Every finding on record at Grace Hospice of Indiana LLC

Based on record review and interview, the Interdisciplinary Group (IDG) failed to ensure the plan of care (POC) included all interventions based on problems identified in the comprehensive assessment in 1 of 2 active records reviewed for patient with wounds living in own home (Patient #1). Findings include: --- 1. Review of an agency policy titled ";Interdisciplinary Group Plan of Care Policy" indicated the POC will include an assessment of the patients needs and treatment necessary to meet the needs of the patient. 2. Review of the agency job description titled ";RN (registered nurse) Case Manager" indicated the RN develops the POC that specifically addresses identified patient problems. 3. Review of the clinical record of Patient #1, identified a hospice benefit election date of 02/12/2024 with diagnosis, but not limited to, gangrene (death of body tissue due to lack of blood flow or a serious bacterial infection). Review of the start of care visit note completed by RN 1 on 02/12/2024 indicated Patient #1 had gangrene to both lower legs. Documentation indicated Patient #1 declined aggressive treatment for wounds and desired to remain comfortable. Review of a coordination note entered by RN 1 on 03/08/2024 indicated Patient #1 had second thoughts about not pursuing aggressive treatment for lower extremities and RN 1 would contact physician. Documentation failed to evidence orders for wound care of lower extremities. Review of a visit note entered by RN 1 on 05/27/2024 indicated Patient #1 arrived at Entity B for respite care (short term inpatient care to provide relief to caregivers). Patient #1 was transported to emergency room for evaluation of bilateral extremities and transported back to Entity B. Review of medical record from Entity B included wound care orders for both lower extremities, dated 05/29/2024 through 06/02/2024 during respite stay. Review of a physician order dated 06/10/2024 indicated a new order to apply antifungal (treats skin infection) lotion to the intact skin of both lower legs, apply ABD dressing (thick adsorbent pad), and apply kerlix (secures primary dressing) to prevent injury to gangrenous areas and to change dressing every other day and as needed. 4. During an interview on 07/03/2024 at 10:30 PM, when asked how often an assessment of the lower extremities of Patient #1 occurred, RN 1 indicated they assessed as often as the patient would allow. When asked when orders were received to provide care to the lower extremities of Patient #1, RN 1 indicated Patient had gangrene when admitted, there were no orders for treatment when Patient started service. When Patient was in respite care his/her extremities were wrapped in kerlix. During an interview on 07/03/2024 at 3:00 PM, when asked where the wound care orders were for Patient #1 when admitted on 2/12/24 with gangrene to both lower extremities, the clinical manager indicated could not find wound care orders. When asked what aggressive treatment would be for both lower extremities with gangrene, the clinical manager indicated would be amputation. When asked what palliative treatment would be both lower extremities, the clinical manager indicated would be wrapping the legs.

Based on observation, record review, and interview, the agency failed to ensure the Hospice Aide only performed tasks permitted under state law (Hospice Aide 1). Findings include: --- 1. Review of an agency job description titled ";Hospice Aide" indicated the HA will not administer medications. 2. Review of the Indiana Department of Health nurse aide curriculum indicated the nurse aide will not administer any medications, perform treatments, or apply dressings. 3. Review of the clinical record of Patient #3 included a visit note completed by HA 1 on 06/14/2024 that indicated HA 1 applied nystatin (prescription medication used to treat fungal infections of the skin) powder to the reddened area of the left side of groin area (junction where the upper body or abdomen meet the thigh) and covered with gauze. Review of the HA care plan for benefit period 05/09/2024 – 08/06/2024 included services the HA could provide to Patient #3. Documentation failed to evidence the HA was to apply nystatin powder to the skin and to cover it with gauze. 4. During an interview on 07/03/2024 at 1:41 PM, when asked what was done when she noticed redness to the groin of Patient #3, HA 1 indicated she gave patient a shower and applied nystatin powder to reddened area of groin. HA 1 indicated she had been using nystatin with patients as a HA for years. During an interview on 07/03/2024 at 3:00 PM, when asked if a HA could apply nystatin powder to a patient, the clinical manager indicated no because it was a prescription.

Based on record review and interview, the hospice agency failed to coordinate with nursing facility to ensure the plan of care included all medications necessary to meet the needs of the patient in 1 of 3 active records reviewed of patients residing in a nursing facility (Patient #6). Findings include: --- 1. Review of an agency policy titled ";Interdisciplinary Group Plan of Care" indicated the plan of care will include the drugs and treatments necessary to meet the needs of the patient. 2. Review of the clinical record of Patient #6 indicated Patient resided in Entity A, a nursing facility. Review of Entity A medication administration record for Patient #6 titled ";July 2024 Medications" used by Entity A in the administration of medications indicated the following medication orders that were not found in the hospice plan of care: Morphine (narcotic to treat moderate to severe pain), Milk of Magnesia (used to treat constipation), and Aspirin (used as a blood thinner). Review of the nursing facility medications indicated differences in the frequency of administration between the nursing facility and the hospice medication orders for the following medications: Acetaminophen (used for mild to moderate pain) and Bisacodyl suppository (used for constipation). Review of the nursing facility medications indicated a difference in the dose for administration between the nursing facility and the hospice medication order for Zoloft (used as an antidepressant). Review of the hospice plan of care for Patient #6 for benefit period 06/13/2024 – 08/11/2024 failed to evidence orders for the following medications: Morphine, Milk of Magnesia, and Aspirin. 3. During an interview on 07/03/24 at 12:20 PM, when ask how she coordinates the medication orders between hospice and a nursing facility, registered nurse (RN) 2 indicated she reviews the orders between hospice and the nursing facility. When asked why there were differences between the medication orders of the hospice and the nursing facility, RN 2 indicated she had missed those orders.

It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure that the plan of care included a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. Clinical Record 2: The patient elected the hospice benefit on 01/31/2024. The plan of care dated 01/31/2024 documented a wound on the patient's left heel. On 02/06/2024, the physician ordered wound care, "P: Unstageable left heel wound. I: Cleanse area pain area with skin cote pad and leave open to air, G: Promote safety and comfort." The plan of care (POC) did not include documentation of the frequency of the dressing change. The Skilled Nursing (SN) visit notes dated 02/09/2024, 02/13/2024, and 02/16/2024 documented that the patient refused wound care. A review of the clinical record revealed no documented evidence that the caregiver had been performing wound care for the patient. Documentation dated 02/20/2024 was the first documentation found that addressed wound care. During a joint record review and an interview, the Quality Assurance Nurse confirmed there was no frequency for the dressing change. Clinical Record 3: The patient elected the hospice benefit on 12/16/2023. On 02/06/2023, the Registered Nurse (RN) documented that the patient had a lesion to the right hip. An order was written on 02/06/2024 to "cleanse the lesion on right hip, pat dry, apply skin cote pad, and leave open to air to promote safety and comfort." The plan of care did not document the frequency of the dressing change.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 11 (9%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that the HA received specific written patient care instructions from the Registered Nurse. Clinical Record 6: The patient elected the hospice benefit on 01/19/2024. The plan of care dated 01/19/2024, ordered HA services one time a week for thirteen weeks and documented that the patient had a gastrostomy tube (G-Tube) for feeding. The HA care plan dated 01/19/2024 through 04/17/2024 assigned the HA the relevant tasks: assist the patient with dressing and a shower every visit. The HA care plan did not document instructions for the HA regarding what to do if the G-Tube was pulled out, the stoma was inflamed, or if there was drainage coming from the G-Tube. During an interview, the staff confirmed that the HA care plan was lacking instruction for the gastrostomy tube.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are: noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record review of a patient who received volunteer services, the agency did not ensure that the volunteer services provided were noted in the plan of care. Clinical Record 11: The patient elected the hospice benefit on 01/09/2024. The volunteer visited the patient on 01/04/2024, 01/06/2024, 01/07/2024, 01/08/2024, 01/10/2024, 01/13/2024, 01/14/2024, and 01/15/2024. The plan of care dated 01/09/2024 did not document the volunteer services provided to the patient. During an interview, the Quality Assurance Nurse confirmed there was no volunteer frequency in the plan of care.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: hospice election form and any advance directives. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 1 (100%) home visit observed of a patient in a skilled nursing facility (SNF), the agency did not ensure that the SNF received a copy of the patient's hospice election form. Home Visit 2/Clinical Record 3: The patient elected hospice care on 12/16/2023 and resided in a SNF. During the home visit with the Registered Nurse (RN) [Personnel Record 5] on 05/30/2024, a review of the patient's SNF chart revealed no evidence that the patient's hospice election of benefits form was available for the SNF staff. During an interview and a joint review of the record, the RN [Personnel Record 5] confirmed the election of benefits form was not present.

Based on record review and interview, the hospice failed to ensure the interdisciplinary group (IDG) documented and updated the comprehensive assessment to include the patient's progress for 1 of 2 active records reviewed with wounds (Patient #3). Findings include: --- 1. A review of an agency policy titled ";Update of the Comprehensive Assessment Policy" indicated reassessment data will be gathered to identify the patients progress. 2. A review of the clinical record for Patient #3 indicated the skilled nurse visited Patient two times a week. A record review included a wound record report that indicated the onset date of 04/05/24 of a Stage II pressure ulcer (skin with intact or open blister) to the left lower buttock area with measurements of length 8 centimeters, width 3.5 centimeters, and depth 0. Skilled nurse (SN) orders for pressure ulcer indicated assess the wound and change dressing every visit and PRN (as needed). A review of skilled nurse visit notes failed to evidence wound measurements were obtained the week of 04/28/24 – 05/04/24. 3. During an interview on 05/15/24 at 10:40 AM, when asked how often the SN should measure pressure ulcer of Patient #3, registered nurse (RN) 3 indicated weekly. When asked what guidelines the agency provided regarding the frequency of measuring wounds, RN 3 indicated at least once every 7 days. During an interview on 05/15/24 at 3:30 PM, when asked what policy and procedure the agency follows regarding the frequency of measuring patients wounds, the administrator indicated the agency does not have a policy or procedure and follows the best practices which are to measure wounds every week.

Based on record review and interview, the agency failed to ensure the interdisciplinary group (IDG) coordinated and directed the care and services of 1 of 1 patient discharged as they were no longer terminally ill (Patient #8). Findings include: --- 1. A policy on care coordination outlined the responsibilities of the IDG to coordinate and communicate regarding significant changes in the patients overall care. The responsibilities included, but were not limited to, initiate discussions with all disciplines regarding changes, to maintain timely communications with other team members, and document the communication in case conference or communication notes, as part of the patient medical record. 2. A review of Patient #8s medical record indicated the patient was admitted 3/11/2024 and was discharged on 5/1/2024. Patient #8s diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD; lung diseases that obstruct airflow from the lungs), congestive heart failure, respiratory failure, and atrial fibrillation (an irregular heart rate which causes poor blood flow). A review of the face to face visit note with Patient #8 on 4/11/2024, indicated the Medical Director found ";The patient is hospice appropriate secondary to increased progression and decline." The Medical Director documented increased fatigue and sleep, reduced appetite, shortness of breath at rest, and was bed bound. A review of the 4/17/2024 IDG meeting notes for Patient #8, indicated the Medical Director ";Reviewed and agree with current POC [plan of care]." The scribe included a notation the Medical Director provided a verbal order for recertification for an additional 60 days of hospice care, for the dates 5/2/2024 – 6/30/2024. The last IDG meeting prior to Patient #8s discharge occurred on 4/23/2024. The notes included the statement the Medical Director ";Reviewed and agree with current POC." The notes failed to evidence discussion of the potential discharge. The scribe included a note that a chart review would be conducted. 3. During an interview on 5/15/2024 at 3:33 PM, the Medical Director indicated there was an IDG meeting to discuss Patient #8s discharge. The Medical Director indicated the note about a chart review (on the 4/23/2024 meeting) evidenced the reason for discharge. 4. When all records regarding the discharge were requested, the Administrator provided a Physician Attestation on agency letterhead, dated 4/25/2024 and signed by the Medical Director on 4/26/2024. The attestation amended the face to face that occurred on 4/11/2024. The amended section stated, ";Review of documentation and collaboration took place after face to face visit, and it was determined that there has not been a decline during the episode that would make the patient eligible for recertification of hospice services." 5. During a phone interview on 5/15/2024 at 2:25 PM, registered nurse (RN) 1 indicated they Patient #8s discharge was a corporate decision and there was a special meeting, but RN 1 did not attend. The meeting to discuss Patient #8s discharge failed to include the RN. 6. During a phone interview on 5/15/2024 at 12:30 PM, the Social Worker indicated they did not know the reason for Patient #8s discharge. The Social Worker indicated they did not know why Patient #8 was discharged. The Social Worker indicated there must have been another meeting after the patient was recertified for hospice care (on 4/17/2024). The meeting to discuss Patient #8s discharge failed to include the Social Worker. 7. During an interview on 5/15/2024, the Corporate Quality Assurance RN indicated they would expect to see documentation which outlined the specific details of why the patient was no longer eligible for hospice and expected to see the IDG involved in the discussion. The Corporate Quality Assurance RN indicated they never saw a physician attestation that rescinded the face to face recertification of terminal illness. They indicated they would have expected the patient to receive hospice services during the new certification period (5/2/2024 – 6/30/2024) and review and the IDG would discuss discharge during that time.

Based on record review and interview, the hospice agency failed to ensure all members of the Interdisciplinary Group (IDG) communicated patient information through documentation in a timely manner according to agency policy for 2 of 3 active records reviewed (Patient #1,2) and for 4 of 5 discharged records reviewed (Patient #4,5,6,8). Findings include: --- 7. A review of the clinical record for Patient #2 included agency documents titled ";Coordination Notes" which indicated late visit documentation for the following dates: entered 12/17/2023 by RN 1 for a visit on 12/13/2023, 12/30/2023 by RN 1 for a visit on 12/22/2023, entered 1/6/2024 by RN 1 for a visit on 1/4/2024, 1/10/2024 by RN 1 for a visit on 1/8/2024, entered 1/11/2024 by RN 1 for a visit on 1/9/2024, and entered by RN 1 on 1/11/2024 for the death visit on 1/10/2024. 8. A review of the clinical record for Patient #7 included agency documents titled ";Coordination Notes" that indicated late visit documentation for the following dates: entered 2/29/2024 by RN 1 for a visit on 2/27/2024, entered 3/5/2024 by RN 3 for a visit on 3/2/2024, entered 3/13/2024 by RN 1 for a visit on 3/11/2024, entered 3/15/2024 by RN 1 for 3/13/2024, entered 3/21/2024 for a visit on 3/19/2024, entered 3/22/2024 by RN 1 for a visit on 3/20/2024, entered 4/4/2024 by RN 1 for a visit on 4/2/2024, entered 4/8/2024 by RN 1 for a visit on 4/4/2024, entered 4/9/2024 by RN 1 for a visit on 4/6/2024, entered 4/14/2024 by RN 1 for a visit on 4/8/2024, entered 4/14/2024 by RN 1 for a visit on 4/10/2024, entered 4/25/2024 by RN 1 for a phone call on 4/23/2024, entered 4/29/2024 by RN 1 for a visit on 4/24/2024, entered 5/6/2024 by RN 1 for a phone call on 5/1/2024, entered 5/7/2024 by RN 1 for a visit on 4/28/2024, entered 5/11/2024 by RN 1 for a visit on 5/4/2024, and entered 5/14/2024 by RN 1 for a visit on 5/12/2024. 9. A review of the clinical record for Patient #8 included agency documents titled ";Coordination Notes" that indicated late visit documentation for the following dates: entered on 3/16/2024 by RN 1 for a verbal recertification order given on 3/11/2024, entered on 3/16/2024 by RN 1 for an initial assessment visit made on 3/11/2024, entered on 3/16/2024 by RN 1 for a visit on 3/12/2024, entered on 3/30/2024 by RN 3 for a visit on 3/27/2024, entered on4/8/2024 for a visit on 4/6/2024, entered on 4/9/2024 by RN 3 for a visit on 4/2/2024, entered on 4/16/2024 by RN 1 for dates 3/15/2024, 3/18/2024, 3/20/2024, 3/21/2024, and 3/22/2024; 4/17/2024 entered by RN 1 for a visit on 4/14/2024; 4/22/2024 entered by RN 1 for a visit on 4/17/2024; and 4/25/2024 entered by RN 3 for a visit on 4/22/2024. 10. During an interview on 5/15/2024 at 2:20 PM, RN 3 indicated documentation was due within 24 hours, except for assessments, which were 48 hours. 1. A review of an agency policy titled ";Documentation" indicated clinical staff document the care provided to the patient on the same day the service is rendered, and clinical staff submit documentation of care at a minimum, daily. 2. A review of the Registered Nurse (RN) job description indicated documentation for admissions is to be submitted within 2 days of the admission and subsequent visit documentation is to be submitted daily. 3. A review of the clinical record for Patient #5, benefit election date 03/23/24, included an agency document titled ";Coordination Notes" which indicated late visit documentation entered on 03/26/24 by RN 1 for visit made on 03/23/24. A review of a Coordination Note entered by Triage RN 2 while on-call on 03/25/24, indicated a phone call from the family of Patient #5 wanting to know what pain medication could be given and Triage RN 2 indicated no ordered medications were in Patient #5's medical record. Documentation failed to evidence medication orders had been entered into the medical record within 48 hours of admission. 4. A review of the clinical record for Patient #1 included agency documents titled ";Coordination Notes" that indicated late visit documentation for the following dates: entered on 03/25/24 by RN 1 for the visit made on 03/23/24, entered on 03/26/24 by RN 1 for the visit made on 03/23/24, entered on 04/01/24 by RN 1 for the visit made on 03/24/24, entered on 04/04/24 by RN 1 for the visit made on 04/02/24, entered on 04/09/24 by RN 1 for the visit made one 04/04/24, and entered on 04/15/24 by RN 1 for the visit made on 04/12/24. 5. A review of the clinical record for Patient #4 included agency documents titled ";Coordination Notes" that indicated late visit documentation for the following dates: entered on 03/18/24 by RN 1 for a visit made on 03/13/24, entered on 03/20/24 by RN 1 for a visit made on 03/14/24, and entered on 03/25/24 by RN 1 for a visit made on 03/21/24. 6. During an interview on 05/15/24 at 2:25 PM, when asked what the time expectation was for documentation of visits, RN 1 indicated that depends on what he/she is doing that day and tries to complete documentation within 48 hours of a patient visit and within 48-72 hours of an admission or recertification visit.

Based on observation, record review, and interview, the hospice agency failed to ensure all staff followed infection control policies and standard precautions for 2 of 2 home visits observed (Patient #1,2). Findings include: --- 4. A review of the agency's hand hygiene competency training identified the situations when hand hygiene was to be completed. Hand hygiene was required before and after patient contact, before and after performing patient care and procedures, and before and after contact with wounds. 5. A review of RN 1s annual skills competency completed on 11/17/2023 indicated RN 1 successfully completed infection control procedures. 6. An observation occurred on 5/14/2024 at 3:30 PM when registered nurse (RN) 1 performed wound care on Patient #2. RN 1 removed the soiled wound dressing and cleaned the wound area, then removed gloves. RN 1 removed the soiled gloves and donned new gloves. RN 1 failed to complete hand hygiene prior to donning the new gloves. RN 1 applied the new dressing and removed the gloves. RN 1 failed to complete hand hygiene after removing the gloves and prior to contact with Patient #2s skin. During an interview following the observation at 3:30 PM, RN 1 indicated gloves were to be changed between removing a soiled wound dressing and the application of the new dressing. When asked about hand hygiene between the glove changes, RN 1 indicated hand hygiene should have been done. 1. A review of an agency form titled ";Bag Technique Competency Evaluation Form" indicated items needed for patient care are to be placed on a clean, dry surface. 2. During a home visit for Patient #1 on 05/14/24 beginning at 9:30 AM, observed Registered Nurse (RN) 2 placed the clipboard directly on the overbed table in Patients room, placed the tablet on the clipboard, and placed the used oximeter and thermometer on the clipboard. Observation failed to evidence clipboard was placed on a barrier and failed to evidence RN 2 cleaned the clipboard when used equipment was removed from the top of the clipboard and when the clipboard was removed from the overbed table. 3. During an interview on 05/14/24 at 10:15 AM, when asked what he/she used the clipboard for, RN 2 indicated she used it during patient visits to carry paperwork. When asked what measures should be taken when placing the clipboard on Patient's overbed table and after placing the used patient equipment on the clipboard, RN 2 indicated should have placed a barrier on the overbed table and should have cleaned the clipboard.

Based on record review and interview, the hospice agency failed to ensure the licensed professionals participated in evaluation of the plan of care (POC) for 1 of 2 active records reviewed of patients residing in their homes (Patient #3). Findings include: --- 1. A review of an agency policy titled ";Medication Administration Policy" indicated each patient is monitored on an ongoing basis for actual or potential medication-related problems. 2. A review of the clinical record for Patient #3 included an order dated 02/01/24 entered by Registered Nurse (RN) 1 for morphine oral solution (used for pain and air hunger a feeling of not getting enough air in the lungs). A review of an agency document titled ";Hospice Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update Report" dated 02/12/24 and attended by Social Worker 1, Chaplain 1, RN 1, and Medical Director indicated Patient #3 had an allergy to morphine that had been entered into the medical record on 01/18/24 and an order for morphine which had been entered on 02/01/24. Documentation failed to evidence licensed professionals evaluated the ordered medication and the allergy to the ordered medication. 3. During an interview on 05/15/24 at 10:40 AM, when asked why morphine was ordered for Patient #3 who had a morphine allergy, RN 3 indicated morphine should not have been ordered because of the allergy and had probably been entered at time of admission. During an interview on 05/25/24 at 2:25 PM, when asked why morphine was ordered for Patient #3 who had a morphine allergy, RN 1 indicated the request was sent to the physician for approval and then sent to the pharmacy. When asked who checks for medication allergies, RN 1 indicated the nurse and pharmacy check for allergies.

Based on observation, record review and interview, the agency failed to ensure interdisciplinary communication was maintained for 1 of 1 home visits conducted with a hospice aide (Hospice Aide #1). The findings include: --- Record review of an agency policy titled ";Hospice Coordination of Services Policy" revised July 2016, indicated a coordination of care note would be completed with any communication between the case manager and other members of the care team regarding patient care. An observation of a home visit was conducted on 5/25/2023, for patient #1 at Entity #1 (Nursing Facility) with Hospice Aide (HA) #1. At 10:15 AM, the patient complained of left knee pain and HA #1 indicated they will let Registered Nurse (RN) #2 know about the patients pain. Clinical record review on 5/30/2023, for patient #1, of a Hospice Aide visit note from 5/25/2023, failed to evidence the patients pain was documented. Record review failed to evidence a coordination note between HA #1 and RN #2. During an interview on 5/30/2023, at 1:02 PM, the Family Care Coordinator indicated the hospice aide should have documented the pain on their visit note under the narratives section. They indicated the agency will continue to work with the hospice aides with their documentation.

Based on observation, record review and interview, the agency failed to ensure all staff performed hand hygiene when indicated to prevent the transmission of infectious/communicable diseases for 1 of 1 home visit performed with a hospice aide (Hospice Aide #1). The findings include: --- Record review of an agency policy titled ";Infection Control and Occupational Exposure to Bloodborne and Other Pathogens" revised on 5/14/2021, indicated infection control procedures included wearing and changing gloves as necessary during patient care and frequent hand hygiene. This document indicated hand hygiene would occur before moving from a contaminated body site to a clean body site on the same patient and after handling soiled or contaminated materials. An observation of a home visit was conducted on 5/25/2023, from 10:09 AM to 10:50 AM, for patient #1 at Entity #1 (Nursing Facility) with Hospice Aide (HA) #1 and HA #2. During preparation of placing a Hoyer Lift (hydraulic lift to assist the caregivers with patient transfers) sling under the patient at 10:15 AM, the patients diaper was pulled down in front and peri-care (cleansing the groin, genitals, and buttocks) was provided. Hospice Aides #1 and #2 assisted the patient to roll onto their right hip. HA #1 cleaned a bowel movement from the patients buttocks and tucked the soiled diaper and linens under the patient, then tucked the Hoyer Lift sling under the patient. Hospice Aides #1 and #2 rolled patient back to their left side to pull the sling through and removed the soiled diaper and linen from underneath the patient. At 10:21 AM, HA #2 laid the patient on their back over the Hoyer Lift sling and HA #1 steered the Hoyer Lift to the patients bed in position and connected the straps of the sling to the lift. After the patient was set in the shower chair and disconnected from the Hoyer Lift, HA #1 removed soiled gloves, performed hand hygiene and donned new gloves. Observation failed to evidence HA #1 removed gloves and performed hand hygiene when moving from soiled to clean on the same patient. At 10:30 AM, Patient #1 was in the shower on the shower chair, and HA #1 was shaving the patients legs when they discovered more bowel movement on the patients buttocks. HA #1 cleaned the patients buttocks while seated in the shower chair which had an opening at the seat to allow bathroom access. At 10:35 AM, HA #2 brought additional towels to HA #1, which were then used by the patient. Observation failed to evidence HA #1 changed gloves and performed hand hygiene after cleaning bowel movement from the patient in the shower prior to handling clean towels. Observation failed to evidence hand hygiene was performed according to the agency policy. During an interview on 5/25/2023, at 4:18 PM, the Family Care Coordinator indicated a clinician was expected to change gloves and perform hand hygiene before moving on from peri-care.

Based on observation, record review, and interview, the hospice agency failed to maintain the patients right to receive effective pain management and symptom control (Please see tag L512); failed to ensure the patients were involved in developing their hospice plan of care Please see tag L513); failed to maintain the patients right to a confidential clinical record (Please see tag L516); and failed to ensure patients received and were informed about the services covered by the hospice benefit (Please see tag L518). This practice had the potential to affect all patients the agency served. The findings include: --- The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care for the Condition of Participation 42 CFR §418.52 Condition: Patients Rights.

Based on record review, and interview, the hospice agency failed to maintain the patients rights in 3 of 3 active clinical records reviewed with documented ineffective pain management and symptom control issues (Patient #4, #5, #13). The findings include: --- 5. Clinical record review for Patient #13 was completed on 3/23/2023, for certification period 2/21/2023 – 5/21/2023. Record review evidenced an on-call note dated 2/25/2023, at 9:23 PM, which indicated the patient was coughing up dark red blood. Record review evidenced the skilled nurse visited the next day 2/26/2023. Record review evidenced an on-call note dated 3/2/2023, at 2:25 AM, which indicated the family was calling because the patient had been coughing all day, medications were not effective, and family was not comfortable administering morphine (pain medicine) as instructed by the nurse. This visit note indicated the family was requesting the nurse come out to see the patient. Record review evidenced the nurse visited the patient several hours later. Record review evidenced an on-call note dated 3/5/2023, at 8:31 PM, which indicated the family was calling because the patient was having coughing spells and did not have any nebulizer or medications for a nebulizer. This on-call note indicated the nurse would order the medication in the morning. During an interview on 3/22/2023, at 3:41 PM, the Clinical Manager indicated the patients coughing symptoms should have been better controlled, and the nurses should have addressed the issues in the same day. 1. Record review of an undated policy received on 3/14/2023, titled ";Pain Management Policy", stated, ";... To make the patient relatively pain free through pain management ... monitor for new problems ... that may contribute to pain ... Monitor the patients pain therapy through sequential home visits to assess progress or deterioration ... Side effects ... Chronic use of narcotic analgesics invariably results in constipation ... Anticipation of [constipation] can lead to early institution of preventative measures ... If not addressed, constipation can become a severe problem leading to significant discomfort ...." 2. The hospice agencys undated patient home folder binder was received and reviewed on 3/13/2023. Section 2, titled ";Patient Rights and Responsibilities", stated, ";... You [patient] have the right to ... Receive effective pain management and symptom control ...." 3. Clinical record review for Patient #4 was completed on 3/23/2023 at 2:10 PM (start of care date 1/09/2023). Record review evidenced Medical Social Worker (MSW) #1 visited the patient on 3/13/2023, the patient was lethargic, complained of stomach pain, hasnt been able to have a bowel movement, and it was difficult for her; the patients mood was sad and withdrawn, and MSW #1 ended the visit as a result of these observations; and MSW #1 reported her findings to Registered Nurse (RN) #2. The hospice agency failed to maintain the patients rights to receive effective pain management and symptom control for constipation on 3/13/2023. A home visit with Patient #4 occurred on 3/16/23 at 1:30 PM. The patient complained of a problem with her stool softener, it felt like stool was in her rectum- like a ball, she couldnt push it out, it caused excruciating pain, and it made her want to manually remove it. Registered Nurse (RN) #2 stated, ";... Oh, lets not do that ...." The patient complained of pain in her right leg and both hips. The patient grimaced and yelled out in pain When RN #2 sat the patient up from a lying position, and when turned side to side in a lying position. Observed a prescription bottle of norco on the kitchen table, which was prescribed for pain relief. The hospice agency failed to maintain the patients rights to receive effective pain management and symptom control for constipation on 3/16/2023. During an interview on 3/21/2023 at 2:41 PM, the Clinical Manager indicated she expect the nurse to follow a bowel protocol, and get a new order if needed. The Clinical Manager indicated the bowel protocol included a scheduled daily bowel medication, an additional ";as needed" bowel medication if the patient took an opioid/narcotic analgesic, a bowel movement was expected to occur at least every 3 days, and medication adjustments should be made if not effective. The Clinical Manager indicated she didnt know if the agency had a specific bowel program for constipation, and she would have called the physician to manually remove the stool from the patients rectum to relieve her pain and constipation. The Clinical Manager also confirmed the patients complaints of stomach pain and constipation were not mitigated on 3/13/2023. During an interview on 3/21/2023 at 5:51 PM, Person #6 (family/primary caregiver) indicated the nurse visited on 3/16/2023, and then not again until today (3/21/2023). Person #6 indicated he and the patient have been reporting the patients pain to agency staff. Person #6 indicated it was an ongoing, repeating pattern for the patient to get really constipated and then have a ";blow out". 4. Clinical record review for Patient #5 was completed on 3/23/2023 at 2:33 PM (start of care date 1/05/2023). Record review evidenced a coordination note dated 2/20/2023, which indicated the patient had diarrhea over the weekend (date range 2/17/2023 – 2/19/2023), and was instructed on use of imodium. Record review evidenced a coordination note dated 2/23/2023, which indicated the patients diarrhea was resolved, but now the patient hasnt had a bowel movement since Saturday, 2/18/2023 (5 days); and the patient took Ativan for anxiety. The hospice agency failed to maintain the patients rights to receive effective symptom control for constipation/diarrhea. Record review evidenced a coordination note dated 3/13/23, which indicated the patient had a lot of anxiety. The hospice agency failed to maintain the patients rights to receive effective symptom control for anxiety on 3/13/2023. During an interview on 3/23/2023 at 2:33 PM, the Clinical Manager indicated Patient #5 didnt receive effective symptom control for anxiety or bowel management, and it seemed to be a pattern with several of the agencys patients. The Clinical Manager indicated 5 days was too long for a patient to go without having a bowel movement.

Based on observation, record review, and interview, the hospice agency failed to ensure the patients were involved in developing their hospice plan of care in 4 of 10 active clinical records reviewed. (Patients #4, 9, 10, 14) The findings include: --- * Clinical record review for Patient #4 was completed on 3/23/2023 at 2:10 PM (start of care date 1/09/2023). Record review evidenced the patient lived alone, was bedbound, totally dependent on others for all care, and Person #6 (family/primary caregiver) visited several times daily to assist with the patients personal and household needs. Record review evidenced an updated plan of care dated 3/15/2023. The document evidenced nursing was ordered weekly, and hospice aide (HHA) was ordered 3 times weekly. During an interview on 3/21/2023 at 5:51 PM, Person #6 indicated Registered Nurse (RN) #2 told him today that the agency was increasing the patients nursing visits to 2 times per week, and he didnt know why the visit frequency was increased. Person #6 indicated he didnt know if the HHA visit frequency was going to be increased as well, he wished they could get more help, it was very really difficult to provide personal care to the patient- especially cleaning her ";private areas". Person #6 indicated RN #2 just told him how many times per week the staff was allowed to come, never asked him what his or the patients needs were for frequency of visits, and he didnt know if he could request more frequent visits. During an interview on 3/22/2023 at 11:25 AM, the Clinical Manager indicated the patient and family should be involved with determining visit frequencies to meet the patients/caregivers needs. 1. Record review evidenced an admission booklet obtained 3/13/2023, which stated, ";... Decision Making – You have a right to: ... Be involved in developing your hospice plan of care or treatment: and to participate in changing the plan whenever possible and to the extent that you are competent to do so ...." 2. Observation of a home visit for Patient #9 was conducted on 3/15/2023, at 10:00 AM, to observe a routine chaplain visit. During the visit, the patient was observed to reside in a locked memory care unit. The patient was observed to be alert but confused, and minimally interactive. Clinical record review for Patient #9 was completed on 3/23/2023. Record review evidenced a plan of care for certification period 12/14/20222 – 3/13/2023, which indicated the patient was to receive home health aide visits 2 times weekly for 12 weeks, social work visits twice monthly for 3 months, and chaplain visits one time monthly for one month. Record review evidenced the patient failed to receive home health aide visits until 2/3/2023 (51 days after orders), failed to receive social work services twice monthly for 12/2022, 1/2023, and 2/2/2023, and failed to receive chaplain visits until 3/15/2023 (next certification period). During an interview on 3/20/2023, at 9:12 AM, Person #3 (Patient #9s representative) indicated the hospice agency did not mention chaplain services until 1 or 2 weeks prior to 3/20/2023. Person #3 indicated the hospice had mentioned home health aide services, but nobody ever came out to provide home health aide services. Person #3 was unsure why the home health aide never came, but could have used the extra help. Person #3 indicated they thought they were going to have a case conference with the staff from the hospice agency, but it never happened. 3. Clinical record review for Patient #10 was completed on 3/23/2023, for certification period 2/23/2023 – 5/23/2023. Record review evidenced a complaint for Patient #10 dated 3/1/2023, which indicated the patients representative had requested physical therapy services. This complaint indicated therapy would be contacted for an evaluation. Record review evidenced an order for physical therapy dated 3/10/2023 (9 days later). During an interview on 3/21/2023, at 1:48 PM, the Clinical Manager indicated they did not know why the patient didnt receive an order for physical therapy until 9 days after requested. The Clinical Manager indicated the agency based services off of what the patient or caregiver requested. 4. Observation of a home visit for Patient #14 was conducted on 3/16/2023, at 4:00 PM, to observe a routine social work visit. During the visit, the patient indicated to the social worker they wanted a motorized wheelchair due to decreased mobility. The social worker indicated they would have a case conference to obtain this for the patient. Clinical record review for Patient #14 was completed on 3/23/2023, for certification period 1/1/2023 – 3/31/2023. Record review evidenced the hospice held an interdisciplinary group meeting on 3/15/2023 (1 day prior to home visit). Record review on 3/23/2023 (7 days later), failed to evidence any interdisciplinary group communication or case conferences regarding patients request for a motorized wheelchair. During an interview on 3/23/2023, at 1:38 PM, the Clinical Manager indicated they had not heard anything about the patients request for a motorized wheelchair and were unaware of the request. The Clinical Manager indicated they didnt know if there was a case conference to obtain a wheelchair for the patient.

Based on record review and interview, the hospice agency failed to maintain the patients right to a confidential clinical record for all agency patients. The findings include: --- 1. The hospice agencys undated patient home folder binder was received and reviewed on 3/13/2023. Section 2, titled ";Patient Rights and Responsibilities", stated, ";... You [patient] have the right to ... Confidentiality of ... your medical records ...." 2. Review of an undated policy received on 3/21/2023, titled ";Services Under Contract Policy", stated, ";... Personnel who provide services by consultation ... or other arrangements ... must have a written contract between the agency and the personnel ...." 3. On 3/21/2023 at 3:45 PM, an operating agreement (written contract) dated 5/23/2011, was submitted by Corporate Staff #2 (Regional Quality Manager/not an employee of the hospice agency). The agreement was between Entity #8 (corporate owner of hospice agency) and Entity #10 (a hospice agency licensed in Michigan). Corporate Staff #2 confirmed the agreement was not for this agency. A request was made for a written agreement/contract between Entity #8 and the hospice agency being surveyed. Upon survey exit, nothing further was submitted for review. 4. During an interview on 3/20/2023 at 1:55 PM, Corporate Staff #2 indicated corporate level staffs paychecks were all different because they were all assigned to/employed by different, independently licensed Medicare provider agencies within the overall corporate organization. 5. On 3/21/2023 at 2:30 PM, Corporate Staff #1 (Regional Quality Manager/not an employee of the hospice agency) confirmed she was employed by Entity #11, a hospice agency in Ohio; Corporate Staff #2 confirmed she was employed by Entity #12, a hospice agency in Michigan; Corporate Staff #3 (Regional Director of Operations/ not an employee of the hospice agency) confirmed she was employed by Entity #10, a hospice agency in Texas; Corporate Staff #2 confirmed the agencys Bereavement Coordinator was employed by Entity #12. The hospice agency failed to maintain the patients right to a confidential clinical record for all agency patients, as corporate staff had unrestricted access to the patients electronic medical record (EMR).

Based on record review and interview, the home health agency failed to ensure patients received and were informed about the services covered by the hospice benefit in 2 of 3 home visits conducted. (Patients #4, #9) The findings include: --- 2. On 3/15/23 at 1:04 PM, the agencys survey entrance conference forms were reviewed, which evidenced the agency didnt provide homemaker services. 4. A home visit with Patient #4 occurred on 3/16/23 at 1:30 PM. The patient lived alone, was bedbound, and Person #6 (family/primary caregiver) provided personal, financial, and household needs several times daily. The patients environment was soiled/cluttered, and had a strong pet odor. During an interview on 3/16/2023 at 3:29 PM, Person #6 (family/primary caregiver) indicated he and the patient would definitely benefit from the provision of homemaker services, he didnt know it was a hospice benefit, and no one from the agency ever told him about homemaker services. During an interview on 3/21/2023 at 5:51 PM, Person #6 indicated he paid private duty caregivers because he was overwhelmed with the patients care and needs, he was never told he could receive continuous care for uncontrolled symptom management, and he thought you had to be on hospice services for a while before you could request respite services. 5. During an interview on 3/20/2023 at 3:31 PM, Regional Quality Manager #2 (corporate staff, not an agency employee) stated, ";... we dont do homemaker services ...." 6. During an interview on 3/20/2023 at 3:55 PM, Regional Director of Operations #1 (corporate staff, not an agency employee) indicated about the last 12 hospices she worked for didnt offer homemaker services, but also confirmed it was a hospice requirement. Regional Director of Operations #1 confirmed patient information in the admission binder failed to evidence homemaker services was available to the agencys patients. 1. Record review evidenced an undated admission booklet, obtained 3/13/2023, which stated, ";... Hospice services include: Nursing, physician services, medical social services, hospice aide services, physical, occupational and speech therapy, telehealth services, volunteer services and spiritual, dietary and bereavement counseling ...." 2. Observation of a home visit for Patient #9 was conducted on 3/15/2023, at 10:00 AM, to observe a routine chaplain visit. During the visit, the patient was observed to reside in a locked memory care unit. The patient was observed to be alert but confused, and minimally interactive. During an interview on 3/20/2023, at 9:12 AM, Person #3 (Patient #9s representative) indicated the hospice agency did not mention chaplain services until 1 or 2 weeks prior to 3/20/2023, and indicated they were not aware of these services prior to that. Person #3 indicated the hospice had mentioned home health aide services, but nobody ever came out to provide home health aide services. Person #3 did not know about any homemaker services covered under the hospice benefit. Person #3 indicated they were not aware of volunteer services, but would like for Patient #9 to receive volunteer services.

Based on observation, record review, and interview, the hospice agency failed to: ensure the plan of care was developed in collaboration with the physician and/or the patient or representative (Please see tag L543); ensure each patient or caregiver received appropriate education and training regarding their responsibilities for the services ordered in the plan of care (Please see tag L544); ensure patients had an individualized plan of care which included patient and family goals and interventions based on the comprehensive assessment (Please see tag L545); ensure the plan of care included all drugs and treatments necessary to meet the needs of the patient (Please see tag L549); ensure the plan of care included all medical supplies and equipment necessary to meet the patients needs (Please see tag L550); ensure the interdisciplinary group documented the patient or representatives level of understanding, involvement, and agreement with the plan of care, in the clinical record (Please see tag L551); revise and update the plan of care as frequently as the patients condition required (Please see tag L552); ensure the patient's progress/barriers toward outcomes and goals was discussed or included on revised plans of care (Please see tag L553); ensure services were coordinated, and communicated in accordance with the agencys policies and procedures to ensure the interdisciplinary groups responsibility to coordinate and supervise the care and service provided (Please see tag L554); ensure care was provided as ordered on the plan of care (Please see tag L555); and ensure sharing of information between all disciplines providing care (Please see tag L557). This practice had the potential to affect all patients the agency served. The findings include: --- The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care for the Condition of Participation 42 CFR §418.56: Interdisciplinary group, care planning, and coordination of services

Based on observation, record review, and interview, the hospice failed to ensure the plan of care was developed in collaboration with the physician and/or the patient or representative in 3 of 10 active clinical records reviewed (Patients #4, 12, 14). The findings include: --- 5. Clinical record review for Patient #4 was completed on 3/23/2023 at 2:10 PM (start of care date 1/09/2023). The patients consent form indicated Person #2 was the patients chosen attending physician. Record review evidenced IDG revised/updated plans of care for dates 3/01/2023 and 3/15/2023. The documents failed to evidence the plans of care were revised/updated in collaboration with Person #2, the patient, or the patients primary caregiver. During an interview on 3/16/2023, Person #6 (family/primary caregiver) indicated he didnt know who Person #2 or the hospice agencys Medical Director was. During an interview on 3/21/2023 at 2:41 PM, the Clinical Manager indicated the patients attending physicians were not involved with IDG meetings, attending physicians were given updates after the plans of care were developed/revised, the updates were typically faxed, and she believed it would be reflected in the updated plans of care. The Clinical Manager indicated the patient previously resided at Entity #4 (a skilled nursing facility [SNF]), Person #2 was Entity #4s Medical Director, so thats why he was originally listed as the patients primary care/attending physician. 1. Record review evidenced an agency policy revised 7/2016, titled "Interdisciplinary Group Plan of Care Policy" which stated, "... All hospice care and services privided to patietns and their familieis follow an individualized plan of care established by the IDG, in collaboration with the attending physician [if any], the patient or representative, and the primary caregiver in accordance with the patient's needs ensuring all participate in the development of the plan of care and ongoing changes ...." 2. Observation of a home visit for Patient #9 was conducted on 3/15/2023, at 10:00 AM, to observe a routine chaplain visit. During the visit, the patient was observed to reside in a locked memory care unit. The patient was observed to be alert but confused, and minimally interactive. Clinical record review for Patient #9 was completed on 3/23/2023. Record review evidenced a plan of care for certification period 12/14/20222 – 3/13/2023, which indicated the patient was to receive home health aide visits 2 times weekly for 12 weeks, social work visits twice monthly for 3 months, and chaplain visits one time monthly for one month. Record review evidenced the patient failed to receive home health aide visits until 2/3/2023 (51 days after orders), failed to receive social work services twice monthly for 12/2022, 1/2023, and 2/2/2023, and failed to receive chaplain visits until 3/15/2023 (next certification period). During an interview on 3/20/2023, at 9:12 AM, Person #3 (Patient #9s representative) indicated the hospice agency did not mention chaplain services until 1 or 2 weeks prior to 3/20/2023. Person #3 indicated the hospice had mentioned home health aide services, but nobody ever came out to provide home health aide services. Person #3 was unsure why the home health aide never came, but could have used the extra help. Person #3 indicated they thought they were going to have a case conference with the staff from the hospice agency, but it never happened. 3. Clinical record review for Patient #12 was completed on 3/23/2023. Record review evidenced a plan of care for certification period 2/18/2023 – 4/18/2023, which indicated the hospice physician was the Medical Director, and the attending physician was the Medical Director. This document included a section for the attending physician to review and sign the plan of care, and this section stated, ";... Do not send ...." Record review evidenced a consent to treat document dated 12/20/2022, which indicated Physician #16 was the attending physician chosen by the patient. Record review failed to evidence the plan of care was developed in collaboration with the attending physician. During an interview on 3/21/2023 at 2:41 PM, the Clinical Manager indicated the patients attending physicians were not involved with IDG meetings, attending physicians were given updates after the plans of care were developed/revised, the updates were typically faxed, and she believed it would be reflected in the updated plans of care. 4. Observation of a home visit for Patient #14 was conducted on 3/16/2023, at 4:00 PM, to observe a routine social work visit. During the visit, the patient indicated to the social worker they wanted a motorized wheelchair due to decreased mobility. The social worker indicated they would try to have a case conference to obtain this for the patient. Clinical record review for Patient #14 was completed on 3/23/2023, for certification period 1/1/2023 – 3/31/2023. Record review evidenced a plan of care update dated 1/4/2023, which indicated Physician #2 was the attending physician, but also indicated the updated plan of care was not sent to the attending physician for care coordination. Record review failed evidenced the hospice held an interdisciplinary group meeting on 3/15/2023 (1 day prior to home visit). Record review on 3/23/2023, failed to evidence any interdisciplinary group communication regarding patients request for a motorized wheelchair. During an interview on 3/23/2023, at 1:38 PM, the Clinical Manager indicated they had not heard anything about the patients request for a motorized wheelchair and were unaware of the request. The Clinical Manager indicated they didnt know if there was a case conference to obtain a wheelchair for the patient.

Based on record review and interview, the hospice agency failed to ensure each patient or caregiver received appropriate education and training regarding their responsibilities for the services ordered in the plan of care in 1 of 3 active clinical records reviewed with wounds (Patient #10). The findings include: --- Record review evidenced an agency policy revised 7/2016, titled ";Interdisciplinary Group Plan of Care Policy" which stated, ";... As needed, patients will receive written instructions regarding treatments or aspects of care, which will be the responsibility of the patient to provide or follow through with ...." Clinical record review for Patient #10 was completed on 3/23/2023. Record review evidenced a plan of care for certification period 2/23/2023 – 5/23/2023, which indicated the patient was to receive skilled nursing visits 2 times weekly for wound care. The plan of care indicated the patient was to receive the following wound care daily: bilateral hips, buttocks, left ankle: cleanse with wound wash up, apply medihoney (wound ointment), calcium alginate (absorbent wound dressing), and foam dressing; left elbow: apply sure prep and heel cup; all other areas: apply sure prep. Record review evidenced a start of care assessment dated 2/23/2023, which indicated the patient was bedbound, non-verbal, had multiple wounds, a feeding tube, and Person #13 (caregiver/family member) was the patients caregiver. Record review evidenced a skilled nurse visit dated 2/24/2023, which indicated no wound dressings needed to be changed on 2/24/2023, because they were changed the prior day by the caregiver. Record review evidenced a skilled nurse visit note dated 2/28/2023, which indicated no wound care was provided, because the caregiver had changed the dressings on 2/27/2023. This visit note indicated the caregiver requested the dressings not be changed until 3/3/2023 (4 days later). Record review evidenced a skilled nurse visit note dated 3/14/2023, which indicated the nurse cleansed the left hip wound, applied hydrogel, and a foam dressing. This visit note indicated no other wound care was provided, because the caregiver had completed the dressing change the previous day, 3/13/2023. Record review evidenced a skilled nurse visit note dated 3/17/2023, which indicated no wound care was provided because the caregiver had changed the dressing the day prior 3/16/2023. Review of all visit notes failed to evidence the caregiver was provided with education on the necessity of daily dressing changes as ordered. During an interview on 3/21/2023, at 11:17 AM, the Clinical Manager indicated the caregiver should have been provided education regarding daily dressing changes. The Clinical Manager did not know if the caregiver was changing the dressings daily. At 11:19 AM, the Clinical Manager indicated the patient's caregiver was very particular. Surveyor attempted to call the patient's caregiver, on 3/17/2023, at 3:03 PM, and 3/20/2023, at 9:12 AM, with no answer or call back.

Based on record review and interview, the hospice agency failed to ensure patients had an individualized plan of care which included patient and family goals and interventions based on the comprehensive assessment in 8 of 10 active clinical records reviewed (Patient #4, #5, #6, #7, #9, #10, #11, #13) The findings include: --- 6. Clinical record review for Patient #4 was completed on 3/23/2023 at 2:10 PM (start of care date 1/09/2023). Record review evidenced an initial comprehensive assessment dated 1/09/2023. The document evidenced the patient's pain goal was to have no pain, had no cardiovascular needs, poor appetite, and stated "... consider dietary consult ...."; difficulty chewing, high nutritional risk, took nutritional supplemental drinks, and was alert and oriented. Record review evidenced a plan of care for benefit period 1/09/2023 - 3/09/2023. The plan of care evidenced diagnoses included severe protein-calorie malnutrition, chronic pain, and constipation; goals included to follow an effective bowel program, increases in confusion would be addressed, pain would be managed at an acceptable level, and the patient would receive appropriate pain management; diet included soft foods with nectar thick liquids, but also indicated diet was soft diet with chopped meats and thin liquids; and supplies included a foam dressing for the heel. The plan of care failed to be individualized to include the patient's pain goal of no pain, interventions to include dietary consult, what bowel program was appropriate for the patient, what pain management was appropriate for the patient, the patient took nutritional supplements, the patient's actual diet, or interventions/goals for the heel dressing. During an interview on 3/21/2023 at 2:41 PM, the Clinical Manager indicated she didn't know if the agency had a bowel program protocol, and they would have to get an order from the physician. The Clinical Manager indicated a dietary referral wasn't made, the plan of care didn't include the patient's pain goal, wasn't individualized, and the diet was incorrect. 7. Clinical record review for Patient #5 was completed on 3/23/2023 (start of care date 1/05/2023). Record review evidenced an initial comprehensive assessment dated 1/05/2023. The document evidenced the patient did not want CPR or other life-sustaining treatments, patient's pain goal was "2", had no respiratory needs, wore a condom catheter for urinary drainage, feet were red/purple and cold to touch, and the patient used a Trilogy ventilator machine (unknown if invasive or non-invasive) for assistance with breathing at night and intermittently throughout the day. Record review evidenced a plan of care for benefit period 1/05/2023 - 4/04/2023. The plan of care evidenced diagnoses included Amyotrophic Lateral Sclerosis (ALS), dependence on supplemental oxygen, and dependence on other enabling machines and devices; nurse may insert urinary catheter size 16FR-18FR/5-10CC bulb for bladder dysfunction, aspiration precautions, diet as tolerated, and advance directives included both DNR and Full Code. The plan of care failed to be individualized to include the patient's wish to be a DNR, patient's pain goal was "2", any information about the Trilogy ventilator machine, how much oxygen, mode of delivery, or frequency the patient used, or the patient used a condom catheter, not an indwelling catheter; interventions or goals for ALS or risk for aspiration, or for feet that were red/purple and cold to touch. During an interview on 3/23/2023 at 2:33 PM, the Clinical Manager indicated the plan of care didn't include the patient's own goals, it wasn't individualized, lacked patient specific interventions and goals, and should have included information about the Trilogy machine and oxygen. 8. Clinical record review for Patient #6 was completed on 3/23/2023 (start of care date 2/25/2023). Record review evidenced an initial comprehensive assessment dated 2/25/2023. The document evidenced the patient was alert, but nonverbal, impaired cognition, unable to make needs known, unable to provide a personal pain goal, no respiratory concerns, moderate nutritional risk, did not use oxygen, and resided in a facility. Record review evidenced a plan of care for benefit period 2/25/2023 - 5/25/2023. The plan of care evidenced diagnoses included protein-calorie malnutrition and constipation; interventions included nurse may insert urinary catheter size 16FR-18FR/5-10CC bulb for bladder dysfunction, instruct regarding cardiopulmonary symptom relief measures, appropriate bowel protocol, report ineffective pain control, and nurse to assess effectiveness of cardiopulmonary symptom relief measures including oxygen treatment. Goals included a pain goal of "4", goals related to CHF and COPD (heart and lung disease), follow an effective bowel program, pain managed at a level acceptable to the patient, and no signs/symptoms of aspiration. The plan of care failed to be individualized to include if the patient had diagnoses of CHF or COPD, or other cardiopulmonary diagnoses, what bowel program was appropriate for the patient, what pain management was appropriate for the patient, what specific size of urinary catheter the patient would require, or how much oxygen, mode of delivery, or frequency the patient used (comprehensive assessment indicated the patient did not use oxygen). During an interview on 3/23/2023 2:45 PM, the Clinical Manager indicated she saw a trend with the care plans being similar, and not individualized to the patient. 9. Clinical record review for Patient #7 was completed on 3/23/2023 (start of care date 2/17/2023). Record review evidenced an initial comprehensive assessment dated 2/17/2023. The document evidenced the patients pain goal was ";minimal pain", was non-verbal, experienced dizziness/vertigo, had a traumatic wound to facial right forehead, but it wasnt assessed due to a non-removable dressing, which could be removed 2/19/2023; moderate nutritional risk, weight loss with multiple signs of malnutrition, multiple falls resulting in various injuries, poor impulse control; and then indicated the wound to the right facial forehead was open to air. Record review evidenced a plan of care for benefit period 2/17/2023 – 4/17/2023. The plan of care evidenced diagnoses included hypertensive chronic kidney disease; interventions included nurse may insert urinary catheter size 16FR-18FR/5-10CC bulb for bladder dysfunction, instruct regarding cardiopulmonary symptom relief measures, appropriate bowel protocol, and nurse to assess effectiveness of cardiopulmonary symptom relief measures including oxygen treatment. Goals included a pain goal of "4", goals related to CHF, and follow an effective bowel program. The plan of care failed to be individualized to include if the patient had diagnoses of CHF, what bowel program was appropriate for the patient, what specific size of urinary catheter the patient would require, how much oxygen, mode of delivery, or frequency the patient used, orders for wound care/treatment, or individualized interventions/goals for hypertensive chronic kidney disease, dizziness/vertigo, nutritional risk with multiple signs of malnutrition, multiple falls with multiple injuries, or interventions/goals for pain. During an interview on 3/23/2023 2:55 PM, the Clinical Manager indicated the plan of care wasnt individualized to the patient and should have addressed the patients wound treatment. 1. Record review evidenced an agency policy revised 7/2016, titled ";Interdisciplinary Group Plan of Care Policy" which stated, ";... All hospice care and services provided to patients and their families follow an individualized plan of care ...." 2. Clinical record review for Patient #9 was completed on 3/23/2023, for certification period 12/14/2022 – 3/13/2023. Record review evidenced a start of care comprehensive assessment dated 12/14/2022, which indicated the patient was not short of breath, and did not use oxygen. The comprehensive assessment indicated the patient did not have any gastrointestinal issues such as constipation. The comprehensive assessment indicated the patient was a high fall risk, and indicated the patient had too many falls to count. The comprehensive assessment indicated the primary hospice diagnosis was protein calorie malnutrition, and was eating only 3 cups of food daily, and taking a nutritional supplement. Record review evidenced a plan of care for certification period 12/14/2022 – 3/13/2023, which included the following intervention, which was not pertinent to problems identified on the patients comprehensive assessment: hospice nurse to assess effectiveness of cardiopulmonary symptom relief measures including oxygen treatment. The plan of care included the following intervention: instruct patient/caregiver regarding appropriate bowel protocol as needed, but failed to be individualized to specify what the specific bowel protocol was for Patient #9. The plan of care failed to include any interventions to prevent falls. The plan of care failed to be individualized to include the nutritional supplements the patient was taking. During an interview on 3/21/2023, at 12:14 PM, the Clinical Manager indicated the plan of care should have been based on the patients primary diagnosis, medications they were taking, and other pertinent symptoms identified on the assessments. The Clinical Manager indicated the plan of care should have included specific bowel regimen instructions, nutritional supplements, and interventions to prevent falls. At 12:52 PM, the Clinical Manager indicated the plan of care for a patient with malnutrition as a primary diagnosis should have included education on end of life nutritional need changes, offering oral supplements, and offering food they could tolerate. 3. Clinical record review for Patient #10 was completed on 3/23/2023, for certification period 2/23/2023 – 5/23/2023. Record review evidenced a start of care comprehensive assessment dated 2/23/2023, which indicated the patient had labored breathing, hyperventilation, abnormal breath sounds, and increased secretions. Record review evidenced a plan of care for certification period 2/23/2023 – 5/23/2023, which failed to include any interventions related to the respiratory issues identified in the comprehensive assessment. During an interview on 3/21/2023, at 1:48 PM, the Clinical Manager indicated the plan of care should have included interventions and goals to address the patients respiratory issues. 4. Clinical record review for Patient #11 was completed on 3/23/2023, for certification period 2/19/2023 – 4/19/2023. Record review evidenced a plan of care update which indicated the patient had a primary hospice diagnosis of protein calorie malnutrition. Record review evidenced a plan of care and comprehensive assessment update report dated 3/1/2023, which indicated the patient had lower extremity weakness, and was developing contractures (shortening and hardening of muscles) to the lower extremities. Record review evidenced a plan of care for certification period 2/19/2023 – 4/19/2023, which failed to include interventions or goals related to malnutrition or contractures. During an interview on 3/22/2023, at 1:41 PM, the Clinical Manager indicated the plan of care should have included interventions such as doing education on facility staff and end of life nutritional needs, educating the staff and family that it was okay to offer food and fluids but not force them on the patient. The Clinical Manager indicated the plan of care should have included interventions to address contractures such as interventions such as positioning with pillows and other methods to prevent contractures. 5. Clinical record review for Patient #13 was completed on 3/23/2023, for certification period 2/21/2023 – 5/21/2023. Record review evidenced a start of care assessment dated 2/21/2023, which indicated the patient had no pain. Record review evidenced an interdisciplinary group meeting dated 3/1/2023, which indicated the patient required nutritional supplements. Record review evidenced a plan of care for certification period 2/21/2023 – 5/21/2023, which included a pain goal of 3/10 pain. The plan of care failed to include nutritional supplements. During an interview on 3/22/2023, at 3:26 PM, the Clinical Manager indicated the pain goal should have been individualized to the patient and not been 3/10. At 3:35 PM, the Clinical Manager indicated the plan of care should have been individualized to include nutritional supplements.

Based on record review and interview, the hospice agency failed to ensure the plan of care included all drugs and treatments necessary to meet the needs of the patient in 7 of 11 active clinical records reviewed (Patient #4, 5, 7, 9, 10, 12, 13). The findings include: --- 6. A home visit with Patient #4 occurred on 3/16/23 at 1:30 PM. Observed a wound dressing on the patients upper back, over the spine. The patient complained of constipation. RN #2 asked the patient if she was taking her Miralax. The patient indicated she didnt know. The patient complained of a cough and sore throat. Observed over-the-counter cough drops on the bedside table. RN #2 asked the patient if her cough drops were working, to which the patient indicated they were. Clinical record review for Patient #4 was completed on 3/23/2023 (start of care date 1/09/2023). Record review evidenced a plan of care for benefit period 1/09/2023 - 3/09/2023. The plan of care failed to evidence the patients medications included Miralax or over-the-counter cough drops, or any wound care orders. During an interview on 3/21/2023 at 2:41 PM, the Clinical Manager indicated the plans of care should include wound care orders and all drugs the patient used. 7. Clinical record review for Patient #5 was completed on 3/23/2023 (start of care date 1/05/2023). Record review evidenced an initial comprehensive assessment dated 1/05/2023. The document evidenced the patient wore a condom catheter for urinary drainage, and the patient used a Trilogy ventilator machine (unknown if invasive or non-invasive) for assistance with breathing at night and intermittently throughout the day. Record review evidenced a plan of care for benefit period 1/05/2023 - 4/04/2023. The plan of care failed to include what size condom catheter the patient used, or how often it was supposed to be changed; or information about settings on the Trilogy ventilator machine or who managed the use of the ventilator. During an interview on 3/23/2023 at 2:33 PM, the Clinical Manager indicated the plan of care should have included information about the Trilogy machine and oxygen. 8. Clinical record review for Patient #7 was completed on 3/23/2023 (start of care date 2/17/2023). Record review evidenced an initial comprehensive assessment dated 2/17/2023. The document evidenced the patient had a traumatic wound to facial right forehead, but it wasnt assessed due to a non-removable dressing, which could be removed 2/19/2023; and then indicated the wound to the right facial forehead was open to air. Record review evidenced a plan of care for benefit period 2/17/2023 – 4/17/2023. The plan of care failed to evidence orders for wound care/treatment. During an interview on 3/23/2023 2:55 PM, the Clinical Manager indicated the plan of care should have addressed the patients wound treatment. 1. Record review evidenced an agency policy revised 7/2016, titled ";Interdisciplinary Group Plan of Care Policy" which stated, ";... The plan of care will include, but not be limited to: ... Drugs and treatment necessary to meet the needs of the patient ...." 2. Clinical record review for Patient #9 was completed on 3/23/2023. Record review evidenced a plan of care update for certification period 12/14/2022 – 3/13/2023, dated 3/1/2023, which included an order for nystatic (antifungal powder) twice daily as needed topically, but failed to include a location of application. During an interview on 3/21/2023, at 12:26 PM, the Clinical Manager indicated the plan of care should have included location of application for topical medication. 3. Clinical record review for Patient #10 was completed on 3/23/2023. Record review evidenced a plan of care for certification period 2/23/2023 – 5/23/2023, which indicated the patient had a feeding tube, and only took small amounts of pleasure feeds orally. The plan of care included orders for the following medications orally instead of per feeding tube: acetaminophen (for fever/pain), Benadryl (for allergies), Eliquis (blood thinner), ibuprofen (for pain/fever), jevity (tube feeding), Keppra (to prevent seizures), and lorazepam (for anxiety). Record review evidenced a skilled nurse visit note dated 3/7/2023, which indicated the caregiver was instructed on a new hydrogel (wound treatment) dressing to be applied to the wounds. Record review failed to evidence any orders for hydrogel, as indicated in the skilled nurse visit. During an interview on 3/21/2023, at 1:31 PM, the Clinical Manager indicated all Patient #10s medications should have been administered through the feeding tube, not orally. The Clinical Manager indicated the plan of care should have included this information. The Clinical Manager did not see any orders for hydrogel in the chart. 4. Clinical record review for Patient #12 was completed on 3/23/2023. Record review evidenced a plan of care for certification period 2/18/2023 – 4/18/2023, which indicated the patient was to receive skilled nursing once weekly, home health aide twice weekly, social work once weekly, and chaplain visits once weekly. Record review evidenced a social work visit note dated 2/27/2023, which indicated the patient was declining in terms of weakness and trunk control, and this impacted care needs. Record review evidenced a skilled nurse visit note dated 3/3/2023, which indicated the patients caregiver was having trouble getting the patient up to sit on the side of the bed. Record review failed to evidence homemaker services, or increased frequency of home health aide visits was offered to the caregiver to meet patients increasing care needs. The plan of care failed to include all services necessary to meet patients needs. 5. Clinical record review for Patient #13 was completed on 3/23/2023, for certification period 2/21/2023 – 5/21/2023. Record review evidenced a plan of care which included interventions for oxygen use, but failed to include oxygen orders. During an interview on 3/22/2023, at 3:34 PM, the Clinical Manager indicated oxygen orders should have been included under medications in the plan of care.

Based on observation, record review, and interview, the hospice agency failed to ensure the plan of care included all medical supplies and equipment necessary to meet the patients needs in 6 of 11 active clinical records reviewed (Patient #4, 5, 6, 9, 13, 14). The findings include: --- 5. A home visit with Patient #4 occurred on 3/16/23 at 1:30 PM. Observed a wound dressing on the patients upper back, over the spine. Observed boxes of wound care dressings in the patient's bedroom near the bed. Clinical record review for Patient #4 was completed on 3/23/2023 (start of care date 1/09/2023). Record review evidenced a plan of care for benefit period 1/09/2023 - 3/09/2023, which failed to evidence wound care supplies the patient used. During an interview on 3/21/2023 at 2:41 PM, the Clinical Manager indicated wound supplies should be on the plans of care. 6. Clinical record review for Patient #5 was completed on 3/23/2023 (start of care date 1/05/2023). Record review evidenced an initial comprehensive assessment dated 1/05/2023. The document evidenced the patient wore a condom catheter for urinary drainage, used a hospital bed with bedrails, a mechanical lift, and an over the bed table. Record review of a plan of care for benefit period 1/05/2023 - 4/04/2023 failed to evidence the patient's supplies included condom catheters, hospital bed with bedrails, a mechanical lift, or an over the bed table. 7. Clinical record review for Patient #6 was completed on 3/23/2023. Record review evidenced an initial comprehensive assessment dated 2/25/2023. The document evidenced the patient used bedrails, a bedside commode, and a cane. Record review of a plan of care for benefit period 2/25/2023 - 5/25/2023 failed to evidence the patient's supplies included bedrails, a bedside commode, or a cane. 1. Record review evidenced an agency policy revised 7/2016, titled ";Interdisciplinary Group Plan of Care Policy" which stated, ";... the plan of care will contain, but not be limited to: ... Medical supplies and appliances necessary to meet the needs of the patient ..." 2. Observation of a home visit for Patient #9 was conducted on 3/15/2023, at 10:00 AM, to observe a routine chaplain visit. During the visit, the following equipment was observed, which was not included in the plan of care: walker, wheelchair, shower chair, and hospital bed. During an interview on 3/21/2023, at 12:35 PM, the Clinical Manager indicated all equipment in the patients places of residence should have been included in the plans of care. 3. Clinical record review for Patient #13 was completed on 3/23/2023, for certification period 2/21/2023 – 5/21/2023. Record review evidenced a plan of care which included interventions for oxygen use, but failed to include oxygen equipment in the plan of care. During an interview on 3/22/2023, at 3:34 PM, the Clinical Manager indicated oxygen supplies should have been included in the plan of care. 4. Observation of a home visit for Patient #14 was conducted on 3/16/2023, at 4:00 PM, to observe a routine social worker visit. During the visit, the following equipment was observed, which was not included in the plan of care: hospital bed, wheelchair, grabber, cane, walker, and prosthetic leg.

Based on observation, record review, and interview, the hospice agency failed to ensure the interdisciplinary group documented the patient or representatives level of understanding, involvement, and agreement with the plan of care, in the clinical record in 11 of 11 active clinical records reviewed (Patient #4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14). The findings include: --- 8. Clinical record review for Patient #4 was completed on 3/23/2023 at 2:10 PM. Record review evidenced a plan of care for certification period 1/09/2023 - 3/09/2023, which failed to include documentation of the patient or representatives level of understanding, involvement, and agreement with the plan of care. During an interview on 3/21/2023 at 5:51 PM, Person #6 (family/primary caregiver) indicated he was unaware that he could participate in the development of the plan of care, like how many times he needed staff to come. 9. Clinical record review for Patient #5 was completed on 3/23/2023 at 2:33 PM. Record review evidenced a plan of care for certification period 1/05/2023 - 4/04/2023, which failed to include documentation of the patient or representatives level of understanding, involvement, and agreement with the plan of care. 10. Clinical record review for Patient #6 was completed on 3/23/2023. Record review evidenced an updated plan of care dated 3/15/2023, for certification period 2/25/2023 - 5/25/2023, which failed to include documentation of the patient or representatives level of understanding, involvement, and agreement with the updated plan of care. 11. Clinical record review for Patient #7 was completed on 3/23/2023. Record review evidenced a plan of care for certification period 2/17/2023 - 4/17/2023, which failed to include documentation of the patient or representatives level of understanding, involvement, and agreement with the plan of care. 12. Clinical record review for Patient #8 was completed on 3/23/2023. Record review evidenced an updated plan of care dated 3/15/2023, for certification period 2/19/2023 - 4/19/2023, which failed to include documentation of the patient or representatives level of understanding, involvement, and agreement with the updated plan of care. 1. Record review evidenced an agency policy revised 7/2016, titled ";Interdisciplinary Group Plan of Care Policy" which stated, ";... The plan of care will contain the following, but not be limited to: ... Documentation of the patients or representatives level of understanding, involvement, and agreement with the plan of care, in accordance with the hospices own policies ...." 2. Clinical record review for Patient #9 was completed on 3/23/2023. Record review evidenced a plan of care for certification period 12/14/2022 – 3/13/2023, which failed to include documenation of the patient or representatives level of understanding, involvment, and agreement with the plan of care. During an interview on 3/21/2023, at 1:00 PM, the Clinical Manager indicated the patient/representatives level of agreement, understanding, and involvement in the plan of care should have been documented, in the visit notes. 3. Clinial record review for Patient #10 was completed on 3/23/2023. Record review evidenced a plan of care for certification period 2/23/2023 – 5/23/2023, which failed to include documentation of the patient or representatives level of understanding, involvement, and agreement with the plan of care. 4. Clinical record review for Patient #11 was completed on 3/23/2023. Record review evidenced a plan of care for certification period 2/19/2023 – 4/19/2023, which failed to include documentation of the patient or representatives level of understanding, involvement, and agreement with the plan of care. 5. Clinical record review for Patient #12 was completed on 3/23/2023. Record review evidenced a plna of care for certifciation period 2/18/2023 – 4/18/2023, which failed to include documentation of the patient or representatives level of understanding, involvement, and agreement with the plan of care. 6. Clinical record review for Patient #13 was completed on 3/23/2023. Record review evidenced a plan of care for certifciation period 2/21/2023 – 5/21/2023, which failed to include documentation of the patient or representatives level of understanding, involvement, and agreement with the plan of care. 7. Clinical record review for Patient #14 was completed on 3/23/2023. Record review evidenced a plan of care for certification period 1/1/2023 – 3/31/2023, which failed to include documentation of the patient or representatives level of understanding, involvement, and agreement with the plan of care.

Based on record review and interview, the hospice Interdisciplinary Group (IDG) failed to revise and update the plan of care in 2 of 2 active clinical records reviewed with patients who experienced a change in condition (Patient #9, 10). The findings include: --- 1. Record review evidenced an agency policy revised 7/2016, titled ";Interdisciplinary Group Plan of Care Policy" which stated, ";... Documented updates will be based on interdisciplinary group assessments ... The frequency of the updates of the Plan of Care will be based on changes in the patients status ...." 2. Clinical record review for Patient #9 was completed on 3/23/2023. Record review evidenced a plan of care for certifciation period 12/14/2022 – 3/13/2023, which failed to include any interventions related to falling. Record review evidenced a client occurrence report log, which indicated the patient fell on the following dates: 1/5/2023, 1/6/2023, 1/19/2023, and 3/3/2023. Record review evidenced a skilled nurse visit note dated 1/19/2023, which indicated the patient suffered a skin tear as a result of falling at home. Record review evidenced a skilled nurse visit note dated 3/4/2023, which indicated the patient suffered from a black eye as a result of falling. Record review evidenced a skilled nurse visit note dated 3/14/2023, which indicated the patients black eye had now developed a hematoma above the right eye. Record review evidenced the interdisciplinary group updated the plan of care on the following dates (every 15 days) 1/17/2023, 2/1/2023, and 3/15/2023. Record review failed to evidence the plan of care was updated more frequently than every 15 days, to address the change in status which included falls, skin tears, bruising, and hematoma. During an interview on 3/21/2023, at 12:55 PM, the Clinical Manager indicated the plans of care were updated at interdisciplinary group meetings every 2 weeks. 3. Clinical record review for Patient #10 was completed on 3/23/2023. Record review evidenced a plan of care for certification period 2/23/2023 – 5/23/2023, which indicated the patient was to receive the following wound care daily: bilateral hips, buttocks, left ankle: cleanse with wound wash up, apply medihoney (wound ointment), calcium alginate (absorbent wound dressing), and foam dressing; left elbow: apply sure prep and heel cup; all other areas: apply sure prep. The plan of care indicated the skilled nurse was to visit 2 times weekly for wound care. Record review evidenced a start of care visit dated 2/23/2023, which included the following wound measurements: Left hip: 2.6cm (centimeters) x 3.1cm x 0cm; right hip: 2.8cm x 3.8cm x 0 cm; coccyx: 7.4cm x 5.3cm x 0.5 cm. Record review evidenced a skilled visit note dated 3/3/2023, which included the following wound measurements: Left hip: 7cm x 7.2cm x 0cm; right hip: 4.1cm x 3cm x 0 cm; coccyx: 7.4cm x 5.3cm x 2.6 cm. Record review failed to evidence the plan of care was updated due to the enlarging wounds. Record review evidenced a skilled nurse visit note dated 3/7/2023, which indicated the patient had new areas of black skin on toes, but failed to evidence the plan of care was updated or revised. Record review evidenced a skilled nurse visit note dated 3/10/2023, which included the following wound measurements: Left hip: 8cm x 7.9cm x 0cm; right hip: 5cm x 3.8cm x 0 cm; coccyx: 7cm x 5.3cm x 4cm. Record review failed to evidence the plan of care was updated or revised due to enlarging wounds. Record review evidenced interdisciplinary group meetings on the following dates: 3/1/2023, and 3/15/2023. During an interview on 3/21/2023, at 2:00 PM, the Clinical Manager indicated the plan of care and orders should have been updated for enlarging or worsening wounds.

Based on observation and interview, the Interdisciplinary Group (IDG) failed to ensure the patient's progress/barriers toward outcomes and goals was discussed or included on revised plans of care for 1 of 1 IDG meeting observed (3/15/2023). The findings include: --- On 3/15/2023 at 2:00 PM, the hospice agency IDG meeting was observed. The IDG group discussed Patients #4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14. The IDG failed to discuss any of the patients' hospice goals, or progress/barriers toward goals. During an interview on 3/13/2023 at 12:32 PM, the Clinical Manager indicated the purpose of the IDG meetings was to discuss any changes in the patients over the past 2 weeks, and discuss the plan for moving forward for the next 2 weeks. During an interview on 3/21/2023 at 2:41 PM, the Clinical Manager indicated the IDG meetings were documented as, and represented the updated plans of care. Record review evidenced an agency policy revised 7/2016, titled "Interdisciplinary Group Plan of Care Policy" which stated, "... The Plan of Care will contain the following, but not be limited to: ... Measurable outcomes anticipated from implementing and coordinating the plan of care ...." During the interdisciplinary group meeting on 3/15/2023 at 2:00 PM, the Medical Director indicated they did not want to go over everything about the patients, and only wanted to know information if there was an issue with a patient because the meeting would take 3 hours then.

Based on record review and interview, the hospice failed to ensure services were coordinated, and communicated in accordance with the agencys policies and procedures to ensure the interdisciplinary groups responsibility to coordinate and supervise the care and service provided in 1 of 1 clinical records reviewed who had a private pay caregiver (Patient #9). The findings include: --- 1. Record review evidenced an agency policy revised 7/2016, titled ";Hospice Coordination of Services Policy" which stated, ";... If a patient is receiving care or services from two or more disciplines or organizations at the same time, coordination of care will include: ... Staff understanding of each discipline or organizations responsibility in providing care or services ... Initiation of communication with other disciplines or organizations when there are significant changes in the patients overall care; and ... An absence of duplication and conflict of services provided to the patient ... The IDG team maintains primary responsibility for directing, coordinating, and supervising patient care and services provided within the agency ...." 2. Record review evidenced an undated agency policy obtained 3/15/2023, titled ";Reporting and Recording Patient Related Occurrences Policy" which stated, ";... An occurrence may include, but is not limited to: ... Falls ... The employees supervisor or Clinical Manager will notify the patients physician as indicated and coordinate any action and follow-up to assure the patients safety ...." 3. Clinical record review for Patient #9 was completed on 3/23/2023, for certification period 12/14/2022 – 3/13/2023. Record review evidenced a social work visit note dated 12/16/2023, which indicated the patient had a private pay caregiver Monday through Friday 8:00 AM – 5:00 PM, but failed to document the name of the private pay caregiver, coordination of care, or what interventions the private caregiver was providing to the patient. Record review evidenced a plan of care for certification period 12/14/2022 – 3/13/2023, which indicated the patient was to receive home health aide visits 2 times weekly for 12 weeks. Record review evidenced home health aide visit notes which indicated the patient did not receive home health aide visits until 2/3/2023 (51 days after aide visits ordered). Record review failed to evidence any care coordination between the hospice and the private duty caregivers. Record review evidenced an occurrence report which indicated the patient fell on the following dates: 1/7/2023 (twice), 1/19/2023, 3/3/2023, and 3/4/2023. Record review failed to evidence the phsyician was notified of the patients falls on 3/3/2023, and 3/4/2023, as per policy. During an interview on 3/21/2023, at 11:53 AM, the Clinical Manager indicated Patient #9 did not receive a home health aide until 51 days later because the patient was receiving services from a private caregiver. The Clinical Manager indicated the agency should have coordinated care with the private duty caregiver. The Clinical Manager indicated they did not have documentation of what interventions the private duty caregiver was completing. The Clinical Manager indicated the care coordination note was not in the chart as it should have been. At 12:21 PM, the Clinical Manager indicated the hospice staff were not required to notify the physician of falls if there were no injuries. The Clinical Manager indicated the staff determined there were no injuries after a fall if there was no broken skin, the patient had no pain, and the neurological assessment was within normal limits.

Based on record review and interview, the hospice failed to ensure care was provided as ordered on the plan of care in 3 of 11 active clinical records reviewed (Patients #9, 10, 11). The findings include: --- 1. Record review evidenced an agency policy revised 7/2016, titled ";Interdisciplinary Group Plan of Care Policy" which stated, ";... All hospice care and services provided to patients and their families follow an individualized plan of care ...." 2. Clinical record review for Patient #9 was completed on 3/23/2023. Record review evidenced a plan of care for certification period 12/14/2022 – 3/13/2023, which indicated the skilled nurse was to visit 2 times weekly for 13 weeks. The plan of care indicated the home health aide was to visit 1 time weekly for 1 week and 2 times weekly for 12 weeks. Record review evidenced a start of care assessment dated 12/14/2022, which indicated the patient/representative were accepting of chaplain, social work, and home health aide services, and requesting respite care. Record review evidenced a social work plan of care dated 12/16/2022, which indicated the social worker was ordered to visit the patient 2 times per month for 3 months, effective 12/14/2022. Record review evidenced social work visit notes dated 12/16/2022, and 2/3/2023, which failed to evidence the patient received social worker visits twice monthly as ordered for the months of 12/2022 and 1/2023. Record review evidenced skilled nurse visit notes dated 1/7/2023, and 12/20/2023, which indicated the patient only received 1 skilled nurse visit for the weeks of 1/1/2023, and 12/18/2023. Record review failed to evidence the physician was notified of the missed visits. Record review evidenced a home health aide visit note dated 2/3/2023, but failed to evidence any home health aide visit notes prior to 2/3/2023, as ordered on the plan of care. Record review failed to evidence documentation of reason for delay in home health aide services. During an interview on 3/21/2023, at 11:49 AM, the Clinical Manager indicated Patient #9 had missed visits due to inclement weather. The Clinical Manager indicated the physician was not notified of the missed visits. The Clinical Manager indicated the patients should have received the number of visits ordered on the plan of care. At 11:52 AM, the Clinical Manager indicated the family refused the home health aide, but indicated this should have been documented somewhere, and was not. At 12:10 PM, the Clinical Manager indicated the patient may have declined social work services and that was why they didnt receive the visits twice monthly as ordered. 3. Clinical record review for Patient #10 was completed on 3/23/2023. Record review evidenced a plan of care for certification period 2/23/2023 – 5/23/2023, which indicated the patient was to receive the following wound care daily: bilateral hips, buttocks, left ankle: cleanse with wound wash up, apply medihoney (wound ointment), calcium alginate (absorbent wound dressing), and foam dressing; left elbow: apply sure prep and heel cup; all other areas: apply sure prep. Record review evidenced a start of care visit dated 2/23/2023, which failed to specify what specific wound care was provided to all wounds. Record review evidenced a skilled nurse visit dated 2/24/2023, which indicated no wound dressings were changed during the visit, because they were changed the prior day. Record review evidenced a skilled nurse visit note dated 2/28/2023, which indicated no wound care was provided. Record review evidenced a skilled visit note dated 3/3/2023, which indicated wound care was provided, but failed to specify what specific dressing changes were performed. Record review evidenced a skilled nurse visit note dated 3/7/2023, which indicated wound care was provided for a coccyx (area at base of spine), left hip, and right ankle, but failed to specify what wound care was provided. This visit note indicated the patients caregiver applies hydrogel to unstageable wounds, but failed to specify which wounds were unstageable, or evidence an order for hydrogel. Record review evidenced a skilled nurse visit note dated 3/10/2023, which indicated wound care was provided to all wounds, but failed to evidence what specific wound care was provided. Record review evidenced a skilled nurse visit note dated 3/14/2023, which indicated the nurse cleansed the left hip wound, applied hydrogel, and a foam dressing. This visit note indicated no other wound care was provided. Record review evidenced a skilled nurse visit note dated 3/17/2023, which indicated no wound care was provided. During an interview on 3/21/2023, at 1:45 PM, the Clinical Manager indicated wound care should have been provided every visit, as ordered on the plan of care. The Clinical Manager did not see an order for hydrogel dressings. 3. Clinical record review for Patient #11 was completed on 3/23/2023, for certification period 2/19/2023 – 4/19/2023. Record review evidenced an order dated 2/24/2023, which indicated the patient was to receive home health aide visits 2 times weekly effective 2/19/2023. Record review evidenced home health aide visit notes dated 2/23/2023, and 3/2/2023, which indicated the patient only received 1 home health aide visit the week of 2/26/2023. During an interview on 3/22/2023, at 1:29 PM, the Clinical Manager indicated Patient #11 should have received 2 home health aide visits weekly.

Based on record review and interview, the hospice agency failed to ensure sharing of information between all disciplines providing care in 1 of 2 clinical records reviewed for which physical therapy was ordered (Patient #10). The findings include: --- Record review evidenced an undated agency policy obtained 3/21/2023, titled ";Services Under Contract Policy" which stated, ";... The contract shall include, but not be limited to the following: ... The role, if any, of the agency and the contracting individual or organization in: ... Coordination, supervision and evaluation of patient care ... The submission to the agency of appropriate documentation of services provided ...." Clinical record review for Patient #10 was completed on 3/23/2023, for certification period 2/23/2023 – 5/23/2023. Record review evidenced an order for physical therapy dated 3/10/2023. Record review failed to evidence documenation of the physical therapy notes or visit dates. During an interview on 3/21/2023, at 1:36 PM, the Clinical Manager indicated the contracted therapy agency should have sent over whatever the therapy schedule was. The Administrator indicated the contracted therapists documented their visits on paper, and indicated no visit notes were sent over yet. The Administrator indicated the therapists were visiting Patient #10 twice weekly, and the therapist had conducted an initial visit. The Administrator did not know the dates of any visits. The Administrator did not know who specifically the therapist was who was seeing Patient #10.

Based on observation, record review, and interview, the Registered Nurse (RN) failed to properly disinfect reusable equipment, and failed to properly perform hand hygiene practices (Please see tag L579); and failed to ensure it tracked COVID-19 vaccination status for all applicable employees, contracted staff, and other person(s) who had the potential to transmit COVID-19 to the agency's patients (Please see tag L900). This practice had the potential to affect all agency patients. The findings include: --- The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation 42 CFR §418.60: Infection Control.

Based on observation, record review, and interview, the Registered Nurse (RN) failed to properly disinfect reusable equipment, and failed to properly perform hand hygiene practices, during 1 of 1 home visits observed with a RN (Patient #4). The findings include: --- Review of an agency policy dated 6/27/2022, titled "Infection Control an Occupational Exposure to Bloodborne and Other Pathogens", stated, "... BAG TECHNIQUE ... Hand hygiene is performed prior to entering/re-entering the clinician bag ... Equipment is cleaned and disinfected prior to returning to bag ... Blood pressure equipment ... [cleaned/disinfected] ... After each use ... [by] ... Clinician using the equipment ...." A home visit was observed with Patient #4 and RN #2 on 3/16/23 at 1:30 PM. Observed RN #2 obtain the patient's blood pressure. After removing the blood pressure cuff from the patient's arm, RN #2 failed to cleanse/disinfect the cuff, failed to perform hand hygiene, and then placed the blood pressure cuff back into the bag. During an interview on 3/21/2023 at 2:41 PM, the Clinical Manager indicated RN #2 should have disinfected the cuff and performed hand hygiene prior to replacing it back in the nursing bag.

Based on observation, record review, and interview, the hospice agency failed to ensure the hospice Medical Director and/or Physician Designee was responsible for palliation and management of the terminal illness and conditions related to the terminal illness for the agency's patients; failed to ensure the physician designee and/or contracted Nurse Practitioner(s) functioned under the supervision of the hospice Medical Director; failed to ensure the Medical Director and Physician Designee provided services either directly to agency patients or through coordination with the patient's attending physician; and failed to ensure the Physician Designee was responsible to meet the medical needs of the patients in the absence of the Medical Director (Please see tag L590); the Clinical Manager failed to ensure the nursing needs of the patient were met (Please see tag L591); and the hospice agency failed to ensure the core counseling service of Bereavement Coordinator was provided by a direct employee of the hospice agency; and failed to develop a bereavement plan of care, which specified the kind of bereavement services to be provided (Please see tag L596). This practice had the potential to affect all patients who received services from the agency. The findings include: --- The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care for the Condition of Participation 42 CFR §418.64 Condition: Core Services.

Based on record review and interview, the hospice agency failed to ensure the hospice Medical Director and/or Physician Designee was responsible for the patients' palliation and management of the terminal illness and conditions related to the terminal illness; failed to ensure the Physician Designee and contracted Nurse Practitioner(s) functioned under the supervision of the Medical Director; and failed to ensure a dedicated Physician Designee was responsible to meet the medical needs of the patients in the absence of the Medical Director. The findings include: --- Record review evidenced a Medical Director Job Description obtained 3/15/2023, which stated, ";... Physician, in conjunction with the Hospice Patients Attending Physician, if any, is responsible for the palliation and management of the terminal illness and conditions related to the terminal illness of the hospice patient ... Such services shall either be provided directly by Physician or through coordinating the patient care with the Attending Physician ... Physician is responsible for supervising all physician employees and those under contract with Hospice ...." Review of the hospice agency's organizational chart, updated 3/14/2023, failed to evidence a physician designee. The organizational chart indicated the medical director reported to the administrator. Review on 3/16/2023, of the Indiana State license verification website evidenced Medical Director #1, received their Indiana Physician license on 3/13/2023. Personnel record review evidenced a personnel file for Medical Director #1, which failed to include orientation to the position of medical director. During an interview on 3/13/2023, at 12:50 PM, the Administrator and the Clinical Manager indicated they did not know who the physician designee was. During the interdisciplinary group meeting on 3/15/2023 at 2:00 PM, the Medical Director indicated they did not want to go over everything about the patients, and only wanted to know information if there was an issue with a patient because the meeting would take 3 hours then. During an interview on 3/15/2023, at 3:17 PM, the Medical Director indicated they reported to the Regional Medical Director. The Medical Director did not know who the Regional Medical Director was. The Medical Director did not know who the Physician Designee was. The Medical Director indicated they did not physically go to see patients, but the nurses and nurse practitioners did the assessments. The Medical Director indicated their role in hospice was to review hospice eligibility and update orders. During an interview on 3/16/2023, at 9:30 AM, the Physician Designee indicated they were put in the physician designee position emergently in October 2018, because no other physician had an Indiana drug license. The Physician Designee indicated they reported to the medical director, but did not know who the medical director was. The Physician Designee did not know who the administrator was. The Physician Designee indicated the nurses and nurse practitioners who called them for orders were responsible for the medical component of the hospice. The Physician Designee indicated their only role in hospice was to order medications the patients needed. The Physician Designee indicated they did not fill in for other physicians, they did not participate in interdisciplinary group meetings, and they did not know who was responsible for performing certification of terminal illnesses. During an interview on 3/21/2023, at 2:30 PM, Corporate Staff #3 (Regional Director of Operations/not employee of agency) confirmed there was no delegation of physician designee on the organizational chart. During an interview on 3/22/2023, at 1:41 PM, the Clinical Manager indicated Nurse Practitioner #3 was contracted under the Physician Designee to perform face-to-face assessments on patients. The Clinical Manager indicated the Medical Director and Physician Designee did not see patients in person. Review of a contract between the hospice agency and the Medical Director, effective date 11/30/2022, titled "Hospice Medical Director Agreement", evidenced the Medical Director was responsible for the medical component of the Hospice's patient care program, hospice services included physician services to the extent that these services are not provided by the attending physician, responsible for the certification of terminal illness (CTI), hospice agency will assess skills and competency, maintain a written description of in-service training, provide orientation about the hospice philosophy, and physician reports to the Medical Director of Hospice. Review of a contract between the hospice agency and the Physician Designee, effective date 12/01/2022, titled "Hospice Medical Director Agreement", evidenced hospice services included physician services to the extent that these services are not provided by the attending physician, responsible for the certification of terminal illness (CTI), hospice agency will assess skills and competency, maintain a written description of in-service training, provide orientation about the hospice philosophy, and physician shall be accountable to the Administrator of the hospice. The document failed to evidence it was a contract for a Physician designee, or included specific duties/responsibilities of a Physician Designee. Review of a contract between the Physician Designee and Nurse Practitioner (NP) #3, dated 12/01/2022, evidenced NP #3 provided care/treatment to the agency's patients, was supervised by the Physician Designee, but not the Medical Director.

Based on observation, record review, and interview, the Clinical Manager failed to ensure the nursing needs of the patient were met, for 3 of 3 clinical records reviewed with patients with wounds (Patient #4, #8, #10). The findings include: --- *. Clinical record review for Patient #10 was completed on 3/23/2023. Record review evidenced a plan of care for certification period 2/23/2023 – 5/23/2023, which indicated the patient was to receive the following wound care daily: bilateral hips, buttocks, left ankle: cleanse with wound wash up, apply medihoney (wound ointment), calcium alginate (absorbent wound dressing), and foam dressing; left elbow: apply sure prep and heel cup; all other areas: apply sure prep. The plan of care indicated the skilled nurse was to visit 2 times weekly for wound care. Record review evidenced a start of care visit dated 2/23/2023, which failed to specify what specific wound care was provided to all wounds. This visit note included the following wound measurements: Left hip: 2.6cm (centimeters) x 3.1cm x 0cm; right hip: 2.8cm x 3.8cm x 0 cm; coccyx: 7.4cm x 5.3cm x 0.5 cm. Record review evidenced a skilled nurse visit dated 2/24/2023, which indicated no wound dressings were changed during the visit, because they were changed the prior day. Record review evidenced a skilled nurse visit note dated 2/28/2023, which indicated no wound care was provided. Record review evidenced a skilled visit note dated 3/3/2023, which indicated wound care was provided, but failed to specify what specific dressing changes were performed. This visit note included the following wound measurements: Left hip: 7cm x 7.2cm x 0cm; right hip: 4.1cm x 3cm x 0 cm; coccyx: 7.4cm x 5.3cm x 2.6 cm. Record review failed to evidence the physician was notified of the enlarging wounds. Record review evidenced a skilled nurse visit note dated 3/7/2023, which indicated wound care was provided for a coccyx (area at base of spine), left hip, and right ankle, but failed to specify what wound care was provided. This visit note indicated the patients caregiver applied hydrogel to unstageable wounds, but failed to specify which wounds were unstageable, or evidence an order for hydrogel. This visit note indicated the patient had new areas of black skin on toes, but failed to evidence the physician was notified. Record review evidenced a skilled nurse visit note dated 3/10/2023, which indicated wound care was provided to all wounds, but failed to evidence what specific wound care was provided. This visit note included the following wound measurements: Left hip: 8cm x 7.9cm x 0cm; right hip: 5cm x 3.8cm x 0 cm; coccyx: 7cm x 5.3cm x 4cm. Record review failed to evidence the physician was notified of the enlarging wounds, lack of wound care as ordered, or caregiver knowledge deficit. Record review evidenced a skilled nurse visit note dated 3/14/2023, which indicated the nurse cleansed the left hip wound, applied hydrogel, and a foam dressing. This visit note indicated no other wound care was provided. This visit note indicated the patients caregiver had informed the nurse on 3/13/2023, that the left hip wound had a foul smell, the patient had a fever of 99.4, and the left leg was warm to the touch. This visit note indicated the patient had been started on antibiotics for a wound infection. Record review evidenced a skilled nurse visit note dated 3/17/2023, which indicated no wound care was provided. Record review failed to evidence wound measurements for the week of 3/12/2023. Record review failed to evidence any education was completed with the caregiver regarding need for daily dressing changes to prevent infection and worsening wounds. Record review failed to evidence the physician was notified of the worsening wounds. During an interview on 3/21/2023, at 1:45 PM, the Clinical Manager indicated wound care should have been provided every visit, as ordered on the plan of care. The Clinical Manager did not see an order for hydrogel dressings. The Clinical Manager did not know if the daughter was performing daily dressing changes as ordered. The Clinical Manager indicated the caregiver should have been educated on daily dressing changes. At 1:56 PM, the Clinical Manager indicated the goal of hospice should have been to prevent wound infections. The Clinical Manager indicated the wounds were worsening, so the caregiver should have been educated on repositioning the patient more frequently. The Clinical Manager indicated the physician should have been notified that the dressings werent getting changed daily and the wounds were getting bigger. The Clinical Manager indicated the physician should have been notified to obtain any new wound care orders. 1. Review of an agency job description dated10/25/2021, dated and signed by the Clinical Manager on 8/29/2022, evidenced the Clinical Manager was accountable for all RNs, and supervise the care rendered to patients and families. 2. Review of an undated agency policy received on 3/21/2023, titled "Significant Change in Condition Policy", evidenced it was the policy of the agency to reassess the patient when there was a significant change in condition, and a significant change in condition included skin breakdown due to pressure or debilitation of condition. 3. A home visit with Patient #4 occurred on 3/16/23 at 1:30 PM. Observed boxes of wound care dressings in the patient's room near the bed. RN #2 indicated the patient had a boil on her spine, and thats what the boxes of wound dressings were for. The dressing was well-adhered, and there was dark/bloody drainage visible within the dressing. The skin on the top portion of the dressing and beyond the dressing border was dark red/purple in color. RN #2 failed to remove the soiled dressing, assess or measure the wound, or provide wound care. RN #2 failed to meet the nursing needs of the patient. Clinical record review for Patient #4 was completed on 3/23/2023 at 2:10 PM (start of care date 1/09/2023). Record review evidenced nursing visits were provided once weekly, and failed to evidence any weekly assessment or measurements of the wound. During an interview on 3/21/2023 at 2:41 PM, the Clinical Manager indicated RN #2 should have assessed the wound, should have performed wound care, and confirmed the clinical record failed to evidence the patient had a wound, or any wound care was ever provided to the patients wound on her back. 4. Clinical record review for Patient #8 was completed on 3/23/2023 at 3:10 PM (start of care date 12/21/2022, benefit period 2/19/2023 - 4/19/2023). Record review evidenced the patient had 4 pressure injuries (wounds caused by unrelieved pressure), which all originated prior to the current benefit period, and failed to evidence any wound measurements were obtained during the current benefit period. During an interview on 3/23/2023, the Clinical Manager indicated she believed the patient only had 3 current pressure injuries. *During an interview on 3/20/2023 at 3:29 PM, Corporate Staff #2 (Regional Quality Manager/not an agency employee) stated, "... I know we dont have a specific wound policy ...." *During an interview on 3/21/2023 at 9:50 AM, Corporate Staff #2 indicated wound management was included in the policy titled ";Significant Change in Condition Policy". *During an interview on 3/21/2023 at 1:45 PM, the Clinical Manager indicated wounds were measured weekly, and the nurse should do ordered wound care during the visit.

Based on record review and interview, the hospice agency failed to ensure the core counseling service of Bereavement Coordinator was provided by a direct employee of the hospice agency; and failed to develop a bereavement plan of care, which specified the kind of bereavement services to be provided in 1 of 1 patients who were identified as requiring pre-bereavement services (Patient #13). The findings include: --- Review of an undated agency policy received on 3/21/2023, titled "Services Under Contract", indicated personnel who provided services by other arrangements (not an agency employee) must have a written contract between the agency and the personnel, and shall clearly delineate the authority and responsibility of the contracting parties. During an interview on 3/13/2023 at 12:32 PM, the Administrator indicated Corporate Staff #4 (Bereavement Coordinator) worked out of Entity #19 (a Medicare licensed hospice in Kalamazoo, Michigan). During an interview on 3/14/2023 at 3:20 PM, Corporate Staff #3 (Regional Director of Operations/not an agency employee) indicated there wasn't a contract to "share services" between separately licensed Medicare providers owned by the corporation. During an interview on 3/20/2023 at 1:55 PM, Corporate Staff #2 (Regional Quality Manager/not an agency employee) indicated corporate staff was assigned to different Medicare hospice providers (separately licensed hospice agencies) that geographically matched where they lived. During an interview on 3/21/2023 at 2:30 PM, Corporate Staff #3 indicated Corporate Staff #4 was an employee of Entity #12 (a Medicare licensed hospice in Grand Rapids, Michigan). Record review evidenced an agency policy revised 7/2016, titled ";Bereavement Services Policy" which stated, ";... The Admitting RN, Bereavement Coordinator, or Social Worker is responsible for completing the Bereavement Risk Assessment ... The assessment is included in the patients permanent electronic medical record, and the bereavement record ... The Bereavement Coordinator, with input from the IDG, develops the Bereavement Plan of Care based on the Bereavement Risk Assessment ...." Clinical record review for Patient #13 was completed on 3/23/2023, for certifciation period 2/21/2023 – 5/21/2023. Record review evidenced a start of care comprehensive assessment dated 2/21/2023, which indicated the patient required a referral for pre-bereavement based on the risk assessment. Record review failed to evidence a bereavement plan of care. During an interview on 3/22/2023, at 3:35 PM, the Clinical Manager indicated if the risk assessment indicated the patient was at risk, they would create a bereavement plan of care. The Clinical Manager indicated they would provide me with the bereavement plan of care, and by end of survey, nothing was provided.

Based on record review and interview, the hospice agency failed to ensure it was responsible for, and tracked COVID-19 vaccination status for all applicable employees, contracted staff, and other person(s) who had the potential to transmit COVID-19 to the agency's patients. The findings include: --- Review of a policy dated 2/09/2022, marked on each page as a "DRAFT", titled "Pinnacle Senior Care (PSC) and Grace/Comfort Hospice Mandatory Vaccination Policy", evidenced the policy applied to all employees who provided patient facing services, who were required to report vaccination status/proof of vaccination to the corporate Human Resource (HR) department, corporate HR would determine acceptance/declination of exemption requests, and corporate HR tracked and documented all COVID-19 vaccination information. Review of the Medical Director's personnel file on 3/14/2023 failed to evidence COVID-19 vaccination status. During an interview on 3/13/2023 at 12:32 PM, the Administrator indicated HR/ personnel records were maintained at the corporate level, corporate tracked all COVID-19 information, and the information was not readily available to her without requesting it. The agency failed to evidence it was responsible for, or knew it's employees' COVID-19 vaccination status. During an interview on 3/14/2023 at 1:09 PM, Corporate Staff #1 (Regional Quality Manager/not an agency employee) indicated the agency had no access to the Medical Director's HR file or contract agreement, and it would have to be requested vis the the corporate quality team. During an interview on 3/14/2023 at 3:20 PM, Corporate Staff #3 (Regional Director of Operations/not an agency employee) indicated the corporate staff personnel/HR files were not kept at this agency. During an interview on 3/14/2023 at 3:56 PM, the Administrator indicated the corporate ";Credentialing Department" sent all of the Medical Director's personnel documents. The agency failed to know the Medical Director's COVID-19 vaccination status. During an interview on 3/14/2023 at 4:13 PM, Corporate Staff #3 (Regional Director of Operations/not an agency employee) indicated they asked for the Medical Director's HR file, and thats all they got. During an interview on 3/21/2023 at 1:39 PM, Surveyor requested Physical Therapist (PT) #1's personnel record (contracted staff). Corporate Staff #5 (Director of Quality/Governing Body member) indicated the agency didn't have personnel files for contracted staff at Entity #7 (contracted therapy services), Corporate Staff #3 (Regional Director of Operations/not an agency employee) indicated the agency didn't have to have their HR files. The agency failed to ensure it knew PT #1's COVID-19 vaccination status prior to providing direct patient care for the agency's patients. During an interview on 3/22/2023 at 10:58 AM, Corporate Staff #2 indicated Corporate Staff #3 was out performing nursing supervisory visits with 6 agency patients today. The agency failed to ensure it knew Corporate Staff #3's COVID-19 vaccination status prior to visiting agency patients in their place of residence.