Every finding on record at Envoy Hospice, LLC

Upon patient record review, 2 of 19 (Patient #6,#8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 6:The medication profile contains entries of lidocaine patch 5% for pain, 2 patch daily and rectal enema 1 unit PRN for constipation. There is no evidence that the medication profile includes the location for placement of the lidocaine patch or the type and amount of rectal enema to be administered. Patient 8:The medication profile includes entries for MiraLAX 1 scoop at bedtime and Acetaminophen 500 mg q 6 hours po as needed, Acetaminophen rectal suppository 650 mg q 4 hours as needed and Norco 5/325mg po q 8 hours as needed. There is no evidence that the entries include the type and amount of diluent for MiraLAX administration or instructions not to exceed 4000 mg of acetaminophen daily.

Upon patient record review, 1 of 19 (Patient #6) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 6: There is no evidence in the medical record that a bereavement assessment was completed within 5 days.

Upon patient record review, 3 of 19 (Patient #1#4,#8) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1:The medical record contains nursing documentation of the patient requiring intermittent suction as needed for secretions. There is no evidence that the plan of care contains problems, goals and interventions for management of secretions and use of intermittent suction. Patient 4:The medical record contains nursing documentation of the patient requiring oxygen 2-4 liters per minute via nasal cannula as needed for shortness of breath. There is no evidence that the plan of care contains problems, goals and interventions related to the use, management and safety of oxygen. Patient 8:The medical record includes nursing documentation on admission that the patient requires anticoagulation therapy using Eliquis. There is no evidence that the plan of care includes problems, goals and intervention related to the risk of bleeding.

Upon patient record review, 3 of 19 (Patient #2,#6,#8) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 2:The plan of care includes a wound care order on admission related to right hip stage 2 pressure ulcer that notes to cleanse with wound cleanser, pat dry, apply xeroform to wound bed, cover with 4x4 and dry dressing. There is no evidence that the order includes a frequency for wound care to be completed. Patient 6:The plan of care contains orders for lidocaine patch 5% for pain, 2 patch daily and rectal enema 1 unit PRN for constipation. There is no evidence that the order includes the location for placement of the lidocaine patch or the type and amount of rectal enema to be administered. Patient 8:The plan of care contains orders for MiraLAX 1 scoop at bedtime and Acetaminophen 500 mg q 6 hours po as needed, Acetaminophen rectal suppository 650 mg q 4 hours as needed and Norco 5/325mg po q 8 hours as needed. There is no evidence that the orders include the type and amount of diluent or instructions not to exceed 4000 mg of acetaminophen daily.

Upon patient record review, 2 of 19 (Patient #4,#5) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 4:The aide plan of care includes the task of shampoo noted as minimal of 1 time per week. There is no evidence of a specific frequency for the task to be completed. Patient 5:The aide plan of care includes the task of assist with transfers and ambulation using a wheelchair if tolerated. There is no evidence of a specific frequency for the task to be completed.

Upon client record review, 1 of 19 (Patient #6) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 6: The medical record contains SN visit documentation on 5/31/24 with patient reporting pain at moderate level of 4 out of 10. The plan of care includes a problem statement for pain with the intervention of collaboration with the facility to ensure that patient has adequate pain relief. There is no evidence that the SN collaborated with the facility staff regarding patient's pain.

Based on record review and interview, the agency failed to follow an individualized written plan of care established by the hospice interdisciplinary team in accordance with the patient's needs for one of two active patients (Patient#2) and for one of two inactive patients (Patient#4) whose records were reviewed, in that: 1. Patient #2 did not have weekly wound measurements done for Week 2 (7/9/22 through 7/15/22) and Week 4 (7/23/22 through 7/29/22); and 2. Patient #4 did not have initial wound measurements and weekly wound measurements performed on her Stage 2 coccyx (tailbone) after it was discovered on 3/12/22 and the SN did not perform weekly wound measurements for right heel blister (due to deep tissue injury) after initial measurements were performed on 3/8/22. This deficient practice places the active hospice patients at risk of further skin breakdown when wounds are not assessed and measured according to policy. The findings included: 1. Review of Patient #2's clinical record revealed a revealed SOC on 1/8/21 for a POC certification period from 7/2/22 through 8/30/22 with a diagnosis of Senile Degeneration of the Brain (dementia) (a decrease in cognitive abilities or mental decline) with a SN frequency starting 7/3/22 three visits a week x eight (8) weeks and HHA three times a week. Further review revealed Wound Care to Coccyx (tailbone) clean with NS (solution) and pat dry with gauze, apply antibiotic ointment and collagen powder to wound bed. Cover with dry bordered dressing three times a week. In addition, Wound Care to LLE and RLE-clean wound with NS and pat dry with gauze, Apply antibiotic ointment and collagen powder to the wound bed. cover with dry dressing then secure with kerlix (gauze bandage roll) and tape three times a week. Review of the SN note dated 7/8/22 revealed Patient #2 had a Stage 3 pressure sore (wound) (full thickness of tissue loss) on her coccyx that measured 1 cm x 0.8 cm x 0.4 cm (depth) and Stage 3 on her right lower extremity (measured 19 cm x 12.5) and Stage 3 located on her left lower extremity (24 cm x 13.5 cm). Further review revealed there were no measurements done week 2 (7/9/22 through 7/15/22). Further review revealed measurements were performed on 7/22/22. Review of the SN visit notes revealed no documented evidence that measurements were done on week 4 (7/23/22 through 7/29/22). During an interview on 8/9/22 at 2:30 p.m., with RN E she stated that she was Patient #2's CM and that measurements were not done the week she went on vacation. She further stated that on the client's lower extremities she had difficulty measuring the wounds because there were so many smaller one's "cluster" that it was difficult to measure. She added that she discussed the client's wounds at the case conference but had not discussed about the difficulty she had with obtaining the measurements. She further stated she did not know how to count the wounds. She added that she should have discussed why she did not follow the plan of care at the case conference meetings. 2. Review of Patient #4's clinical record revealed the "Physician's Orders/Plan of Care" dated 2/18/22 through 4/18/22 revealed a SOC date of 10/24/21 with a diagnosis of Alzheimer's Disease (AD) (A progressive disease that destroys memory and other important mental functions) with behavioral disturbances and the client was to receive SN visit one time a week and eight prn and HHA visit three times a week. Review of the "SN Routine Visit" dated 3/8/22 revealed "Right heel blister length 2.5 cm and width 2.5 (2.5 x 2.5) no drainage noted. Review of "SN Routine Visit" dated 3/12/22 revealed "Rt. heel Suspected deep tissue injury, not measured, small amount drainage (fluid that seeps out slight bloody); Coccyx (tailbone): Stage 2 (partial thickness of tissue lose) not measured, skin beefy red, small serosanguineous drainage, not measured. Review of the form titled "Team Care Plan" (Physician's orders) dated 3/12/22 revealed "RN to perform wound care to coccyx on days scheduled as follows: Cleanse with NS (solution) and 4x4 (gauze pad), pat dry and apply foam dressing, RN to perform wound care to Rt heel on days scheduled, CG to perform on all other days as follows: cleanse with NS and 4x4 pat dry, paint with betadine (aides healing) and apply foam dressing." Review of Skilled Notes from 3/15/22 to 4/16/22 revealed no documented evidence that the wounds were measured. 4. During an interview on 8/9/22 at 9:50 a.m., with the Alternate Admin/DON she stated that "I looked yesterday" and could not find wound measurements except the one time on 3/8/22 on the right heel. She further stated that wounds should be assessed weekly and did not know why the nurses did not perform measurements. During an interview on 8/9/22 at 10:10 a.m. with RN A (CM for Patient #4 and primary nurse), she stated that she took measurements of the wound and "I forgot to add it to the notes." During interviews on 8/9/22 at 10:55 a.m., with RN C (performed SN visit on 3/25/22 and at 11 a.m., with RN D (performed SN visit on 3/26/22) they stated that they did not do wound measurements. RN D stated that she changed out the client's indwelling urinary catheter (hollow tube that drains urine into a drainage bag) and at RN C stated that the CM for that client was the one that did the measurements. During an interview on 8/9/22 at 3:30 p.m., with the Admin and the Alternate Admin/DON, the Admin stated that not performing wound care according to the physician's orders and not performing measurements of wounds could impact client care because you would not know if the intervention were working, and the wound could get worse. She further stated that the nurses should follow the policy. 5. Review of the agency's policy titled "PC. W10 Wound Assessment and Evaluation" (undated) revealed in part "Assessment and evaluation of skin and documentation of wounds occurs on admission to hospice, at the first sign of a wound, and at weekly intervals. The assessment and evaluation and plan of care should be clearly documented...3. Wounds are reassessed, including measurements, at a minimum of weekly or more often as determined by the MD..."

Based on record review and interview, the plan of care must include all services necessary for the management of the terminal illness and related conditions in that all drugs were not listed on the medication list for one of four patient (Patient #4) whose records were reviewed in that, it did not include Fentanyl (for moderate pain) on the medication list. This deficient practice places the active hospice patients at risk for medication errors and possible drug-drug interactions when the client medication list is not accurate, current, or complete. The findings included: 1. Review of the agency's policy titled "Medication Profile" (medication list) revealed "3. The patient's medication profile is reviewed by the IDG (a team that consists of a physician, nurse, social worker, and a chaplain that meet every 15 days to review the client's care) whenever there is a significant change and, at a minimum, every 15 days...5. The patient's medication profile review includes, but is not limited to: a. Determining accuracy and completeness..." 2. Review the "Patient Profile" (a list of medications that the local pharmacy provided to the client) dated 1/1/22 through 8/8/22 revealed on 3/14/22 five (5) Fentanyl patches 25 mcg/hr. patch was dispensed and on 3/26/22 five Fentanyl 25 mcg/hr. patch was dispensed. Review of the SN noted dated 3/13/22 revealed "New orders from physician Fentanyl 25 mcg apply one (1) patch to skin every three days, remove old patch prior to placing new patch. There was no documented evidence in the physician order section for Fentanyl. Review of the "Case Conferences Summary Report" (interdisciplinary meeting that is held every two weeks to discuss the client's care) (also called IDG) dated 3/23/22 revealed Fentanyl was not listed on the medication list and in section titled "Care Plan Pain Care Plan: Goal Patient/family establishes desired pain control and Intervention Assess level of comfort/discomfort and identify comfort goal with a start date of 2/8/22." There was no documented evidence that the patient's pain was discussion nor that the intervention was revised to include the Fentanyl. Review of an e-mail (from the Alternate DON and Supervising Nurse in the Alice Alternate Delivery Site) revealed in part that she spoke with Patient #4's FM and the FM was upset that she did not receive education on administering the Fentanyl patch...Further review revealed that "Fentanyl was not listed in MAR..." Review of the "Physician's Orders/Plan of Care" dated 2/18/22 through 4/18/22 and Plan of Care from 4/19/22 through 6/17/22 (post death) revealed no documented evidence that the client received Fentanyl and in section titled "Medications," there was no documented evidence that the patient was to receive Fentanyl. 3. During an interview on 8/9/22 at 8:15 a.m. with the Alternate Admin/DON, she stated that the Fentanyl was started on 3/13/22 according to the nurse's notes and she could not find an order. She further stated that since there was no order, it was not listed on the medication list and not discussed in IDG, and it should have been. During an interview on 8/9/22 at 10:10 a.m. with RN A, she stated that she did not know why she did not write an order for the Fentanyl but listed it in her notes. She further stated that all changes in the orders or new medications need to be in the medication list and placed as a physician's order. During an interview on 8/9/22 at 11:00 a.m., with the Alternate DON she stated that she spoke with Patient#4's FM about issues and concerns about the care Patient#3 received. She further stated that the FM was upset about lack of education concerning administration of the Fentanyl. She added that when she reviewed the medication list, she found there was no order for the Fentanyl, and it was not on the medication list. She further added that she spoke with RN A to correct this, but she did not check whether RN A followed through, and she should have. During an interview on 8/9/22 at 3:30 p.m. with the Admin and the Alternate Admin/DON, the Administrator stated that the medication list should be complete accurate. She further stated that this can impact client care by perhaps worsening the client's signs and symptoms and the agency would not be able to pick up on adverse reactions.

Based on record review and interview the agency failed to enforce a written policy to control infections that included requirements to document infections that the patient acquires while receiving services from the agency for one of two closed records (Patient #4) whose records were reviewed, in that: Patient #4 received Diflucan (antifungal) (used to treat vaginal yeast infections), Augmentin (antibiotic that kills bacteria) (used to treat UTI), and Cephalexin (antibiotic that kills bacteria) (used to treat UTI) and there was no documented evidence that that the infections were listed on the agency's adverse event log (list of infections). This deficient practice places the active hospice patients at risk of receiving inadequate care and services when the agency does not track, monitor, and trend infections acquired while receiving care from the agency. The findings included: 1. Review of the agency's "5.1 Infection Control Program and Exposure Control Plan" (undated) revealed in part "Purpose: To maintain and document a coordinated, effective, agency-wide infection control program that includes active monitoring, surveillance, identification, and reporting of known or suspected infectious and communicable diseases among the hospice's patients and colleagues...To determine the effectiveness of the infection control plan, the Hospice will measure, assess, improve, review and revise, as appropriate the Infection Control Program...5. A summary of all infection control activities performed, and results of aggregated surveillance data analysis are discussed during quarterly QAPI meeting..." 2. During the entrance conference on 8/8/22 at 8:10 a.m., with the Administrator and the DON/Alternate Administrator the surveyor requested the infection control log for 2021 through 2022. They further stated that the agency called the infection log the Adverse Event log. 3. Review of the POC dated 10/24/21 through 12/19/21 revealed the Patient #4's SOC was on 10/24/21 with a diagnosis of Alzheimer's Disease (AD) (A progressive disease that destroys memory and other important mental functions) with behavioral disturbances and SN visit two time a week for 13 weeks and HHA visit three times a week for 13 weeks. Review of the Skilled Nurse notes (RN visit notes) revealed the following: 11/2/21 - Antibiotic for UTI completed. 11/9/21 - No longer on antibiotic 11/11/21 - New order for Augmentin 500 mg bid for seven days 11/16/21 - FM reported brownish green discharge found in brief (incontinent pad), continue antibiotic 12/2/21- Per Interdisciplinary Team (IDT) (a team conference that includes a physician, nurse, social worker, and chaplain) (a meeting that discusses the client's care and condition every two weeks) orders client started on antifungal for vaginal discharge. 12/15/21 - (client on respite care) (client was at a nursing home temporarily to give relief to family) instructed staff to do frequent peri care (cleaning the bottom and vaginal area) as client was prone to UTIs. 12/22/21 and 1/5/22 - No vaginal infections or s/s of UTI 1/26/22 - Physician ordered Fluconazole 150 mg one time 2/1/22 - New order to insert indwelling urinary catheter (a hollow tube that drains urine from the bladder into a bedside drainage bag). 2/17/22 - White vaginal discharge noted 2/21/22 - client continues with prophylactic antibiotic. Cephalexin 250 mg ordered 2/25/22 - Client febrile (has fever) 2/27/22 - Urinalysis (UA) and urine culture for sensitivity (C&S) ordered and performed (lab unable to perform test) 3/2/22 - No changes following UA results, urine cloudy and light colored 3/15/22 - Continue with prophylactic antibiotic Review of the "Adverse Event, Detail" (list of infections) dated 8/8/21 through 8/8/22 revealed no documented evidence that Patient #4 was listed. Review of the following physician's orders: Augmentin 500-125 mg bid po times seven (7) days (Start on 11/12/21 through 11/19/21). Diflucan (brand name for Fluconazole) dated 12/8/21 revealed 150 mg po one time. Diflucan 150 mg 1-tab po one time (Start on 1/26/22 and end 1/27/22 and "Cipro" (Ciprofloxacin) 250 mg 1 cap bid po to start on 1/26/22 through 1/31/22 Cephalexin 250 mg 1 cap po bid start date 2/1/21 through 4/15/22 Diflucan 150 mg po tab start on 2/7/22 through 2/9/22 4. During an interview on 8/8/22 at 12:22 p.m. with RN A, she stated that the HHAs would report to her that when they did peri care (cleaned her bottom and vaginal area) the client's brief was always saturated and the client's FM was the one that requested an indwelling urinary catheter. She further stated that the physician ordered the indwelling urinary catheter because of perhaps she was retaining urine. During an interview on 8/9/22 at 8:15 a.m., with the Alternate Admin/DON she stated that the Infection Control Plan was not specific to what needed to be documented on the log for agency acquired infections but the policy and what she told the nurses was that any time a client got put on an antibiotic the nurse should complete an adverse event form. During a second interview on 8/9/22 at 10:10 a.m., with RN A she stated that anytime a client gets placed on an antibiotic the nurse was to complete an adverse event form. She further stated that she did not know why she did not complete the form but thinks she was newly hired and did not know she had to. During an interview on 8/9/22 at 3:30 p.m. with the Administrator, she stated that the agency reviewed the infection log at each QAPI meeting. She further stated that when infections were not reported accurately it could impact client care by not looking for trends of type of infection nor whether the treatment was appropriate and give the agency a wrong picture of how it is doing to control infections.

Based on record review and interview the agency failed to enforce a written policy describing the procedures that its staff must follow when receiving a physician's order for one of four patients (Patient #4) whose records were reviewed in that, there was no written order for Fentanyl (for moderate pain). This deficient practice places the patients at risk of receiving inadequate care when physician's orders are not documented when obtained. The findings included: 1. Review of the agency's policy "PC.M25 Medication Administration" dated 2019 revealed in part "...If the drug order is verbal or given by or through electronic transmission it must be given only by a licensed nurse, pharmacist, or physician; and the person receiving the order must record and sign it immediately and have the prescribing person sign it in accordance with the agency's policies and applicable state and federal regulations..." 2. Review the Patient #4's "Patient Profile" (a list of medications that the local pharmacy provided to the client) dated 1/1/22 through 8/8/22 revealed on 3/14/22 five (5) Fentanyl patches 25 mcg/hr. patch were dispensed and on 3/26/22 five Fentanyl 25 mcg/hr. patch were dispensed. Review of the SN noted dated 3/13/22 and signed by (RN A) revealed "New orders from physician Fentanyl 25 mcg apply one (1) patch to skin every three days, remove old patch prior to placing new patch." There was no documented evidence in the physician order section for Fentanyl. Review of the "Case Conferences Summary Report" (interdisciplinary meeting that is held every two weeks to discuss the client's care) (also called IDG) dated 3/23/22 revealed Fentanyl was not listed on the medication list and in section titled "Care Plan Pain Care Plan Goal: Patient/family establishes desired pain control and Intervention Assess level of comfort/discomfort and identify comfort goal with a start date of 2/8/22." There was no documented evidence that the patient's pain was discussed nor that the intervention was revised to include the Fentanyl. Review of an e-mail (from the Alternate DON and Supervising Nurse in the Alice Alternate Delivery Site) dated 3/25/22 revealed in part that she spoke with Patient#4's FM and the FM was upset that she did not receive education on administering the Fentanyl patch...Further review revealed that "Fentanyl was not listed in MAR..." Review of the "Physician's Orders/Plan of Care" from 4/19/22 through 6/17/22 (post death and at discharge) revealed no documented evidence that the patient received Fentanyl and in section titled "Medications" there was no documented evidence that the patient was to receive Fentanyl. 3. During an interview on 8/9/22 at 8:15 a.m. with the Alternate Admin/DON, she stated that the Fentanyl was started on 3/13/22 according to the nurse's notes, and she could not find an order. She further stated that since there was no order it was not listed on the medication list and not discussed in IDG, and it should have been. During an interview on 8/9/22 at 10:10 a.m. with RN A, she stated that she did not know why she did not write an order for the Fentanyl but listed it in her notes. She further stated that all changes in the orders or new medications need to be in the medication list and placed as a physician's order. During a second interview on 8/9/22 at 10:30 a.m. with the Alternate Admin/DON, she stated that the nurse received a verbal order from the physician for the Fentanyl and added it to her nurses' notes. She further stated that RN A did not do perform a "read back" (a safety measure that the nurse repeated what she documented to the physician to assure the order was correct) and she did not document it in the orders. In addition, changes in the patient's condition such as pain level, and new medication orders should be discussed at the case conference. During an interview on 8/9/22 at 11:00 a.m. with the Alternate DON, she stated that she spoke with Patient#4's FM about issues and concerns about the care Patient#4 received. She further stated that the FM was upset about lack of education concerning administration of the Fentanyl. She added that when she reviewed the medication list, she found there was no order for the Fentanyl, and it was not on the medication list. She further added that she spoke with RN A to correct this, but she did not check whether RN A followed through, and she should have. During an interview on 8/9/22 at 3:30 p.m., with the Admin and the Alternate Admin/DON, the Administrator stated that the medication list should be complete accurate. She further stated that this can impact client care by perhaps worsening signs and symptoms and the agency would not be able to pick up adverse reactions.