Every finding on record at Harmony Home Health Services, LLC

Based on interview and review of the facility's Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP policies addressed the use of federal and/or state healthcare volunteers to meet staffing requirements during an emergency event. This failure had the potential to affect the current 32 patients receiving care from the hospice agency. --- Findings include:Review of the facility's EPP on 04/23/25 at 3:35 PM with the Director of Nursing (DON) revealed no policy inclusion regarding the use of State and/or Federal healthcare professional volunteers in an emergency or other emergency staffing strategies.During an interview on 11/08/23 at 4:09 PM regarding federal and state healthcare volunteers, the DON stated, "No, it's not in there."

Based on interview, record review, and policy review, the facility failed (1) to ensure one of 16 sampled patients (Patient (P) 10) was assessed by the Social Worker (SW) and Chaplain within five days of the election of Hospice benefits, and (2) the documentation of the Physician involvement in the comprehensive assessment was not included in three of 16 sampled patients (P6, P11, and P14). These failures had the potential to delay medically needed social services and spiritual service provision to the patient. --- Findings include:1. Review of P10's facility printed "Intake Referral Sheet" showed a start of care date of 02/01/25 with a primary medical diagnosis of adult failure to thrive.Review of P10's electronic medical record (EMR) on 04/24/25 with the Executive Director (ED) revealed the SW assessment was completed on 02/13/25. This was 12 days after the start of care date. It was also revealed that the Chaplain assessment was completed on 02/14/25. This was 13 days after the start of care date.The ED reviewed the EMR for documentation of earlier contact or documented patient preference in regard to the SW assessment and stated at 2:03 PM that there was "nothing." The ED reviewed the EMR for documentation of earlier contact or documented patient preference in regard to the Chaplain assessment and stated at 2:04 PM, "[He/She] [Chaplain] always gets in there so it was probably a scheduling issue, but nothing is documented."2. Review of P6's facility printed "Intake Referral Sheet" showed a start of care date of 09/05/23 with a diagnosis of repeated falls.Review of P11's facility printed "Intake Referral Sheet" showed a start of care date of 01/28/25 with a diagnosis of primary spontaneous pneumothorax.Review of P14's facility printed "Intake Referral Sheet" showed a start of care date of 04/02/24 with a diagnosis of toxic effects of other halogen derivatives.Review of the four EMR's on 04/24/25 with the ED revealed the section on the comprehensive assessment for "Attending Physician" had areas to be checked of the following:"-Reporting patient status-Reported on plan of care problems, interventions, goals & patient response-Received new ordersConsultation results [blank line for comment]"The assessments for P6, P11, and P14 did not contain any documentation the physician was involved.During an interview on 04/24/25 at 5:31 PM, the ED stated, "They [SW and Chaplain] normally do a fantastic job. I feel there is a reason, but the documentation is not there." The ED stated the expectation was for assessments to be completed within five days or less or that there is documentation regarding the delay. The ED stated physician involvement was "probably done via their messaging system," but the expectation was for there to be documentation of the physician involvement in the comprehensive assessment. Review of the facility policy titled "Comprehensive Assessment – Hospice," reviewed 11/2024, revealed:". . . 3. The comprehensive assessment is completed, as appropriate to the patient's needs, or within the following time frames:a. There is a 5-day window to complete the whole comprehensive assessment . . . "

Based on interview and review of the agency documentation, the agency failed to ensure volunteers provided day-to-day administrative and/or direct patient care services equaling a minimum of 5 percent of the total patient care hours of all paid hospice employees and contract staff. This had the potential to cause 32 of 32 residents to have unmet needs. --- Findings include:Review of the agency provided "Volunteer Time" report for the time period of 01/01/24 – 12/31/24 showed:"Volunteer Total Time 10.5Total Hospice Visit Time: 10,938.13 hoursPercentage [of Volunteer Hours]: 0.10%"Review of the agency provided "Volunteer Time" report for the time period 01/01/25 – 12/31/25 (printed on 04/22/25) showed:"Volunteer Total Time 30.58Total Hospice Visit Time: 3604.95Percentage [of Volunteer Hours]: 0.85%In an interview on 04/24/25 at 5:28 PM, the Executive Director (ED) confirmed the volunteer hours did not reach 5%. The ED stated, "When I look at volunteers I don't look at cost savings benefits for patient and families, but I don't look at it as a cost aspect. I know it's supposed to be at 5% and I would like to have more."Review of the undated agency policy titled, "Value of Volunteer Service/Cost Saving," revealed, ". . . -Quarterly reports on volunteer services are present to the Governing Board. The agency volunteers provide a minimum of 5 percent of the total patient care hours of all paid employees and contract staff.-Each office will strive towards a minimum of 5 percent of the total patient care hours . . ."

Based on observation, interview, and policy review, the Hospice Agency failed to ensure that supplies kept for patient use were not expired. This had the potential to negatively affect 32 of 32 patients receiving services. Expired products may not perform as intended, leading to ineffective treatment, and/or increase the risk of infection. --- Findings include:During an observation on 04/22/25 at 4:10 PM, the following were observed in one of two supply rooms:9 Wound Vacuum Dressings:Granufoam large – 4, expired 5/31/24Medela medium – 2, expired 2/27/25Dermatec medium – 3, expired 12/31/2410 Foley catheters:26 French (F, size) 30 milliliter (ml, retention bulb size) – 4, expired 7/28/2322F 30ml – 2, expired 8/28/2424F 5ml – 1, expired 11/20/2430F 30ml – 2, expired 4/28/24300ml cannisters for wound vacuums – expired 11/30/2433 red top blood vacutainer tubes expired 04/01/25Medline Latex Surgical gloves, size 8 – 6, expired 11/28/24Versatel Silicone Wound contact layers – 1, expired 06/2024 During an interview on 04/22/25 at 4:30 PM, the Executive Director reviewed all products found, confirmed the expiration dates, and stated all the products were expired. Review of the facility policy titled "Supply Inventory," revised 06/2024, revealed, ". . . -Please keep in mind, [sic] that Medical Supplies are for client use and when those supplies become either damaged, contaminated or their effectiveness is diminished through an effective date, those supplies need to be discarded.. . . Inventory Disposal-If a Branch has any Medical Supply item that becomes damaged, contaminated or obsolete and need to be discarded from inventory, they should use the Medical Supply checkout form to discard those items and mark on the form – Inventory Disposal . . ."

Based on interview, record review, and policy review, the facility failed to ensure the Skilled Nursing Facility (SNF) received the original certification of terminal illness and other admission documentation for one of one patient (Patient (P) 5) reviewed who lived at a SNF out of a total sample of 16. This had the potential to affect the care and services provided to the patient. --- Findings include:Review of P5's hospice "Intake Referral Sheet" revealed a hospice start of care date of 04/08/25.During a home SNF visit on 04/23/25 at 10:00 AM, a review of the Hospice notebook for P5 did not reveal a certification of terminal illness (CTI), election of hospice benefits, or hospice plan of care.During an interview on 04/23/25 at 11:00 AM, the SNF Director of Nursing (DON) stated P5's hospice information would be in a notebook at the Nurse's Station.Review of P5's hospice notebook on 04/23/25 at 11:07 AM revealed a three-ring binder with dividers that were empty for the CTI, hospice election form, and plan of care sections.During an interview on 04/23/25 at 11:25 AM, the Minimum Data Set (MDS, a federally mandated assessment) Coordinator (MDSC) reviewed the facility electronic medical record (EMR) for a hospice plan of care and CTI. The MDSC stated "I let medical records know and talked to the Business Office Manager regarding not having documentation."During an interview on 04/23/25 at 4:55 PM, the Hospice Executive Director (ED) confirmed that the documentation had not been sent and provided an email with attachments that was verified as received by the facility on 04/23/25 at 3:54 PM. It was noted that the CTI was unsigned by the physician. During a follow-up interview on 04/24/25 at 5:30 PM, the ED stated, "It [documentation] should be to them [SNF] right away. Our timing of document delivery and signing documents could be improved. They [SNF] should have [the documents] withing the first 24 – 48 hours."Review of the facility policy titled, "Facility Admission Process," dated 05/2024, revealed, ". . . CMA (Care Coordinatory [sic]) will fax required paperwork to facility including:--Face Sheet--Order (POC [Plan of Care])--Medication Sheet--POLST [Cardiopulmonary Resuscitation directive]--Hospice Election--Most recent nursing assessment--Current History and Physical (must be within 30 days, if available)-Case Manager is responsible for facility packet. (Fill out completely, put in facility chart and attach all stickers according to facility protocol."

Based on medical record review, policy review, and interview, the hospice agency failed to include all components of a plan of care (POC) in the patient document identified by the agency as the individualized POC. Review of the one-page POC in the electronic medical record (EMR) for 11 of 11 patient (Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11) records reviewed revealed patient/family goals, outcomes, medical supplies/equipment, and specific staff interventions to manage symptoms were not identified on the POC. The POC format utilized by the hospice agency only identified the following: (1) a checklist of potential problems, (2) services/frequency (for example, nurses 2x/week), (3) diagnosis, and (4) factors precipitating hospice care. Findings include: Review of the POC format in the EMR for the 11 patients, P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11 revealed the following: 1. The hospice agency failed to develop and individualized patient POC which included patient and family goals. (See L545) 2. Interventions/treatment provided by members of the interdisciplinary team based on the problems identified in the assessment were not included in the POC or the updated POC. (See L546) 3. The POC did not include identification of measurable outcomes anticipated from implementation of the POC. (See L548) 4. Medical supplies and equipment needed by the patient were not included on the POC. (See L550)

Based on record review, policy review, and interview, the hospice agency failed to develop an individualized patient plan of care (POC) that included patient and family goals for 11 of 11 patent (Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, P10, and P11) records reviewed. The lack of individualized goals based on an assessment and discussion with the patient had the potential to exclude the patient and family in decision making which could impact the patient's well-being and treatment progress for all patients receiving hospice services from the agency. Findings include: Review of the POC located under the "Orders" tab in the electronic medical record for P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, and P11 revealed the one page document format for the hospice agencies POC included four sections which consisted of (1) check boxes to identify the patients "Immediate Plan of Care Problems," (2) Services (Nurses, Social Work, Hospice Aide, Chaplain) and frequency of visits, (3) Primary Diagnosis, and (4)Factors precipitating hospice admission. The "Medication Profile" located under the "Medication" tab identifies on the bottom of the page that it is "Part of the Plan of Care." The POC did not include patient and/or family goals. Review of an undated hospice agency policy titled, "Hospice Plan of Care" revealed, "The plan of care is based on the following data: A. Patient/family goals ... The plan of care includes: A. Goals/Outcomes." During an interview on 04/22/22 at 10:10AM, the Administrator confirmed the agency's POC format did not included identification of patient/family goals or measurable outcomes expected from implementation of the POC. The Administrator also stated that patient/family goals were not located in the EMR or any other location.

Based on record review, policy review, and interview, the hospice agency failed to identify the interdisciplinary team interventions to manage pain and symptoms based on the assessment for 11 of 11 patient (Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, P10, and P11) records reviewed. This failure had the potential to result in needs not being met for all patients receiving hospice care from the agency. Findings include: Review of the POC located under the "Orders" tab in the electronic medical record (EMR) for P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, and P11 revealed the POC documentation format did not include the interventions that were to be provided by each member of the disciplinary team to manage problems and symptoms identified during the assessments. Review of an undated hospice agency policy titled, "Hospice Plan of Care" revealed, "The plan of care includes: ... Scope, frequency, and type of services, including team member interventions ... " During an interview on 04/22/22 at 10:10AM, the Administrator confirmed the agency's POC format did not include the interventions provided by members of the interdisciplinary team to manage the patients' symptoms.

Based on record review, policy review, and interview, the hospice agency failed to identify measurable outcomes anticipated from implementation of the plan of care (POC) for 11 of 11 patients (Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, P10, and P11). The failure to identify measurable outcomes had the potential to result in the interdisciplinary team being unable to identify if the patient/family goals are being met. Findings include: Review of the POC located under the "Orders" tab in the electronic medical record (EMR) for P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, and P11 revealed the POC documentation format did not include measurable outcomes anticipated from implementation of the POC. The hospice agency did not identify goals, outcomes, or data elements on the POC. Review of an undated hospice agency policy titled, "Hospice Plan of Care" revealed, "The plan of care includes: Goals/outcomes." During an interview on 04/22/22 at 10:10AM, the Administrator confirmed the agency's POC format did not included identification of measurable outcomes expected from implementation of the POC. The Administrator also confirmed that measurable outcomes were not located any where else in the EMR.

Based on record review, policy review, and interview, the hospice agency failed to include medical equipment and supplies needed to meet patients' needs on the plan of care (POC) for 11 of 11 patients (Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, P10, and P11). Failure to identify medical equipment and supplies on the plan of care had the potential for the hospice agency to not identify or provide needed medical equipment. Findings include: Review of the POC located under the "Orders" tab in the electronic medical record (EMR) for P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, and P11 revealed the POC documentation format did not include a designated area for identification of medical supplies or equipment needed by the patient for management of symptoms associated with the terminal illness. None the 11 patient POC's included identification of medical supplies anywhere on the one-page document. Review of an undated hospice agency policy titled, "Hospice Plan of Care" revealed, "The plan of care includes: ... medical supplies and equipment to be provided." During an interview on 04/22/22 at 10:10AM, the Administrator confirmed the agency's POC format did not included identification of medical supplies or equipment needed by the patient.

Based on review of Quality Assessment Performance Improvement (QAPI) quality indicators, policy review, and interview, the hospice agency failed to investigate and analyze the contributing factors associated with patient falls and infections. The failure to identify factors that may relate to adverse events, including falls and infections, had the potential to contribute to future falls and infections for all patients receiving hospice services from the agency due to preventative actions not being identified and implemented. Findings include: Review of the QAPI data provided for the four quarters of 2021, January 2021 through December 2021, showed a total of nine falls and three infections during that period of time. The QAPI documentation did not include information to show the investigation and analysis of the data elements presented in the graph. Review of an undated hospice agency policy titled, "Quality Assessment and Performance Improvement (QAPI)," revealed, "Scope of the QAPI Program ... The program will measure, analyze, and track quality indicators, including adverse patient events ...The following criteria will be used in setting QAPI activities ... Selecting high risk, high volume, or problem prone processes to monitor ... Affect outcomes, patient safety and quality of care ... Quality indicators will include ... Problem identification, assessment, correction, monitoring, and documentation." During an interview 04/21/22 at 3:30 PM, the Administrator stated that there was no other QAPI information other than the QAPI graph which showed the total number of adverse events for 2021. The Administrator stated he/she did not have documentation that would show that the individual events were investigated and the potential factors contributing to falls, infections, or other adverse patient events were analyzed, and preventative actions implemented.

Based on policy review and interview, the hospice agency failed to maintain a program for surveillance, identification, prevention, control, and investigation of infections. The failure to maintain ongoing surveillance and investigation of infections had the potential to increase the risk of communicable disease and miss opportunities to prevent infections for all patients receiving hospice services from the agency. Findings include: During an interview on 04/22/22 at 10:15 AM, the Administrator stated that the agency did not have ongoing surveillance, identification, and investigation of infections. Review of an undated agency policy titled, "Infection Prevention and Control Program," revealed "Purpose ... Establish the mechanism by which the organization will address surveillance, prevention, identification, control and reporting of infections, utilizing current scientific methods and epidemiologic principles ... Infection control data are an integral part of the organization's quality assurance/performance improvement program ... collecting and/or screening data to identify isolated incidents or potential infectious outbreaks ...Analyzing data for problem or undesirable trends ... determining if infections are organization acquired or community acquired ... integrating outcomes from surveillance and control activities to allow for internal comparison, for trend analysis and comparison with external databases for benchmarking purposes as indicated."

Based on interview, and document review, the hospice agency failed to provide a plan of care (POC) that was established in coordination with the skilled nursing facility for one of one patient (Patient (P)4) residing in a skilled nursing facility (SNF) observed during a home visit. The failure to provide a POC to the SNF and coordinate care had the potential for unmet patient needs due to provider responsibilities not being clearly identified and delineated. The coordinated POC must identify which provider is responsible for specific services. Findings include: During an interview on 04/21/22 at 10:10 AM, the SNF Administrator stated the hospice agency had not provided a copy of the hospice POC to the SNF. During an interview on 04/21/22 at 10:25 AM, the SNF Social Worker stated the facility did not have a POC from the hospice agency for P4 and that the POC should be located in the hospice binder at the nursing station desk. Review of a binder located at the nursing station and labeled as belonging to the hospice agency revealed it did not include P4's POC. Review of an undated hospice agency document titled, "Hospice Agency Agreement for Professional Services Nursing Facility," revealed, "In accordance with applicable Federal and state laws and regulations, Hospice shall coordinate with a Nursing facility to develop a Plan of Care for each new Residential Hospice Patient. Hospice shall furnish Nursing Facility with a copy of the Plan of Care and specifies the inpatient services to be furnished if they are admitted for inpatient care." During an interview on 04/21/22 at 2:20 PM, the Administrator stated, "The plan of care should have been there."