorie malnutrition and acute hematogenous osteomyelitis (an infection that usually affects the growing skeleton). The patient lived at home with his/her mother as primary caregiver. Review of the initial/comprehensive assessment, dated 03/10/2022, showed the following: - Wound site: * Site 1 - right hip, active; * Type - pressure ulcer; * Size - unable to measure; * Wound care treatment - normal saline, wet to dry dressing three times day (TID); * Site 2 - left hip, active; * Type - pressure ulcer; * Size - unable to measure; * Stage - stage 2 (Partial thickness skin loss involving, epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater); * Consistency - granulation; * Wound care treatment - OTA (open to air); * Site 3 - sacral - active; * Type - pressure ulcer; * Size - unable to measure; * Stage - stage 2; * Consistency - granulation; * Drainage type - none; * Wound care treatment - normal saline wet to dry dressing; - Musculoskeletal: other issues - ";atrophy", ";bed bound", ";risk for pressure ulcers", ";unable to feed self"; and - Narrative: 20 year old admitting to hospice services due to sepsis which patient and family have decided not to continue to treat with antibiotics. The patient was shot in the neck in July of last year leaving him/her a quadriplegic. According to medical records patient refused therapy resulting in severe contractures. Patient continues to exhibit feelings of anger and agitation, refuses care and becomes verbally agitated when attempting to assess. Alert and orientated times three, able to make needs known. Incontinent of urine and utilizing a catheter. Patient has a colostomy, stage 3 pressure ulcer to left hip being treated with wet to dry dressing, stage 2 draining wound to left hip, and stage 2 pressure ulcer to coccyx. Review of initial/comprehensive assessment, dated 03/10/2022, showed no full skin assessment. Review of the comprehensive assessment, dated 03/11/2022, showed the following: - Wound site: * Site 1 - right hip, active; * Type - pressure ulcer; * Size - unable to measure; * Wound care treatment - normal saline, wet to dry dressing TID; * Site 2 - left hip, active; * Type - pressure ulcer; * Size - unable to measure; * Stage - stage 2; * Consistency - granulation; * Drainage type - none; * Wound care treatment - OTA; * Site 3 - sacral - active; * Type - pressure ulcer; * Size - unable to measure; * Stage - stage 2; * Consistency - granulation; * Drainage type - none; * Wound care treatment - normal saline wet to dry dressing; and - Narrative: Patient found lying supine, contracted, head of bed 10 degrees, asleep, will arouse with coaxing. Patient refusing blood pressure assessment as well as assessment of wounds and colostomy site/bag. Patient attempting to curse at this nurse and patients primary caregiver encourages patient to ";be polite" and not curse at ";those here to help you". Patient initially denying pain but grimaces with very slight movement of extremities. Pain medication administered and education provided regarding comfort medications. Patient squints eyes and clinches mouth shut to not speak to this nurse when attempting to assess pain and other needs. Patient refusing much of this assessment. Patient again attempting to speak poorly to this nurse. Primary caregiver reports a complex situation with patient being discharged from several facilitys due to his/her behaviors/anger over situation. Review of discharge summary dated 01/17/2023, showed the patient was discharged due to stabilization and no longer terminally ill with a prognosis of six months or less to live. During an interview on 06/02/2023 at11:26 AM, the clinical manager stated the following: - She would expect wounds to be measured; - She described the patients wounds as huge like softball size, and unstageable; - Staff evaluated if wounds were improving by sight and a decrease in drainage; - Staff should document what they were seeing and if wound better and the wounds should have been measured at some point during patients period on hospice care; and - Staff communicated with the physician by verbally calling and talking to him/her but staff should document what they were seeing. ";If not documented, not done".

Based on employee file review and interview the hospice provider failed to ensure one employee received training regarding the hospice philosophy of care in one of six employee files reviewed (Employees #6). This deficient practice has the potential to affect all patients served by the hospice provider. --- Findings included: EMPLOYEE #6: Review of the training modules for the employee provided by the hospice provider showed in part the employee training included basic pain management, hospice coordination of services, infection control, bag technique, and hand hygiene. The training modules failed to include hospice philosophy of care. Review of the skills competency signed by the clinical manager and employee on 03/21/2023 showed the employee passed the section regarding hospice philosophy. During an interview on 05/23/2023 beginning at 2:20 PM, the clinical director stated that they provided training on hospice philosophy and typically started discussing this on the first day of orientation in their hospice 101 class. They have an orientation binder for new employees. The employee no longer worked for the hospice. He/she will look for the employees training on the hospice philosophy. Review of an email sent by the administrator on 05/25/2023 at 1:43 PM the administrator stated that they did not have a training checklist for Employee #6.

Based on policy review, record review, and interview the provider failed to ensure the clinical record included an initial nursing comprehensive assessment and ensure documentation was entered timely as per policy in one of 11 records reviewed (Record/Patient #11). This deficient practice has the potential to affect all patients served by the hospice provider. --- Findings included: Review of the providers policy titled, ";Point of Service Documentation (Charting at Bedside or Point of Care)," renewed 05/26/2022, showed in part that the hospice requires all staff complete clinical documentation at point of service where and when care is provided. Review of the providers policy titled, ";Initial (Nursing Admission) Assessment/Immediate Needs," renewed 05/23/2022, showed in part that an initial (admission) assessment will be completed preferably at the time of election/admission to services but no later than 48 hours after the election of hospice care. The patient assessment is an individualized patient specific, patient driven-data necessary to ensure a proper plan of care is initiated. The comprehensive assessment must be completed within five calendar days of the date of hospice election. The comprehensive assessment must identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness RECORD/PATIENT #11: Review of the record showed the patient elected hospice care on 08/24/2022. Review of a physician order dated 08/24/2022 showed an order from the medical director to admit the patient to hospice routine level of care. Review of an email from the admission nurse to STL (St. Louis) nurses dated 08/24/2022 showed in part he/she reviewed the patient with the medical director and had a call out to the patients attending physician who the patient wished to follow him/her while on hospice care. Awaiting return call. The nurse failed to include any information regarding the patients oxygen order or whether the oxygen had been ordered for the patient. Review of the record failed to include an initial nursing comprehensive assessment. Review of an RN comprehensive assessment patient assessment report dated 08/25/2022 (performed by a different nurse other than the admission nurse) showed an addendum note dated 08/25/2022 that stated the nurse instructed to enter missing note per DAL (unsure what this is) due to RN unable to chart at bedside, curantis (electronic medical record system) chart was not activated at time of post admit visit. Throughout the body of the note showed a date of 12/28/2022 (this was almost two months after the patients date of death). This included a note to the administrator and clinical director that stated instructed to enter missing note per DAL due to RN unable to chart at bedside. During an interview on 05/23/2023 beginning at 2:20 PM, the administrator stated that there was not an initial comprehensive assessment in the patients record. They knew at a later time that this had happened, but the nurse that did the initial assessment had already left the company. The initial comprehensive assessment should have been turned in by 8:30 AM the next business day. The administrator stated that DAL was their time sheet and stood for daily activity log. Regarding the dates of 12/28/2022, the administrator thought maybe they did an audit and found that this note was not in the system. The nurse must have had notes with him/her for the visit, and it was put in very late by the nurse. The charting should be completed at the bedside.

Based on policy review, clinical record review, and interview the hospice provider failed to obtain and document physician orders for all discipline visits and treatments in one of five records reviewed (Record/Patient #21). This deficient practice has the potential to affect all patients served by the hospice provider. Findings included: Review of the hospice providers policy titled, ";Wound Care Protocol in End-Of-Life Care," dated/renewed 05/23/2022, showed in part: - Assess for wounds/impaired skin integrity on admission and document on initial/comprehensive assessment or document within the electronic medical record (EMR); - Contact physician and review findings and wound care protocol with physician and obtain appropriate orders; - Document physician orders and submit per policy to obtain signature; - A skilled nurse (SN) will perform required wound care, as ordered by the physician; - If or when facility staff are performing wound care, the hospice nurse must obtain report of the wound from the facility staff each visit and hospice staff are required to visualize the wound, at least weekly and document findings; - Review wound care protocol with ordering physician and determine if protocol is acceptable to physician; and - Obtain physician order, document physician order. Review of the hospice providers policy titled, ";Standards of Practice (SOP) – Change of Acuity/Level of Care Form Usage SOP," dated/renewed 07/01/2022, showed in part: - The change in acuity/level of care form is designed to communicate and reflect changes in a patients acuity level, level of care or other clinical / demographic information; - The change of acuity/level of care form will be completed by the staff member initiating the change; - The form will be completed for the following changes/issues and these changes will require the signature of a physician; - Change in acuity; - Change of status; - Level of care change; - Change in physician; - Diagnosis change; and - Demographic/Billing information change. --- RECORD/PATIENT #21: Review of the document titled, ";Authorized Admission Prescriber Orders for Hospice Patients (Standing Orders)," dated/signed by physician 12/18/2022, showed the following: - Abrasions – Topical antibiotic ointment (TAO), apply topically PRN (Pro re nata – commonly used to mean as needed) for skin tears or minor abrasions. Apply dry bandage/band-aid (brand – but also a term used to describe any brand of adhesive bandage); - Physician will be notified within 72 hours upon implementation of any order; and - All orders will be transcribed upon implementation. Review of the SN notes with dates ranging from 03/06/2023 to 05/30/2023 showed: - 15 wound sites were identified by the hospice providers nursing staff during the visits; * #1- left arm skin tear; * #2 – right arm skin tear; * #3 – right leg/feet arterial ulcer; * #4 – left leg/feet venous stasis ulcer; * #5 – redness to buttock; * #6 – left upper buttocks at sacral area pressure ulcer; * #7 – left upper buttocks at sacral area pressure ulcer; * #8 – right hand skin tear; * #9 – left ankle skin tear; * #10 – right hand skin tear; * #11 – right forearm skin tear; * #12 – right upper forearm skin tear; * #13 – right shin skin tear; * #14 – right shin skin tear; * #15 – right elbow skin tear; - Treatments and dressing changes for the 15 wounds were initiated using the standing orders in the patient record (the standing orders did not contain orders for arterial ulcers or venous stasis ulcers); - The SN notes failed to contain documentation that the physician was notified when wounds were discovered or when standing orders were initiated; and - The SN notes failed to contain documentation that a physician order was obtained for the wound treatments and dressing changes. Review of the initial POC, dated 12/06/2022, showed the SN visit frequency was two times a week. Review of the recertification/comprehensive assessment, dated 02/23/2023, showed the registered nurse (RN) documented a narrative note that stated that the frequency of SN visits will increase to three times a week because the ALF does not do wound care. Review of the physician orders showed an order, dated 05/17/2023, that decreases visits from two times a week to one time a week (the record failed to contain documentation of when the SN visits went from three times a week back to two times a week). Review of the clinical record showed the record failed to contain: - Physician orders for the treatment of the skin tears when the standing orders were initiated; - Physician orders for wound treatment of venous and arterial ulcers; - Physician orders for the visit frequency to increase from twice a week to three times a week as identified on the 02/23/2023 comprehensive/re-certification assessment; and - Physician orders for the visit frequency to decrease from three times a week to twice a week (as indicated in the order for the decrease in frequency on 05/17/2023). Findings were reviewed with the administrator and RN coordinator on 06/02/2023 at 10:45 AM. Per an interview conducted during the review, the RN coordinator stated that there should be an order every time there was a change in the nursing visit frequencies. The standing orders are only for emergencies and the nurses should have notified the physician and obtained a written order for the wound treatments and dressings. The nurse has to have an order before anything is done. They cannot add to the order and they must do what the order says. They always have to have an order.

Based on policy review, record review, and interview the provider failed to document a complete discharge summary containing all the components required by this regulation and provide evidence it was sent in two of two patients who revoked hospice services (Records/Patients #28 and #29). This deficient practice has the potential to affect the post-hospice medical care of all the hospice provider's live discharged patients. --- Findings included: Review of the hospice providers policy titled, "Change In Designated Hospice/Transfer To Another Hospice/Contracting With Outside Hospice During Leave Of Absence," renewed on 05/23/2022, showed in part: - This hospice recognizes the patients rights to change hospice providers and according to Medicare regulations, this may occur one time during each of the Medicare benefit periods; - A change in designated hospice may occur for the need for services hospice is unable to provide; - All hospice discharge processes must be followed: * Review and update the Plan of Care and ensure that the medication profile is up to date; * If the patient is being transferred to a Medicare/Medicaid certified facility, the agency will forward to the receiving facility, at minimum, a copy: * The discharge summary; * A copy of the Certification of Terminal Illness or information regarding the current benefit period; * The patients medical record, if requested; * If the receiving hospice is not a Medicare certified hospice, a Hospice Benefit Revocation form must be completed and signed by the patient/family as this would not be viewed as a true transfer by Medicare. Continuity of care should still be maintained, and this hospice provider will send; and * A copy of the discharge summary should be submitted. RECORD/PATIENT #28: Review of the clinical record showed the patient was admitted to hospice services on 04/18/2023 and revoked hospice on 05/04/2023 to seek aggressive, curative treatment or care outside the hospice philosophy/plan of care. Review of the clinical record provided showed an incomplete discharge summary with the following missing items: - No evidence the discharge summary was sent to the physician; - Incomplete summary of the patient's stay including treatments, symptoms and pain management dosage; - The patient's current plan of care; - The patient's latest physician orders; and - Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician. During an interview on 06/02/2023 at 11:18 AM, the administrator stated that if the patients physician is the hospice medical director, he doesnt want the discharge summary sent to him. RECORD/PATIENT #29: Review of the clinical record showed the patient was admitted to hospice services on 09/02/2022 and revoked hospice on 01/03/2023 to seek aggressive treatment. Review of the clinical record provided showed an incomplete discharge summary with the following missing items: - No evidence the discharge summary was sent to the physician; - Incomplete summary of the patient's stay including treatments, symptoms and pain management dosage; - The patient's current plan of care; - The patient's latest physician orders; and - Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician. During an interview on 06/02/2023 at 11:21 AM, the clinical manager stated that the records failed to show evidence of a complete discharge summary being sent to a physician.

Based on policy review, record review, and interview the provider failed to document a transfer summary that included a summary of the patient's stay including treatments, symptoms, and pain management in two of two revocation records reviewed (Records/Patients #28 and #29). This deficient practice has the potential to affect all patients discharged by the provider. --- Findings included: Review of the hospice providers policy titled, "Change In Designated Hospice/Transfer To Another Hospice/Contracting With Outside Hospice During Leave Of Absence," renewed on 05/23/2022, showed in part: - All hospice discharge processes must be followed: * Review and update the Plan of Care and ensure that the medication profile is up to date; * If the patient is being transferred to a Medicare/Medicaid certified facility, the agency will forward to the receiving facility, at minimum, a copy: * The discharge summary; * A copy of the Certification of Terminal Illness or information regarding the current benefit period; * The patients medical record, if requested; * If the receiving hospice is not Medicare certified agency, a Hospice Benefit Revocation form must be completed and signed by the patient/family as this would not be viewed as a true transfer by Medicare. Continuity of care should still be maintained, and this agency will send; and * A copy of the discharge summary should be submitted. RECORD/PATIENT #28: Review of a revocation form dated 05/04/2023 showed the patient chose to revocate hospice services to seek aggressive, curative treatment or care outside the hospice philosophy/plan of care. Review of the clinical record provided showed an incomplete discharge summary with the following missing items: - No evidence the discharge summary was sent to the physician; - Incomplete summary of the patient's stay including treatments, symptoms and pain management dosage; - The patient's current plan of care; - The patient's latest physician orders; and - Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician. During an interview on 06/02/2023 at 11:18 AM, the administrator stated that if the patients physician is the hospice medical director, he doesnt want the discharge summary sent to him. RECORD/PATIENT #29: Review of a revocation form dated 01/03/2023 showed the patient chose to revocate hospice services to seek aggressive treatment. Review of the clinical record provided showed an incomplete discharge summary with the following missing items: - No evidence the discharge summary was sent to the physician; - Incomplete summary of the patient's stay including treatments, symptoms and pain management dosage; - The patient's current plan of care; - The patient's latest physician orders; and - Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician. During an interview on 06/02/2023 at 11:21 AM, the clinical manager stated that the records failed to show evidence of a complete discharge summary being sent to the patients physician and she would expect it to be.

Based on clinical record review and interview the hospice provider failed to document they supplied the inpatient provider with a copy of the patient's plan of care which included the respite services to be furnished by the long-term care facility, in one of one applicable case reviewed for respite (Record/Patient #26). This deficient practice has the potential to affect all patients admitted for respite care while receiving hospice services from the provider. --- Findings included: RECORD/PATIENT #26: Review of the clinical record showed the patient was admitted to hospice services on 09/01/2022. The hospice staff failed to document they furnished the long-term care facility (LTCF) a current hospice plan of care that included the respite services to be provided from 05/22/2023 until 05/26/2023. During an interview on 06/02/2023 at 11:21 AM, the clinical manager stated there was no documentation to show the patient's care plan was provided or that it included the inpatient services to be furnished during respite care.

Based on policy review, observation, record review, and interview the hospice provider failed to ensure the coordinated plan of care between a long-term care facility (LTCF) and the hospice was updated to include what hospice services were provided, when, and by which hospice staff in two of two records sampled in which the patient was a resident of a LTCF (Records/Patients #22 and #24). This deficient practice has the potential to affect all patients served by the hospice provider who reside in a LTCF. Findings included: Review of the hospice providers policy titled, ";Providing and Coordination of Hospice Care to Residents of a SNF/NF (Skilled Nursing Facility/Nursing Facility), Long Term Care (LTC) or ICF/MR/DD (Intermediate Care Facility/Mental Retardation/Developmental Disability) Facility and Contractual Agreements," dated/renewed 05/09/2022, showed in part: - All care will be coordinated with the SNF; - A written plan of care (POC) is established and maintained for every hospice patient; - All hospice care is provided in accordance with the hospice POC; - The written POC will be established and maintained for each patient in accordance with all state and federal guidelines; - The written plan will identify services and providers of those services; and - The hospice plan of care reflects the participation of the hospice, the SNF and the patient and family to the extent possible. --- RECORD/PATIENT #24: Observation on 05/31/2023 beginning at 3:40 PM, during the patients long-term care facility (LTCF) home visit, showed that the hospice binder failed to contain a copy of the patients plan of care. During an interview on 06/02/2023 beginning at 10:45 AM, the clinical manager stated that he/she would expect the plan of care to be available to the LTCF. RECORD/PATIENT #22: Review of the clinical record showed the patient was admitted to hospice services on 07/21/2022 with a terminal diagnosis of cerebral infarction (a stroke). The patient lived in a LTCF. Review of the hospice binder maintained in the LTCF showed the coordinated task plan was in the front of the binder paper clipped together with other forms. All of the forms were blank. During an interview on 05/31/2023 at 12:10 PM, RN (Registered Nurse) – A stated that the paperwork probably got lost when the patient moved to a different floor in the facility but he/she would work on fixing the binder. During an interview on 06/02/2023 at 10:45 AM, the RN coordinator stated that the RN case manager is responsible for taking the required paperwork (the coordinated task plan, a current POC, the hospice election form, advance directives, physician certification and recertification, names and contact information for hospice personnel involved in the care of the patient, a current medication profile, hospice physician and attending physician orders) into the LTCF. He/she would expect the coordinated task plan and all of the required paperwork to be updated and complete and in the hospice binder at the LTCF.

Based on policy review, clinical record review, and interview the hospice provider failed to provide the skilled nursing facility (SNF) with the following items specific to each patient: - The most recent hospice plan of care; - The hospice election form and any advance directives; - Physician certification and recertification of the terminal illness; - Names and contact information for hospice personnel involved in hospice care; - Hospice medication information; and - Hospice physician and attending physician (if any) orders; In two of two records sampled in which the patient was a resident of a long-term care facility (LTCF) (Records/Patients #22 and #24). This deficient practice has the potential to affect all patients served by the hospice provider who reside in a LTCF. Findings included: Review of the hospice providers policy titled, ";Providing and Coordination of Hospice Care to Residents of a SNF/NF (Skilled Nursing Facility/Nursing Facility), Long Term Care (LTC) or ICF/MR/DD (Intermediate Care Facility/Mental Retardation/Developmental Disability) Facility and Contractual Agreements," dated/renewed 05/09/2022, showed in part: - The hospice provider ensures that the interdisciplinary group (IDG) communicates with the SNF medical director, the patients attending physician, and other physicians participating in the provision of care to the patient as needed to coordinate the hospice care of the hospice patient with the medical care provided by other physicians; - The hospice will ensure coordination of services by; * A designated individual to provide overall coordination of care with facility, and communicates with facility to implement the hospice plan of care (POC); * The hospice ensures IDG communication with outside physicians; - The hospice provides the SNF with the following information; * The most recent hospice POC specific to each patient; * Hospice election form and any advance directives specific to each patient; * Physician certification and recertification of the terminal illness specific to each patient; * Names and contact information for hospice personnel involved in the hospice care of each patient; * Instructions on how to access the hospices 24-hour on-call system; * Hospice medication information specific to each patient; and * Hospice physician and attending physician (if any) orders specific to each patient. --- RECORD/PATIENT #24: Observation on 05/31/2023 beginning at 3:40 PM, during the patients long-term care facility (LTCF) home visit, showed that the hospice binder failed to contain a copy of the hospice plan of care, a signed election form, physician certification and/or recertification, the names and contacts of the hospice personnel involved in the patients care, medication information, physicians orders, and an advanced directive. During an interview on 06/02/2023 beginning at 10:45 AM, the clinical manager stated that he/she would expect all of the items necessary to be available to the LTCF. RECORD/PATIENT #22: Review of the clinical record showed the patient was admitted to hospice services on 07/21/2022 with a terminal diagnosis of cerebral infarction (a stroke). The patient lived in a LTCF. Review of the hospice binder maintained in the LTCF showed the interdisciplinary comprehensive hospice POC form, the hospice election form, and the physician certification/recertification of terminal illness forms were in the front of the binder paper clipped together with the coordinated task plan form and all of the forms were blank. Any advance directive information, the names and contact information of hospice personnel involved in the patients care, the patients current medication profile, and hospice physician orders/attending physician orders were all missing from the hospice binder. During an interview on 05/31/2023 at 12:10 PM, RN (Registered Nurse) – A stated that the paperwork probably got lost when the patient moved to a different floor in the facility but he/she would work on fixing the binder. During an interview on 06/02/2023 at 10:45 AM, the RN coordinator stated that the RN case manager is responsible for taking the required paperwork (the coordinated task plan, a current POC, the hospice election form, advance directives, physician certification and recertification, names and contact information for hospice personnel involved in the care of the patient, a current medication profile, hospice physician and attending physician orders) into the LTCF. He/she would expect the coordinated task plan and all of the required paperwork to be updated and complete and in the hospice binder at the LTCF.