Every finding on record at Heavenly Gates Hospice, Inc

Based on interview and record review, the hospice agency failed to ensure the Physician Orders for Life-Sustaining Treatment (POLST – a process and a form that communicates your wishes for health care treatment during a medical emergency) information was accurately documented in the clinical record of one of three sampled patients (Patient 12) to reflect the patients/legal representatives wishes for end-of-life care. This failure had the potential to violate Patient 12s rights and wishes for end-of-life care. --- Findings: On 9/19/24 at 2 p.m., a scheduled visit was conducted at Patient 12's residence with agency employee (4) to observe the implementation of the ordered skilled nursing services as indicated on Patient 12's plan of care. During a review of Patient 12s, ";Patient Handbook (home packet provided by the hospice agency containing information including the patients rights, medication profile, and advanced directive)," the information documented in the patients ";POLST," dated 8/19/24, was reviewed. The boxes in Section A [Cardiopulmonary Resuscitation (CPR – emergency lifesaving procedure performed when the heart stops beating or when someone is no longer breathing)] of Patient 12s POLST were left blank. Section B (Medical Interventions) of Patient 12s POLST, indicated a check mark on the box ";Full Treatment... Use intubation, advanced airway interventions, mechanical ventilation...." During a concurrent interview and record review, on 9/19/24 at 2:08 p.m., with Patient 12, her legal representative, and Employee 4, who also served as the language interpreter (Patient 12 and her legal representative primarily spoke Spanish), the contents of Patient 12s POLST, dated 8/19/24, were reviewed. Employee 4 discussed with Patient 12 and her legal representative that the POLST indicated the patient agreed to full treatment and further explained that in case of a medical emergency, interventions will be provided to the patient including intubation (insertion of tube into the airway to keep it open and deliver air or oxygen), advanced airway interventions and mechanical ventilation (use of a machine to aid the movement of air in and out of the lungs for people with respiratory failure). Patient 12 and her legal representative frustratingly disagreed and verbalized that they never agreed to any type of life-saving procedure or medical intervention in case of a medical emergency. During a review of the agencys policy & procedures (P&P), titled, ";Advanced Directives," revised 11/18, the P&P indicated in part, ";POLICY... It is the policy of (agency name) to encourage patients and their family/caregivers to participate in decisions regarding care and treatment. The P&P indicated further, ";PROCEDURE... 1) Upon admission, the clinician will provide information regarding a patient's right to make decisions concerning health care, which include the right to accept or refuse medical or surgical treatment, even if that treatment is life-sustaining...."

Based on observation, interview, and record review, the hospice agency failed to ensure patient medical records in paper form were stored in a secured area to prevent unauthorized access. This failure had the potential for breach of protected patient health information. --- Findings: During an observation on 9/18/24 at 10:14 a.m. inside the employee break room, five boxes containing paper documents were observed in a corner of the room. Upon further inspection, the paper documents revealed they were patient medical records. During a concurrent observation and interview, on 9/18/24 at 10:25 a.m., inside the employee break room with an agency employee (1), the contents of the boxes were inspected. Employee 1 verified the boxes contained multiple patient medical records and verbalized that those records should not have been stored in the employee break room. Employee 1 further verbalized that patient medical records were stored in locked file cabinets inside the Administrators (ADM) office with authorized key access given to the ADM (or designee) and office manager only. During a review of the agencys policy and procedures (P&P), titled, ";Safeguarding/Retrieval of Clinical Records," revised 11/2018, the P&P indicated in part, ";Policy... Hospice will safeguard the clinical record against loss or unauthorized use." The P&P indicated further, ";Procedure... 1) All physical patient clinical records will be maintained in locked, waterproof file cabinets in a designated clinical records room... d) If the room must be left unattended, the door will be locked, e) Only authorized personnel will have access...."

Based on interview and record review, the hospice agency failed to ensure medications were reviewed and reconciled to reflect the current medication regimen for two of three sampled patients (Patients 14 and 12). These failures had the potential to result in suboptimal medication therapy for these patients which could affect their quality of life. --- Findings: On 9/18/24 at 3 p.m., a scheduled visit was conducted at Patient 14's residence with agency employee (2) to observe the implementation of the ordered skilled nursing services as indicated on Patient 14's plan of care. During a concurrent interview and record review on 9/18/24 at 3:30 p.m., with Employee 2, Patient 14s medications were reconciled. A comparative review of Patient 14s, ";Medication Profile (MP)," dated 7/18/24, and ";Medication Reminder Sheet (MRS – medication administration record from Patient 14s place of residence)," dated 9/2024, indicated the following discrepancies: a. MP indicated Patient 14 was on Divalproex (medication used to treat seizures) 250 mg (milligram) PO (by mouth) BID (twice a day), the actual dose in the MRS indicated Divalproex 20 mg PO BID. b. MP indicated Patient 14 was on Cholecalciferol (Vitamin D3) 600 mg PO once a day, the actual dose in the MRS indicated Cholecalciferol 2000 IU (international units) PO QD (once a day). c. MP indicated Patient 14 was on Risperdal (an antipsychotic medication) 0.5 mg PO BID, this medication was not documented in the MRS. Employee 4 verbalized that this medication has been discontinued. d. MP indicated Patient 14 was on Clonidine (medication to treat high blood pressure) 0.1 mg / 24 hour, one (1) patch transdermal (application of medication through the skin) once a week, this medication was not documented in the MRS. Employee 4 verbalized that this medication has been discontinued. On 9/19/24 at 2 p.m., a scheduled visit was conducted at Patient 12's residence with agency employee (4) to observe the implementation of the ordered skilled nursing services as indicated on Patient 12's plan of care. During a concurrent interview and record review on 9/19/24 at 2:30 p.m., with Employee 4, Patient 12s medications were reconciled. A comparative review of Patient 12s, ";MP," dated 8/19/24, and home medication list indicated the following discrepancies: a. Home medication list indicated Patient 12 was taking Metformin (an oral diabetes medicine to lower blood sugar) 500 mg PO BID, not documented in the patients MP. b. Home medication list indicated Patient 12 was taking Furosemide (a medication that treats high blood pressure and fluid retention) 40 mg PO QD, not documented in the patients MP. c. Home medication list indicated Patient 12 was taking Digoxin (a medication used to treat heart failure) 0.125 mg PO QD, hold for heart rate less than (<) 60 beats per minute, not documented in the patients MP. Employee 4 verbalized that Patient 12s MP will be updated. During a review of the agencys policy and procedures (P&P), titled, ";Medication Profile," revised 11/2018, the P&P indicated in part, ";Policy... Patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications."

Based on interview and record review, the hospice agency failed to ensure a bereavement plan /assessment was updated following the death of one patient (Patient 4) This failure has the potential to cause the patient and family members to not receive all of the hospice services they signed up for, resulting in unresolved emotional and psychological distress. --- Review of the clinical record of Patient 4, on 9/20/24, indicated a start of care (SOC) of 6/13/24, with the certification date of 6/13/24 to 9/10/24 with the admitting diagnosis of Alzheimer's disease late onset (memory loss). The plan of care dated 6/13/24, had documentation of skilled nursing services for 1 week for 90 days. For Chaplain /Clergy the entered documentation indicated declined starting on 6/13/24, so with Medical Social Worker (MSW) - declined starting 6/13/24. The Initial bereavement was imitated by the Hospice Agency's administrator (ADM) on 6/14/24. Further review of the patient's clinical record indicated on 7/1/24, Patient 4 expired, 29 days after the SOC date. No documentation was located in the patient's clinical record, of a bereavement assessment update after the patient' death up to 9/20/24. Review of the Hospice Agency's policy and procedures on Bereavement Services revised, November 2018, stated in part." Bereavement risk assessment will be completed by hospice social worker at the time of admission to hospice. After the bereavement risk assessment is completed, a plan will be developed to address bereavement/grief issues and will be implemented and updated as needed. After death has occurred, the bereavement assessment will be updated, and the family/caregiver needs will be discussed at the next interdisciplinary group meeting. During a concurrent record review and interview with the ADM, on 9/20/24 at 3:53pm, the ADM indicated the bereavement assessment should have been done on admission and updated after the patient's death. For Patient 4 this was not done per Hospice Agency's policy and procedure.

Based on record review and interview the Hospice Agency failed to ensure the plan of care for two of 11 sampled patients (Patients 4 and 7) included the following: How to determine pain signs /assessment when patient was not able to verbally express pain after being assessed with pain and plan to address shallow breathing when the patient is agitated- tugging on flow mask- oxygen mask (Patient 4). Shortness of breathing and monitoring of occurrences as part of care approach and assessed for Patient 7). These failures placed Patients 4 and 7 for care needs not attended, which are crucial for needing Hospice Care. --- 1.Review of the clinical record for Patient 4 on 9/20/24, indicated a start of care (SOC) of 6/13/24 with the certification period of 6/13/24 to 9/10/24. The clinical record further indicated the patient was admitted with the diagnosis of Alzheimer's Disease late onset and expired on 7/1/24. Review of the Patient 4's medical profile dated 6/13/24, had documented orders for Acetaminophen and codeine 300/30 mg one tablet by mouth as needed every 6 hours for pain. The RN (registered nurse) hospice assessment (RNHA) dated 6/27/24 indicated a pain assessment of 7 (severe pain) with aching sensation and intermittent. Review of the continuous care notes (CCN) dated 6/27/24 at 8am to 10 pm indicated, Patient 4 was not in pain (0) but with periods of shallow breathing, with tugging of the high flow mask, with eyes closed at all times with utterance of unintelligible sounds, fatigued and weak. The RNHA dated 6/27/24 was reviewed again and no assessment of breathing issues was noted aside from the aching, intermittent pain. Further review of the clinical record had no documentation or plan to address shallow breathing, with the patient tugging off of the flow mask, and the process to assess pain especially the patient is with unintelligible chatter. During an interview with Employee 3 on 9/20/24 at 3:30 pm, Employee 3 was not able to locate any documentation about a plan for shallow breathing or intermittent pain for Patient 4. Review of the Hospice Agency's policy and procedure titled Pain Assessment dated, November 2018, stated in part, " To outline the responsibilities of hospice clinicians in the assessment and management of patients pain, Pain will be assessed as part of every patient contact if the patient reports pain or is at risk for pain. Ongoing assessment will be completed for patients identifying pain or at risk for pain." 2. Review of the clinical record for Patient 7 on 9/20/24, indicated an admitting diagnosis of Parkinson's disease (uncontrolled body movement).The Plan of Care indicated a SOC of 7/20/24, and a certification date of 7/20/24 to 9/17/24. The skilled visits is once a week x 90 days .The plan of care further indicated the patient has shortness of breathing problem with one of the interventions to check the oxygen saturation as needed for respiration status .. Further review of the clinical record for patient 7, indicated no record for oxygen saturation monitoring to assess the respiration status from 7/1424 to 9/17/24. During an interview with Employee 3 on 9/20/24 at 4pm, no documentation was presented regarding oxygen saturation monitoring for Patient 7. Review of the Hospice Agency's policy and procedure titled, Administration of oxygen, undated, does not address any options to pursue if a patient is uncomfortable with a flow mask . The physician order

Based on interview and record review, the hospice agency failed to ensure care and services were provided in accordance with the plan of care for seven of 14 sampled patients (Patients 5, 1, 6, 10, 12, 13 and 14) when: Patient 5 had four (4) unauthorized skilled nursing and two (2) unauthorized hospice aide visits for the certification period of 6/5/24 - 9/2/24. Patient 1 had one (1) missed skilled nursing visit for the certification period of 4/1/24 - 6/29/24. Patient 6 had seventeen (17) missed hospice aide visits for the certification period of 3/28/24 - 6/25/24. Patient 10 had five (5) missed hospice aide visits for the recertification period of 5/15/24 - 8/12/24. Patient 12 had five (5) missed hospice aide visits for the current certification period of 8/19/24 - 11/16/24. Patient 13 had two (2) missed hospice aide visits for the current certification period of 8/13/24 - 10/16/24. Patient 14 had three (3) missed hospice aide visits for the current certification period of 7/18/24 - 10/15/24. These failures in the coordination and provision of care and services had the potential to result in not meeting the end-of-life goals for these patients. Findings: --- 4. During a review of Patient 10s, ";Plan of Care (POC)," for recertification period 5/15/24 – 8/12/24, the POC indicated in part, the home visit order, ";Hospice Aide (HA) 2x/wk (two times a week) for 90 days," with a start date of 5/15/24. During a concurrent interview and record review on 9/23/24 at 9:58 a.m., with agency employee (3), Patient 10s clinical record was reviewed. A review of Patient 10s ";Home Visit Calendar (HVC - completed home visits per day plotted in calendar form)," for this specific recertification period of 5/15/24 – 8/12/24, failed to indicate documentation that HA staff either conducted or missed 1-2 patient home visits for the weeks of 6/30/24, 7/21/24, 7/28/24 and 8/4/24 respectively, totaling five HA home visits. Employee 3 verbalized that staff would document details of the missed visits in a section of the patients clinical record called ";Communication Note." Further review of Patient 10s clinical record with Employee 3 failed to indicate staff documentation of the missing five HA visits, who stated, ";If its (referring to staff documentation of visits/missed visits) not on here, it wasnt done." 5. During a review of Patient 12s, ";POC," for the current certification period 8/19/24 – 11/16/24, the POC indicated in part, the home visit order, ";HA 2x/wk for 90 days," with a start date of 8/19/24. During a concurrent interview and record review on 9/20/24 at 3 p.m., with Employee 3, Patient 12s clinical record was reviewed. A review of Patient 12s, ";HVC," for this current certification period 8/19/24 – 11/16/24, failed to indicate documentation that HA staff either conducted or missed 1-2 patient home visits for the weeks of 8/19/24, 8/25/24, 9/8/24 and 9/15/24 respectively, totaling five HA home visits. Employee 3 verbalized that staff would document details of the missed visits in a section of the patients clinical record called ";Communication Note." Further review of Patient 12s clinical record with Employee 3 failed to indicate staff documentation of the missing five HA visits, who stated, ";If its (referring to staff documentation of visits/missed visits) not on here, it wasnt done." 6. During a review of Patient 13s ";POC," for the current certification period 8/13/24 – 10/16/24, the POC indicated in part, the home visit order, ";HA 2x/wk for 90 days," with a start date of 8/13/24. During a concurrent interview and record review on 9/20/24 at 2:30 p.m., with Employee 3, Patient 13s clinical record was reviewed. A review of Patient 13s ";HVC," for this current certification period of 8/13/24 – 10/16/24, failed to indicate documentation that HA staff either conducted or missed two patient home visits for the week of 8/13/24. Employee 3 verbalized that staff would document details of the missed visits in a section of the patients clinical record called ";Communication Note." Further review of Patient 13s clinical record with Employee 3 failed to indicate staff documentation of the missing two HA visits, who stated, ";If its (referring to staff documentation of visits/missed visits) not on here, it wasnt done." 7. During a review of Patient 14s, ";POC," for the current certification period 7/18/24 – 10/15/24, the POC indicated in part, the home visit order, ";HA 2x/wk for 90 days," with a start date of 7/22/24. During a concurrent interview and record review on 9/23/24 at 10 a.m., with Employee 3, Patient 14s clinical record was reviewed. A review of Patient 14s ";HVC," for this current certification period of 7/18/24 – 10/15/24, failed to indicate documentation that HA staff either conducted or missed 1-2 patient home visits for the weeks of 8/11/24 and 9/15/24 respectively. Employee 3 verbalized that staff would document details of the missed visits in a section of the patients clinical record called ";Communication Note." Further review of Patient 14s clinical record with Employee 3 failed to indicate staff documentation of the missing three HA visits, who stated, ";If its (referring to staff documentation of visits/missed visits) not on here, it wasnt done." During a review of the agencys policy & procedures (P&P), titled, ";Missed Visits," revised 11/2018, the P&P indicated in part, ";Policy... Missed visits will be documented in the medical record." The P&P indicated further, ";Procedures... 2) If a visit is missed and not rescheduled, the clinician will: a) Notify the interdisciplinary group (IDG – a group of healthcare professionals with various areas of expertise who work together toward the goals of their clients) and the clinical supervisor of the missed visit and reason for missed visit; b) Document in the patients clinical record the following information: 1) Patients name, 2) Date and type of visit that was missed, 3) Reason for the missed visit...." 2) During a review of patient 1s (PT1) health record on 9/19/24 at 4:12 pm, health records indicate PT1 had an order for 2 skilled nursing visits per week for 90 days for certification period 4/1/24 to 6/29/24. On the week of April 7-13,2024, May 5-11,2024 and June 2-8,2024 there was only one skilled nursing visit. During an interview with the clinical supervisor (Employee 3) on 9/20/24 at 2:05 pm, the clinical supervisor indicated ";we cannot find any documentation" regarding the missed visits. 3) During a review of patient 6s (PT6) health record on 9/19/24 at 4:45 pm, health records indicate PT6 had an order for skilled nursing home visit once a week for 90 days, home hospice aide 1 visit for 90 days starting 4/2/24 and updated to 2 visits a week on 4/18/24 for the certification period 3/28/24 to 6/25/24. During that certification period the home hospice aide had 17 missed visits and it as follows: Week of 4/1/24 to 4/6/24 – 1 missed visit Week of 4/7/24 to 4/13/24 – 1 missed visit Week of 4/14/24 to 4/20/24 – 1 missed visit Week of 4/21/24/ to 4/27/24 – 1 missed visit Week of 4/28/24 to 5/4/24 – 1 missed visit Week of 5/5/24 to 5/11/24 – 1 missed visit Week of 5/12/24 to 5/18/24 – 1 missed visit Week of 5/19/24 to 5/25/24 – 2 missed visit Week of 5/26/24 to 6/1/24 – 1 missed visit Week of 6/2/24 to 6/8/24 – 2 missed visits Week of 6/9/24 to 6/15/24 – 2 missed visits Week of 6/16/24 to 6/22/24 – 2 missed visits Week of 6/23/24 to 6/29 – 1 missed visit During an interview with the clinical supervisor (Employee 3) on 9/20/24 at 2:05 pm, Employee 3 acknowledged missed visits. Employee 3 indicated they dont have documentations of missed visits. The facility policy and procedure titled ";Missed Visits" dated November 2018 indicates missed visits will be communicated to the interdisciplinary group at the IDG meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. 1. On 9/19/24 at 4:30 p.m. reviewed Patient 5s medical records. The ";Initial Physicians Orders and IDG Notification" (IDG-Interdisciplinary Group) certification period 6/5/24 to 9/2/24 included Physician orders for Patient 5 to receive skilled nursing (SN) visits once per week and certified home health aide (CHHA) visits twice per week. Also, the ";CHHA Instructions and Care Plan" dated 6/5/24 provided clarification for CHHA to visit Patient 5 twice weekly. Continued record review of the ";Nursing Clinical Note" (direct care visit) indicated Patient 5 received additional unauthorized SN visits during July and August 2024. The July 2024 twice weekly visits occurred July 10,12,19 (twice in same day), and 26 (twice in same day). The August 2024 unauthorized visits occurred in the second, third, and fourth weeks: August 8 & 9, 14 &16, 19 & 23. Also reviewed Patient 5's ";CHHA/Hospice Aide Note" (direct care visit) for July and August 2024. The documents indicated Patient 5 received an additional unauthorized visit during the last week of July and first week of August: July 15, 17, 19, 29, 31, and August 2. The Hospice policy titled "The Plan of Care" dated 11/2023 indicated, "The care provided to the patient must be in accordance with the plan of care... On 9/23/24 at 5:41 p.m. the Director of Nursing (DON) reviewed the above medical records for Patient 5 and indicated, ";The Physicians orders in Patient 5s Plan of Care was for skilled nurse visits once a week and CHHA visits twice a week. Patient 5s Plan of Care was not followed."

Observed in Record Review. In 3 of 4 patient records reviewed written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for HSRR #2, the patient had recently had oxygen delivered, on B12 injections and orders for labs but the only goal on the POC was for the healing of a wound. In the chart for HSHV #3, notes reflect that patient needs assistance will all ADLs, and is monitoring diabetes with blood glucose check and started on a new antibiotic for UTI therapy, and there was no goals on the POC to reflect those care needs for the patient. On review of HSRR #4, the patient is noted to be incontinent of bowel and bladder, active teaching for nutrition status to caregiver and there is no goals on the plan of care to reflect the care being provided. This was discussed with the DPCS.

Observed in Record Review. On 2 of 4 patient records reviewed, the plan of care revisions were not based on information from updates to the patient’s comprehensive assessment and did not address the patient’s progress toward goals and outcomes. On the charts for HSRR#1, there was no documentation of progress toward goals and outcomes. The IDT simply moved the anticipated achievement date out every two weeks to the next IDT date. On review of HSRR #3, the their was only one goal on the recent Plan of Care yet patient is assessment reveals other issues such as needing assistance with ADLs and being diabetic with BS monitoring that are not addressed in goals or outcomes. This was discussed with the DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization had not assessed potential medication-related problems. In the chart for HV#3, the patient was on daily Amlodipine for hypertension. He was also on Droxidopa twice daily and Midodrine three times daily for hypotension. There was no indication in the record that this was discussed with the physician to determine if all the medications were still necessary. This was discussed with the DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, the hospice had not conducted and documented a patient-specific comprehensive assessment and reassessment that identified the patient’s need for hospice care and services. The assessment did not include Survivor risk factors, such as the nature of the relationship with the patient, circumstances surrounding the death, behaviors before and after the death, availability of coping mechanisms, and potential for pathological grief reactions. In the chart for RR#1, there was no bereavement risk assessment completed as part of the initial comprehensive assessment, though the RN assessment indicated it should be performed. This was discussed with the DPCS.

Observed in Record Review. In 4 of 11 patient records reviewed, the patient record was not complete, promptly and accurately documented, readily accessible, and systematically organized to facilitate retrieval. In the chart for RR#8, there were 2 orders upon admission, labeled admission order and referral order signed by both RN and physician with asfasfsaItfa in the order text area. In the charts for RR#6 the POC stated SN daily x 90 days and RR#7, the POC stated SN daily x 90 weeks; In the chart for RR#4, SN was ordered daily. It should have been every other week. The office manager confirmed these frequencies were incorrect.

Observed in Record Review. In 2 of 11 patient records reviewed, the written plan of care (POC) was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for HV#1, the patient was on narcotics for pain control and had medications ordered prn for bowel management, however the POC did not include any goals related to this potential issue. Additionally, all goals on the POC had as an anticipated time frame for achievement as two weeks and had not been individualized to the problem, such as pain control or knowledge of oxygen safety/falls safety/high risk medication knowledge, such as Eliquis. In the chart for HV#3, all goals were expected to be met in 2 weeks. Some goals were not measurable, i.e., The patient will have adequate food and fluids as tolerated or desired in 2 weeks of hospice care. This was discussed with the DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. In the chart for HV#3, the POC indicated aide visits had been declined. However, the patient has been receiving aide visits twice weekly since admission more than six months prior to the survey. This was discussed with the DPCS.

Observed in Record Review. In 11 of 11 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: medications and treatments necessary to meet the needs of the patient. This complete medication list was missing on the POC for the charts reviewed for HV#1, HV#2, HV#3, RR#1, RR#2, RR#3, RR#4, RR#5, RR#6, RR#7, RR#8. Examples included: in the chart for HV#1, the hospice POC included only those medications which were included in specific interventions related to actual or potential problems, such as the patient's oxygen and pain medications. The patient's nebulizers, inhalers and other medications on the medication list were not on the POC as confirmed with the DPCS; In the chart for RR#5, Basaglar KwikPen 100 units/ml 24 Unit/s Sub-cutaneous once a day, in the morning for Diabetes Mellitus was not on the POC, yet it was on a physician order. Metformin was on the POC and med profile, yet there was no physician order for this medication. In the chart for RR#3, the wound care order was missing the frequency that care was to be provided. This was discussed with the Office Manager

Observed in Record Review. In 3 of 11 patient records reviewed, the plan of care revisions were not based on information from updates to the patient’s comprehensive assessment and did not address the patient’s progress toward goals and outcomes. In the charts for HV#1, HV#2 and HV#3, there was no documentation of progress toward goals and outcomes. The IDT simply moved the anticipated achievement date out every two weeks to the next IDT date. This was discussed with the DPCS.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization had not provided the patient with care, treatment, or services according to the patient's individualized plan of care (POC). In the chart for HV#2, SN visits were ordered weekly for the past and current benefit period. SN visits were provided every other week. Additionally, the aide was ordered at three visits/week. Some weeks two visits were provided, some three, some four visits with no indication why the frequency of visits did not match the POC. This was confirmed with the DPCS. In the chart for RR#5, the POC stated SN 2/week. Actual was 3x/week for first and second benefit periods. This was discussed with the Office Manager.

Observed in Data Session. The quality assessment and performance improvement program did not demonstrate improvement in the indicators related to improved palliative outcomes and hospice services. The organization collects data related to palliative outcomes, however had no improvement projects related to these. The current project is related to the amount/cost of supplies provided to patients as confirmed with the DPCS.

Observed in Patient Home. In 2 of 2 home visits conducted, the organization had not implemented infection prevention and control activities when doing the following: Cleaning and performing disinfection of medical supplies and devices. During HV#1 and HV#3 (the only visits in which reusable equipment was used) the organization had not followed it's policy for cleaning. The LVN in both visits used Cavicide wipes provided to her by the organization to clean equipment that she personally owned - the thermometer and automatic blood pressure cuff. The organizational policy for bag technique stated reusable equipment will be cleaned using alcohol and/or soap and water as appropriate...and equipment and supplies will be returned to the bag. This included thermometer - stated soap and water, wiping tip to end and Blood pressure cuff will be cleaned in accordance with the manufacturer's guidelines such as with soap and water at a frequency recommended by the cuff manufacturer and when the cuff has been soiled with blood, other body fluid, or spills. The LVN was unaware of the manufacturer's recommended solution, nor frequency of cleaning. This was discussed with the DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, the hospice had not conducted and documented a patient-specific comprehensive assessment that identified patient and family spiritual orientation, including their desire for the involvement of a religious group - Spiritual concerns or needs identified by the patient or family, such as despair, suffering, guilt, and forgiveness. In the chart for RR#3, spiritual needs had not been assessed as part of the initial comprehensive assessment as spiritual care was declined and the RN assessment did not include any assessment of spiritual items. This was discussed with the Office Manager

Observed in Record Review. In 2 of 11 patient records reviewed, a registered nurse had not prepared complete written patient care instructions for the hospice aide. In the charts for HV#2 and RR#4 the aide care plan included both a bed bath and shower with no further indication as to when to provide as shower and when the provide a bed bath. Additionally, the patient in HV#2 had oxygen ordered prn, yet the aide care plan did not address what the aide was to do in regard to oxygen use. This was discussed with the DPCS.

Observed in HR File Review. In 1 of 8 HR files reviewed, the hospice had not provided orientation about the hospice philosophy to all employees and contracted staff who have patient and family contact. This was missing in the file for the MSW as discussed with the Assistant DPCS.

Observed in Record Review. In 3 of 11 patient records reviewed, the patient record did not contain the following clinical information: A list of medications, including dose, strength, frequency, route, date and time of administration for prescription and nonprescription medications, herbal products, and home remedies that relate to the patient's care, treatment, or services. During HV#1, the patient confirmed that he takes Dulcolax prn for bowel management. The medication list in the hospice EMR and home list indicated the patient is taking Colace and MiraLAX for bowels which the patient denied. Additionally, the medication list indicated that the patient had been ordered Oxycodone, yet the patient indicated during the visit that he is not taking Oxycodone and is still taking Norco. Norco was not on the current medication list nor the list in the home as discussed with the nurse during the visit. In the chart for HV#3, the medication list in the EMR and home were incorrect. The patient is taking Lactulose 15ml prn constipation which was not on the POC. MiraLAX was on the POC/med list, yet there was none in the home and the caregiver confirmed patient does not take this, he uses Lactulose. The med profile indicated the patient takes Tylenol 325mg; actual was 500mg. This was discussed with the DPCS.In the chart for RR#8, the record did not include information about how the hospice found out the patient was to be transferred to another hospice. There is a discharge/transfer summary indicating that the patient was transferred to another hospice. The Office Manager indicated that this is incorrect, and the patient was transferred to the hospital, and a revocation occurred with the patient subsequently going to another hospice. There is no documentation in the chart to support what actually happened to the patient.

Observed in Record Review. In 3 of 11 patient records reviewed, all entries in the patient record were not legible, clear, complete, and appropriately authenticated in accordance with the organization’s policy and currently accepted standards of practice. In the chart for RR#7, the hospice POC was not signed by any clinician. In the chart for RR#4, the oxygen was on the hospice POC, however the POC was not signed by physician. There was no separate order found for the oxygen. In the chart for RR#2, the initial POC was not signed by anyone but the RN. This was confirmed with the Office Manager.