Every finding on record at Harbor Grace Hospice, Inc

Based on review of records, review of policy ";Interdisciplinary Team Plan of Care," and staff interview, it was determined the agency failed to ensure the requirements for the Interdisciplinary Group (IDG), care planning and coordination of services were met for four patients (P) (P#1, P#2, P#3 and P#4) of four sampled patients. · --- Findings include: Review of policy titled "Interdisciplinary Team Plan of Care" effective 3/2004 revealed the following: Policy: Data gathered from discipline-specific assessments (nursing, social work, chaplaincy, etc.) will be integrated into the IDT plan of care. 1. Review of the IDG assessment for P#1 dated 12/17/24 failed to reveal coordination of care between all disciplines. The IDG Assessment Details revealed a SN visit note narrative. The IDG failed to reveal assessments or updates from other disciplines. 2. Review of the IDG assessment for P#2 dated 12/17/24 and 12/31/24 failed to reveal coordination of care between all disciplines. The IDG Assessment Details revealed a SN visit note narrative. The IDG failed to contain assessments or updates from other disciplines. 3. Review of the IDG assessment for P#3 dated 12/17/24 and 12/31/24 failed to reveal coordination of care between all disciplines. The IDG Assessment Details revealed a SN visit note narrative. The IDG failed to contain any assessments or updates from other disciplines. 4. Review of the IDG assessment for P#4 dated 12/3/24 and 12/17/24 failed to reveal coordination of care between all disciplines. The IDG Assessment Details revealed a SN visit note narrative. The IDG failed to contain any assessments or updates from other disciplines. During an office interview on at 1/15/25 11:00 a.m. with the Director of Homecare and the Administrator it was confirmed that the IDG notes lacked documentation of coordination of patient care with all disciplines and all disciplines are responsible for participating in IDG meetings.

Based on record reviews, review of policy "Ongoing Procedures of Active Patient Care," and staff interview, it was determined the hospice agency failed to ensure the clinical record contained complete, clear and timely documentation for services provided for three patients (P) (P#1, P#3, and P#4) of four patient records reviewed. --- Findings include: Review of policy titled "Ongoing Procedures of Active Patient Care," effective 3/2004 revealed: • Document all visits and phone calls on progress notes. Sign and date all entries. 1. Review of the POC for P#1 revealed the skilled nurse (SN) was required to visit the patient one time a week starting 7/27/24. The SN failed to visit the patient the weeks of 12/22/24 and 12/29/24. The clinical record failed to reveal documentation of a missed visit note with physician notification of the missed visits. Review of the clinical record revealed a wound care order which reads as follows: tumor wound care: cleanse with normal saline and apply 4X4's, wet to dry bandage and cover with abdominal (ABD) pad (absorbent padding), secure with paper or silk tape. The wound care order failed to reveal a frequency for wound care to be provided. The SN failed to obtain a complete physician's order for wound care. 2. Review of the POC for P#3 revealed SN services were ordered two times a week starting 11/16/24. The SN failed to visit the patient the week of 12/22/24. The clinical record failed to reveal documentation of a missed visit note with physician notification of the missed visits. Review of the clinical record revealed a wound care order as follows: sacrum: cleanse with soap and water. Pat dry and apply the Mepilex Border (flexible and highly absorbent foam dressing) pad. The wound care order failed to reveal a frequency for wound care to be provided. The SN failed to obtain a complete physician's order for wound care. 3. Review of the POC for P#4 revealed a wound care order dated 11/18/24 which reads as follows: cleanse bilateral hip wounds with saline or wound cleanser, pat dry, apply border gauze every 3 days and as needed for soiled dressing or if dressing falls off. The SN visited the patient weekly from 12/2-12/23/24. The SN documents the wound care was provided however, failed to identify the steps or supplies used to perform the wound care. The clinical record failed to reveal SN visit notes for the month of December. Review of the clinical record contained SN visit notes dated 12/2, 12/11, 12/17and 12/23/24. The clinical notes indicate the SN completed and signed these notes on 1/14/25 (greater than 30 days after the initial visit). During an in-office interview with the Director of Homecare and the Administrator on 1/14/25 at approximately 1:30 p.m., the Director confirmed the clinical record lacked SN visit notes or missed visits for the month of December. The Administrator explained if a visit is missed the clinician is responsible for putting documentation in the record of the missed visit and the reason why the visit was missed. The Director of Homecare confirmed the wound care orders were incomplete in that they lacked a frequency for wound care to be provided. The Administrator and Director of Homecare reported that clinical staff are expected to document care and services on the day services are provided. It was confirmed the SN failed to document home visits on the day of service as required.

Based on review of records, staff interviews, and review of policy ";Plan of Care," it was determined the agency failed to ensure the requirements for the interdisciplinary group, care planning and coordination of services were met. Specifically, the agency failed to follow the plan of care (POC) to ensure that visit frequencies were met, and wound care was provided as ordered for three patients (P) (P#1, P#2 and P#3) of four sampled patients. --- Findings include: Review of the policy titled ";Plan of Care," effective date 3/2004 revealed the following:Purpose:The Administrator is responsible for ensuring interventions by hospice employees are consistent with the initial and integrated plans of care. 1. Review of the POC for P#1 revealed the skilled nurse (SN) was required to visit the patient one time a week starting 10/22/24 and provide wound care to the right forearm as follows: cleanse right lower forearm with normal saline, apply wet to moist normal saline soaked dressing, cover with kerlix (made of prewashed, fluff-dried 100% woven gauze with unique crinkle-weave pattern for loft and bulk to cushion and protect wound) every 12 hours and as needed. The SN visited the patient on 10/23/24 and documented wound care to lower anterior forearm as follows: cleansed with saline, cover with Vaseline gauze, wet saline on top, and cover with kerlix. The SN failed to complete wound care as ordered. 2. Review of the POC for P#2 revealed SN services were ordered two times a week starting 7/4/24. It was determined the SN failed to visit the patient the week of 10/27/24. The clinical record lacked documentation of a missed visit note with physician notification of the missed visits. 3. Review of the POC for P#3 revealed SN services were ordered two times a week starting 5/2/24. It was determined the SN failed to visit two times the week of 10/20/24, failed to visit the patient the week of 10/27/24, and failed to visit two times the week of 11/3/24. The clinical record failed to reveal documentation of a missed visit note with physician notification of the missed visits. The clinical record failed to reveal coordination of care with the interdisciplinary team to ensure the missed visits could be rescheduled to provide consistent care and services. During an in-office interview with the Administrator and Director of Homecare on 11/25/2024 at approximately 1:30 p.m., both were unable to locate SN visit notes or missed visits for the weeks requested. The Administrator explained if a visit is missed the clinician is responsible for putting documentation in the record of the missed visit and the reason why the visit was missed. The Administrator confirmed the clinicians are required to follow the ordered plan of care to include following all physician's orders. The Director of Homecare was unable to provide documentation of missed visit notes for the visits missed and confirmed the SN performed the incorrect wound care protocol on 10/23/24.

Based on record reviews, policy review, and staff interviews, it was determined that the agency Interdisciplinary Team (IDT) failed to ensure that skilled nurse visits were provided as ordered and wound care was provided as ordered in the plan of care (POC) for three patients (P) (P#1, P#2, P#3) of four sampled records reviewed. --- The findings include: Review of the policy titled ";Wound Care Protocols," approved 12-5-11, revealed the following:Always follow the doctor's order when providing wound care. 1. Review of the POC for P#1 revealed the skilled nurse (SN) was required to visit the patient one time a week starting 10/22/24 and provide wound care to the right forearm as follows: cleanse right lower forearm with normal saline, apply wet to moist normal saline soaked dressing, cover with kerlix (made of prewashed, fluff-dried 100% woven gauze with unique crinkle-weave pattern for loft and bulk to cushion and protect wound) every 12 hours and as needed. The SN visited the patient on 10/23/24 and documented wound care to lower anterior forearm as follows: cleansed with saline, cover with Vaseline gauze, wet saline on top, and cover with kerlix. The SN failed to complete wound care as ordered. 2. Review of the POC for P#2 revealed SN services were ordered two times a week starting 7/4/24. It was determined the SN failed to visit the patient the week of 10/27/24. The clinical record failed to reveal documentation of a missed visit note with physician notification of the missed visits. 3. Review of the POC for P#3 revealed SN services were ordered two times a week starting 5/2/24. It was determined the SN failed to visit two times the week of 10/20/24, failed to visit the patient the week of 10/27/24, and failed to visit two times the week of 11/3/24. The clinical record failed to reveal documentation of a missed visit note with physician notification of the missed visits. The clinical record failed to reveal coordination of care with the interdisciplinary team to ensure the missed visits could be rescheduled to provide consistent care and services. During an in-office interview with the Administrator and Director of Homecare on 11/25/2024 at approximately 1:30 p.m., both were unable to locate SN visit notes or missed visits for the weeks requested. The Administrator explained if a visit is missed the clinician is responsible for putting documentation in the record of the missed visit and the reason why the visit was missed. The Administrator confirmed the clinicians are required to follow the ordered plan of care to include following all physician's orders. The Director of Homecare was unable to provide documentation of missed visit notes for the visits missed and confirmed the SN performed the incorrect wound care protocol on 10/23/24. During a telephone interview on 11/26/2024 at approximately 10:00 a.m., with RN CC, RN CC confirmed that she had not documented any skilled nurse visits for the months of October and November 2024. RN CC offered to document the skilled nurse visit notes on 11/26/24 (2 months later) from when the skilled nurse visits were initially made.

Based on record reviews, personnel file reviews, agency document, and staff interviews, it was determined the hospice governing body and Administrator failed to ensure hospice staff followed the plan of care to ensure visit frequencies were met and wound care was provided as ordered for the palliation and management of the terminal illness for three patients (P) (P#1, P#2, and P#3) of four sampled patients and to ensure competency assessments were completed for staff prior to performing independent patient care for two of two sampled personnel files. --- Findings include: A review of document titled ";267 Plan of Care" effective date 3/2004 revealed the Administrator is responsible for ensuring interventions by hospice employees are consistent with the initial and integrated plans of care. 1. Review of Registered Nurse (RN) AA and RN BB personnel file was reviewed and the document titled "Nursing Competency Evaluation" was found to be blank failed to indicate RN AA and RN BB had been deemed competent to perform independent care in the field. 2. Record review reveals P#1 was admitted to hospice on 10/22/24. Physician order dated 10/22/24 revealed wound care to the right forearm as follows: cleanse right lower forearm with normal saline, apply wet to moist normal saline soaked dressing, cover with kerlix (made of 100% cotton gauze with crinkle-weave pattern for wound protection and cushioning) every 12 hours and as needed. The skilled nurse (SN) visited the patient on 10/23/24 and documented wound care to lower anterior forearm as follows: cleansed with saline, cover with Vaseline gauze, wet saline on top, and cover with kerlix. The SN failed to complete wound care as ordered. Record review revealed P#2 was admitted 7/4/24. Review of the plan of care (POC) for P#2 revealed SN services were ordered two times a week starting 7/4/24. The SN failed to visit the patient the week of 10/27/24, and the clinical record failed to reveal documentation of a missed visit note with physician notification of the missed visit. Record review revealed P#3 was admitted on 5/2/24. Review of the POC for P#3 revealed SN services were ordered two times a week starting 5/2/24. The SN only visited the patient one time the week of 10/20/24, failed to visit the patient the week of 10/27/24, and only visited one time the week of 11/3/24. The clinical record lacked documentation of a missed visit notes with physician notification of the missed visits. The clinical record failed to reveal documentation of any coordination with the physician regarding the missed visits or incorrect wound care provided. During an in-office interview with the Administrator and Director of Homecare on 11/25/2024 at approximately 1:30 p.m., both were unable to locate SN visit notes or missed visits for the weeks requested. The Administrator further revealed if a visit is missed the clinician is responsible for putting documentation in the record of the missed visit and the reason why the visit was missed. The Director of Homecare did review the record and was unable to provide documentation of missed visit notes for the visits missed. It was also confirmed the SN performed the incorrect wound care protocol on 10/23/24. During an in-office interview on 11/26/24 at 11:00 a.m., the Administrator verbalized not being aware that the nursing competency evaluation was not completed for RN AA and RN BB and acknowledged that all clinicians are required to complete competency assessments prior to providing independent care in the field.

Based on personnel file reviews and staff interviews, it was determined that the agency failed to ensure staff competency assessments were completed prior to performing independent care in the field for two employees, Registered Nurse (RN) AA and RN BB of two sampled employees. --- Findings include: RN AA and RN BB personnel files were reviewed and revealed a hire date of 9/10/24. The document titled "Nursing Competency Evaluation" was found in each file blank and failed to indicate RN AA and RN BB had been deemed competent to perform independent care in the field however, both clinicians have been performing skilled nurse visits in the field independently. During an in-office interview on 11/26/2024 at 11:00 a.m., with the Administrator and the Director of Homecare, the Administrator verbalized not being aware that the nursing competency evaluation was not completed for RN AA and RN BB and acknowledged that all clinicians are required to complete competency assessments prior to providing independent care in the field. The Director of Homecare stated the clinicians did have a preceptor during orientation but did and confirmed the personnel files lacked documentation to show the nurses were competent to perform independent care in the field.

Based on record review, review of policy ";Quality Management," and staff interview, the agency failed to measure, analyze and track quality indicators, including adverse patient events and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations. --- Findings include: Review of policy titled ";Quality Management," dated March 2004, revealed that hospice shall appoint a multidisciplinary quality management committee that reflects the hospice scope of services, The committee shall develop and implement a comprehensive and ongoing quality management, utilization, ad peer review program that evaluate the quality and appropriateness of patient care provided, including the appropriateness of level of service received by patient, and submits required patient incident reports to the Department. Procedure: The quality management, utilization, and peer review program shall establish and use written criteria as the basis to evaluate the provision of patient care. The written criteria shall be based on accepted standards of care and shall include at a minimum, systematic reviews of: o Appropriateness of admissions, continued stay, and discharge o Appropriateness of professional services and level of care provided o Effectiveness of pain control and symptom relief o Patient injuries, such as those related to falls, accidents, and restraint use o Errors in medication, administration, procedures, or practices that compromise patient safety o Infection control practices and surveillance data o Patient and family complaints and on-call logs o Inpatient hospitalizations o Staff adherence to the patients plan of care o Appropriateness of treatment o Findings of the quality management utilization, and peer review program shall be utilized to correct identified problems, revise hospice policies, and improve the care of patients. o There shall be an ongoing evaluation of the quality management, utilization, and peer review committee to determine its effectiveness, which shall be presented at least annually for review and appropriate action to the medical staff and the governing body. The agency failed to reveal quantitative data that they could improve quality as measured by their own indicators. Requested infection control tracking data and the data was not received by survey exit date. An interview with the Administrator in the agency's office on 10/9/2024 at approximately 10:40 am confirmed that the agency had not met the specific requirement to track adverse events as defined in hospice policy.

Based on record review, and staff interview, it was determined that governing body failed to ensure the Quality Assessment and Performance Improvement (QUAPI) program was created and is working to address any problem areas in patient care and hospice operations, and to improve performance in these areas. Governing body failed to ensure that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained, and is evaluated on quarterly basis. --- Findings include: The agency QUAPI program and meeting minutes was requested. After review of the QUAPI binder, it was revealed that the agency failed to have a QUAPI meeting since 2021. On 10/9/24 at approximately 11:20 am, an interview with the Administrator acknowledged that the agency has not had a QUAPI program and meetings since 2021.

Based on clinical record reviews, staff interviews,home visit observation and review of the agency's policy labeled "Medication Administration" updated 3/2020, it was determined the agency failed to ensure patient's medication profile was updated to reflect current medications at the time of the assessment for 1 of 1 patient (P#1) observed during a visit at the inpatient unit. The findings include: Review of the medication administration record (MAR) for P#1 documented received several as needed medications for agitation and aggressive behaviors. According to the policy labeled "Medication Administration" updated 3/2020, all PRN (as needed) medications will be documented in the MAR with the reason and response to the medication and exceptions to administration, such as refused or not needed, will be documented in the electronic medical record. However, the skilled nurse failed to document the reason the PRN medication was given or the effectiveness of the medication and failed to document the exceptions to administration in the medical record. 1. Haldol 5MG/ML 5mg every 4 hours OTHER As Needed, documented as administered on: -4/23/22, at 0800 Patient noted with delirium, hallucinations, and confusion. Haldol 5 IM given (no comments of effectiveness or site given). -4/23/22, at 19:00 Patient noted with agitation, confusion, combativeness delirium and restlessness. Haldol 5mg IM given via right deltoid. (no comments on effectiveness). -4/24/22, at 04:00 5.0mg (no comments on effectiveness). -4/24/22, at 08:30 Patient noted with agitation, delirium, hallucinations, restlessness, and confusion. Haldol 5mg IM given. (no comment on effectiveness or site given) -4/24/22, at 18:30 Patient noted with agitation, delirium hallucinations, restlessness, and confusion. Haldol 5 mg IM given. (no comment on effectiveness or site given). -4/25/22 01:00 5.0 mg (no comments on behaviors, effectiveness or site given). -4/27/22 at 00:00 5.0 mg (no comments on behaviors, effectiveness or site given). -4/27/22 at 17:00 5.0 mg Right thigh (no comments on behaviors or effectiveness). -4/29/22 at 01:30 5.0 mg (no comments effectiveness or site given). -4/29/22 at 08:00 mg Patient noted with agitation, delirium hallucinations, restlessness, and confusion. Haldol 5mg IM given (no comments on effectiveness). -4/29/22 at 18:00 Patient noted with agitation, delirium hallucinations, restlessness, and confusion . Haldol 5mg IM given (no comments on effectiveness). -4/30/22 at 17:45 Patient noted with agitation, confusion, hallucinations, and restlessness. Haldol 5mg IM given (no comments on effectiveness). -5/1/22 at 09:00 Patient noted with agitation, confusion, and restlessness. Haldol 5mg IM given via right vastus laterallis muscle (no comments on effectiveness). 2. Lorazepam (used for anxiety) 2MG/ML 1ml every 4 hours as needed Agitation and Anxiety, documented as administered on: (No comment on effectiveness) -4/22/22 at 20:00 for restlessness (no comments on effectiveness). -4/23/22 at 13:30 Patient noted with confusion, combativeness, agitation, delirium, hallucinations, and restlessness. Ativan 2mg/1ml given IM via right deltoid (no comments on effectiveness). -4/24/22 at 21:00 agitation (no specific comments on behaviors or effectiveness). -4/27/22 at 21:00 left deltoid (no comments of behavior/effectiveness). -4/29/22 13:00 Patient noted with agitation, confusion, combativeness, delirium, hallucinations and restlessness 2mg/1m. given via left deltoid muscle. (No comment on effectiveness) -4/29/22 at 20:00 IM right thigh.(no comments behaviors/effectiveness). -4/30/22 at 13:30 Patient noted with Cheyne-stokes pattern of breathing with agitation and hallucinations. Ativan 2mg/ml given via left deltoid muscle. (No comment on effectiveness) -4/30/22 at 20:00 1.0ml (no comment for behaviors/effectiveness).

Based on review of clinical records, personnel records, policy review and staff interview, it was determined Harbor Grace Hospice Inpatient Unit failed to ensure that the requirements for the use and monitoring of restraints were met for patient #1, as evidenced by the agency's failure to document the use of attempts to use less restricted or alternative methods for behavior modification The immediate jeopardy was related to the agency's noncompliance with the program requirements for 42 CFR Part 418.110, Condition of Participation: Hospices that provide inpatient care directly (L719), less restrictive measures ( L738), type of restraint and the frequency of monitoring (L741), failed to ensure initial restraint order contained the necessary elements to ensure patient safety such as: time limit of restraint, failed to ensure subsequent restraint orders were obtained prior to initiating restraints (L742), failed to ensure restraints were released at the earliest possible time ( L745) and failed to ensure a 1:1 medical and behavior evaluation was conducted to manage violent behaviors prior to writing ongoing orders ( L752). The cumulative effects of these systemic problems resulted in the hospice's inability to effectively apply, monitor and evaluate the application and use of restraints which could result in serious patient injury/harm or death.

Based on clinical record review, staff interview and review of the agency's policy title "Restraint and Seclusion", it was determined the hospice failed to ensure the least restrictive measures were attempted and documented prior to the use of restraints for 1 of 1 patients (P#1). The findings include: Review of the clinical record for Patient #1 with an admission date of 4/22/22, and diagnosis of Alzheimer's Disease revealed a verbal order dated 4/22/22, for the patient to be placed in restraints if the patient becomes combative. According to the clinical record, the patient was kept in a vest restraint and bilateral hand mitts on 4/22, 4/23, 4/24, 4/25, 4/26, 4/27, 4/28, 4/29, 4/30, 5/1, and 5/2/22. However, the clinical record lacked any documentation of less restrictive measures attempted prior to the use of restraints. Review of the policy titled , " Restraint or Seclusion: with an effective date of 7/2013, restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient from harm". During an interview on 5/5/22, at 3:00 p.m., the Director of Compliance acknowledged the record lacked any documentation of less restrictive measures attempted prior to the use of restraints as required.

Based on clinical record review and staff interview, it was determined the hospice failed to ensure the verbal order was obtained prior to the use of restraints for 1 of 1 patients (P#1) reviewed with restraints. The findings include: Review of the clinical record for Patient #1 with an admission date of 4/20/22, and diagnosis of Alzheimer's Disease revealed a verbal order dated 4/22/22, for the patient to be placed in restraints if the patient becomes combative. According to the clinical record, the patient was kept in restraints on 4/23, 4/24, 4/25, 4/26, 4/27, 4/28, 4/29, 4/30, 5/1, and 5/2/22. However, the record lacked any signed orders by the physician for the use of restraints on these days. During a telephone interview on 5/3/22, at 11:18 a.m. with the Medical Director of Longleaf Hospice, the Medical Director stated that he did not give any orders to restrain P#1 after 4/22/22. During a telephone interview on 5/5/22, at 4:00 p.m., with RN JJ it was comfirmed that physician orders were not obtained daily and staff were using the restraint order dated 4/22/22, as an as needed order for restraints .

Based on clinical record review, staff interview and review of the agency's policy title "Restraint and Seclusion", it was determined the hospice failed to ensure the verbal order for the application of restraints were complete and not used as needed (PRN) order for 1 of 1 sampled patients (P) (#1). The findings include: Review of the clinical record for Patient #1 with an admission date of 4/20/22, and diagnosis of Alzheimer's Disease revealed a verbal order dated 4/22/22, for the patient to be placed in restraints if the patient becomes combative. Review of the policy titled , "Restraint or Seclusion: with an effective date of 7/2013" included, Orders for use of restraint or seclusion must never be written as a standing order or on an ans needed basis (prn). Documented in the clinical record, the patient was kept in restraints on 4/22, 4/23, 4/24, 4/25, 4/26, 4/27, 4/28, 4/29, 4/30, 5/1, and 5/2/22. According to the non-violent flow sheets completed daily and every 2 hours, P#1 was assessed every 2 hours however, the restraints remained in place even while the patient was calm and asleep. During an interview on 5/5/22, at 9:00 a.m., the inpatient care unit (IPU) Charge Nurse stated the restraints were released every 2 hours but they were not taken off the patient. During an interview on 5/5/22, at 3:00 p.m., the Director of Compliance acknowledged the restraints should have been removed if the patient was calm and asleep.

Based on clinical record review and staff interview, it was determined the hospice failed to ensure the restraints were discontinued at the earliest possible time or as the patient's behavior warranted for 1 of 1 patients (P) #1 that was restrained. The findings include: Review of the clinical record for Patient #1 with an admission date to Harbor Grace Inpatient Hospice unit on 4/22/22, P#1 diagnosis included Alzheimer's Disease. The medical record revealed a verbal order dated 4/22/22, for the patient to be placed in restraints if the patient becomes combative. According to the clinical record, the patient was kept in restraints on 4/22, 4/23, 4/24, 4/25, 4/26, 4/27, 4/28, 4/29, 4/30, 5/1, and 5/2/22. However, the non violent flow sheets were completed daily from 4/23-5/2/22, with periods documented that the patient was asleep for extended periods of time or exhibited no aggressive behaviors however, the patient continued to be restrained. During an interview on 5/5/22, at 9:00 a.m., the inpatient care unit (IPU) Charge Nurse reported that the restraints were released every 2 hours but they were not taken off the patient. During an interview on 5/5/22, at 10:00 a.m., with the Director of Compliance it was comfirmed the patient should have been released from restraints immediately when the behavior no longer warranted restraints.

Based on record review, staff interview and observation it was determined the hospice failed to ensure a medical and behavioral evaluation was conducted to manage behaviors with less restrictive interventions attempted. The agency failed to document alternatives to the use of restraints and a rational for continued use of restraints. These failures resulted in the application of phyiscal restraints and as needed (PRN) intramuscular (IM) Haldol (an antipsychotic used for schizophrenia) and Lorazepam (used for anxiety) for 1 of 1 patients (P) #1. Review of the clinical record for P#1 admitted to the inpatient unit (IPU) on 4/20/22, with diagnosis of Alzheimers disease lacked documentation for a medical or behavioral evaluation to manage the reported violent behaviors which resulted in the application of restraints and the use of 2 antipsychotic and anxiety medications. There was no documented attempts of alternatives and other less restrictive measures. The documentation on the medication administration records behaviors exhibited as combative behavior, agitation, hallucinations and restlessness. 4/22, 4/23,4/24, 4/25, 4/26, 4/27, 4/28, 4/29, 4/30, 5/1 and 5/2/22. There was no documented evidence of non-pharmalogical interventions. During observation on 5/2/22, at approximately 10:30 a.m., with the Registered Nurse (RN) AA from Longleaf Hospice, this surveyor observed an elderly gentleman laying in bed with a vest restraint applied and tied to the bed frame, hand mittens on both hands with full side rails raised on both sides of the bed. The patient was lying still in bed with eyes closed and appeared to be asleep. During the visit, the patient did mumble at times but this surveyor was unable to understand what was said. The RN AA assessed the patient and completed vital signs assessment without difficulty. RN AA prompted patient to drink from straw but patient was unable to follow this command. This surveyor questioned RN AA why patient was restrained and RN AA answered she did not know however, reported P#1 had been grabbing and squeezing the staff's arms forcefully. No combative or aggressive behavior was exhibited during the visit. The patient required several prompts to awaken and appeared lethargic when awaken with eyes slightly open, mumbling and slow movement. Review of the patient's medication administration record (MAR) indicated the patient has scheduled medications ordered which include Depakote (used for anticonvulsant's, bi-polar and migraines) 250mg 2 tablets 1 time a day Oral; Depakote 250mg 1 tablet every 12 hours Oral; Depakote DR 500 mg 1 time a day Oral and Seroquel (an antipsychotic used for schizophrenia, depression and bi-polar) 50mg 1 tablet 1 time a day ORAL.. The current MAR noted the following PRN orders (intramuscular) (IM) Haldol and Lorazepam. Haldol (an antipsychotic used for schizophrenia) 5MG/ML 5 mg every 4 hours OTHER As Needed Agitation Haldol 1 mg Capsule 1 Capsule every 4 hours ORAL As Needed Agitation, Anxiety, and Hallucinations (1 mg Capsule) and Lorazepam (used for anxiety) 2MG/ML 1ml every 4 hours as needed Agitation and Anxiety. . The following Haldol PRN was documented as administered on the MAR. -4/23/22, at 0800 Patient noted with delirium, hallucinations, and confusion. Haldol 5 IM given (no comments of effectiveness or site given). -4/23/22, at 19:00 Patient noted with agitation, confusion, combativeness delirium and restlessness. Haldol 5mg IM given via right deltoid. -4/24/22, at 04:00 5.0mg (no comments on behaviors/effectiveness or site given) . -4/24/22, at 08:30 Patient noted with agitation, delirium, hallucinations, restlessness, and confusion. Haldol 5mg IM given.(no comment on effectiveness or site given) -4/24/22, at 18:30 Patient noted with agitation, delirium hallucinations, restlessness and confusion. Haldol 5 mg IM given. (no comment on effectiveness or site given). -4/25/22 at 01:00 5.0 mg (no comments on behaviors, effectiveness or site given). -4/25/22 at 09:27 1.0 capsule every 4 hours ORAL as needed (no comment on effectiveness or behaviors noted) -4/27/22 at 00:00 5.0 mg (no comments on behaviors/effectiveness or site given). -4/27/22 at 17:00 5.0 mg Right thigh (no comments on behaviors or effectiveness). -4/29/22 at 01:30 5.0 mg (no comments on behaviors/effectiveness or site given). -4/29/22 at 08:00 mg Patient noted with agitation, delirium hallucinations, restlessness and confusion . Haldol 5mg IM given ( no comments on effectiveness or site given). -4/29/22 at 18:00 Patient noted with agitation, delirium hallucinations , restlessness, and confusion . Haldol 5mg IM given ( no comments on effectiveness or site given). -4/30/22 at 17:45 Patient noted with agitation, confusion, hallucinations, and restlessness . Haldol 5mg IM given ( no comments on effectiveness or site given). -5/1/22 at 09:00 Patient noted with agitation, confusion, and restlessness . Haldol 5mg IM given via right vastus laterallis muscle (no comments on effectiveness). The following Lorazepam PRN was documented as administered on the MAR. -4/22/22 at 20:00 1.0 ml restlessness (no comments of effectiveness or site given). -4/23/22 at 13:30 1.0 ml (Patient noted with confusion, combativeness, agitation, delirium, hallucinations, and restlessness. Ativan 2mg/1ml given IM via right deltoid (no comments of effectiveness). -4/24/22 at 21:00 1.0 ml agitation (no specific comments effectiveness or site given). -4/27/22 at 15:30 1.0 ml left deltoid (no comments of behavior/effectiveness). -4/29/22 at 13:00 1.0 ml Patient noted with agitation, confusion, combativeness, delirium, hallucinations and restlessness 2mg/1m. given via left deltoid muscle. (No comment on effectiveness) -4/29/22 at 20:00 1.0 ml.IM right thigh.(no comments behaviors/effectiveness). -4/30/22 at 13:30 1.0 ml Patient noted with Cheyne-stokes pattern of breathing with agitation and hallucinations. Ativan 2mg/ml given via left deltoid muscle. -4/30/22 at 20:00 1.0 ml (no comment for behaviors/effectiveness or site given). During an interview on 5/4/22, at 10:00 a.m., the Director of Compliance acknowledged there was not a medical or behavioral evaluation. According to the Director of Compliance, the IPU physician would not have completed an evaluation as the patient was not a Harbor Grace patient. During a telephone interview the Hospice and Home Health Program Manger with the Harbor Grace Administrator and the Clinical Director on 5/9/22, at 2:00 p.m., the Administrator stated to the Hospice Home Health Program Manager, the patient is a Longleaf Hospice patient, and the Harbor Grace staff was following the Longleaf Hospice physician orders. When asked who administered medications, she replied Harbor Grace Nurses.

Based on clinical record reviews, home observations and staff interviews, it was determined that the Interdisciplinary Group (IDG) failed to ensure comprehensive assessments were updated and included evaluation and documentation of the patient's response to wound care (surgical/drainage site), pressure ulcer treatments and progress toward desired outcomes. The IDG failed to ensure that accurate and current information regarding the patient was provided to the patient and or family in order to make accurate care planning decisions. The agency also failed to ensure assessment updates and changes were documented in the clinical record for three of sixteen patients (P#) (P#10, P#11, and P#12) reviewed for altered skin conditions. The findings include: 1. Review of the clinical record for P#10 revealed the patient was admitted to the hospice inpatient unit (IPU) on 9/21/21, with an admitting diagnosis of chronic stage IV sacral wound and necrotic hip wound. The initial assessment of the wound dated 9/22/21, as follows: stage 4 full thickness skin loss with extensive destruction tissue necrosis. The wound has tunneling, slough and necrotic. The measurement of the wound was noted as 22 cm (centimeters) in length and 26 cm in width. The wound care treatment as follows: cleanse wound with wound cleanser, apply wet to dry dressing with ¼ strength Dakin's solution. Cover area with gauze and ABD (Abdominal Dressing Pad) with tape every shift and as needed. The care plan for the wound dated 9/28/21, requires the skilled nurse (SN) to measure and describe wound upon admission and on weekly basis. However, the clinical notes dated 9/21/21 to 10/13/21, lacks explicit description and measurement of the wounds. Furthermore, IDT meeting notes from 9/27/21 to 10/11/21, lacked documentation of the current status and the size of the wound/pressure ulcer. The IDT notes also lacked documentation regarding the progress, or lack of progress toward the desired outcomes/goals and the patient's response to the treatment. During an interview in the hospice agency office with the Administrator and the Clinical Care Coordinator (CCC) for the IPU on 10/15/21, at 10:00 a.m., the CCC stated, "the wound has not been measured until 10/14/21." The CCC also verbalized, "the wound will be measured on weekly basis and as needed and will obtain verbal order for treatment based on the status of the wound". The CCC provided the surveyor with the visit note dated 10/14/21, which included the measurement, and the complete assessment of the wound as follows: stage 4 sacral pressure ulcer with full thickness, skin loss with extensive destruction tissue necrosis. The wound with slough, eschar, and granulation. The measurement as follows: 50 cm in length, 28 cm in width and 4 cm in depth. The pressure ulcer has increases in length and width since admission to the hospice agency on 9/21/21. 2. Review of the plan of care for P#11 revealed the patient was admitted to the inpatient unit (IPU) on 10/2/21, with the diagnosis of acute cholecystitis and obstruction and patient has a biliary drainage to the right upper abdomen. However, the clinical notes dated from 10/2/21 to 10/13/21, lacked assessment and care of the biliary drainage site. The IDT meeting notes from 10/4/21 to 10/11/21, lacked documentation of the current treatment and the status of the drainage site and the amount of the drainage. The IDT notes also lacked documentation regarding the progress or lack of progress toward the desired outcomes/goals and the patient's response to the treatment. During an interview in the hospice agency office with the Administrator and the Clinical Care Coordinator CCC for the IPU on 10/15/21, at 10:00 a.m., the CCC provided the surveyor with a verbal order dated 10/15/21, for the treatment and drainage management. 3. Review of the plan of care for P#12 revealed the patient was admitted to the inpatient unit IPU on 9/7/21, with the diagnosis of toxic liver disease with chronic ascites and congestive heart failure. Review of a verbal order dated 9/18/21, reads : Pleurix catheter placed on 9/17/21. Catheter to be drained as needed and dressing to be changed following each draining. Clinical notes dated 9/18 to 10/14/21, lacked documentation of dressing changes to the catheter insertion site and the amount of drainage noted in the drainage bag. The IDT meeting notes from 9/20/21 to 10/11/21, lacked documentation of the current treatment and the status of the drainage site and the amount of the drainage. The IDT notes also lacked documentation of progress or lack of progress toward the desired outcomes/goals and P#12's response to the treatment. During an interview on 10/15/21, at 10:00 a.m., in the hospice agency office with the Administrator and the Clinical Care Coordinator for the IPU she/he provided the surveyor with a clarification order dated 9/17/21, for the treatment for the pleurax drainage management.

Based on clinical record reviews, home observations and staff interviews, it was determined the hospice failed to ensure that the requirements for the Interdisciplinary Group (IDG), care planning and coordination of services were met for four of sixteen patients P# (#9 #10, #11, and #12) who were hospice beneficiaries. The condition level citations were related to the agency's noncompliance with the program requirements at 418.52 Condition of Participation : Interdisciplinary Group, Care Planning, and Coordination of Services (L536), Update of the Comprehensive Assessment (L533), and Content of the Plan of Care (L545).

Based on observations, clinical record reviews and staff interviews, it was determined that the interdisciplinary group failed to ensure that the plan of care addressed specific, individualized interventions necessary for the palliation and management of the terminal diagnosis for four of sixteen patients (P#) (P #9, #10, P#11, and P#12) reviewed with wounds and pressure ulcers. The findings include: 1. Review of the plan of care for P# 9 revealed the patient was admitted to hospice on 10/10/21, with the diagnosis of cancer of the lung. Review of standing order for Foley catheter as follows: condom catheter placement and care as appropriate. However, the skilled nurse (SN) visit note dated 10/12/21, documents 16 FR. Foley catheter inserted for bladder retention, patient had 1,200 cc (cubic centimeter) of brown urine. The plan of care lacked specific orders for the care and treatment of the Foley catheter. The agency failed to ensure the plan of care included the Foley catheter orders for the GU treatment for P#9. During an office interview with the Administrator and the Clinical Care Coordinator on 10/15/21, the surveyor was provided with an incomplete verbal Foley catheterorder dated 10/15/21. 2. Review of the clinical record for P#10 revealed the patient was admitted to the hospice inpatient unit (IPU) on 9/21/21, with an admitting diagnosis of chronic stage IV sacral wound and necrotic hip wound and patient has an ileostomy and urostomy pouch. However, the plan of care lacked specific orders for the care and treatment of urostomy and ileostomy site and drainage. The agency failed to ensure the plan of care included a specific treatment plan for P#10's GI/GU needs. During a hospice agency office interview with the Administrator and the clinical care coordinator on 10/15/21, at 10:00 a.m., the clinical care coordinator provided the surveyor with verbal order dated 10/15/21, for urostomy and ileostomy site/drainage care. 3. Review of the plan of care for P#11 revealed the patient was admitted to the inpatient unit (IPU) on 10/2/21, with the diagnosis of acute cholecystitis and obstruction and patient has a biliary drainage to the right upper abdomen. However, the plan of care lacked assessment and care of the biliary drainage site. The agency failed to ensure the plan of care included a specific treatment plan for P#11's biliary care needs. During an interview in the hospice agency office with the Administrator and the clinical care coordinator for the IPU on 10/15/21, at 10:00 a.m., the clinical care coordinator provided the surveyor with a verbal order dated 10/15/21, for the treatment of the drainage site as follows: cleanse site around biliary drain with normal saline, pat dry and apply split gauze, secure with tape. Change dressing twice daily and as needed when soiled. 4. Review of the plan of care for P#12 revealed the patient was admitted to the inpatient unit (IPU) on 9/7/21, with the diagnosis of toxic liver disease with chronic ascites and congestive heart failure. Review of a verbal order dated 9/18/21 reads : Pleurix catheter placed on 9/17/21. However, the plan of care lacks specific orders to clean the Pleurix catheter insertion site and assess the drainage amount to identify any complication with the drainage . Furthermore, the initial plan of care revealed a standing order for Foley catheter that reads as follows: Foley catheter placement and care as appropriate. The plan of care lacked specific orders for Foley catheter insertion such as size of the catheter, amount and type of solution to inflate the balloon and the frequency to change the catheter. The agency failed to ensure the plan of care included a specific treatment plan for P#12'spleurix drainage management and Foley catheter management. During an interview in the hospice agency office with the Administrator and the clinical care coordinator for the IPU on 10/15/21, at 10:00 a.m. The clinical care coordinator provided the surveyor with a clarification order to 9/17/21, for the treatment of the pleurax drainage site treatment as follows: cleanse site with normal saline, pat dry and apply dry gauze, secure with tape. Change dressing after each draining and as needed.

Based on clinical record reviews and staff interview, it was determined that the hospice failed to ensure that the care and services were provided in accordance with the plan of care for one of sixteen sampled patients (P#10) who are current hospice beneficiaries. The findings include : 1. Review of the clinical record for P#10 revealed the patient was admitted to the hospice inpatient unit (IPU) on 9/21/21, with an admitting diagnosis of chronic stage IV sacral wound and necrotic hip wound. The wound care treatment as follows: cleanse wound with wound cleanser, apply wet to dry dressing with ¼ strength Dakin's solution . Cover area with gauze and ABD (Abdominal drainage) pads with tape every shift and as needed. The care plan for the wound dated 9/28/21, requires the skilled nurse (SN) to measure and describe wound upon admission and on weekly basis. However, the SN notes dated 9/23 to 10/13/21, lacked explicit description and the measurement of the wounds. The SN visit notes lacked step by step process and supplies used to provide wound care to P#10. During an interview in the hospice agency office with the Administrator and the Clinical Care Coordinator (CCC) for the IPU on 10/15/21, at 10:00 a.m., the clinical care coordinator stated, the wound has not been measured until 10/14/21. The CCC provided the surveyor with a SN note dated 10/14/21, which included the measurement, and the complete assessment of the wound.

Based on clinical record reviews and staff interviews, it was determined the agency failed to ensure patients' clinical record contained complete, concise, and clear documentation of all services including evaluations, treatments, progress notes, and individualized plan of care including all required elements to address the patients' needs for two of sixteen sampled patients (P#) ( P#9 and P#10) reviewed. The finding include: 1. Review of the plan of care for P#9 revealed the patient was admitted to hospice on 10/10/21, with the diagnosis of cancer of the lung. The review of the verbal order dated 10/15/21, for the Foley catheter was noted as follows: foley catheter 16 FR (french) , 10 ML(milliliters) foley inserted to assist with keeping skin clean and dry. Routine catheter care and change foley catheter for any signs of infection or compromise in drainage system. The order lacked the balloon size, amount, and type of solution to instill in the balloon. The agency failed to ensure that the clinical record contained clear, concise, and complete documentation related to Foley catheter care. During an interview in the agency's office with the Administrator and the Clinical Care Coordinator or the hospice inpatient unit (IPU) on 10/15/21, at 10:00 a.m., they both acknowledged that the clinical record contained an incomplete Foley catheter order. 2. Review of the clinical record for P#10 revealed the patient was admitted to the IPU on 9/21/21, with an admitting diagnosis of chronic stage IV sacral wound and necrotic hip wound. The wound care treatment as follows: cleanse wound with wound cleanser, apply wet to dry dressing with ¼ strength Dakin's solution . Cover area with gauze and ABD (Abnormal drainage) pads with tape every shift and as needed. The care plan dated 9/28/21, for the wound requires the skilled nurse (SN) to measure and describe wound upon admission and on weekly basis. However, the clinical notes dated 9/23 to 10/13/21 lacked step by step process required for the wound care and supplies used to provide the wound care to sacral and hip area. The agency failed to ensure that the clinical record contained clear, concise, and complete documentation related to the wound care. During an interview on 10/15/21, at 10:00 a.m., in the agency's office with the Administrator and the Clinical Coordinator (CCC) for the IPU they both acknowledged that the clinical record contained an incomplete wound care treatment. The CCC verbalized, clinicians are recording a check box in the MAR (Medication Administration Record) to indicate that the wound care has been provided.