Every finding on record at Gardens of Western Reserve Hospice

Condition of Participation: Emergency Preparedness

Upon observation, there was no evidence the Emergency Preparedness plan: • Is based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach • Includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon observation, there was no evidence the Emergency Plan communication plan includes all of the following: • Names and contact information for the following: • Entities providing services under arrangement • Patients' physicians • Other hospices

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies. Upon observation the agency did not have evidence of having alternate means of communication for Hospice employees as part of their communication plan. Corrected on site.

Upon personnel record review, 4 of 14 (Personnel #5,7,8,12) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. The agency had a table top exercise in 2023 and 2024 though no evidence of an exercise being completed in 2022. They have not completed a full scale exercise from 2022-2024.

Upon patient record review, 1 of 14 (Patient #13) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient 13: No evidence of any admission consents/ election statement/ no signatures for patient rights and responsibilities, or release of information.

Upon patient record review, 1 of 14 (Patient #13) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient 13: No evidence of any admission consents/ election statement/ no signatures for patient rights and responsibilities.

Upon patient record review, 1 of 14 (Patient #13) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 13: No evidence of consents, election statement or choice of attending physician.

Upon patient record review, 1 of 14 (Patient #13) did not have evidence of the appropriate documentation for release of confidential information. Patient 13: No evidence of a signed release of information.

Upon patient record review, 1 of 14 (Patient #13) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient 13: No evidence of any admission consents/ election statement/ no signatures for patient rights and responsibilities, or release of information.

Upon patient record review, 1 of 14 (Patient #13) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient 13: No evidence of any admission consents/ election statement/ no signatures for patient rights and responsibilities, or release of information.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 2 of 14 (Patient #3,5) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 3: The pt was admitted 7/10/24 there was no evidence of psychosocial comprehensive assessment until 7/18/24. Patient 5: The spiritual comprehensive assessment was completed 5/14/24. Psychosocial comprehensive assessment completed 5/13/24. Admission was 5/7/24.

Upon patient record review, 14 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1,2,3,4,5,6,7,8,9,10,11,12,13,14: There is no evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. The SN documents “Less than 6 months” on all of the comprehensive assessments.

Upon patient record review, 7 of 14 (Patient #1,2,3,4,5,7,8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1: The medication profile contains Polyethylene Glycol with no diluent. The medication profile contains an order for Nystatin with no site for administration. Corrected on site. Patient 2: Facility MAR lists the following medications that are not on the Hospice medication profile: Fleets enema, Ipratropium PRN order. Corrected on site. Patient 3: Index card at home listed AZO OTC and Centrum silver, these were not on hospice medication profile. The medication profile listed Miralax 17gm with no dilutant, listed the Tylenol route as "Nasogastric" instead of oral, also had order for Amoxicillin 500mg (4) once daily...which appears to have been for a prophylactic dental appointment and should have been a one time dose and then discontinued. Corrected on site. Patient 4: The medication profile contains orders for Dulcolax PRN, Melatonin PRN, Milk of magnesia PRN all with no indication for PRN use. The medication profile contains Polyethylene Glycol with no diluent. Corrected on site. Patient 5: The medication profile contains budesonide, and O2 have no frequencies and an invalid Morphine order stating Morphine 0.5 scheduled every 6 hours however, does not indicate proper dose such as mg or mL. Corrected on site. Patient 7: Morphine orders is for 0.25 sublingual every 4 hours no dose in mL or mg. Depakote sprinkles order remains active on med profile, physician order to D/C 4/12/24. Corrected on site. Patient 8: The POC contains Geri-lanta, Tums, Tylenol, Bisacodyl all as needed with no indication for as needed. The medication profile contains a duplicate Morphine order, one complete and correct, the other has no frequency or indication. Corrected on site.

Upon patient record review, 2 of 14 (Patient #3,5) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 3: The pt was admitted 7/10/24 there was no evidence of Initial Bereavement assessment until 7/18/24. Patient 5: The Bereavement assessment was completed 5/13/24. Admission 5/7/24.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 2 of 14 (Patient #1,2,) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1: The RN documented on the comprehensive initial assessment pt has dysphagia. There is no nursing care plan for risk for aspiration. The pt is taking Eliquis and there is not risk for bleeding care plan. Patient 2: The SN documented on 6/12/24 “Pt on nectar thickened liquids for dysphagia”. There is no risk of aspiration care plan with goals and interventions.

Upon patient record review, 8 of 14 (Patient #1,2,3,4,5,7,8,9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: The POC 10/25/22 contains Polyethylene Glycol with no diluent. The medical record contains an order on 7/11/24 for Nystatin with no site for administration. Narrative Nurse note 6/11/24 states patient wearing TED Hose. No evidence of an order for TED Hose. Corrected on site. Patient 2: The SN documented on 7/22/24 “Pt is on a pureed diet”. On 6/12/24 SN documented “Pt on nectar thickened liquids for dysphagia” There are no diet orders on the POC. Facility MAR lists the following medications that are not on the Hospice POC: Fleets enema, Ipratropium PRN order. Corrected on site. Patient 3: The SN documented on the initial comprehensive assessment 7/10/24 “Pt taking Boost twice daily” There is no diet order on the POC and Boost is not listed on the POC. The POC has 7/11/23 Has orders to “Insert foley catheter and change PRN, irrigate PRN”. There is no frequency to change the foley, a solution to irrigate the foley with. There is not evidence the patient ever had a foley. Family had index card with meds written on it which did not match the hospice medication profile in the EMR. The caregiver verified she is taking the meds listed on the index card. Medication discrepancies as follow: Index card at home listed AZO otc and Centrum silver, these were not on hospice POC. The hospice POC listed Miralax 17gm with no dilutant, listed the Tylenol route as "Nasogastric" instead of oral, also had order for Amoxicillin 500mg (4) once daily...which appears to have been for a prophylactic dental appointment and should have been a one time dose and then discontinued. Corrected on site. Patient 4: The medication profile contains orders for Dulcolax PRN, Melatonin PRN, Milk of magnesia PRN all with no indication for PRN use. The medication profile contains Polyethylene Glycol with no diluent. Corrected on site. Patient 5: The POC contains budesonide, and O2 have no frequencies and an invalid Morphine order stating Morphine 0.5 scheduled every 6 hours without evidence of proper dose i.e. mL or mg and DME not listed on POC. No diet order on POC. Corrected on site. Patient 7: Morphine orders is for 0.25 sublingual every 4 hours no dose in ML or MG. Depakote sprinkles order remains active on POC and med profile, physician order to D/C 4/12/24. There is no diet order on the POC. Patient 8: "As needed" with no indication x5 meds and duplicate Morphine order, one complete and correct, the other has no frequency. Corrected on site. Patient 8: The POC contains Geri-lanta, Tums, Tylenol, Bisacodyl all as needed with no indication for as needed. There are duplicate Morphine orders, one complete and correct, the other has no frequency or indication. Corrected on site. Patient 9: There are orders on care plan for a Texas Catheter and education for a Texas Catheter. This pt is female and does not have a Texas Catheter. Corrected on site.

Upon patient record review, 2 of 14 (Patient #3,5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 3: The SN documented on the RN Comprehensive assessment on 7/10/24 the patient has a transport chair and walker. These items are not listed on the POC. Patient 5: Comprehensive assessment RN documents pt has a rollator and nebulizer these are not on the POC. Corrected on site.

Upon client record review, 3 of 14 (Patient #2,3,7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: The POC 7/11/24 has orders for SN twice weekly with 6 PRN per certification period. The SN performed a routine visit on 7/8/24, a PRN visit on 7/13/24 though no second routine visit that Medicare week. There is no evidence of a refusal or any missed visit documentation. The Medicare week of July 14-20, the SN made 3 routine visits on 7/14,7/15,7/18. There is no evidence of an order to increase the visits that week or that the 3rd visit was PRN. The SN finds a necrotic wound on 7/13/24 and documented “This nurse cleansed the wound with soap and water and applied clean dry dressing”. There is no evidence of an order for this wound care. Patient 3: The SN documented on 7/19/24 “Instructed PCG on O2 use and use of suction”. There are no orders for O2 or suction on the POC. Patient 7: The POC has orders for SN 2 times per week. The RN saw the pt the week of 6/16-6/22 on 6/18, the week of 6/23-6/29 on 6/27, the week of 7/9-7/15 on 7/9. There is no evidence of an order to decrease visits that week or any refusals.

Condition of Participation: Quality Assessment and Performance Improvement.

Upon observation, there was no evidence the program shows measurable improvement in indicators related to improved palliative outcomes and hospice services.

Upon observation, there was no evidence the QAPI program uses quality indicator data, including patient care and other relevant data in the design of its program. The hospice must use the data collected to: • Monitor the effectiveness and safety of services and quality of care • Identify opportunities and priorities for improvement, The agency is tracking falls and reviewing safety measures each time. They are also tracking infections though are not identifying opportunities and priorities for improvement. They are just documenting the antibiotic was ordered. There is no evidence they are identifying opportunities and priorities for improvement.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Upon clinical record review, patient #5 the SN documented pt drank a bottle of rubbing alcohol on 7/22/24. There is no evidence of an incident report being filed. The agency DPCS states there is no way in Consolo EMR to report incidents other than falls. The fall reports the agency does complete do not include a development of a plan of correction to prevent the same or similar event from occurring again. The report lists who fell, when the fall and where the fall occurred and if any injuries. The DPCS did speak with Consolo and they educated her on how to complete the report.

Upon observation, there was no evidence a written plan of correction is developed in response to any QAPI activity that does not meet an acceptable threshold. They are tracking infections and falls. They have no acceptable thresholds, PI projects, or any system to track performance to ensure that improvements have happened or are sustained.

Upon observation, there was no evidence in the QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. The agency has documented 12 infections in first quarter 2024, no second quarter report available. 2023 QAPI report first quarter with 3 infections, Second quarter with 10 infections, Third quarter with 5 infections reported. The agency has no evidence that data is utilized to assess the effectiveness of the infection control program. There was no evidence of any corrective action plans and steps for improvement implemented.

Upon patient record review, 1 of 14 (Patient #13) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 13: passed on 6/4/23. -Bereavement services were not offered for a full 12 months. -The Bereavement POC showed the following: 6/5/23 condolence phone call to son, Scott with "permission to follow up in a few weeks". 6/22/23 card mailed, 7/7/23 phone call, NA, no response, 7/14/23 phone call with no response, 7/20/23 newsletter, 7/30/23 states, "Discontinue services if I do not hear back"-no further documentation found.

Upon personnel record review, 1 of 14 (Personnel # 6) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel 6: The aide competency did not include sponge bath or sink, tub, bed shampoo.

Upon patient record review, 11 of 14 (Patient #1,2,5,6,7,8,9,10,11,13,14) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 1: The aide POC contains a frequency of PRN next to the following tasks: Assist with feeding PRN, oral care PRN, barrier cream each visit and PRN, brief change PRN. Corrected on site. Patient 2: The aide POC 7/2/24 contains the following task frequencies: Assist with feeding prn, nailcare weekly and prn, oral care every visit and PRN, shave every visit and PRN. Corrected on site. Patient 7: The aide POC contains clothing assist per pt desires, foot care per pt desires, oral care every visit and prn, shower 1 time a week and prn. Corrected on site. Patients 5-11,13-14: The aid POC's all have tasks that contain PRN or "as desires" or "as needed". Corrected on site.

Upon patient record review 4 of 14 (Patient #5,6,7,10) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 5: The aide POC contains ordered tasks of shower each visit. The aide documents on all visits from 5/29/24-7/3/24 that pt is refusing a shower. The aide did not complete any of the ordered tasks on their written assignment and it was not documented that they refused those ordered tasks such as apply lotion, clean nails, foot care, brush teeth, shave. Visit note 7/23/24 a partial bed bath is documented, which is not an ordered task. Patient 6: Aide documents, "patient washed up," not an ordered task. Patient 7: Aide visit 6/7/24 the aide did not perform the following that were ordered every visit: barrier cream, position in bed, shave, clothing assist. The week of 6/9/24 the aide saw pt 6/7 and 6/12 and did not shower the pt and it was ordered 1 time per week and there is no documentation of refusal. Aide documented on 6/18/24 “Pt in Broda chair taken to bathroom to be washed up and toileted”. These tasks were not ordered. The week of 6/21-6/27 the aide saw pt 1 time on 6/26, with no documented refusals. Patient 10: SOC 03/28/24 with Aide frequency ordered for 2x/week- first aide visit documented on 4/8/24. No evidence of missed visit documentation or refusal.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. There is no evidence the Board of Directors/governing body have ensure Quality Assessment/Performance Improvement program and proper emergency preparedness for agency.

Upon patient client record review, 3 of 14 (Patient #4,6,13) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 4: The election of benefits has a box marked indicating the pt chose an attending physician. The physician’s name is not on the form. The form also does not indicate the election of hospice date. Patient #6: Election statement "start of care date" is left blank. Patient 13: No evidence of any admission consents/ election statement/ no signatures for patient rights and responsibilities, or release of information.

Upon patient client record review, 12 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,14) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1: The SN documented on 6/6/24 “b/b” and “w/” these are not approved abbreviations. Patient 2: Chaplain note 6/13/24 uses unapproved abbreviations of CH and PT. Patient 3: The SN documented on 7/10/24 “POX wnl RA” and “Needs AB prior to dentist”. These are not approved abbreviations. The SN documented against a nursing care plan 7/19/24 “Insert 14fr foley and change PRN, intervention performed: yes, outcome: effective, engagement: engaged. Use of Texas Catheter: Intervention performed : yes, engagement: engaged, outcome: effective. Instruct family irrigating procedure: Intervention performed: yes, outcome: effective, engagement: Engaged. This pt is a female and does not have a foley and there is no evidence the pt ever had one. The SN documented on 7/19/24 “Toileting per ECF protocol” pt is in a private home. IDT note on 7/11/24 uses unapproved abbreviations, CH, PT, ISA. Patient 4: The SN documented wound care on 6/12/24, 6/14/24,7/8/24 by restating the order. The documentation is not in past tense to indicate she performed the wound care. On 7/19/24 the SN documented “Dressing changed as prescribed”. There is no evidence of details of dressing change. The SN documented on 7/19/24 “FN”. This is not an approved abbreviation. Patient 5,6,7,8,10,14: The SC documents in their SC initial assessment “PT” and “CH”. These are not approved abbreviations. Patient 9: 4/16/24 admission assessment "POX" "IV ATB". Patient 10: SN narrative 7/19 "WNL","VSS". Patient 11: Chaplain note 12/2/23 contains "PT" and "CH". These are not approved abbreviations.

Upon client record review, 1 of 14 (Patient #12) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient 12: The patient transferred to another hospice. The MSW completed a transfer form for change of hospice, however; did not list the name of the hospice the pt transferred to. There is no evidence of what documents were forwarded to the receiving hospice.

Upon patient record review, 2 of 14 (Patient #3,9) did not have evidence in the patient record that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home. If the patient and/or family are not capable of safely administering drugs and biologicals in the home, the hospice must address this issue in the patient's plan of care. Patients 3,9: were the only home patients reviewed. There is no evidence of education provided to the patient/family to safely self-administer drugs and biologicals to the patient in his or her home. There is no documentation in the plan of care that the patient and/or family are not capable of safely administering drugs and biologicals in the home.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. Patient 13: No evidence of any admission consents/ election statement/ no signatures for patient rights and responsibilities, or release of information.

Upon observation, there was no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs. Patient 13: No evidence of any admission consents/ election statement/ no signatures for patient rights and responsibilities, or release of information.

Upon client record review, 1 of 14 (Patient #13) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient 13: No evidence of any admission consents/ election statement/ no signatures for patient rights and responsibilities, or release of information.

Upon SNF/NF contract review, 1 of 3 (Anna Maria) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation.

Upon client record review, 1 of 14 (Patient #4) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 4: The POC has orders for wound care, pt is in a facility, the order does not state who is to perform the wound care.