Every finding on record at Grateful Palliative Care and Hospice, LLC

Based on interview and record review, the hospice agency failed to ensure the Condition of Participation for Interdisciplinary Group (IDG), Care Planning, and Coordination of Services was met as follows: --- 1. The hospice agency failed to ensure care and interventions needed for one of 7 sample patients (Patient 7), who had difficulty breathing was provided. This deficient practice resulted to the delay of care and had the potential to cause respiratory complications leading to the patients discomfort and poor-quality nursing care. (Refer to L539). 2. The hospice agency failed to ensure patients home medications were labeled and home medication lists were provided for 1 of 7 sampled patients, (Patient 5). This deficient practice had the potential to cause administration medication errors and can cause medical complications to the affected patient. (Refer to L554). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure the highest quality of care are provided to the patients accurately assessed to receive hospice care and services.

Based on interview and record review, the hospice agency failed to ensure care and interventions needed for one of 7 sample patients (Patient 7), who had difficulty breathing was provided. This deficient practice resulted to the delay of care and had the potential to cause respiratory complications leading to the patients discomfort and poor-quality nursing care. --- During a review of Patient 7's admission record, the admission record indicated a start of care date (SOC) of 12/4/23, with a terminal diagnosis of unspecified acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood). During a review of Patient 7's Physician's order dated 12/4/23, the physicians order indicated to perform oxygen saturation (the amount of oxygen in the bloodstream with normal range of 95-100%) check every visit; to administer oxygen two (2) liters via nasal cannula (a device that delivers extra oxygen through a tube into the nose)/mask as needed for shortness of breath and discomfort; to administer Morphine Sulfate (pain medicine) liquid 20 mg (milligrams) 0.25 mg under the tongue every 2 hours as needed for shortness of breath and moderate to severe pain. During a review of Patient 7's Plan of Care (POC)/Interdisciplinary Group (IDG - a team responsible for the holistic care of the hospice beneficiary) form dated 12/4/23, indicated the frequency of visits for skilled nurse (SN) was 7 per week plus 1 prn (as needed) visits for symptom management and support and for any change of patients condition. During a review of Patient 7's License Vocational Nurse (LVN) Visit Note dated 12/4/23, indicated Patient 7 had shallow and labored breathing, lung sounds were diminished (reduced) with occasional crackles (a lung sound that indicate a person's lungs have fluid inside or are not inflating correctly) through auscultation (method used to listen to the sounds of the body during a physical examination by using a stethoscope [a medical instrument]). The patient also had shortness of breath with oxygen saturation of 67 percent (normal saturation is 95% and higher), with oxygen therapy at 2 liters via nasal cannula. The visiting nurse was unable to rate pain level, but the patient was moaning and groaning to tactile stimuli (touch). However, there was no documented evidence the visiting nurse had provided comfort measures to relieve Patient 7's existing pain and troubled breathing during the visit. During a review of Patient 7's LVN Visit Note dated 12/5/23, the visit notes indicated Patient 7 had shortness of breath, had heavy breathing, respiration of 28, and was very agitated with facial grimace. There was no documented evidence that the visiting nurse checked Patient 7's oxygen saturation level and did not provide oxygen 2 liters via nasal cannula or mask as ordered. On 12/29/23, at 12 p.m., during a phone interview with Family Member (FM 1), FM 1 complained that on two nursing visits, Patient 7 was in pain, struggled to breathe and was grasping for air, but the visiting nurse did not provide a mask nor provided comfort measures to ease down the patient's pain and difficulty in breathing. FM1 further stated he was very upset that the agency did not provide proper care for his dying father. On 12/29/23, at 1:30 p.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated the hospice agency provided daily visits for the patient and provided care as ordered for Patient 7. A review of the undated hospice agency's policy and procedure (P&P), titled "Interdisciplinary Group Membership Responsibilities", the P&P indicated the interdisciplinary group will collaborate with the patient's attending physician to develop an individualized written plan of care. When there is more than one (1) interdisciplinary group, the hospice will designate in advance the group responsible for program oversight and the establishment of policies that govern the day-to-day provision of hospice care and services. The hospice interdisciplinary group membership includes at a minimum: Physician, Registered Nurse, Social Worker and Pastoral or other counselor.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure patients home medications were labeled and home medication lists were provided for 1 of 7 sampled patients, (Patient 5). This deficient practice had the potential to cause administration medication errors and can cause medical complications to the affected patient. --- During a review of Patient 5s face sheet, the face sheet indicated an admission date of 9/28/2023 with the medical diagnosis of atherosclerotic heart disease of native coronary artery (the buildup of fats, cholesterol and other substances in and on the artery walls causing the arteries to narrow and blocking blood flow) and angina pectoris (chest pain). During a review of Patient 5's document titled " Physician's Certification for Hospice Benefit" for the re-certification period #2, dated 12/27/2023 to 3/25/2023, revealed that Patient 5 was a 103-year-old woman, with continued medical decline. Patient 5 was consuming 50% or less of meals, a puree with honey thickened liquids. Patient 5 had a mid back deep tissue injury (DTI- a form of pressure ulcer or pressure sore, with localized areas of necrotic or damaged tissue) and a DTI at the left lower extremity DTI. The mid-arm circumference (MAC, measure of nutritional status and a good predictor of risk of imminent death) had decreased from 24 cm (centimeters- a unit of measurement) to 23.5cm. The Karnofsky Performance Scale (KPS, an assessment tool for functional impairment) score of 40% (disable; requires special assistance) and Palliative Performance Score (PPS -a useful tool for measuring the progressive decline of a palliative resident, with five functional dimensions: ambulation, activity level and evidence of disease, self-care, oral intake, and level of consciousness) score of 40% (which was mainly in bed; unable to do most activity), the New York Heart Association (NYHA) Classification (a simple way of classifying the extent of heart failure) was Class IV (unable to carry out any physical activity without discomfort), activities of Daily living (toileting, dressing, eating) maximum assist. During a joint home visit conducted at Patient 5's residence with the Licensed Vocational Nurse 1 (LVN) on 12/28/2023 at 10:00 a.m., the medication review was conducted with Patient 5's family member. The following medications were observed with no labels: 1. Deplin levomefolate 15mg daily (antidepressant). 2. CNU nail renewal gel daily (solution for the nail bed and nail plate from the podiatrist. Per the family member, Patient 5 goes to the clinic every 3-4 months. 3. Rexulti 0.5mg 1 tablet (medication for agitation). During a concurrent interview and record review with Patient 5's family member and LVN 1, the patients handbook did not contain a copy of Patient 5s medication lists. LVN 1 stated that he opens the electronic medical record on his phone to check the patient's medications. LVN 1 further stated that the nurse should have checked the medications and lists every home visit and compare it with the list they have at the patients home and do the necessary updates. During an interview with the Director of Nursing (DON) on 12/29/2023 at 12:56 p.m., the DON stated that this is the first time she had heard about the patient's medications with no labels. The DON stated that if the visiting nurse observed or seen medications without labels, they should call the office and report it, so the case managers will call the pharmacy and provide the labels for the medications. The DON stated that the admission nurse or the visiting nurse will provide an updated medication list and leave it at the patients binder for reference when they do medication reconciliation. A review of the hospice agency's (HA) policy and procedure (P&P) titled, " Interdisciplinary Group Coordination of Care", revised 11/2017, indicated that hospice personnel will communicate changes in a timely manner via telephone, one-to-one meetings, interdisciplinary group meetings, and home visits. Documentation of all communications will be included in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication. A review of the HA's P&P titled, " The Plan of Care", revised 11/2017, indicated during subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to:A. Using the medication profile to evaluate the use of the drugs in the home settingB. Using the medication profile to teach purpose of medication, dosages, routes, administration times, side effects, and contraindicationsC. Using the medication profile as a communication tool for other clinicians involved in careEach patient will receive appropriate written material for specific medications he/she is receiving. The material will contain information on actions of the medication, potential side effects, contraindications the patient should be aware of, and any special instructions when taking the specific medication.Based on review of the medication profile as well as the written material, changes in the plan of care may be required. Any conclusions and findings of patient medication use or monitoring should be communicated to the pharmacist, when appropriate, and other clinicians. Deviations from taking medications as ordered will be documented in clinical notes, and the physician (or other authorized independent practitioner) will be notified.

Based on interview and record review, the hospice agency failed to notify the physician regarding the current medical condition for one out of seven patients, (Patient 7). This failure had the potential to cause the patients comfort and a poor quality nursing care that can affect the quality of end of life care the patient deserved. --- During a review of Patient 7's admission record, the admission record indicated a start of care date (SOC) of 12/4/23, with a terminal diagnosis of unspecified acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood). During a review of Patient 7's Plan of Care (POC)/Interdisciplinary Group, IDG - a team responsible for the holistic care of the hospice beneficiary) form dated 12/4/23, indicated the frequency of visits for skilled nurse (SN) to 7 per week plus 1 prn (pro re nata, which means ";as needed") visits for symptom management and support and for any change of patients condition. During a review of Patient 7's initial Comprehensive Nursing Assessment dated 12/4/23, the comprehensive nursing assessment indicated Patient 7 was restless, lethargic, confused, had pain (but no pain scale was provided), had moderate dyspnea (difficulty breathing), oxygen saturation level of 91 percent in room air. The visiting nurse had re-inserted a foley catheter (a tube inserted into the bladder that drains the urine) and had 150 cc of serous drainage out to the foley bag. The foley was irrigated with 200 cc of normal saline and had 50 cc returned of serous urine output. However, there was no documented evidence the visiting nurse notified the physician regarding the patient's current condition. During a further review of Patient 7's clinical records, the clinical record did not indicate documented evidence of a clinical note to justify the visiting nurse had notified the physician regarding Patient 7's health condition during the visit. On 12/29/23, at 1:30 p.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated the medical director had a face-to-face encounter via face time during the initial visit, but the DPCS could not show any documentation that the face-to-face encounter happened. A review of the facilitys undated policy and procedure titled, "Interdisciplinary Group Coordination of Care," indicated the interdisciplinary group should maintain responsibility for the provision and coordination of care, regardless of the setting where care is provided to its patient.

Based on observation, interview and record review, the hospice agency failed to ensure gloves were changed before and after touching a patients wound and failed to perform hand hygiene in between dressing changes and gloves changed for 1 of 7 patients, Patient 5. This failure had the potential for cross contamination and wound infection. --- A review of Patient 5s face sheet indicated an admission date of 9/28/2023 with the medical diagnosis of atherosclerotic heart disease of native coronary artery (the buildup of fats, cholesterol and other substances in and on the artery walls causing the arteries to narrow and blocking blood flow) and angina pectoris (chest pain). A review of Patient 5's document titled " Physician's Certification for Hospice Benefit" for the re-certification period #2, dated 12/27/2023 to 3/25/2023, revealed that Patient 5 was a 103-year-old woman, with continued medical decline. Patient 5 was consuming 50% or less of meals, a puree with honey thickened liquids. Patient 5 had a mid back deep tissue injury (DTI- a form of pressure ulcer or pressure sore, with localized areas of necrotic or damaged tissue) and a DTI at the left lower extremity DTI. The mid-arm circumference (MAC, measure of nutritional status and a good predictor of risk of imminent death) had decreased from 24 cm (centimeters- a unit of measurement) to 23.5cm. The Karnofsky Performance Scale (KPS, an assessment tool for functional impairment) score of 40% (disable; requires special assistance) and Palliative Performance Score (PPS -a useful tool for measuring the progressive decline of a palliative resident, with five functional dimensions: ambulation, activity level and evidence of disease, self-care, oral intake, and level of consciousness) score of 40% (which was mainly in bed; unable to do most activity), the New York Heart Association (NYHA) Classification (a simple way of classifying the extent of heart failure) was Class IV (unable to carry out any physical activity without discomfort), activities of Daily living (toileting, dressing, eating) maximum assist. A joint home visit was conducted at Patient 5's residence with the Licensed Vocational Nurse 1 (LVN) on 12/28/2023 at 10:00 a.m. Patient 5s family member was present. During the observation of the home visit, LVN 1 donned gloves and removed the dressings from the patient's left and right leg and proceeded to apply the creams using the same gloves. LVN 1 then reached into his bag to get clean dressings with the same pair of gloves on his hands. LVN 1 removed the pair of gloves and applied a new pair of gloves when he started to clean his equipment. During an interview with the Director of nursing (DON) on 12/29/2023 at 12:35 p.m., the DON stated that stated that "I agree with you, our policy do state that the visiting nurse should observe proper bag technique and proper infection control when they are doing wound care for the patients." The DON stated the nurse should disinfect or perform one wound care at a time so as not to cross contaminate germs on each wound. A review of the hospice agencys policy titled " Bag Technique", revised 11/2017, indicated gloves are to be changed between tasks and procedures on the same patient.

It is required that each patient’s individualized written plan of care includes measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 6 of 19 (32%) clinical record reviews, the agency did not ensure the individualized plan of care included measurable outcomes. Clinical Record 2: The patient elected hospice benefit on 03/08/2023 with a terminal diagnosis of malignant neoplasm of bladder. The initial nursing assessment dated 03/08/2023 included documentation that the patient was on oxygen at 5 liters per minute. The skilled nurse visit note dated 11/12/2023 included documentation that a BiPap (a machine that assist in providing oxygen to the lungs) had been ordered for the patient. The plan of care dated 12/11/2023 included a respiratory goal that stated "Problem: Respiratory. Goal: "Patient will have optimum level of oxygen." The plan of care did not include a description of how this goal would be measured. Clinical Record 3: The patient elected hospice benefit on 08/04/2023 with a terminal diagnosis of acute on chronic systolic congestive heart failure. The plan of care dated 08/04/2023 included a goal that stated "Problem: Cardiovascular. Goal: patient will have optimum peripheral circulation." The plan of care did not include a description of how the cardiovascular goal would be measured. Clinical Record 9: The patient elected hospice benefit on 02/17/2023 with a terminal diagnosis of protein calorie malnutrition. The initial nursing assessment dated 02/17/2023 documented the patient was incontinent of bowel. The plan of care dated 02/17/2023 included a goal that stated, "Problem: Gastrointestinal. Incontinent of bowels. Goal: Patient will have optimal bowel elimination and comfort." The plan of care did not include a description of how the goal would be measured. Clinical Record 10: The patient elected hospice benefit on 12/04/2023 with a terminal diagnosis of Non-Hodkins Lymphoma. The plan of care dated 12/12/2023 included a goal that stated, "Problem: Respiratory. Goal: optimum level of oxygen." The plan of care did not include a description of how the goal would be measured. Clinical Record 12: The patient elected hospice benefit on 05/02/2023 with a terminal diagnosis of combined systolic and diastolic heart failure. The plan of care dated 05/02/2023 included a goal that stated, "Problem: Cardiovascular. Goal: Edema will be decreased, and the patient will maintain optimum peripheral circulation." The plan of care did not include a description of how to measure the edema for reduction or how to measure optimal peripheral circulation. Clinical Record 13: The patient elected hospice benefit on 08/21/2023 with a terminal diagnosis of malignant neoplasm of right female breast. The plan of care dated 10/16/2023 included a goal that stated, "Problem: Spiritual Distress Goal: Healing Road to peace." The plan of care did not include a description of how the goal would be measured. During a joint clinical record review and interview on 12/14/2023, the Director of Patient Care Services reviewed the plans of care and confirmed the goals were not measurable.

It is required that a revised plan of care includes Information from the patient’s updated comprehensive assessment and a record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure the plan of care was updated as the patient's condition required. Clinical Record 2: The patient elected hospice benefit on 03/08/2023 with a terminal diagnosis of malignant neoplasm of bladder. Clinical record review revealed the physician wrote an order dated 12/11/2023 changing the patient’s diet to "nothing by mouth (NPO)." The plan of care was not updated to include nutritional goals or interventions related to the physician’s order for change in diet. Clinical Record 12: The patient elected hospice benefit on 05/02/2023 with a terminal diagnosis of chronic combined systolic and diastolic heart failure. The skilled nurse visit note dated 11/28/2023 documented the patient had "multiple falls last few days." The skilled nurse visit note dated 12/04/2023 documented the patient "continues to experience falls." The plan of care dated 05/02/2023 included a goal that stated, "Problem: At risk for Falls. Goal: Primary caregiver will verbalize understanding of fall precautions." The plan of care was not updated or revised to include the new assessment findings of falls related to the skilled nurse visit notes dated 11/28/2023 and 12/04/2023. During a joint clinical record review and interview on 12/14/2023, the Director of Patient Care Services confirmed that the plans of care had not been updated regarding the falls and nutrition order since admission and agreed that an updated plan of care should have been added.

It is required that written patient care instructions for a hospice aide are prepared by a RN (Registered Nurse) who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, observation, and interview. In 5 of 9 (56%) clinical records reviewed with aide services provided, the agency did not ensure patient specific written care instructions were provided for the hospice aide. Clinical Record 1/Home Visit 1: The patient elected hospice benefit on 09/18/2022 with a terminal diagnosis of Alzheimer's disease. The aide care plan assignment dated 12/06/2022 assigned the tasks of showering the patient every visit and dressing the patient every visit. The Skilled Nurse (SN) visit note dated 01/12/2023, included documentation of a wound care order for a skin tear on the patient’s left elbow to be covered with Xeroform gauze. The SN visit note dated 01/13/2023 included documentation of a stage II pressure ulcer to the patient’s right buttock to be covered with bordered gauze. The SN visit note dated 10/28/2023 documented a right-hand skin tear was covered with Xeroform. The SN visit note dated 11/06/2023 documented a skin tear on the right hand covered with Xeroform and wrapped with Kerlix. The SN visit note dated 12/07/2023 described a new right elbow skin tear which was covered with bordered gauze. During the home visit observation, the patient was observed to have an island dressing to the right elbow. The aide care plan assignment was not updated after the SN visits that identified new or changed patient wounds and did not include instructions to the aide related to care of the wounds and wound dressing(s) during showering and dressing the patient. Clinical Record 8: The patient elected the hospice benefit on 11/29/2022 with a terminal diagnosis of chronic obstructive pulmonary disease. The initial nursing assessment dated 11/29/2022 documented the patient was on oxygen continuously at 3 liters per minute. The aide care plan assignment dated 11/29/2022 assigned the tasks of showering the patient every visit and dressing the patient every visit. The aide care plan assignment did not include instructions to the aide related to the patient’s use of oxygen and if the oxygen could be removed during patient care, including showering and dressing. Clinical Record 10: The patient elected the hospice benefit on 12/04/2023 with a terminal diagnosis of non-Hodgkin lymphoma. The nursing assessment dated 12/04/2023 documented the patient had a stage III wound to the right trochanter covered with gauze. The skilled nurse visit dated 12/12/2023 showed the patient was placed on 5 liters per minute of continuous oxygen. The aide care plan assignment dated 12/05/2023 assigned the tasks of showering the patient, providing incontinent care, dressing, and applying adult diapers every visit. The aide care plan assignment did not include instructions to the aide related to the patient’s continuous use of oxygen and the right trochanter dressing. Clinical Record 14: The patient elected the hospice benefit on 07/13/2023 with a terminal diagnosis of multiple sclerosis. The plan of care dated 07/13/2023 included an order to "leave right arm brace in place except for showering." The plan of care also included documentation that the patient was on seizure precautions and ordered three medications for seizures (Keppra, Lamictal, and Depakote.) The aide care plan assignment dated 08/20/2023 assigned the aide the tasks of bathing the patient in a shower chair but listed the patient as bedbound and dressing the patient every visit. The aide care plan assignment did not provide instructions to the aide related to the patient’s arm brace and did not include that the patient was on seizure precautions. The aide care plan listed the task of "take vital signs" but did not include parameters to guide the aide in when to report vital signs values to the Registered Nurse. Clinical Record 19: The patient elected the hospice benefit on 07/11/2022 with a terminal diagnosis of malignant neoplasm of bronchus of lung. The skilled nurse visit note dated 07/12/2023 documented the patient had a skin tear to the right lateral forearm with a dry dressing. The aide care plan assignment dated 07/12/2022 assigned the aide the tasks of showering and dressing the patient every visit. The aide care plan assignment did not include instructions to the aide on how to care for the skin tear and dressing while providing care for showering and dressing the patient. A joint clinical record review and interview was performed on 12/14/2023 with the Director of Patient Care Services (DPCS). DPCS agreed that the items had not been added or updated in the aide care plans.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the recertification of the terminal illness was completed in the required time frame. Clinical Record 2: The patient elected hospice benefit on 03/08/2023 with a terminal diagnosis of malignant neoplasm of bladder. The second benefit period was effective 06/06/2023 to 09/03/2023. The recertification certification of terminal illness (CTI) was signed by the hospice Medical Director on 06/12/2023, 6 days after the first day of the benefit period. A joint clinical record review and interview was performed on 12/14/2023 with the Director of Patient Care Services (DPCS). DPCS confirmed the CTI had been signed late and a verbal order was not present in the clinical record.

It is required that a patient's clinical record contains correct clinical information including physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure the clinical record contained complete physician orders. Clinical Record 1: The patient elected hospice benefit on 09/18/2022 with a terminal diagnosis of Alzheimer's disease. Clinical record review revealed a physician order dated 12/26/2022 that stated, "Please monitor blood pressure daily." The physician order did not include instructions for who was responsible for monitoring the blood pressure daily and did not include when blood pressure values should be reported to the physician. Clinical Record 2: The patient elected hospice benefit on 03/08/2023 with a terminal diagnosis of malignant neoplasm of bladder. Clinical record review revealed a physician order dated 03/08/2023 that stated, "caregiver to empty drainage bag when 1/2 full." The physician order did not specify what type of drainage bag that was to be emptied. A joint clinical record review and interview was performed on 12/14/2023 with the Director of Patient Care Services (DPCS). DPCS stated that the orders were written for the "facility staff or caregivers" but agreed that they should have been clarified to include specific instructions.

It is required that the hospice has written policies and procedures for the management and disposal of controlled drugs in the patient’s home. The policies and procedures address the circumstances under which controlled drugs are disposed of (e.g., the patient’s death, a change in drug regimen, etc.) and the method to be used in accordance with the state and federal law and regulation. This standard was not met as evidenced by document review and interview. Review of the agency’s policies and procedures for disposal of controlled substances provided to the patient or family upon admission revealed the agency did not ensure the patient or family received concise information. Agency policy Management and Disposal of Controlled Substances, which is included in the patient and family admission binder behind the medication tab, stated in part, "disposal instructions: 2. drugs/pharmaceutical waste must NEVER be placed in drains or flushed down the toilet." Patient and Family Care Handbook, dated 2009, which is included in the back of the patient and family admission binder, stated in part, "Flush prescription drugs down the toilet only if the label of accompanying information specifically instructs to do so. The FDA (food and drug administration) advises the following drugs to be flushed down the toilet instead of thrown in the trash: ..." EPA (Environment Protection Agency) Medication Disposal flyer which is located in the patient and family admission binder, behind the medication tab, stated in part, disposal of certain medications by flushing them down the toilet should be prevented in most circumstances. During a joint review on 12/13/2023, the Alternate Administrator confirmed the agency's admission binder and patient and family care handbook included conflicting information related to disposal of medications. Review of the polices and procedures for disposal of controlled substances provided to the patient or family upon admission revealed the agency did not ensure the patient or family received concise information.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included 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 reviewed where hospice care was provided in a SNF (Skilled Nursing Facility), the agency did not ensure the written plan of care identified which provider was responsible for performing functions in the plan of care. Clinical Record 18: The patient elected the hospice benefit 05/25/2023 with a terminal diagnosis of Alzheimer's disease. The patient's level of care was changed to respite from 08/10/2023 to 08/14/2023 and the patient was moved to a SNF. The clinical record did not include a plan of care update regarding coordination of care and delineation of duties during the patient's respite stay. During a joint clinical record review and interview on 12/15/2023, the Director of Patient Care Services confirmed the plan of care did not describe the coordination of care between the hospice and the skilled nursing facility.

Based on interview and record review, the hospice agency nursing staff failed to ensure a completed pressure wound assessments was conducted that included the location, stage, size, tunneling (a wound that's progressed to form passageways underneath the surface of the skin), undermining (the region underneath the overlying loose skin around a pressure ulcer), peri-wound description, exudates (drainage), color, odor, necrotic (dead) tissue, and granulation (a wound progressing from the inflammatory phase of healing to the proliferative phase of healing) in accordance with the hospice policy and procedure for one of 14 sampled patients (Patient 11). This deficient practice resulted in the delayed provision of wound treatment that could lead to infection and deterioration of the wounds causing patient's discomfort and or pain. --- Findings: A review of Patient 11's admission record indicated a start of care (SOC) date of 4/19/23, with a terminal diagnosis of Alzheimers disease, unspecified (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A review of Patient 11s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 8/08/23, indicated the frequency of visits of skilled nurse (SN) to one visit per week plus 3 prn (pro re nata, which means ";as needed") visits to assess and monitor cardiac status, effectiveness of medications, pain and severity on every visit and to provide wound treatment. A review of Patient 11s Skin Impairment Assessment record indicated the skin assessment was not completed on the following dates: On 7/26/23, sacrum pressure injury Stage 2 (are usually open wounds, like an ulcer, with swelling, discoloration, and pain). The assessment did not include wound measurement, peri-wound description, color, odor, and presence of drainage. On 9/06/23, sacrum pressure injury Stage 3 (a full-thickness loss of skin that extends to the subcutaneous tissue [the deepest layer of your skin]). The assessment did not include wound measurement, peri-wound description, color, odor, and presence of drainage. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 10/29/23 at 11:46 a.m., the DPCS stated she was not able to find documented evidence Patient 11 wounds on sacrum were assessed completely by the agencys SN with the size measurement, and wound status on the above days. The DPCS stated the patient's wound should have been assessed completely. A review of the agency's undated policy procedure titled " Assessment/Staging of Pressure Ulcers" indicated in assessing pressure ulcer, the following parameters should be addressed consistently. - Site, stage of ulcer, and size of ulcer (include length, width, and depth). - Presence of tunneling and undermining. - Presence of necrotic tissue (slough or eschar). - Drainage amount, color, and odor. - Granulation. - Pain. - Condition of surrounding tissue.

Based on observation, interview and record review, the hospice agency failed to develop an individualized care plan for one out of 14 sampled patients (Patient 2), who had an existing Stage 1 sacral pressure sore (non-blanchable redness of a localized area usually over a bony prominence). This deficient practice placed the patient at risk for slow wound healing and possible wound complications. --- During a review of Patient 2's admission record indicated a start of care (SOC) date of 8/9/23, with a terminal diagnosis of congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should). During a review of Patient 2s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 10/3/23, indicated the frequency of visits of skilled nurse (SN) to one visit per week plus three prn (as needed) visits to assist with personal care and activities of daily living and to provide wound care. During a review of Patient 2s physician orders dated 10/9/23, indicated to cleanse sacrum pressure ulcer Stage 1 with soap and water, pat dry, apply thin layer of Dermseptin ointment (type pf topical ointment) at every diaper change and after bathing. During a home visit conducted on 10/27/2023, at 2 p.m., at Patient 2's residence with License Vocational Nurse 1 (LVN), Patient 2 was observed with reddened skin at her sacral area. During a further review of Patient 2's Plan Of Care/ Interdisciplinary Group Review dated 10/17/23, did not indicate a care plan was developed for the existing Stage 1 (skin redness) in the sacral area that was being treated for Patient 2. During an interview on 10/29/2023 at 1 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated the license nurses failed to develop a care plan pertaining to Patient 1's existing Stage 1 sacral pressure sore.

Based on observation, interview and record review, the hospice agency failed to ensure physician orders the sacral wound care were implemented for 1 of 14 sampled patients (Patient 2). This deficient practice had the potential to result in slow wound healing and possible wound complications. --- During a review of Patient 2's admission record indicated a start of care (SOC) date of 8/9/23, with a terminal diagnosis of congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should). During a review of Patient 2s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 10/3/23, indicated the frequency of visits of skilled nurse (SN) to one visit per week plus three prn (as needed) visits to assist with personal care and activities of daily living and to provide wound care. During a review of Patient 2s physician orders dated 10/9/23, indicated to cleanse sacrum pressure ulcer Stage 1 with soap and water, pat dry, apply thin layer of Dermseptin ointment at every diaper change and after bathing. During a home visit conducted on 10/27/2023 at 2 p.m. at Patient 2's residence with License Vocational Nurse (LVN) 1, Patient 1 was observed with reddened skin at her sacral area. During a review of Patient 2's Visit Note/RN (registered nurse) dated 10/9/23, 10/16/23, and 10/23/23, did not indicate a documented evidence that a wound care was provided as ordered to Patient 2. During an interview o 10/29/2023 at 1 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated the visiting nurse should have specified in their documentation notes each wound care treatment provided as ordered.

Based on interview and record review, the hospice agency failed to revise (update) the plan of care for one of 14 sampled patients (Patient 11), who had a Stage 2 (skin that breaks open, wears away, or forms an ulcer, which is usually tender and painful) pressure injury at the sacral area, that progressed to stage 3 (a wound in the skin that is deep and painful) pressure sore. This deficient practice had the potential to negatively affect the quality of care and services provided to Patient 11. --- During a review of Patient 11's admission record indicated a start of care (SOC) date of 4/19/23, with a terminal diagnosis of Alzheimers disease, unspecified (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). During a review of Patient 11s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 8/08/23, indicated the frequency of visits of skilled nurse (SN) to one visit per week plus three prn (as needed) visits to assess and monitor cardiac status, effectiveness of medications, pain and severity on every visit and to provide wound treatment. A review of Patient 11s Skin Impairment Assessment record indicated the following: On 7/26/23, sacrum pressure injury Stage 2 (skin that breaks open, wears away, or forms an ulcer, which is usually tender and painful) On 9/06/23, sacrum pressure injury Stage 3 (deep and painful wounds in the skin) During a review of Patient 11s physician orders dated 9/6/23, the physician order indicated to cleanse the sacrum pressure injury Stage 3 with normal saline, pat dry, apply calcium alginate, and cover with bordered dressing. Treatment to be done two times a week and as needed if soiled or dislodged. During a review of Patient 11's POC/IDG form dated 9/19/23, the plan of care for Integumentary/Skin indicated Patient 11 had a sacrum pressure injury Stage 2, however, Patient 11s pressure injury in the sacral area had progressed to a Stage 3. The care plan was not revised to reflect Patient 11s pressure injury that had worsened to a Stage 3. Patient 11s care plan did not address the specific treatment provided for the current Stage 3 pressure injury. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 10/29/2023 at 11:46 a.m., the DPCS stated Patient 11s plan of care for integumentary/skin was not revised and agreed that Patient 11s care plan should have been updated to reflect the change in condition of the patients pressure injury. During a review of the agencys policy and procedure titled, ";The Plan of Care", revised November 2017, indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The plan of care will be reviewed and revised as frequently as deemed necessary based on the ongoing comprehensive assessments of the patient and family/caregiver. Review of the plan of care will be documented in the clinical record. Revision dates will be noted on the plan of care.

Based on observation, interview, and record review, the hospice agency failed to promptly notify the physician regarding the newly identified left breast rash for one out of 14 sampled patients, (Patient 1). This deficient had the potential inappropriate wound care that could result to the slow healing process of the wound. --- A review of Patient 1's admission record indicated a start of care (SOC) date of 7/13/23, with a terminal diagnosis of Alzheimers disease, unspecified (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A review of Patient 1s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 10/17/23, indicated the frequency of visits of skilled nurse (SN) to one visit per week plus 3 prn (as needed) visits to assess and monitor cardiac status, effectiveness of medications, pain and severity and symptom management /changes on patient's condition on every visit. During a home visit conducted on 10/28/2023, at 11 a.m. with License Vocational Nurse (LVN) 2 at Patient 1's residence in an assisted living facility, Patient 1 was observed lying in bed asleep. During an interview on 10/28/2023 at 11:20 a.m. with LVN 2, LVN 2 stated Patient 1's left breast fold rash had cleared when he saw Patient 1 during his last weeks home visit. During an interview on 10/28/2023 at 11:40 a.m. with LVN 3 (facility's supervising nurse), in front of LVN 2, LVN 3 stated Patient 1 developed a new rash on the left breast fold last night and had started treating the rash by washing the area with soap and water and applying Nystatin powder a topical medicine in powder form). During Patient 1s clinical record review on 10/29/2023 at 11 a.m., the clinical record did not indicate a documented evidence of a communication note that LVN 2 notified Patient 1s physician regarding the new rash on the left breast fold. During an interview on 10/29/2023, at 11:30 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated LVN 2 should have notified the physician regarding Patient 1's new rash on the left breast fold area to obtain skin treatment orders. A review of the agency's undated policy and procedure titles, "Plan of Care", indicated it is the staff member's responsibility to report any condition or problems to the physician.

Based on interview and record review, the hospice agency failed to ensure Spiritual Counselling services was offered to one of 14 sampled patients (Patient 12). This failure had the potential that support services in the care of the terminally ill patients will not be provided to the affected patient. --- During a review of Patient 12's admission record indicated a start of care (SOC) date of 6/26/23, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (refers to the accumulation of plaque on the inner walls of blood vessels, and this plaque consists of substances found in the bloodstream, such as fat, cholesterol, and calcium) without angina pectoris (medical term for chest pain or discomfort due to coronary heart disease). During a review of Patient 12's Comprehensive Nursing Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process), dated 6/26/23, indicated Patient 12 was awake, alert, oriented x2 (to place and person), verbally responsive with clear speech. The Comprehensive Nursing Assessment indicated ancillary services by hospice MSW (Social worker), Chaplain and Volunteer were explained and offered to the family and the patient, but they did not have a need for these services at this time. The Comprehensive Nursing Assessment further indicated that per hospice protocol, MSW and Chaplain will call the patient and family to introduce themselves and the explain services available to them. During a telephone interview with the agency's Spiritual counselor (SC 1) on 10/27/2023 at 1:37 p.m., SC 1 stated that even if the patient or the patients family decline spiritual counseling service during the initial visit and assessment by the registered nurse, she will still try to contact them and explain the kind of service she offers. SC 1 stated this initial interaction with the patient and/or patients family will be documented in the patients clinical record. During a review of Patient 12's clinical record indicated no documented evidence a spiritual counseling assessment or notes that the Chaplain explain the services being offered by the agency was completed since SOC. A review of the agency's policy and procedure titled "Spiritual Care Counseling Services", revised November 2017, indicated hospice will provide spiritual care counseling in keeping with the patients/familys/caregivers belief system and practice, and in accordance with the plan of care. All referrals, assessments, clinical notes, intervention letters and phone calls will be documented in the patients clinical record.

Based on interview and record review, the hospice agency failed to ensure clinical record for one of 14 sampled patients (Patient 9). were completed and documented timely This failure had the potential to result in inability to evaluate the care provided to the patient and to compromise patient care. --- During a review of Patient 9's admission record indicated a start of care (SOC) date of 5/18/23, with a terminal diagnosis of Alzheimers disease, unspecified (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A review of Patient 9s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 9/05/23, indicated the frequency of visits of skilled nurse (SN) to one visit per week plus three prn (as needed) visits for symptom management, MSW (social worker) to 1 visit on recertification plus one(1) prn visit for psychosocial support, SC (spiritual counselor) to 1 visit on recertification plus bi-monthly visits for spiritual support, and hospice aide (HA) to 1 visit per week to assist with personal care and activities of daily living. Volunteer service was declined. A review of Skilled nurse (SN) visit calendar for the week starting on 10/01/23 and ending on 10/07/23, indicated there was no SN visit notes submitted. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 10/29/2023 at 11:46 a.m., the DPCS stated the agencys policy for submission of SN visit notes was to submit within seven days. The DPCS stated SN visited Patient 9 on 10/03/23 but acknowledged the SN visit notes was not submitted in a timely manner.