Every finding on record at Harmann, Inc.

Observed in Tracer Activities. the hospice surveyor observed that the volunteer HR #11 was not retrained on Emergency Management. This was reviewed and validated with the COO.

Observed in Regulatory Review. In 1 of 2 patient records reviewed, the hospice surveyor noted that the agencies' revocation form did not include time and the reason for the revocation as required by their Revocation of Hospice Benefit Election Policy 2-068.1. The supervisor did update the form to meet the policy during the survey. This was reviewed and validated with the DON.

Observed in Record Review. In 8 of 16 patient records reviewed, the organization failed to assesses and reassess the patients pain per their policy. In HOSRRHV #1, HOSRRHV #2, HOSRRHV #3, HOSRRHV #4 , and HOSRRNHV #10 an observational pain tool was used and per the organizational Pain Assessment 2-032.1 if the patient is unable to communicate pain using the rating scale, is cognitively impaired, the clinician will assess behavioral factors that signal pain or discomfort and include this information in the assessment. In all five patients the nurse documented that the patient will have an acceptable level for pain, this was not assessed in any of the patients as the observational tool was used. In HOSRRNHV #4, HOSRRNHV #7 and HOSRRNHV #8 pain was not assessed per the organizational Pain Assessment Policy. Pain care plan states that patient will have an acceptable level of pain. This was reviewed and validated with the DON. Observed in Patient Home. In 1 of 4 home visits conducted, the RN failed to assess the patient's pain during the home visit. The patient grimaced and moaned a number of times during the home visit and the RN never asked the patient if she had pain per the Pain Assessment Policy 1-032.1 which states that the RN will assess pain with each visit. This was reviewed and validated with the DON. Observed in Record Review. In 4 of 16 patient records reviewed, the agency process required wounds to be measured weekly, but they were not done monthly or only with recertification. In HOSRRHV #2 there were no wound measurements for the last 3 months. In HOSRRHV #4 the RN completed one wound measurement one month after admission. In HOSRRNHV #8, and HOSRRNHV #9 there were no measurements done for 8 months. This was reviewed and validated with the DON.

Observed in Record Review. In 7 of 16 patient records reviewed, the organization's records included discrepancies regarding hospice covered medications in patient records. In HOSRRHV #3 the Patient Notification of Hospice Non-Covered Items, Services, and Drugs the RN documented that the Atorvastatin, and Plavix were not related to the terminal illness and would not be covered. The medication list states they are both covered items. The nurse leaders thought the organization was not covering the medications. In HOSRRHV #4 the Addendum states that Losartan would not be covered as it was not related to the terminal illness but on the medication list it shows that it is covered. In HOSRRNHV #2 the Glucagon is not covered on the addendum but it is covered on the medication list. In HOSRRNHV #5 the Addendum states Propranolol was not covered but on the Medication list it states it is covered. In HOSRRNHV #6 Toprol is not covered in the Addendum but it is covered in the Medication List. In HOSRRNHV #7 the Memantine, Ketoconazole shampoo, Calcium, and Donepezil were not covered on the Medication List and not listed on Addendum as not covered. In HOSRRNHV #10 the Addendum states that Dorzolamide, Latanoprost, Folic Acid, Losartan, Metoprolol, and Clopidogrel are not covered but on the Medication list they are covered. This was reviewed and validated with the DON.

Observed in Record Review. In 3 of 16 patient records reviewed, the organization failed to plan the patient's care. The hospice nurse surveyor noted that in HOSRRHV #1, HOSRRHV #2, and HOSRRHV #3 where an observational tool was used to assess pain but the Plan of Care included a verbal descriptor was used. Per the agency policy Pain Assessment 2-032.1 if the patient is unable to communicate pain using the rating scale, is cognitively impaired, the clinician will assess behavioral factors that signal pain or discomfort and include this information in the assessment. In all three patients the nurse document that the patient will have an acceptable level for pain, this was not assessed as both patient's are nonverbal. This was reviewed and validated with the DON.

Observed in Patient Home. In 2 of 4 home visits conducted, the medication list did not contain all required elements such as dose, strength, frequency, and route. The Hospice nurse surveyor observed in HOSRRHV #1 that the patient had an order for Jevity 1 can four times per day via G tube with a 50 ml water flush, before and after feeding. Per the patient's daughter she is using a 30 ml flush before and after feeding. This patient has severe dysphagia and is unable to swallow so she receives all of her medications via her G tube. She was just ordered Amoxicillin-Pot Clavulanate 875-125 mg twice daily for 10 days and the route was per mouth. The daughter states that she crushed the antibiotic and gave it to the patient via the G tube. In HOSRRHV #2 the patient had an order for Gentamycin Sulfate ophthalmic drops and in the route it states 2 drops to the affected eye, the drops were for the right eye only. This patient also had an order for senna plus and Hyoscyamine Sulfate 0.125 mg with no route entered. This was reviewed and validated with the DON.

Observed in Tracer Activities. In 8 of 16 patient records reviewed, the surveyor noted that in HOSRRHV #3 that the patient was on Plavix 75 mg and ASA 81 mg daily and the aide care plan did not include safety precautions such as bleeding. Additionally, this patient was deemed a fall risk and this too was missing from the aide care plan. In HOSRRNHV # 1, HOSRRNHV #5, HOSRRNHV #7 and HOSRRNHV #9 the patient is on ASA 81 mg and there is no bleeding precaution in the Home Health Aide care plan. In HOSRRNHV #6 the patient is on Clopidogrel and there is no bleeding precaution aide care plan. In HOSRRNHV #3 and HOSRRNHV #8 the patient has seizures and there is no seizure precautions listed for the Home Health Aide. This was reviewed and validated with the DON.

Observed in Record Review. In 9 of 16 patient records reviewed, the organization failed to plan the patient's care. In HOSRRHV #3 the patient was on Plavix 75 mg and ASA 81 mg every day. The RN did not include a bleeding risk care plan. This patient was also on Oxygen 3 Liter via nasal cannula continuous, titrate to 5 Liters as needed. The RN failed to document when the caregiver should use 3, 4, or 5 liters of oxygen. HOSRRNHV #1, HOSRRNHV #5, HOSRRNHV #7, and HOSRRNHV #9 patient on ASA 81 mg no care plan for bleeding precautions for RN. In HOSRRNHV #6 and HOSRRNHV #10 the patient is on Clopidogrel 75 mg, no bleeding precautions care plan. In HOSRRNHV #3 and HOSRRNHV #8 the patient was diagnosed with seizures and on medications and there was no seizure precaution care plan. This was reviewed and validated with the DPCS. Observed in Record Review. In 3 of 16 patient records reviewed, there were no foley change orders obtained by the nurse. In HOSRRHV #2 the patient has had a foley catheter for three years. The patient has gone from a 16 French to a 26 French catheter and there are only two orders for foley catheter changes . One was in 2022 for a 16 French and the other was June 2025 for a change from a 22 French to a 26 French catheter. Both the RN and the DON state that the patient has progressed up to the 26 French catheter, from a 18 French, 20, and 22 French catheter.. There were no orders found for these catheter changes or the type of fluid and amount to instill in the balloon. In HOSRRHV #8 the patient has a wound to the bilateral heels and shins and there is no wound care order. This patient also has a foley catheter and there is no order for catheter changes, what to instill in the balloon, or any securement device. In HOSRRNHV #9 the patient had a wound to the right trochanter and there are no orders for the dressing change. This was reviewed and validated with the DON.

Observed in Patient Home. In 1 of 4 home visits conducted, the nurse failed to follow the manufacturer's guidelines for equipment cleaning. In HOSRRHV #2 the nurse cleansed the pulse oximeter with a Caviwipe which is not an approved cleaner per manufacture's guidelines. This was reviewed and validated with the DON. Observed in Patient Home. In 1 of 4 home visits conducted, the Hospice surveyor observed that the home health aide performed a bed bath on HOSRRHV #3. The home health aide used the same pair of gloves for washing the perineal and she then dressed the patient with the same gloves. This was reviewed and validated with the DON.

Observed in Tracer Activities. the hospice surveyor observed that the volunteer HR #11 did not receive education on Blood Borne Pathogens. This was reviewed and validated with the COO.

Observed in Record Review. In 3 of 3 patient records reviewed, the bereavement care plans were the same for all families no matter what risk level was assessed. In HOSRRBRV #1, HOSRRBRV #2, and HOSRRBRV #3 all of the care plans were the same for each of the families as a template was used. All three families were low risk but the Bereavement Coordinator conceded that the same care plan template is used for all levels of risk. This was reviewed and validated with the Bereavement Coordinator.

Observed in Tracer Activities. Staff did not participate in twelve months of ongoing education and training. The hospice survey noted during tracer activity that there were between 9 to 13 home health aides who were employed by the organization. In one calendar year there were 122 staff that should have attended in-service training. The surveyor noted that only 83 staff completed training. Staff did not participate in twelve months of ongoing education and training. This was reviewed and validated with the RN supervisory.

Observed in Pharmacy. In 1 of 4 home visits conducted, where the home health aide services were provided the organization failed to provide treatment or services. In HOSRRHV #4 the home health aide care plan states shower to be provided and when talking with the patient's daughter in law she states the patient is unable to ambulate and the aide performed a bed bath only with the patient. This was reviewed and validated with the DON.

Observed in Patient Home. In 1 of 4 HR files reviewed, the aide failed to provide care as instructed in the POC. In HOSRRHV #3 the patient had orders for oral hygiene and denture care, nail care, and to comb her hair with each visit. These services were not offered or provided by the home health aide. This was reviewed and validated with the DON.

Observed in Tracer Activities. The Hospice surveyor noted that the organization did not define competencies for the Volunteer Coordinator and the Bereavement Coordinator. This was reviewed and validated with the COO.

Observed in Record Review. In 2 of 16 patient records reviewed, treatments performed such as dressing changes or foley catheter changes were not fully described in the record. In HOSRRHV #2 the patient has been on service for 3 years and the foley catheter change and the wound care provided were not fully described in the medical record. The staff documented that wound care was provided as ordered and the foley catheter change was documented as foley catheter changed per order. The nurse did not document the size of the foley catheter used, the amount or type of fluid used to inflate the balloon or if a securement device was used. In HOSRRHV #4 the patient had wound care performed and in the last 2 months of visits the RN documented wound care provided per orders. This was reviewed and validated with the DON

Observed in Record Review. In 1 of 2 patient records reviewed, the deemed hospice did not provide a discharge summary to the receiving facility when the patient was transferred. In HOSRRDC #1 the patient was transferred to another hospice agency and the organization failed to send a discharge summary to the receiving organization. The organization failed to follow their policy Transfer Information 2.070.1. This was reviewed and validated with the DON.

Observed in Record Review. the hospice deemed organization failed to provide the PCP with a discharge summary. In HOSRRDC #2 the patient revoked from hospice and the organization failed to send the community provider a discharge summary. The organization failed to follow the Revocation of Hospice Election Policy 2-068.1. This was reviewed and validated with the DON.

Observed in Individual Tracer. In 1 of 13 patient records reviewed, the hospice IDG did not update the assessment with changes that have taken place after the initial assessment. RR#1 was started on antianxiety medication and the IDG immediately following this new medication did not reflect this change or its effectiveness. This observation was discussed with the alternate director.

Observed in Individual Tracer. In 2 of 13 patient records reviewed, the hospice did not update care plan goals. The comprehensive care plan of RR#2 reflected problems identified upon admission to the program and that had target dates for achievement that should have been achieved two years ago. All of the target dates for the goals of RR#1 reflected that they would be achieved within the certification period. These goals reflected issues with dyspnea, pain, and constipation. These observations were discussed with the alternate director.

Observed in Individual Tracer. In 1 of 13 patient records reviewed, the hospice comprehensive care plan did not reflect the frequency of services necessary. RR#3 had a Foley and the orders did not include the frequency of the Foley change. This observation was based on review of the updates to the plan of care, the doctor's orders and was confirmed by discussions with the director.

Observed in Individual Tracer. In 2 of 3 home visits conducted, the hospice comprehensive care plan did not reflect all of the drugs necessary to meet the patient needs. The nursing home medication administration record of RR#1 reflected that she was on 8 units of insulin to be taken with meals. This medication had been given to the patient for the last three months. This insulin dose was not reflected on the hospice medication record. The hospice medication record of RR#3 reflected that the patient was on acetaminophen extra strength and the medication administration record of the assisted living facility did not reflect this medication. These observations were discussed with the director.

Observed in Individual Tracer. In 3 of 4 tracers conducted, the hospice aide care plan did not reflect all of the services/interventions required to meet the patients assessed needs. RR#1 had a history of dysphagia and swallowing precautions were not reflected on the hospice care plan. RR#2 was maximally dependent, was on oxygen and utilized a wheelchair. The hospice aide care plan reflected that the RR#2 received a shower with no other qualification such as a shower chair. RR#10 was dependent on others for ambulation and transfers and the hospice aide care plan reflected that the patient receive a shower without any further qualifications. These observations were discussed with the alternate director and the director who indicated that these patients probably utilized shower chairs/bench for safety.

Observed in Tracer Activities. In 3 of 3 patient records reviewed, of expired individuals, there was no documentation of bereavement follow up for the same 5 month period. Based on a review of Bereav #1-#3 there was a gap in the documentation of planned monthly mailings. Per discussions with the social worker, the mailings were completed by her but she has not had the opportunity to enter the information into the patient records.

Observed in Individual Tracer. In 2 of 3 patient records reviewed, that were either transferred to a hospital and or another hospice, did not have the discharge summary form sent to the next provider. RR#6 and RR#7 were transferred to another Medicare/Medicaid facility and there was no documentation that the discharge summary was sent to the next provider. These observations were discussed with the alternate director.

Observed in Tracer Activities. In 1 of 2 tracers conducted, the hospice did not ensure that the durable medical equipment supplier met the Medicare DMEPOS Supplier Quality and Accreditation. One of the DME suppliers reviewed was not accredited. This observation was discussed with the COO.

Observed in Individual Tracer. In 1 of 3 tracers conducted, of patients that resided in a nursing home, the comprehensive hospice care plan did not identify which provider would be responsible for required services. RR#4 resided in a nursing home and had a wound that required daily wound care. The hospice comprehensive care plan did not delineate whether the hospice nurse or the nursing home staff would be performing the wound care. This observation was discussed with the director.