Every finding on record at First Choice Hospice, LLC

Based on Medical Record (MR) review, and interviews with staff members it was determined the agency failed to ensure the staff obtained and completed orders for all care performed for the patient. This affected MR # 14, one of 14 MR's reviewed, and had the potential to negatively affect all patients cared for by this agency. --- 1. MR # 14 was admitted to the agency on 1/13/25 with a primary diagnosis of Malignant Neoplasm of the Bladder, Unspecified. A review of the nurse Visit Note Report dated 1/24/25 revealed the nurse documented a foley catheter was placed during the visit to promote wound healing. A review of the Hospice Certification and POC dated 1/13/25 revealed no documentation of an order for the placement of a foley catheter. Further review of the Hospice IDG Comprehensive Assessment and POC Update Reports dated 1/17/25, 1/31/25 and 2/14/25 revealed no documentation of an order for the placement of a foley catheter. A review of the nurse Visit Note Report dated 2/3/25, revealed a pressure wound stage two was identified on the coccyx. The nurse documented wound care provided as ordered. The previous nurse visit notes did not identify this wound. A review of the Hospice Certification and Plan of Care (POC) dated 1/13/25 revealed no documentation of an order for the care of a wound to the coccyx. Further review of the Hospice Interdisciplinary Group (IDG) Comprehensive Assessment and POC Update Reports dated 1/17/25, 1/31/25, and 2/14/25 revealed no documentation of an order for the care of a wound to the coccyx. An interview was conducted on 2/27/25 at 12:25 PM with EI # 1, Manager of Accreditation, Regulatory, and Compliance who confirmed the clinician failed to obtain an order and document the order for the foley placement or the care performed on 2/3/25 to the wound on the coccyx

Based on Medical Record (MR) review, interviews with staff and agency policies and procedures it was determined the agency failed to document missed visits per agency policy. This affected MR # 14 and MR # 9, 2 of 14 MR's reviewed and had the potential to negatively affect all patients cared for by this agency. Findings include: Agency Policy: Missed Visits Policy Number: 1-028 Review date: None listed Purpose: To ensure that missed visits are documented and does not affect the quality of patient care. Policy: Missed visits will be communicated to the Interdisciplinary Group (IDG) at the IDG Meeting. A missed visit will be rescheduled that the same week if possible. Missed visits will be documented in the medical record. Procedure: ...2. If a visit missed and not rescheduled in the same week, the clinician will: ...B. Document in the patient's medical record the following information: Patient name Date and type of visit missed Reason for the missed visit Description of any unmet needs and how the patient's needs were met Any follow-up needed Any other person(s) that were notified of the missed visit Signature of the staff reporting the information --- 1.MR # 14 was admitted to the agency on 1/13/25 with a primary diagnosis of Malignant Neoplasm of the Bladder, Unspecified. A review of the Hospice Certification and Plan of Care (POC) dated 1/13/25 revealed an ordered frequency for the Hospice Aide (HA) of four times a week for one week and five times weekly for twelve weeks. A review of the HA visit notes week of 1/19/25 revealed the HA visited two times, and not five as ordered. The HA completed one missed visit note dated 1/23/25. There were no missed visit notes documented for the remaining two visits scheduled. A review of the HA visit notes week of 2/2/25 revealed the HA visited four times, and not five as ordered. No missed visit note was completed for the remaining visit scheduled. An interview was conducted on 2/27/25 at 12:25 PM with Employee Identifier (EI) # 1, Manager of Accreditation, Regulatory, and Compliance, who confirmed the clinician did not complete the documentation for the missed visits per agency policy. 2. MR # 9 was admitted to the agency on 1/27/25 with a primary diagnosis of Hypertensive Heart Disease without Heart Failure. A review of the Hospice Certification and POC dated 1/27/25 revealed an ordered frequency for the Skilled Nurse (SN) of four times a week for one week and two times a week for twelve weeks with three as needed visits for symptom management, and an ordered frequency for the Volunteer Coordinator once a month for one month. A review of the SN visit notes dated 1/27/25 revealed the SN completed three of the four scheduled visits ordered. No missed visit note was completed for the fourth visit. A review of the MR revealed no visit was made by the volunteer coordinator as ordered by the physician. An interview was conducted on 2/27/25 at 12:39 PM with EI # 1, who confirmed the clinician did not complete the documentation for the missed visit per agency policy, and the volunteer coordinator visit was never assigned to the clinician.

Based on medical record (MR) review, agency policy and procedure, and interviews with staff it was determined the agency failed to ensure the Registered Nurse (RN) supervised the Hospice Aide (HHA) at least every 14 days. This deficient practice did affect 2 of 10 patients receiving HHA services including MR # 6, Home Visit (HV) # 2, and had the potential to affect all patients receiving HHA services. Findings include: Agency Policy: Standards of Care, Service, and Practice Policy Number: 2-001 Policy Date: Not Listed Purpose: To provide guidelines for developing and implementing standards of care, service, and practice... Certified Nursing Assistants (Hospice Aides): A supervisory visit will be conducted by the Registered Nurse for each Hospice Aide not less than every 14 days, if any areas of concern are noted during the visit, the Registered Nurse will provide a follow up on-site supervisory visit with the Aide in order to further assess and provide education... --- 1. MR # 6 transferred to ACG Hospice from another Hospice agency on 1/6/25 and recertified from 1/12/25 to 3/12/25 with a primary diagnosis of Parkinson's Disease. Review of the Aide Care Plan Report dated 1/12/25 revealed orders for HHA two times a week and SN three times a week. Review of the physician's order dated 1/19/25 revealed orders to increase HHA to three times a week. Review of the HHA Visit Notes revealed the HHA visited MR # 6 three times a week from 1/14/25 to 1/21/25. Review of the SN Visit Notes dated 1/14/24 to 2/24/25 revealed no documentation an HA supervisory visit was conducted. An interview was conducted on 2/27/24 at 8:40 AM with Employee Identifier (EI) # 5, Director of Operations, Montgomery, who confirmed the agency failed to ensure an Aide Supervisory visit was conducted every 14 days. 2. HV # 2 was admitted on 11/20/24 and recertified for hospice from 1/19/25 to 3/19/25. Review of the POC dated 11/20/24 revealed orders for HA two times a week for one week then three times a week for eight weeks. Review of the Aide Care Plan Report dated 1/19/25 revealed orders for HHA two times a week for one week then three times a week for eight weeks. Review of the HHA Visit Notes revealed the HHA completed three visits per week beginning 1/20/25 to 2/7/25. Review of the SN Visit Notes from 1/20/25 to 2/10/25 revealed a HHA Supervisory Visit was not conducted until 2/10/25, which was 21 days after the start of HHA services. An interview was conducted on 2/27/25 at 8:45 AM with EI # 5 who confirmed the agency failed to ensure an Aide Supervisory visit was conducted every 14 days.

Based on Medical Record (MR) review, interviews with staff and the Alabama Board of Nursing Standards of Nursing Practice and Standards for Wound Assessment and Care it was determined the agency failed to ensure the clinician documented the wound and care performed. This affected MR # 14, one of three wound care charts reviewed, and had the potential to negatively affect all wound care patients served by this agency. Findings include: Alabama Board of NursingChapter 610-x-6: Standards of Nursing Practice 610-X-6-.06 Documentation Standards: (1) The standards of documentation of nursing care provided to patients by registered nurses or licensed practical nurses are based on principles of documentation regardless of the documentation format. (2) Documentation of nursing care shall be:(a) Legible(b) Accurate(c) Complete. Complete documentation includes reporting and documenting on appropriate records a patient's status, including signs and symptoms, response,treatments, medications, other nursing care rendered, communication of pertinent information to other health team members, and unusual occurrences involving the patient... --- 1. MR # 14 was admitted to the agency on 1/13/25 with a primary diagnosis of Malignant Neoplasm of the Bladder, Unspecified. A review of the Hospice Certification and Plan of Care (POC) dated 1/13/25 revealed an order for Hospice Nurse/Caregiver to perform wound care to stage two pressure ulcer on left hip and left ear. Utilizing clean technique, cleanse with water, pat dry, apply Medihoney, and change every day and as needed if soiled or dislodged. Instruct caregiver in wound care. A review of the Hospice Start of Care Visit Note Report dated 1/13/25 revealed two wounds, wound number one: a stage two pressure ulcer to the left hip measuring 6 centimeters (cm) x 6 cm x 0 cm. Wound number two: a stage two pressure ulcer to the left ear measuring 1 cm x 1 cm x 0 cm. A review of the twenty nurse Visit Note Reports dated 1/14/25 to 2/25/25 revealed there was no documentation of the assessment or care performed to the wound on the left ear. A review of the seven nurse Visit Note Reports dated from 1/15/25 to 2/3/25 revealed no documentation of the wound care performed to the left hip. An interview was conducted on 2/27/25 at 12:25 PM with Employee Identifier (EI) # 1, Manager of Accreditation, Regulatory, and Compliance, who confirmed the nurse did not document the wound assessment and care of the left ear and left hip as ordered.

Based on review of agency policy, medical records (MR), and interview it was determined the agency failed to follow it's own policy and ensure pain assessment was completed on each Skilled Nurse (SN) visit. This deficient practice affected 4 of 11 records reviewed including MR # 4, Home Visit (HV) # 3, MR # 2, MR # 8, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Pain and Symptom Assessment/Management Revised: 12/2018 ...1. The clinical staff discusses pain and other symptom management with the patient/and caregivers. 2. An initial pain assessment is completed on every patient admitted for service... 3. Goals for pain control: Staff establishes with the patient/caregiver the patient's preferred goal for pain control as a score on the pain scale. ... 6. Staff will follow hospice-established treatment protocols and algorithms, which are based on recognized standards of practice... 1. MR # 4 was admitted to hospice on 12/22/2021 with a hospice diagnosis of Chronic Obstructive Pulmonary Disease. Review of the Interdisciplinary Plan of Care (POC) dated 12/22/2021 to 2/19/22 revealed Pain and Pain Management Interventions included for SN to "assess pain on every visit..." Review of the Progress Notes dated 1/11/22 and 1/13/22 revealed no documentation the SN assessed the level of pain. In an interview conducted on 2/9/22 at 1:50 PM, Employee Identifier (EI) # 1, Administrator, and EI # 3, Accounts Receivable, confirmed the level of pain was not assessed on each SN visit. 2. HV # 3 was admitted to hospice on 12/14/2021 with a primary diagnoses of Cirrhosis. Review if the POC dated 12/14/2021 to 3/13/22 revealed Pain and Pain Management Interventions included to "assess pain on every visit..." Review of the Progress Notes dated 12/16/2021 and 12/17/2021 revealed no documentation the SN assessed the level of pain. In an interview conducted on 2/9/22 at 2:50 PM, EI # 1 confirmed the patients pain was not assessed on each SN visit. 3. MR # 2 was admitted to the agency on 4/26/21 with a diagnoses of End Stage Dementia. Review of the Interdisciplinary POC dated 4/26/21 to 7/16/21 revealed documentation of Pain and Pain Management Interventions for SN to "assess pain on every visit..." Review of the Progress Notes dated 5/12/21, 5/26/21, 6/3/21 and 7/1/21 revealed no documentation of a SN pain assessment. In an interview conducted on 2/9/22 at 1:26 PM EI # 8, Director of Clinical Services/Medical Director, who confirmed there was no documentation of a pain assessment on the above visit dates. 4. MR # 8 was admitted to the agency on 5/16/2020, recertified for continued care from 5/1/21 - 6/29/21, with a diagnoses of End Stage ALS (Amyotrophic Lateral Sclerosis). Review of the Interdisciplinary POC dated 5/6/2020 - 7/12/21 revealed documentation of Pain and Pain Management Interventions for SN to "assess pain on every visit..." Review of the Progress Notes dated 5/4/21 and 5/28/21 revealed no documentation of a SN pain assessment. An interview was conducted on 2/9/22 at 2:36 PM with EI # 3, Accounts Receivable, who confirmed there was no documentation there was no documentation of a pain assessment on the above visit dates.

Based on observations, review of medical records (MR), National Hospice and Palliative Care Organization (NHPCO) 2018 Standards of Practice for Hospice Programs and interviews with staff, it was determined the hospice staff failed to ensure all patient medication profiles (MP) were current and accurate. This affected 1 of 3 home visits (HV) conducted, including HV # 2. This deficient practice had the potential to negatively affect all patients served by the agency. Findings include: NHPCO 2018 Standards of Practice for Hospice Programs ...Standard: ...4. The pharmacotherapeutic needs of patients are met while adhering to applicable state and federal laws and regulations and accepted standards of practice. ...4.2 A patient-specific medication profile is maintained and continuously reviewed to reconcile medications... 1. HV # 2 was admitted to the agency on 1/18/22 with a diagnoses of End Stage Lung Cancer. Review of the Interdisciplinary Team Meeting dated 1/18/22 and 2/4/22 revealed a Skilled Nurse frequency of once a week. A HV was conducted on 2/8/22 at 9:23 AM with Employee Identifier (EI) # 7, Chaplain to observe care performed. During the HV, the patient, caregiver and the surveyor compared the home medications with the agency Medication Form. The following discrepancies were found: Benzonatate 100 mg (milligrams) 1 tablet three times daily as needed was found in home with 9/8/21 documented on the prescription bottle, the patient's caregiver verbalized the patient takes 1 tablet every night. There was no documentation of the Benzonatate on the agency Medication Form. Acidophilus Probiotic OTC (over the counter) was found in the home. The patient's caregiver verbalized the patient has taken 1 tablet every night "since the last of December 2021." There was no documentation of the Acidophilus Probiotic OTC on the agency Medication Form. The agency Medication Form documented Basaglar Kwikpen 100 Units per milliter (ml) 20 Units daily. The patient verbalized she/he has been taking 10 Units daily of the Basaglar Kwikpen for "about a year." Levothyroxine 100 mcg (micrograms) 1 tablet in the morning was found in home with 1/11/22 documented on the prescription bottle. The agency Medication Form documented Levothyroxine 125 mcg 1 tablet in the morning. The agency Medication Form documented Levaquin 250 mg 1 tablet daily. The patient verbalized the medication was not in home and he/she has not took Levaquin since the "middle of January 2022." The agency Medication Form documented Oral Nystatin 100,000 Units/ml 5 ml 3 to 4 times daily with a date of 1/20/22. The patient verbalized the medication was not in home and he/she was "only on it for 10 days." The agency Medication Form documented Prednisone 20 mg 1 table daily. The patient verbalized the medication was not in home and was discontinued the day he/she was started on Dexamethasone, which per the agency Medication Form was on 1/20/22. An interview was conducted on 2/9/22 at 2:50 PM with Employee Identifier # 3, Accounts Receivable, who confirmed staff failed to update the Medication Form.

Based on review of agency policy, medical records (MR) and interview with staff it was determined the agency Skilled Nurse (SN) failed to updated each patient's plan of care (POC) with changes related to increased edema. This deficient practice affected 2 of 11 records reviewed, including MR # 8 and Home Visit (HV) # 2 and had the potential to negatively affect all patients served by this agency. Findings include: Agency Policy: Interdisciplinary Team (IDT) Effective Date: 6/20/06 Policy: ...3. The core members of the IDT involved in the care of the patient consist of... A. The patient's attending physician B. The Medical Director C. Registered nurse/Case manager D. Social worker E. Chaplain/pastor/spiritual counselor... ...5.. The IDT meeting address each of the patient's needs and problems. These meeting are documented and may include... ...C. ...modifying the patient/caregiver care plan, taking into consideration the patient's clinical status... 1. MR # 8 was admitted to the agency on 5/16/2020, recertified for continued care from 5/1/21 - 6/29/21, with a diagnoses of End Stage ALS (Amyotrophic Lateral Sclerosis). Review of the IDT meeting dated 5/14/21 and 5/28/21 revealed a SN frequency of once a week and as needed. Review of the SN Visit Note dated 5/26//21 revealed documentation the patient had no edema present. Review of the SN Visit Note dated 5/28/21 revealed documentation of "...Pt with +2 pitting edema to bilateral ankles..." There was no documentation the physician and/or IDT was notified of the patient's edema. Review of the IDT meeting dated 5/28/21 and 6/11/21 revealed no documentation the IDT was updated on the patient's edema. An interview was conducted on 2/9/22 at 2:36 PM with Employee Identifier (EI) # 3, Accounts Receivable, who confirmed there was no documentation the SN updated the IDT on the patient's edema. 2. HV # 2 was admitted to the agency on 1/18/22 with a diagnoses of End Stage Lung Cancer. Review of the IDT meeting dated 1/21/22 revealed a SN frequency of once a week and as needed. Review of the SN Visit Note dated 1/26//22 revealed documentation the patient had trace edema present to the bilateral lower extremities. Review of the SN Visit Note dated 2/1/22 revealed documentation of the patient had +3 edema to the bilateral lower extremities. There was no documentation the physician and/or IDT was notified of the patient's increased edema. Review of the IDT meeting dated 2/4/22 revealed no documentation the IDT was updated on the patient's increased edema. An interview was conducted on 2/9/22 at 2:50 PM with EI # 3, who confirmed there was no documentation the SN updated the IDT on the patient's increased edema.

Based on review of agency policies and procedures, medical records (MR), Assessing The Patient With a Wound as the Basis for Home Care Wound Management, Fundamentals of Nursing by Potter-Perry 6th Edition and interviews with the staff it was determined the hospice failed to ensure: 1. The staff documented the return demonstration of wound care per the patient (pt)/caregiver (cg) 2. The staff documented the specific education related to wound care, oxygen precautions, nebulizer use, diet, medication, disease process, equipment, procedures and stress relief, the pt/cg was provided in order to ensure the patient received all education needed to promote pt/cg self management skills to enhance pt health outcomes. This affected 7 of 11 MR's reviewed and did affect MR # 2, MR # 8, MR # 7, Home Visit (HV) # 2, HV # 1, MR # 4, MR # 6, and had the potential to negatively affect all patients served by the agency. Findings include: Assessing the Patient With a Wound as the Basis for Home Care Wound Management Source: Home Healthcare Now February 2005, Volume :23 Number 2 , page 82 - 92 ...The care plan must consider the patient's or caregiver's ability to participate in care, including their ability to change dressings and provide basic care... When a patient or caregiver is able to participate in care, the nurse provides written instructions, demonstrates the dressing change, and supervises the patient and caregiver until they are able to perform the procedure independently. ...Once the patient and caregiver demonstrate satisfactory performance of wound care, the home care clinician reduces the frequency of visits but continues to assess the wound and measure its healing at specific intervals. Fundamentals of Nursing by Potter-Perry 6th Edition Chapter 24 Client Education Page 473 Key Concepts-....A nurse evaluates a client's learning by observing performance of expected learning behaviors under desired conditions... Agency Policy: Pt/Cg Education Effective Date: 6/20/06 Policy: The agency plans for and supports the provision and coordination of patient and family education. Purpose: To promote pt/cg self management skills to enhance pt health outcomes. Procedure: ...4. The teaching method is individualized and may include....return demonstration. 5. Pts/cgs education and response is documented in clinical record. ...9. Pt and cg will receive education related to the following as appropriate to care and services rendered: ...Pt/cg/family responsibilities during care... ...Medical gases... Agency Policy: Clinical Staff Functions Effective Date: 6/20/06 Purpose: To define the function of the clinical professional...in the delivery of patient care services. ...Procedure: ...3... Skilled nursing (SN) services may include, but are not limited to: ...D. Providing education...with the pt and cg regarding the disease process and self-care techniques Agency Policy: Interdisciplinary Team (IDT) Effective Date: 6/20/06 ...Procedure: ...2. The nurse coordinates the plan of care as follows: ...D. Educates the pt/cg in the care needed... Agency Policy: Administration of Oxygen Effective Date: Not documented ...Procedure: ...2. Discuss the indications, purposes, and anticipated outcomes of oxygen therapy with the client and family. ...6. Teach or review oxygen safely (safety) precautions with the client and family: a. Do not smoke. b. Do not use oxygen near stove, space heater or heat source, c. Do not use electric blankets or heating pads. d. Do not use polyester or nylon bed linens or clothing... e. Make sure that all electrical equipment is properly grounded. f. Avoid the use of alcohol and oil-containing skin care products... g. Do not run oxyben tubing under clothes, bed linens, furniture, rugs, etc. h. Keep the oxygen container upright. i. Turn off the oxygen when it is not in use. j. Alert the local fire department and rescue squad about the use and storage of oxygen in the home... 1. MR # 2 was admitted to the agency on 4/26/21 with a diagnoses of End Stage Dementia. Review of the IDT Meetings from 4/30/21 to 7/23/21 revealed a SN frequency of once a week. Review of the Admission Clinical Assessment Note dated 4/26/21 revealed documentation of SN performed: "...(Specific Instruction/Procedures)...3) Disease Process 4) Safety...6)Complete med (medication) review: dose, route, action, frequency (freq), poss (possible) side effects (S/E)..." There was no documentation of the specific disease process taught and what education was provided about the disease process, what safety measures were instructed and what medication(s) were instructed. Review of the SN Visit Notes dated 5/4/21, 5/11/21, 5/18/21, 5/25/21, 6/1/21, 6/3/21, 6/8/21, 6/15/21, 6/22/21, 6/29/21, 7/6/21, and 7/13/21 revealed documentation of "...taught:...diet...medications...procedures...equipment......Emergency Measures..." Further review revealed documentation under the Actions: Procedures/Treatment section of disease process education and comprehensive medication review with route, dose, Frequency, and S/E. There was no documentation of the specific diet taught, what education was provided about the diet, what medication were instructed, what procedures, equipment and emergency measures were instructed on and the specific education provided, what disease process was taught and what education was provided about the disease process. Review of the Physician's Orders dated 5/27/21 revealed documentation of an order to "clean wound # 1 with NS (Normal Saline). Pat dry Apply bacitracin ointment & (and) cover with Telfa pad qd (every day) & prn (as needed) until resolved...Clean wound # 2 to L (left) knee with NS. Pat dry. Apply bacitracin ointment & leave open to air q (every) day & prn until resolved...Clean wound # 3 to L knee with NS. pat dry. Apply bacitracin ointment & leave open to air qd & prn until resolved...Clean wound # 4 to L knee with NS. Pat dry. Apply bacitracin ointment & leave open to air qd & prn until resolved..." Review of the SN Progress Note dated 5/27/21 revealed documentation of "Pt has x (times) 3 area/abrasions to L knee...Pt with skin tear to L elbow...SN Cleansed L elbow wound # 1 with NS & patted dry. SN applied bacitracin ointment & covered with Telfa pad...SN cleansed wound #2, # 3 & # 4 with NS & patted dry. SN applied bacitracin & left open to air..." There was no documentation the SN instructed the pt/cg on the wound care to wounds # 1, # 2, # 3, # 4 and/or the pt/cg provided a return demostration on the wound care to wounds # 1, # 2, # 3 and # 4. Review of the Physician's Orders dated 7/7/21 revealed documentation of an order to "clean wound # 5 to L eyebrow with NS. Pat dry. Apply bacitracin ointment and leave open to air q day until resolved..." Review of the SN Progress Note dted 7/7/21 revealed documentation of "...pt received scratch to L eyebrow with bruising noted. SN cleansed (wound # 5) with NS & patted dry. Sn applied bacitracin ointment & left open to air..." There was no documentation the SN instructed the pt/cg on the wound care to wound # 5 and/or the pt/cg provided a return demostration on the wound care to wounds # 5. Review of the MR revealed no documentation the SN instructed the pt/cg and/or provided a return demostration on the wound care to wounds # 1, # 2, # 3 # 4 and # 5. The agency staff failed to document the specific education the pt/cg was instructed on in order to ensure the pt/cg received all education needed to promote pt/cg self management skills to enhance pt health outcomes, educate the pt/cg on daily wound care and obtain a pt/cg return demostration of wound care to ensure competency with wound care. An interview was conducted on 2/9/22 at 1:26 PM with Employee Identifier (EI) # 8, Director of Clinical Services/Medical Director, who confirmed there was no documentation of the specific education the patient/cg was provided on the above dates, the pt/cg was provided wound care education and the pt/cg provided a return demostration on wounds # 1, # 2, # 3 # 4 and # 5. 2. MR # 8 was admitted to the agency on 5/16/2020, recertified for continued care from 5/1/21 - 6/29/21, with a diagnoses of End Stage ALS (Amyotrophic Lateral Sclerosis) Review of the IDT Meeting dated 5/14/21 - 6/11/21 revealed a SN frequency of once a week. Review of the SN Visit Notes dated 5/18/21, 5/26/21 and 6/2/21 revealed documentation of "...taught:...diet...medications...procedures...equipment......Emergency Measures..." Further review revealed documentation under the Actions: Procedures/Treatment section of disease process education and comprehensive medication review with route, dose, Frequency, and S/E. There was no documentation of the specific diet taught, what education was provided about the diet, what medication were instructed, what procedures, equipment and emergency measures were instructed on and the specific education provided, what disease process was taught and what education was provided about the disease process. Review of the Physician's Orders dated 5/18/21 revealed documentation of an order to "...clean skin tear...to R (right) elbow with NS pat dry apply bacitracin cover with non-adherent bandage change q day/prn...clean skin tear...to L elbow with NS pat dry, apply bacitracin cover with non-adherent bandage change q day & prn..." Review of the SN Visit Note dated 5/18/21 revealed documentation of "skin tear to R elbow...clean areas with NS pat dry apply bacitracin cover with non-adherent bandage." There was no documentation the SN instructed the pt/cg on the wound care to the R elbow and/or the pt/cg provided a return demostration on the wound care to the R elbow wound. Review of the SN Progress Note dated 5/26/21 revealed documentation of a skin tear to the L hand with a verbal wound care physician order received by the SN to "clean wound...to top of L hand with NS. pat dry. Apply bacitracin ointment. Cover with gauze & secure with tape q day & prn until resolved..." The SN documented wound care was performed by the SN at the visit. There was no documentation the SN instructed the pt/cg on the wound care to the L hand and/or the pt/cg provided a return demostration on the wound care to to the L hand. There was no documentation the SN wrote the verbal wound care order for the physician's signature. Review of the MR revealed no documentation the SN instructed the pt/cg and/or provided a return demostration on the wound care to the R elbow and the L hand wounds. The agency staff failed to document the specific education the pt/cg was instructed on in order to ensure the pt/cg received all education needed to promote pt/cg self management skills to enhance pt health outcomes, educate the pt/cg on daily wound care and obtain a pt/cg return demostration of wound care to ensure competency with wound care. An interview was conducted on 2/9/22 at 2:36 PM with EI # 3, Accounts Receivable, who confirmed there was no documentation of the specific education the patient/cg was provided on the above dates, the pt/cg was provided wound care education and the pt/cg provided a return demostration on the R elbow and L hand wounds. 3. MR # 7 was admitted to the agency on 10/4/21, recertified for continued care from 1/2/22 - 4/1/22, with a diagnoses of End Stage Chronic Lymphocytic Leukemia. Review of the IDT Meetings dated 1/7/22 - 2/4/22 revealed a SN frequency of once a week. Review of the SN Visit Notes dated 1/12/22, 1/17/22, 1/24/22 and 1/31/22 revealed documentation of "...taught:...diet...medications...procedures...equipment......Emergency Measures..." Further review revealed documentation under the Actions: Procedures/Treatment section of disease process education and comprehensive medication review with route, dose, Frequency, and S/E. There was no documentation of the specific diet taught, what education was provided about the diet, what medication were instructed, what procedures, equipment and emergency measures were instructed on and the specific education provided, what disease process was taught and what education was provided about the disease process. The agency staff failed to document the specific education the pt/cg was instructed on in order to ensure the pt/cg received all education needed to promote pt/cg self management skills to enhance pt health outcomes. An interview was conducted on 2/9/22 at 2:21 PM with EI # 2, Director of Quality Assurance, who confirmed there was no documentation of the specific education the patient/cg was provided on the above dates. 4. HV # 2 was admitted to the agency on 1/18/22 with a diagnoses of End Stage Lung Cancer. Review of the Interdisciplinary Plan of Care (POC) and Medication Form dated 1/18/22 revealed documentation the patient was on Oxygen (O2) at 3 Liters (L) continously. Further review of the Interdisciplinary POC revealed documentation of "...instruct patient and caregiver in safe use of equipment...cleaning of equipment...maintenance of equipment..O2...nebulizer..." Review of the Interdisciplinary Team (IDT) Meetings dated 1/21/22 and 2/4/22 revealed a SN frequency of once a week. Review of the SN Progress Note dated 1/20/22 revealed documentation of "...visit to home, delivered new nebulizer tubing and diffuser..." There was no documentation the pt/cg was provided education on the safe use, cleaning and maintenance of the new nebulizer diffuser. Review of the MR revealed no documentation the pt/cg were instructed on O2 safety precautions. Review of the SN Visit Notes dated 1/26/22 and 2/1/22 revealed documentation of "...taught:...diet...medications...procedures...equipment......Emergency Measures..." Further review revealed documentation under the Actions: Procedures/Treatment section of disease process education and comprehensive medication review with route, dose, Frequency, and S/E. There was no documentation of the specific diet taught, what education was provided about the diet, what medication were instructed, what procedures, equipment and emergency measures were instructed on and the specific education provided, what disease process was taught and what education was provided about the disease process. Review of the Physician Order dated 2/1/22 revealed documentation of "clean wound # 1 to R buttock with soap/water. Pat dry. Apply abreva to wound and leave open to air bid (twice daily)...until resolved..." Review of the SN Visit Note dated 2/1/22 revealed documentation of "SN cleansed wound # 1 to R buttock with soap/water and patted dry. SN applied abreva to wound and left open to air..." There was no documentation the SN instructed the pt/cg on the wound care to the R buttock and/or the pt/cg provided a return demostration on the wound care to to the R buttock. Review of the MR revealed no documentation the SN instructed the pt/cg and/or provided a return demostration on the wound care to the R buttock. The agency staff failed to provide education to the pt/cg on O2 precautions, safe use, cleaning and maintaince of the new nebulizer diffuser, the wound care to the R buttock and document the specific education the pt/cg was instructed on in order to ensure the pt/cg received all education needed to promote pt/cg self management skills to enhance pt health outcomes. An interview was conducted on 2/9/22 at 2:21 PM with EI # 3, who confirmed there was no documentation the pt/cg was provided education on O2 precautions, safe use, cleaning and maintaince of the new nebulizer diffuser, the wound care to the R buttock and of the specific education the patient/cg was provided on the above dates. 5. HV # 1 was admitted to the agency on 10/28/21, recertified for continued care from 1/26/22 - 4/25/22, with a diagnoses of End Stage Chronic Obstructive Pulmonary Disease. Review of the SN Visit Notes dated 1/31/22 and 2/7/22 revealed documentation of "...taught:...diet...medications...procedures...equipment......Emergency Measures..." Further review revealed documentation under the Actions: Procedures/Treatment section of disease process education and comprehensive medication review with route, dose, Frequency, and S/E. There was no documentation of the specific diet taught, what education was provided about the diet, what medication were instructed, what procedures, equipment and emergency measures were instructed on and the specific education provided, what disease process was taught and what education was provided about the disease process. The agency staff failed to document the specific education the pt/cg was instructed on in order to ensure the pt/cg received all education needed to promote pt/cg self management skills to enhance pt health outcomes. An interview was conducted on 2/9/22 at 2:21 PM with EI # 1, Administrator, who confirmed there was no documentation of the specific education the patient/cg was provided on the above dates. 6. MR # 4 was admitted to hospice on 12/22/2021 with a hospice diagnosis of Chronic Obstructive Pulmonary Disease. Review of the IDT Meetings dated 12/23/2021, 1/7/22, and 1/21/22 revealed orders for SN frequency of 1 x a week. Review of the SN Visit Notes dated 12/28/2021, 1/5/22, 1/10/22, 1/18/22, 1/25/22, and 2/1/22 revealed documentation of " ... taught ... diet ... medications ... procedures ... equipment ... Emergency Measures ..." Further review of the SN Visit Notes dated 12/28/2021 to 2/1/22 revealed documentation under the Actions: Procedures/Treatment section of disease process education and comprehensive medication review with route, dose, Frequency, and S/E (side effects). There was no documentation of the specific diet taught, what education was provided about the diet, what medication were instructed, what procedures, equipment and emergency measures were instructed on and the specific education provided. The agency staff failed to document the specific education the pt/cg was instructed on in order to ensure the pt/cg received all education needed to promote pt/cg self management skills to enhance pt health outcomes. In an interview conducted on 2/9/22 at 1:50 PM EI # 3, Accounts Receivable, and EI # 1, Administrator, confirmed the staff failed to document specific education provided. 7. MR # 6 was admitted to the agency on 1/16/22 with a primary diagnosis of Heart Disease. Review of the IDT Meeting dated 1/21/22 revealed orders for SN frequency of 1 x a week. Review of the SN Visit Notes dated 1/19/22, 1/25/22, and 2/1/22 revealed documentation of " ... taught ... diet ... medications ... procedures ... equipment ... Emergency Measures ..." Further review of the SN Visit Notes from 1/19/22 to 2/1/22 revealed documentation under the Actions: Procedures/Treatment section of disease process education and comprehensive medication review with route, dose, Frequency, and S/E. There was no documentation of the specific diet taught, what education was provided about the diet, what medication were instructed, what procedures, equipment and emergency measures were instructed on and the specific education provided. In an interview conducted on 2/9/22 at 2:45 PM EI # 1 confirmed the staff failed to document specific education provided.

Based on review of medical records (MR), observation, and interviews with staff, it was determined the agency failed to ensure the Hospice Aide (HA) performed assigned tasks as developed and written by the Registered Nurse (RN) and documented incomplete tasks correctly for 1 of 1 Home Visits (HV) conducted with a HA. This affected HV # 1 and had the potential to negatively affect all patients with HA services. Findings Include: HV # 1 was admitted to the agency on 10/28/21, recertified for continued care from 1/26/22 - 4/25/22, with a diagnoses of End Stage Chronic Obstructive Pulmonary Disease. Review of the HA Plan of Care dated 1/13/22 revealed documentation of a HA frequency of 5 times a week to perform "...Personal Care...Hair Care...Foot Care...Nail Care...Oral Care Assist/Brush Teeth...Apply/Change draw sheet on bed each visit or as requested by patient/caregiver. " A HV was conducted on 2/7/22 at 2:29 PM with Employee Identifier (EI) # 5, HA, to observe a bed bath. During the HV, EI # 5 did not provide hair care, foot care, nail care, oral care or apply/change the patient's draw sheet due to patient request. Review of the HA visit note dated 2/7/22 revealed documentation the hair care, foot care, nail care, oral care and the patient's draw sheet was applied/changed on HV # 1 was completed, which was not completed at the HV. The HA failed to document a incomplete task correctly and to follow the HA Care Plan developed by the RN. An interview was conducted on 2/9/22 at 2:22 AM with EI # 1, Administrator, who confirmed the HA documenting task not completed as completed was against the agency policy.