Every finding on record at Fine Home Health, Inc.

Based on interview and record review the hospice failed to review and revise the emergency preparedness plan annually and provide emergency preparedness training to the staff. This failure had the potential for the staff would not be able to respond accordingly that would placed all patients at risk in the event of an emergency or disaster. Findings: On 12/14/21 at 2:45 p.m., during an interview with the Director of Patient Care Services (DPCS), stated she was aware that the emergency preparedness policy should be reviewed annually. The DPCS, however, was unable to provide the documented evidence the hospice reviewed or revised the emergency preparedness plan, and was unable to provide documentation of emergency preparedness training to all facility staffs. A review of the hospice's policy and procedure titled "Emergency Management Plan", indicated the policy was not reviewed or revised since 11/15/2017. During a review of the disaster drill training also indicated no evidence it was provided to all staffs annually.

Based on interview and record review, the Skilled Nurse (SN) failed to ensure care followed the written plan of care for one of 11 patients (Patient 1). The SN failed to perform a skin assessment to Patient 1's open wound to the right big toe. This deficient practice placed the patient at risk for slow wound healing. Findings: a. A review of Patient 1's face sheet indicated an admission to the hospice agency on 5/16/21, with primary diagnosis of end stage congestive heart failure ( a chronic condition in which the heart does not pump blood as well as it should). A review of Patient 1's "Plan of Care (POC)" dated 5/16/21, indicated for the Skilled Nurse (SN) visits two to three times a week, Medical Social Worker (MSW) visit one time then as needed, and the hospice aid (HA) service was declined. A review of Patient 1's physician's order dated 11/27/21, included to cleanse Stage II (partial thickness skin loss) open wound to the right big toe with Normal Saline, apply Curasol, and dry dressing daily. A review of Patient 1's SN visit note dated 11/29, and 11/30/21, indicated no documented evidence Patient 1's wound to the right toe was assessed. A review of Patient 1's Plan of Care dated 11/27/21, identified alteration for skin integrity. SN was to assess the patient's skin and pressure points for signs of breakdown every visit. A review of the agency's undated policy titled, "Wound Management Policies", indicated that each patient's wounds must be documented on the wound assessment note and wound care plan, monitoring and evaluation documentation that details the history and evaluation of the wound. This documentation must include details of the site, stage of wound healing, exudates (color, amount, odor), pain, wound measurements and include any underlying medical conditions.

Based on interview and record review, the hospice agency failed to ensure the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) was met by failing to: 1. Provide documented evidence of an effective QAPI program with an annual review of the program (Refer to L 560). 2. Provide documented evidence of performance improvement projects with reasons for projects and measurable outcomes (Refer to L 573). 3. Follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions (Refer to L579). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance to ensure provision of quality health care in a safe environment.

Based on interview and record review, the hospice governing body failed to ensure there was an ongoing, periodic collection, and assessment of data-driven quality assessment to identify whether a problem exists at the hospice agency. This deficient practice has the potential for the identified problems that will not be resolved and that could affect the patient's quality of care. Findings: On 12/17/2021 at 12:45 p.m., during a review of the QAPI (Quality Assurance Performance Improvement) program indicated, "The program will objectively and systematically monitor and evaluate the effectiveness and safety of services and quality of care provided for patient/families." The QAPI policy was last approved on 1/15/2015. During an interview with the Director of Patient Care Services (DPCS) on 12/17/2021 at 12:50 p.m., the QAPI meeting minutes was requested. DPCS was not able to provide the meeting minutes. DPCS stated the policy should be reviewed annually and there should be evidence of a functioning QAPI program. DPCS was unable provide any current documentation. DPCS further stated the QAPI program was important to improve operations.

Based on interview and record review, the hospice agency failed to provide documented evidence of performance improvement projects based on the results of their quality monitoring and other quality information such as the results of State or accreditation surveys performance. This failure had the potential to affect the care being provided to the patients. Findings: A review of the hospice's QAPI (Quality Assurance Performance Improvement) program on 12/17/21 at 12:45 p.m., indicated the hospice did not have any ongoing performance improvement projects. The hospice last recertification survey was in 2018. During an interview with the Director of Patient Care Services (DPCS) on 12/17/21 at 12:50 p.m., she stated they should have at least four projects but could not provide any evidence of performance improvement projects.

Based on observation, interview, and record review, the hospice agency staff failed to ensure hospice staff followed the standards of practice to prevent the transmission of infections for care provided for two of 11 sampled patients (Patients 6 and 7), as indicated in the hospice's policies on hand hygiene and standard precautions. The hospice staff member failed to wash hands after providing care to Patient 6 and failed to disinfect equipment used for these patients. This deficient practice had the potential to spread infection to patients whose health status were already compromised. Findings: During a home visit observation on 12/15/2021 at 11:45 a.m., the Director of Patient Care Services (DPCS) was observed entering Patient 7's room after providing care to Patient 6. DPCS was donning a new pair of gloves without washing hands. DPCS then proceeded to Patient 7 to take vital signs using the same blood pressure (BP) cuff and stethoscope used by Patient 6. The BP cuff and stethoscope were not disinfected. DPCS confirmed she should be disinfecting the equipment after each use and failed to do so. a. A review of Patient 6's face sheet indicated a start of care date of 9/25/20221 with a primary diagnosis of heart disease (type of thickening or hardening of the arteries). A review of Patient 6's "Initial Plan of Care/physician's order" dated 9/25/021, indicated the Skilled Nurse (SN) was to visit the patient two to three times a week and twice as needed. A review of Patient 7's face sheet indicated a start of care date of 9/19/2021 with a primary diagnosis of cerebral aneurysm (weak or thin spot on an artery in the brain that balloons or bulges out and fills with blood). b. A review of Patient 7's "Initial Plan of Care/physician's order" dated 9/19/2021, indicated the SN was to visit the patient two to three times a week and twice as needed. A review of the hospice's policy and procedure titled, "Hand Hygiene," dated 11/2017, indicated hand decontamination should be performed before direct contact with patient using either an alcohol based hand rub or wash hands with an antimicrobial soap and water. A review of the hospice's policy and procedure titled, "Standard Precautions," dated 11/2017 indicated the medical equipment will be wiped down with an organization-approved disinfectant after patient use.

Based on interview and record review, the hospice agency failed to hire a qualified volunteer coordinator to provide services to four of 11 sampled patients (Patients 1, 2, 6 and 7). This deficient practice had the potential for the volunteer not being able to fulfill its duties and provide appropriate services based on the patient's plan of care. Findings: On 12/13/2021, at 11:30 a.m., during an interview, the director of patient care services (DPCS) stated, Registered Nurse (RN 1) 1 was the designated volunteer coordinator. A review of RN 1's personnel file, did not indicate a certificate to indicate RN 1 had completed online training or had a volunteer coordinator experience in her resume. On 12/13/2021, at 12 p.m., during an interview with the DPCS, she stated that RN 1 used to be a volunteer coordinator from a previous employment with another hospice agency, but she was not able to provide any documented credentials.

Based on interview and record review, the hospice agency failed to ensure the Condition of Participation for Volunteers was met by failing to: 1. Ensure volunteer service program was maintained, and was offered/provided for two of 11 sampled patients (Patients 1 and 7). (Refer to L 642) 2. Provide documented evidence of volunteer orientation and training before a volunteer was being assigned to a patient/family (Refer to L 643). 3. Employ volunteers in order to provide services for four of 11 sampled patients (Patients 1, 2, 6, and 7). (Refer to L 645) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with volunteer services to ensure provision of quality healthcare to meet the patients' needs.

Based on observation, interview and record review, the hospice failed to ensure volunteer service program was maintained and was offered/provided to the patients for two of 11 sampled patients (Patient 1 and 7). This deficient practice had the potential to affect the patient's treatment and quality of life. Findings: 1. A review of Patient 1's face sheet indicated the patient was admitted to hospice agency on 5/16/2021, with a primary diagnosis of end stage congestive heart failure ( a chronic condition in which the heart does not pump blood as well as it should). A review of Patient 1's "Plan of Care (POC)" dated 5/16/2021, indicated the Skilled Nurse (SN) visit was two to three times a week, the Medical Social Worker (MSW) visit was one time then as needed, and the hospice aid (HA) service was declined. However, the volunteer service was not indicated in the patient's POC. On 12/15/2021, at 11 a.m., during a joint home visit with Registered Nurse 2 (RN 2), Patient 1 was observed lying in bed, sleeping, and receiving oxygen at two liters per minute via a nasal cannula. Patient 1 was not able to communicate. On 12/15/2021 at 11:30 a.m., during an interview, the board and care home's owner stated Patient 1's family member would like a volunteer for Patient 1 to run errands. The owner stated the hospice agency has not informed the patient's family member or her (owner) that the hospice was to provide the volunteer services for free and available if they need it. A review of Patient 1's clinical record indicated there was no documented evidence the patient and/or family member was informed or being offered of their volunteer services as part of the agency's core services. On 12/17/2021, at 1 p.m., during an interview with the Director of Patient Care Services (DPCS), she was not able to provide the documented evidence the hospice staff had explained to Patient 1 and/or family member regarding volunteer services program to the patient/caregiver, or assessed the need of volunteer services, and offered/provided the volunteer services. b. A review of Patient 7's face sheet indicated a start of care date of 9/19/202021 with a primary diagnosis of cerebral aneurysm (weak or thin spot on an artery in the brain that balloons or bulges out and fills with blood). A review of Patient 7's "Initial Plan of Care/Physician's Order" dated 9/19/2021, indicated the Skilled Nurse (SN ) was to visit the patient two to three times a week and twice as needed. Patient 7's plan of care indicated volunteer services were declined. During an interview with Patient 7's responsible party (ARP) on 12/17/2021 at 11:45 a.m., RP stated the volunteer services were never offered for Patient 1, and did not know Patient 7 could received volunteer services. During an interview with the Director of Patient Care Services (DPCS) on 12/18/2021 at 12 p.m., she stated she should have documented what was explained to Pateint 7's RP regarding volunteer services. DPCS confirmed that there was no documentation in the patient's record regarding volunteer services.

Based on interview and record review, the hospice failed to provide documented evidence of volunteer orientation and training before a volunteer was being assigned to a patient/family for four of 11 sampled patients (Patients 1, 2, 6, and 7). This deficient practice had the potential for not providing quality volunteer support that patient/family may need due to lack of training and orientation. Findings: On 12/17/2021, at 10 a.m., a review of the agency's list indicated there were four active patients (Patients 1, 2, 6, and 7). On 12/17/2021 at 1:30 p.m., during an interview, the director of patient care services (DPCS) was requested for volunteer training and orientation documentations. During a concurrent interview, DPCS stated that the hospice had no monthly orientation and training offered for their volunteers since May 2018.

Based on interview and record review, the hospice agency 2 failed to employ volunteers in order to provide services for four of 11 sampled patients (Patients 1, 2, 6, and 7). This deficient practice resulted in patients not being provided an opportunity to receive volunteer services. Findings: On 12/13/2021, at 10 a.m., a review of the agency's list indicated there were four active patients (Patients 1, 2, 6, and 7). On 12/13/2021 at 2 p.m., during an interview, the director of patient care services (DPCS) stated that the hospice agency had no active volunteers available to send to the patient's home to provide volunteer services. DPCS also stated that the hospice was in the process of hiring two candidates for volunteer work.

Based on interview and record review, the agency failed to ensure the Condition of Participation for Organizational Environment was met by failing to: Maintain a written description of the in-service training provided during the previous 12 months and not providing in-services to nine of nine hospice employees (Registered Nurses 1, 2, 3, and 4, Certified Nurse Assistants 1, 2, and 3, Registered Dietician 1, and Social Worker 1). (Refer to L 663) The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutorily mandated compliance with organizational environment to ensure provision of quality healthcare in a safe environment..

Based on interview and record review, the hospice agency failed to maintain a written description of the in-service training provided during the previous 12 months by not providing in-services to to nine of nine hospice employees (Registered Nurses 1, 2, 3, and 4, Certified Nurse Assistants 1, 2, and 3, Registered Dietician 1, and Social Worker 1). This deficient practice prevents the patients from receiving optimum quality of care and services by well trained staff. Findings: On 12/13/2021, at 10 a.m., a review of the hospice active employee files indicated Registered Nurse (RN) 1, 2, 3, 4, Certified Home Health Assistants (CNA) 1, 2, 3, one Registered Dietician (RD 1), and one Social Worker (SW 1) indicated there was no current inservices training on their files. The last inservice was held on December 2017. There was no documented evidence of the current training and inservices for these employees. On 12/13/2021, at 10:30 a.m., during an interview, the Director of Patient Care Service (DPCS) stated she could not provide any information regarding training and in-services for the past years. DPCS stated she did not have any documented evidence that meetings/inservices took place. A review of the agency's undated policy titled, "Competency Program," indicated the organization would establish and annually re-evaluate its job specific "Competency Based Orientation Checklist" which reflects duties commonly required in the performance of patient contact positions.

Based on interview and record review, the hospice agency failed to ensure the Condition of Participation for Medical Director was met by failing to: Ensure the hospice's Medical Director provided accurate initial certification of terminal illness in order to validate the diagnoses and life limited prognoses for three out of 11 sampled patients (Patients 1, 6 and 7). For the initial certification of terminal illness for Patients 1, 6, and 7, there were no attending physician signatures to support the diagnoses of terminal illnesses. This deficient practice resulted in the hospice's Medical Director certifying patients to receive services from the hospice agency with lacking evidence to determine these patients were qualified to receive hospice services (Refer to 667). The cumulative effect of this systemic practice resulted in the failure of the hospice agency's inability to provide services that meet the patient's needs and ensure the provision of quality and safe health care to the patients.

Based on observation, interview and record review, the hospice agency failed to ensure the hospice's Medical Director provided accurate initial certification of terminal illness in order to validate the diagnoses and life limited prognoses for three out of 11 sampled patients (Patient 1, 6 and 7). For the initial certification of terminal illness for Patient 1, 6, and 7, there were no attending physician signatures to support the diagnoses of terminal illnesses. This deficient practice resulted in the hospice's Medical Director certifying patients to receive services from the hospice agency with lacking of evidence to determine these patients were qualified to receive hospice services (Refer to 667). Findings: a. A review of Patient 1's face sheet indicated the patient was admitted to the hospice agency on 5/16/2021, with primary diagnosis of end stage congestive heart failure ( a chronic condition in which the heart does not pump blood as well as it should). Patient 1's face sheet indicated Physician 1 was the Medical Director, who signed as the patient's attending physician and the referring doctor. A review of Patient 1's "Plan of Care (POC)" dated 5/16/2021, Benefit period #1, indicated the Skilled Nurse (SN) visit was two to three times a week, the Medical Social Worker (MSW) visit was one time then as needed, and the hospice aid (HA) service was declined. However, the volunteer service was not indicated in the patient's POC. A review of Patient 1's "Physician's Certification for Hospice Benefit" for the initial benefit period #1 from 5/16/2021 to 11/12/021, signed by Physician 1 (hospice Medical Director), indicated Patient 1 had a life expectancy of six months or less, if the terminal illness runs its normal course. The certification was based on "Medical history, record, patient's status, and team assessment. In the space for "RN Progress Summary" the patient had End Stage Congestive Heart Failure with comorbidities of depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), insomnia (hard to fall asleep), chest pain, seizure (a sudden, uncontrolled electrical disturbance in the brain), dementia (loss of thinking, remembering, and reasoning). A review of Patient 1's Local Coverage Determination (LCD) hospice eligibility determination (determination terminal status) indicated that the Registered Nurse who did the initial visit did not use this form to determine if the patient was a candidate for hospice service. A further review of Patient 1's clinical record indicated there was no documentation provided by Physician 2 which confirmed the patient had been ruled out as a candidate for surgical procedures, or declined surgical procedures. On 12/14/2021, at 1 p.m., during a telephone interview with Physician 1, when she was asked why she signed the attending physician referral section of the Certification of Terminal Illness (CTI, document required for all hospice patients which the Medical Director and patient's primary physician must certify a patient as being terminally ill) form for Patient 1, Physician 1 stated that she was not the attending physician for Patient 1. Physician 1 also stated since Patient 1 was admitted to their hospice agency, Patient 1 was under her care now and considered the attending physician. Physician 1 further stated she did not do a face to face encounter visit with Patient 1, but only based her decision from reviewing the patient's medical history from the acute hospital. On 12/14/2021, at 2 p.m., during an interview with the DPCS, she stated that Patient 1's family member referred the patient to their hospice agency. DPCS also stated that Patient 1 has an attending physician but did not refer the patient for hospice services. A review of the hospice's undated policy titled, "Admission Criteria and Process," indicated the patient must have a life-limiting illness with a life expectancy of six months or less as determined by the attending physician and hospice medical director, utilizing standard clinical prognosis criteria in the organization's intermediary local coverage determination. b. A review of Patient 6's face sheet indicated a start of care date of 9/25/2021, with a primary diagnosis of heart disease (type of thickening or hardening of the arteries). A review of Patient 6's "Initial Plan of Care/physician's order" dated 9/25/2021, indicated the Skilled Nurse (SN) was to visit the patient two to three times a week and twice as needed. A review of the Certification of Terminal Illness for Patient 6 dated 9/27/20221, indicated the Medical Director signed with no attending physician's signature. c. A review of Patient 7's face sheet indicated a start of care date of 9/19/2021 with a primary diagnosis of cerebral aneurysm (weak or thin spot on an artery in the brain that fills with blood). A review of Patient 7's "Initial Plan of Care/Physician's Order" dated 9/19/2021, indicated the Skilled Nurse (SN) was to visit the patient two to three times a week and twice as needed. A review of the Certification of Terminal Illness dated 9/20/2021 for Patient 7 indicated the Medical Director signed for Medical Director and attending physician. During an interview with the Medical Director on 12/14/2021 11:30 a.m., the MD confirmed that there was no communication to the attending physician's of the patients. During an interview with the Director of Patient Care Services (DPCS) on 12/14/2021 at 11:34 a.m., she confirmed that both attending physicians for Patient 6 and 7 did not refer the patient to the hospice but referred by a friend.

Based on interview and record review, the agency failed to ensure the Condition of Participation for Medical Records was met by failing to: Ensure the clinical record, its contents and the information contained therein must be safeguarded against loss or unauthorized use. The hospice must be in compliance with the Department's rules regarding personal health information as set out at 45 CFR parts 160 and 164 (Refer to L680). The cumulative effect of this systemic practice had the potential to cause problems in health outcome, patients safety and quality of care to go unreconized.

Based on observation, interview and record review, the hospice failed to ensure the patients medical records were stored and safeguarded against loss and or unauthorized use. This deficient practice has the potential risk for the patient's confidential information could be accessed, identity theft, and or electronic altering by unauthorized users. Findings: On 12/13/2021, at 10 a.m., during an initial tour of the agency, upon entry to the facility, there were 20 to 30 medical records were scattered on top of the 6 desks in an opened non-specific room. The scattered patient's medical records were stacked in pile on top of the desks. The scattered medical records contained patient's confidential information that included face sheets, physician's orders, and billings with patient's name. There was no staff present in the room where the medical records were stored to safeguard these records. On 12/13/2021, at 10:20 a.m., during an interview, the director of patient care services (DPCS) confirmed the medical records were un-attended and stated she will make sure the patient's medical records were stored in their locked cabinet. A review of agency's undated policy titled, " Protection of Records," indicated that medical records should be stored in cabinets locked if not in use.

Based on observation, interview, and record review, the hospice failed to administer the medication as ordered by the physician for one of 11 sampled patients (Patient 7). This failure had the potential to affect the patient's progress by not providing the medication. Findings: During an observation on 12/15/21, with the Director of Patient Care Services (PCS) at 11:50 a.m., Patient 7 did not have the multivitamin as ordered by the physician on 9/19/21. The caregiver present indicated the patient has never taken the multivitamin. The PCS stated she would follow-up on the physician's order. A review of Patient 7's face sheet indicated a start of care date of 9/19/21 with a primary diagnosis of cerebral aneurysm (weak or thin spot on an artery in the brain that fills with blood). A review of Patient 7's "Initial Plan of Care/Physician's Order" dated 9/19/21, indicated the Skilled Nurse (MSN) was to visit the patient two to three times a week and twice as needed. The hospice undated policy and procedure titled, " Medication Profile Policy" indicated the medication profile records will be an ongoing record of current medications, reflecting changes and updates in chronological order.