Every finding on record at Fernando Hospice Care, LLC

Based on interview and record review, the hospice agency failed to ensure and document that its emergency preparedness policy and procedure was reviewed and updated annually. This deficient practice had the potential to affect the safety of the patients and put them at risk for delayed services in the event of an emergency or disaster. Findings On 05/31/2022, a review of the agency's emergency preparedness program was conducted. The policy and procedure provided by the Director of Patient Care Services Designee (DPCSD), did not indicate a date of when the last time the policy and procedure was reviewed and updated. During an interview with the DPCSD on 05/31/2022, at 2:16 p.m., she stated that the emergency preparedness policy and procedure was reviewed and updated annually. A review of the agency's policy and procedure titled "Emergency Management Plan," revised 10/2011, indicated that the purpose of the policy and procedure is to establish a plan which will allow for continuation of services in the event of a disaster affecting the organization or the community.

Based on interview and record review, the Hospice Agency (HA) failed to safeguard one of eight sampled patients (Patient 1) clinical record. Patient 1's folder (containing medical and personal information) was found at Patient 3's home. This deficiency practice resulted in Patient 1's medical and personal information was being compromised, which could be access and used by others. Findings: A review of Patient 3's face sheet indicated Patient 3 was admitted on 3/15/2022 with a diagnoses of essential heart disease (conditions that affect the heart), Hypertension (high blood pressure), Alzheimer's disease (dementia that affects thinking, memory and behavior) and depression (mood disorder causing persistent feeling of sadness). A review of Patient 3's "Start of Care - Plan of Care" dated 3/15/2022 to 6/13/2022 indicated Patient 3 was scheduled to have Skilled Nursing (SN) twice a week and receive routine care. Patient 3 declined social worker, volunteer, and aide services. During a joint home visit on 5/27/2022 at 10 a.m. with License Vocational Nurse 1 (LVN1) to Patient 3's home revealed Patient 3's hospice home folder was not hers. The folder belonged to Patient 1. LVN1 stated that he must have grabbed the wrong folder. Patient 3's daughter stated that the folder was brought to the house on Tuesday 5/24/2022. During an interview on 5/31/2022 at 10:40 a.m. with Director of Patient Care Services designee (DPCSD), the DPCSD stated, the patients folders were taken by the Registered Nurse (RN) to the patients' home at the initial visit. During an interview on 5/31/2022 at 12 p.m., the DPCSD stated that the hospice folder at Patient 3's home was not Patients 3. DPCSD stated, "no, it was not hers. I think it was duplicate patient folder made for the other patient I don't know how it got there. Usually, the Registered Nurse (RN) takes the folder to the patients' home when he does his admitting visit. He sits down and speaks to the patient and the caregiver and lets them know what their care will be and who will be there visiting them on their scheduled visits. The following visit made by the Skilled Nurse (SN), the SN should check the folder ..." A review of facility's policy titled, "Rights/Responsibilities" revised October 2011 indicated the patient will have the right to privacy, security ...

b. A review of Patient 3's face sheet indicated Patient 3 was admitted on 3/15/2022 with a diagnoses of essential heart disease (conditions that affect the heart), Hypertension (high blood pressure), Alzheimer's disease (dementia that affects thinking, memory and behavior) and depression (mood disorder causing persistent feeling of sadness). A review of Patient 3's "Start of Care - Plan of Care" dated 3/15/2022 to 6/13/2022 indicated Patient 3 was scheduled to have Skilled Nursing (SN) twice a week and was receiving routine care. Patient 3 declined social worker, volunteer, and aide services. A review of Patient 3's Medication Profile dated 3/15/2022 - 6/13/2022 indicated Patient 3 was currently prescribed: 1. Nexium 40 milligrams (mg) 1 tablet (tab) daily orally. 2. Voltaed Gel 1% apply daily as needed topically. 3. Meclizine 25 mg 1 tab daily as needed orally. 4. Escitalopram 10 mg 1 tab daily orally. 5. Olmesartan 40mg 1 tab daily orally. 6. Lorazepam 1mg 1 tab daily orally. 7. Eszopiclone 1 tab daily orally. 8. Aspirin 81mg 1 tab daily orally. 9. Tylenol 500 every 4 hours (hrs) as needed orally. 10. Topiramate 25mg 1 tab twice daily orally. 11. Symbacort 160/4.5 micrograms (mcg) 1 puff daily. 12. Magnesium (MG) 400 1 tab daily orally. 13. Norco 5/325mg 1 tab every 6 hrs as needed orally. 14. Vitamin D3 5000 units 1 tab daily orally. 15. KCL 8mEq 1 tab daily orally. 16. Vascepa 1 gram 1 tab twice daily orally. 17. Creon 24000 units 1 tab 3 ties per day orally. 18. Hydrocortisone 1% ointment apply daily topically. 19. Colace 100mg 1 tab daily orally. During a concurrent observation and a joint visit on 5/27/2022 at 10 a.m. with License Vocational Nurse 1 (LVN1) of Patient 3's home, indicated there were two expired medications: -Eszopiclone 1 tab daily orally - expired on 4/20/22 -Creon 24000 units 1 tab three times a day orally - expired on 3/28/22. It also indicated there were four medication bottles that had something different written on their labels than what the medication profile had: Medication profile read: -Meclizine 25 mg 1 tab daily as needed Pill bottle read: -Meclizine 25 mg 1 tab daily Medication profile read: -Lorazepam 1mg 1 tab daily orally Pill bottle read: -Lorazepam 0.5mg 1 tab as needed daily orally Medication profile read: -KCL 8mEq 1 tab daily orally Pill bottle read: -KCL 8mEq 1 tab every other day for 1 month orally Medication profile read: -Vascepa 1 gram 1 tab twice daily orally Pill bottle read: -Vascepa 1 gram 2 tabs twice a day orally LVN1 stated that it is important to reconcile medications to prevent problems to patients and it is also not safe to take expired medications because it can cause problems and it is not as effective as it's supposed to be. During an interview on 5/31/2022 at 10:40 a.m. with Director of Patient Care Services designee (DPCSD), the DPCSD stated that medication reconciliation is done when the patient is being seen by the Registered Nurse (RN), the LVN following the RN visits should do a reconciliation in case there is a change. Every visit there should be a medication reconciliation recertification, at discharge and every change of condition. A review of facility's Policy titled, "Medication Profile" revised October 2011 indicated medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. A review of facility's policy titled, "Medication Monitoring" revised October 2011 indicated the information obtained through patient medication monitoring will be documented in the patient's clinical record ... Based on observation, interview and record review the Hospice Agency (HA) failed to review and document all the medications the patient currently taking for 2 of 8 sampled patients (Patient 1 and Patient 3). This failure had the potential to result in placing the patients at risk for drug interactions, adverse actions, and medication errors that could affect the patient's already compromised health status. Findings: a. A review of Patient 1's clinical record indicated a start of care date (SOC) of 12/08/2021, with diagnoses which included atherosclerotic heart disease (condition that develops when a sticky substance called plaque builds up inside your artery), hypertension (high blood pressure) and Alzheimer's disease (progressive disease that destroys memory and other important mental functions). A review of Patient 1's Plan of Care for the certification period of 03/09/2022 to 06/07/2022, indicated that a skilled nurse (SN) is scheduled to visit patient two times a week and was receiving routine care. Patient 1 declined social worker, volunteer, aide services and spiritual care. On 05/27/2022, at 11:40 a.m., a joint home visit with the Licensed Vocational Nurse (LVN 1) was conducted at Patient 1's residence. A review of Patient 1's Medication Profile provided by the agency, indicated that patient had an order for Imipramine (used to treat symptoms of depression) 10 milligram (mg - unit of measurement) one tablet daily, Hydralazine (used to treat high blood pressure) 25 mg one tablet daily and levothyroxine (used to treat an underactive thyroid gland) 25 micrograms (mcg) one tablet daily. A review of Patient 1's Imipramine prescription label on the bottle indicated to take 25 mg, one tablet daily, Hydralazine prescription label on the bottle indicated to take 25 mg, one tablet every eight hours as needed if systolic blood pressure is greater than 160, and levothyroxine prescription label on the bottle indicated 112 mcg, take one tablet in the morning. Further review of Patient 1's medication indicated that patient had Timolol Maleate Ophthalmic Solution (used to treat glaucoma,) 0.5 percent and Fluticasone Propionate Nasal Spray (used to relieve seasonal and year-round allergic and non-allergic nasal symptoms) 50 mcg but there were no prescription labels on the bottles. During an interview with LVN 1 on 05/27/2022 at 12:15 p.m., he stated that it was his mistake, and that the medication profile was different from the prescription bottles.

Based on interview and record review, the hospice agency failed to conduct an initial bereavement assessment for six of 11 sampled patients (Patient 6, 7, 8, 9, 10 and 11). This deficient practice resulted in patients not receiving bereavement assessments. Findings: a. A review of Patient 6's clinical record indicated a start of care date (SOC) of 4/24/2021, with a diagnosis of Alzheimer's disease (progressive disease that destroys memory and other important mental functions). A review of Patient 6's Plan of Care for the certification period of 8/17/2022 to 10/15/2022, indicated a Skilled Nurse (SN) and Certified Home Health Aide (CHHA) are scheduled to visit the patient two times a week and was receiving routine care. A review of Patient 6's clinical record indicated there was no initial bereavement assessment conducted. b. A review of Patient 7's clinical record indicated a start of care date (SOC) of 12/11/2020, with a diagnosis of Alzheimer's disease. A review of Patient 7's Plan of Care for the certification period of 8/3/2021 to 10/1/2021, indicated a Skilled Nurse (SN) and Certified Home Health Aide (CHHA) are scheduled to visit the patient two times a week and was receiving routine care. A review of Patient 7's clinical record indicated there was no initial bereavement assessment conducted. c. A review of Patient 8's clinical record indicated a start of care date (SOC) of 4/14/2021, with a diagnosis of Alzheimer's disease. A review of Patient 8's Plan of Care for the certification period of 8/7/2022 to 10/5/2022, indicated a Skilled Nurse (SN) and Certified Home Health Aide (CHHA) are scheduled to visit the patient two times a week and was receiving routine care. A review of Patient 8's clinical record indicated there was no initial bereavement assessment conducted. d. A review of Patient 9's clinical record indicated a start of care date (SOC) of 10/19/2021, with a diagnosis of Alzheimer's disease. A review of Patient 9's Plan of Care for the certification period of 8/15/2022 to 10/13/2022, indicated a Skilled Nurse (SN) is scheduled to visit the patient one time a week and Certified Home Health Aide (CHHA) is scheduled to visit the patient two times a week and was receiving routine care. A review of Patient 9's clinical record indicated there was no initial bereavement assessment conducted. e. A review of Patient 10's clinical record indicated a start of care date (SOC) of 10/22/2021, with a diagnosis of Alzheimer's disease. A review of Patient 10's Plan of Care for the certification period of 8/18/2022 to 10/06/2022, indicated a Skilled Nurse (SN) is scheduled to visit patient one time a week and Certified Home Health Aide (CHHA) is scheduled to visit the patient two times a week and was receiving routine care. A review of Patient 10's clinical record indicated there was no initial bereavement assessment conducted. f. A review of Patient 11's clinical record indicated a start of care date (SOC) of 3/21/2022, with a diagnosis of chronic atrial fibrillation (an irregular and often very rapid heart rhythm). A review of Patient 11's Plan of Care for the certification period of 3/21/2022 to 6/18/2022, indicated a Skilled Nurse (SN) and Certified Home Health Aide (CHHA) are scheduled to visit the patient two times a week and was receiving routine care. A review of Patient 11's clinical record indicated there was no initial bereavement assessment conducted. During an interview with the Administrator (ADM) on 9/12/2022, at 2:15 p.m., he stated the social worker does not complete an initial bereavement assessment and only does a post death assessment. A review of the agency's undated policy and procedure titled "Bereavement Assessment," indicated the purpose of the policy and procedure is to provide guidance for the assessment and reassessment of the bereavement needs of the family/caregivers. The policy and procedure further indicated that on admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that will be given to the Bereavement Coordinator.

Based on interview and record review, the hospice agency failed to provide comfort kits containing emergency medication for three of three sampled patients (Patients 1, 2, and 3). This deficient practice had the potential to put the patients at risk for not receiving medications to meet the needs for the palliation and management of the terminal illness. Findings: a. A review of Patient 1's clinical record indicated a start of care date (SOC) of 12/08/2021, with diagnoses which included atherosclerotic heart disease (condition that develops when a sticky substance called plaque builds up inside your artery), hypertension (high blood pressure) and Alzheimer's disease (progressive disease that destroys memory and other important mental functions). A review of Patient 1's Plan of Care for the certification period of 03/09/2022 to 06/07/2022, indicated that a skilled nurse (SN) is scheduled to visit patient two times a week and was receiving routine care. Patient 1 declined social worker, volunteer, aide services and spiritual care. A review of Patient 1's Medication Profile did not indicate that a comfort kit was ordered by the physician. b. A review of Patient 2's clinical record indicated a start of care date (SOC) of 01/22/2022, with diagnoses which included atherosclerotic heart disease (condition that develops when a sticky substance called plaque builds up inside your artery), and hypertension (high blood pressure). A review of Patient 2's Plan of Care for the certification period of 04/23/2022 to 07/22/2022, indicated that a skilled nurse (SN) is scheduled to visit patient two times a week and was receiving routine care. Patient 2 declined social worker, volunteer, aide services and spiritual care. A review of Patient 2's Medication Profile did not indicate that a comfort kit was ordered by the physician. c. A review of Patient 3's face sheet indicated Patient 3 was admitted on 3/15/2022 with a diagnoses of essential heart disease (conditions that affect the heart), Hypertension (high blood pressure), Alzheimer's disease (dementia that affects thinking, memory and behavior) and depression (mood disorder causing persistent feeling of sadness). A review of Patient 3's "Start of Care - Plan of Care" dated 3/15/2022 to 6/13/2022 indicated Patient 3 was scheduled to have Skilled Nursing (SN) twice a week and was receiving routine care. Patient 3 declined social worker, volunteer, aide services and spiritual care. A review of Patient 3's Medication Profile did not indicate that a comfort kit was ordered by the physician. During an interview with the Director of Patient Care Services Designee (DPCSD) on 05/27/2022, at 3:10 p.m., she stated that Patients 1, 2, and 3 did not have comfort kits ordered by the physician. A review of the agency's policy and procedure titled "Comfort Kits," undated, indicated that all hospice patients not residing in a nursing home will receive a comfort kit containing emergency medication as ordered by the patient's physician or hospice Medical Director. The policy and procedure further indicated that the hospice nurse performing the hospice admission will contact the hospice patient's physician or hospice Medical Director at the time of admission for orders about specific emergency medications to be supplied in the comfort kit for every patient admitted to the hospice agency, excluding those residing in a nursing home.

Based on interview and record review, the Hospice Agency (HA) failed to ensure their Quality Assurance Performance Improvement (QAPI - a data driven and proactive approach to quality improvement) and the Governing Body meeting minutes were documented. This failure resulted in the inability of the HA to identify issues, improve health outcomes, patient safety, and quality of care Findings: During a concurrent interview on 5/31/2022 at 10 a.m. with Director of Patient Care Services designee (DPCSD), and a review of the QAPI folder, the QAPI folder indicated there were no documentation of the governing body minutes. DPCSD stated, "I cannot find the QAPI minutes. I don't have the governing body minutes. The record of meeting is the basis for future or continuous plan of what is working and not working, I would also reflect of what was discussed during the meeting. I don't know if it's with (the Administrator) or not". A review of facility's policy titled, "Organizational Planning" revised October 2011 indicated minutes of management meetings and other committees, as well as minutes from the Governing Body and Interdisciplinary Group, will reflect the planning process. A review of facility's policy titled, "Policy Decision" revised October 2011 indicated minutes of senior management meetings will be kept according to the Conclusion-Recommendation- Action- Follow- up (CRAD) method. The minutes will be kept in the office of the Executive Director/Administrator.

Based on interview and record review, the hospice agency failed to ensure that at least 12 hours of in-service during a 12-month period was given to one of one Certified Home Health Aides (CHHA). This deficient practice had the potential to put the CHHA at risk for not having the updated knowledge and skills to provide highest quality of patient care services. Findings: On 05/26/2022, a review of the agency's in-service record was conducted. The 2021 CHHA in-service log was requested from the Director of Patient Care Services Designee (DPCSD). During an interview with the Director of Patient Care Services Designee (DPCSD) on 05/26/2022, at 1:38 p.m., she stated that she did not know where was the 2021 in-services record for the CHHA staff. A review of the agency's policy and procedure titled "Training/Inservice Education," revised 04/2021, indicated that the agency will provide training and education to give personnel opportunities to learn new skills and improve/expand existing knowledge. The policy and procedure further indicated aides (CNAs/HAs) must receive at least twelve (12) hours of inservice training per calendar year. Additionally, the policy and procedure indicated that an inservice log will be kept to track the number of inservice hours the aides and all staff have obtained on a cumulative basis.

Based on interview and record review, the hospice agency failed to provide volunteer training to the volunteer coordinator. This deficient practice resulted in the volunteer coordinators not having training. Finding: On 9/8/2022, a review of the Administrator Designee (ADMD) employee records indicated that the ADMD was also the Volunteer Coordinator. However, there was no certificate of training on file. During an interview with the Administrator Designee (ADMD) on 09/12/2022, at 2:31 p.m., she stated the only training she received regarding being a volunteer coordinator was what was taught to her by the Administrator. The Administrator Designee further stated that she does not have a certificates or proof of documentation regarding the training. A review of the agency undated policy and procedure titled "Volunteer Services," indicated the purpose of the policy and procedure is to ensure that qualified volunteers provide appropriate services in accordance with the plan of care and hospice program needs.

Based on interview and record review, the hospice agency failed to ensure that the employee records were update and complete for eight out of 10 employees. This deficient practice resulted incomplete employee records. Findings: During a concurrent record review and interview with the Director of Patient Care Services Designee (DPCSD) on 05/31/2022 at 1:50 p.m., she stated that the Administrator/DPCS did not have a resume, no orientation checklist, and that last chest x-ray was on 01/04/2018. DPCSD stated that LVN 1's orientation checklist was incomplete and had no signature of who conducted the orientation. DPCSD stated that the Chaplain/Bereavement Coordinator/Volunteer Coordinator 1 had no application. DPCSD stated that the Licensed Clinical Social Worker (LCSW 1) did not have an application. DPCSD stated that the Volunteer did not have a resume. DPCSD stated that the Certified Home Health Aide (CHHA 1) did not have an application, resume, or orientation checklist. DPCSD stated that Office Staff 1 did not have an employee file because she only works in the office and does not go out in the field. During an interview with the Director of Patient Care Services Designee (DPCSD) on 05/31/2022, at 3:28 p.m., she stated that employee records should be complete and up-to-date. A review of the agency's policy and procedure titled "Personnel Record Content," dated 10/2011, indicated that the agency will maintain accurate and complete personal files on all staff.

Based on interview and record review, the hospice agency failed to provide in-services to all licensed staff. This deficient practice had the potential to put all licensed staff at risk for not having the updated knowledge and skills to provide highest quality of patient care services. Findings: On 05/26/2022, a review of the agency's in-service record was conducted. The 2021 licensed nurse in-service log was requested from the Director of Patient Care Services Designee (DPCSD). During an interview with the Director of Patient Care Services Designee (DPCSD) on 05/26/2022, at 1:38 p.m., she stated that she did not know where was the 2021 in-services records were for the licensed staff. A review of the agency's policy and procedure titled "Training/Inservice Education," revised 04/2021, indicated that the agency will provide training and education to give personnel opportunities to learn new skills and improve/expand existing knowledge. The policy and procedure further indicated that professional staff (direct care staff) will receive al least twelve (12) hours of inservice training per calendar year. Additionally, the policy and procedure indicated that an inservice log will be kept to track the number of inservice hours the aides and all staff have obtained on a cumulative basis.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Clinical Records was met as follows: 1. Hospice Agency (HA) failed to ensure patients' medical records were kept in the agency's office, easily available and accessible to hospice agency's healthcare personnel, for review and update of the medical records/file, for five out of 8 sampled patients (Patient 2, Patient 4, Patient 5, Patient 6, & Patient 8). (Refer to L671) 2. The HA failed to ensure the patient's medical records included a skilled nursing note that reflected the care and services provided on visits and was documented, for three out of 8 sampled patients (Patient 1, Patient 2, & Patient 3). The HA failed for the Licensed Vocational Nurse (LVN 1), to document the care and services provided to the patient and submit to the agency after the visit. (Refer to L672) 3. The HA failed to ensure patients medical records/files were kept secure and in locked cabinet, for 3 out of 8 sampled patient (Patient 1, Patient 3, and Patient 7). (Refer to L680). The cumulative effect of these systemic practices resulted in the Hospice Agency's inability to ensure the provision of quality health care in a safe environment.

Based on observation, interview and record review the Hospice Agency (HA) failed to ensure patients' medical records were at the agency's office, easily available and accessible to hospice agency's healthcare personnel, for review of plan of care, for five out of 8 sampled patients (Patient 2, Patient 4, Patient 5, Patient 6, & Patient 8). This failure had the potential to result in the patients delay and lack of care and services provided to patients due to the patients' medical record were not easily accessible and available. Findings: A review of Patient 2's clinical record indicated a start of care date (SOC) of 01/22/2022, with diagnoses which included atherosclerotic heart disease (condition that develops when a sticky substance called plaque builds up inside your artery), and hypertension (high blood pressure). A review of Patient 2's Plan of Care for the certification period of 04/23/2022 to 07/22/2022, indicated that a skilled nurse (SN) is scheduled to visit patient two times a week for routine care. Patient 2 declined social worker, volunteer, aide services and spiritual care. A review of Patient 4's face sheet indicated Patient 4 is a 90-year-old female admitted on 3/28/2022 with a diagnosis of Hypertension (high blood pressure). A review of Patient 4's "Start of Care - Plan of Care" dated 3/28/2022 to 6/26/2022 indicated Patient 4 was scheduled to have Skilled Nursing (SN) twice a week and was receiving routine care. Patient 4 declined social worker, volunteer, and aide services. A review of Patient 5's face sheet indicated Patient 5 is a 82-year-old female admitted on 9/12/2022 with a diagnosis of Heart Disease (conditions that affect the heart), Hypertension (high blood pressure), and depression (mood disorder causing persistent feeling of sadness). A review of Patient 5's "Start of Care - Plan of Care" dated 9/12/2021 to 12/11/2021 indicated Patient 5 was scheduled to have Skilled Nursing (SN) twice a week and was receiving routine care. Patient 5 declined social worker, volunteer, and aide services. A review of Patient 6's face sheet indicated Patient 6 is a 84-year-old male admitted on 7/7/2021 with a diagnosis of Hypertension (high blood pressure), and Diabetes Mellitus II (sugar in the blood). A review of Patient 6's "Start of Care - Plan of Care" dated 7/7/2021 to 10/5/2021 indicated Patient 6 was scheduled to have Skilled Nursing (SN) twice a week and was receiving routine care. Patient 6 declined social worker, volunteer, and aide services. A review of Patient 8's clinical record indicated a start of care date (SOC) of 06/15/2021, with diagnoses which included atherosclerotic heart disease (condition that develops when a sticky substance called plaque builds up inside your artery), and hypertension (high blood pressure). A review of Patient 8's Plan of Care for the certification period of 06/15/2021 to 09/13/2021, indicated that a skilled nurse (SN) is scheduled to visit patient two times a week for routine care. Patient 8 declined social worker, volunteer, aide services and spiritual care. During an observation and an interview on 5/26/2022 at 1:55 p.m., the Director of Patient Care Services designee (DPCSD) stated, the the gray file cabinet had the previous patients medical records/files. The DPCSD stated, the patients medical records/files for Patient 2, 4, 5, 6, and 8 were not in the office and was taken by the DPCS home. The DPCSD stated, the DPCS would not be available due to health issues, and would need to send the patients, medical records/file back to the office agency. During an interview on 5/26/2022 at 3:49 p.m. the DPCSD stated, the importance to keep patients medical records in the Hospice Agency (HA) for easy access, for reference and continuity of care. A review of facility's policy titled "Safeguard/Retrieval of Clinical Records" revised October 2011 indicated the original clinical records for active patients will remain on premises at all times.

Based on interview and record review the hospice agency (HA) failed to ensure the patient's medical records included a skilled nursing notes that reflected the care and services provided on visits and was documented, for three out of of 8 sampled patients (Patient 1, Patient 2, & Patient 3). The HA failed for the Licensed Vocational Nurse (LVN 1), to document the care and services provided to the patient and submit to the agency after the visit. This failure had the potential to result in inaccurate information, lack of continuity and delay of treatment, care, and services to the patients, that could cause delay in treatments. Findings: A review of Patient 1's clinical record indicated a start of care date (SOC) of 12/08/2021, with diagnoses which included atherosclerotic heart disease (condition that develops when a sticky substance called plaque builds up inside your artery), hypertension (high blood pressure) and alzheimer's (progressive disease that destroys memory and other important mental functions). A review of Patient 1's Plan of Care for the certification period of 03/09/2022 to 06/07/2022, indicated that a skilled nurse (SN) is scheduled to visit patient two times a week and was receiving routine care. Patient 1 declined social worker, volunteer, aide services and spiritual care. A review of Patient 2's clinical record indicated a start of care date (SOC) of 01/22/2022, with diagnoses which included atherosclerotic heart disease (condition that develops when a sticky substance called plaque builds up inside your artery), and hypertension (high blood pressure). A review of Patient 2's Plan of Care for the certification period of 04/23/2022 to 07/22/2022, indicated that a skilled nurse (SN) is scheduled to visit patient two times a week and was receiving routine care. Patient 2 declined social worker, volunteer, aide services and spiritual care. A review of Patient 3's face sheet indicated Patient 3 is a 97-year-old female admitted on 3/15/2022 with a diagnosis of essential heart disease (conditions that affect the heart), hypertension (high blood pressure), Alzheimer's disease (dementia that affects thinking, memory and behavior) and depression (mood disorder causing persistent feeling of sadness). A review of Patient 3's "Start of Care - Plan of Care" dated 3/15/2022 to 6/13/2022 indicated Patient 3 was scheduled to have skilled nursing (SN) twice a week and was receiving routine care. Patient 3 declined social worker, volunteer, and aide services. During an interview on 5/26/2022 at 3:33 p.m. the Director of Patient Care Services designee (DPCSD) stated, that staff has 7 days to document nursing notes. During an interview on 5/26/2022 at 3:35 p.m. with License Vocational Nurse 1 (LVN1) stated, he used a scratch paper while conducting home visits, which he takes home afterwards and documents. LVN1 stated that he had not documented for patients: Patient 1 with a Start of Care (SOC) date of 12/8/2021. Patient 2 with a SOC 1/22/2022. Patient 3 with a SOC 3/15/2022. LVN1 stated, "There are no notes since their start of care. I have notes only for discharge patients, I have only notes for discharges". During an interview on 5/26/2022 at 3:49 p.m. with DPCSD, the DPCSD stated that it is important to have nursing notes on file because they are needed to see patient progress, patient condition and for compliance. A review of facility's policy titled, "Entries into the Clinical Record" revised October 2011 indicated entries into the clinical record will be made on the day care is provided to the patient. All documentation will be turned in to the office at the end of the workday.

Based on observation and interview the hospice agency (HA) failed to ensure 3 of 8 sampled patients (Patient 1, Patient 3, and Patient 7) medical records were kept in a locked cabinet. This failure had the potential to result in placing the patients' personal and medical record information viewed and access by unauthorized personnel. Findings: A review of Patient 3's face sheet indicated Patient 3 is a 97-year-old female admitted on 3/15/2022 with a diagnosis of Essential Heart Disease (conditions that affect the heart), Hypertension (high blood pressure), Alzheimer's Disease (dementia that affects thinking, memory and behavior) and depression (mood disorder causing persistent feeling of sadness). A review of Patient 3's "Start of Care - Plan of Care" dated 3/15/2022 to 6/13/2022 indicated Patient 3 was scheduled to have Skilled Nursing (SN) twice a week and was receiving routine care. Patient 3 declined social worker, volunteer, and aide services. During a concurrent observation and record review on 5/26/2022 at 1:55 p.m. with License Vocational Nurse 1 (LVN1) of the Hospice Agency (HA), a four-drawer grey file cabinet, was not locked, which contained previous patient's medical records inside the cabinet. LVN1 stated that he lost the key to the file cabinet. LVN1 stated, the files/records inside the cabinet was old files/record from previous patient. LVN 1 stated, the files were from 2018, 2019, and 2020. There were two black door file cabinet with patient files was observe open and was not able locked. LVN1 stated, that he does not know why the file cabinet was not lock. During an interview on 5/26/2022 at 3:49 p.m. the Director of Patient Care Services designee (DPCSD) stated, the importantance to keep patients medical records locked to protect the patients' privacy. Director of Patient Care Services Designee (DPCSD) stated she could not locate Patient 2's medical record (active patient) and Patient 4's medical record (discharged yesterday). DPCSD stated, "I don't know where they are, (LVN1) is looking for it". A review of facility's policy titled "Safeguard/Retrieval of Clinical Records" revised October 2011 indicated Hospice will safeguard the clinical record against loss or unauthorized use. The clinical record room itself will be locked each night.

Based on interview and record review, the hospice agency failed to update and implement their coronavirus (COVID-19 - highly contagious respiratory disease caused by a virus that can spread from person to person) employee vaccination policies and procedures to ensure a process of documenting an employee's approval for medical or religious exemption for two of 20 agency employees (Licensed Vocational Nurse [LVN 1] and Certified Home Health Aide [CHHA 1]). This deficient practice resulted in the agency not having an updated policy and procedure for COVID-19 employee vaccination and two employees not having proof that religious exemption was approved. Findings: On 09/08/2022 and 09/12/2022, a review of the agency's COVID-19 policy and procedure and COVID-19 employee vaccination list was conducted. The COVID-19 vaccination list indicated that there were two (LVN 1 and CHHA 1) out of 20 employees who did not receive the COVID-19 vaccine and that they each submitted a COVID-19 Vaccine Exemption/Declination Form. During an interview with the Administrator Designee (ADMD) on 09/12/2022, at 12:55 p.m. and 2:03 p.m., she stated all employees were fully vaccinated except for LVN 1 and CHHA 1. Administrator Designee (ADMD) further stated that both LVN 1 and CHHA 1 submitted declination forms but no other document regarding the approval of the religious exemption. A review of the agency's undated policy and procedure titled "COVID-19 Policy and Procedure," indicated that the organization will comply with all applicable CMS (Centers for Medicare and Medicaid Services) and CDC (Centers for Disease Control and Prevention) recommendations for SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2).