Every finding on record at Homestead Hospice of Augusta, LLC

Observed in Record Review. In 1 of 1 patient records reviewed with a revocation, During RRD/C# 2's patient record review it was noted the organization had not ensured a revocation was signed by the patient. For example: review of RRD/C# 2's patient record revealed documentation the son called to inform the organization that RRD/C# 2 had chosen to continue cancer treatment approximately 10 days after the election of benefit. Further review of RRD/C# 2's patient record revealed no documentation of a revocation. This was reviewed, discussed, and validated with the Branch Manager.

Observed in Record Review. In 5 of 8 patient records reviewed with election of benefit after last CMS survey, During RRHV# 1, RRNHV# 1, RRNV# 2, RRNHV# 6, and RRNHV# 7's patient records review it was noted the organization had not ensured it completed the comprehensive assessment no later than five calendar days after the election of hospice care. For example: review of RRHV# 1's patient record revealed the Initial Bereavement Risk Assessment was completed on the day of the surveyor's home observation. Further review of RRHV# 1's patient record revealed RRHV# 1's the election of benefit was 48 days prior to the surveyor's home observation. Review of RRNHV# 1's patient record revealed the Initial Bereavement Risk Assessment completed on approximately 28 days after the election of benefit. Review of RRNHV# 2's patient record revealed the Initial Bereavement Risk Assessment was completed approximately 29 days after the election of benefit. Review of RRNHV# 6's patient record revealed the Initial Bereavement Risk Assessment was completed approximately 14 days after the election of benefit. Review of RRNHV# 7's patient record revealed the initial Bereavement Risk assessment completed on approximately 33 days after the election of benefit. This was reviewed, discussed, and validated with the Branch Manager.

Observed in Record Review. In 9 of 10 patient records reviewed, During RRHV# 1, RRHV# 2, RRHV# 3, RRNHV# 1, RRNHV# 2, RRNHV# 3, RRNHV# 4, RRNHV# 5, and RRNHV# 6's patient records review it was noted the organization had not ensured staff followed the organization policy Pain and Symptom Management, PC 135 that includes a comprehensive pain or risk for pain assessment at the start of care to include pain severity/intensity, and assessment and impact on usual activities. For example: review of the patients' start of care registered nurse comprehensive assessment revealed documentation under pain severity to include OK, documentation under assessed what relieves/worsen pain to include Yes, and documentation under Effects of pain on quality of life to include Yes with no further documentation of the assessment findings. This was reviewed, discussed, and validated with the Branch Manager.

Observed in Record Review. In 10 of 10 patient records reviewed, During RRHV# 1, RRHV# 2, RRHV# 3, RRNHV# 1, RRNHV# 2, RRNHV# 3, RRNHV# 4, RRNHV# 5, RRNHV# 6, and RRNHV# 7's patient records view it was noted the organization had not ensured the patients' plans of care were developed with the patient's goals and time frames, setting, and services required to meet those goals. For example: review of RRHV# 1's plan of care revealed nursing and medical social worker goals with no time frames and a chaplain goal to establish a plan of care approximately 30 days after the election of benefit. In addition, approximately 21 days after the registered nurse comprehensive assessment or approximately 27 days prior to the surveyor review of the record, RRHV# 1 was assessed with two Stage II pressure ulcers with no goals for the wounds on the update to the plan of care. Review of RRHV# 2's initial plan of care and two subsequent recertification plans of care revealed nursing goals with no time frames. Further review of the initial plan of care and subsequent recertification plans of care revealed both the MSW and Chaplain goals verbatim the same to include the original dates for the time frames documented on the initial plan of care. Review of RRHV# 3, RRRNHV# 1, RRNHV# 2, RRNHV# 3, RRNHV# 4, RRNHV# 5, RRNHV# 6, and RRNHV# 7’s plans of care revealed non-individualized goals that included the pain goal that the patient’s pain would be at an acceptable level for the patient, and safety goal that the patient’s safety needs would be met. In addition, the patient’s plans of care goals were missing time frames, or the time frames were inappropriate, such as 30 days to establish a plan of care after start of care or after recertification. This was reviewed, discussed, and validated with the Branch Manager.

Observed in Record Review. In 2 of 2 bereavement records reviewed, During RRBR# 1, RRBR# 2's patient records review it was noted the organization had not ensured it provided the patient with care, treatment, or services according to the patient's individualized plan of care. For example: review of RRBR# 1's patient record revealed a bereavement plan of care for RRBR# 1's spouse that included and phone call or visit 72 hours after RRBR# 1's death. Further review of the RRBR# 1's patient record revealed no documentation of a phone call or visit with the spouse. Review of RRBR# 2's patient record revealed a bereavement plan of care for RRBR# 2's daughter that included a phone call at six months post death. Review of the patient record revealed no documentation of a phone call at six months. This was reviewed, discussed, and validated with the Bereavement Coordinator and Branch Manager.

Observed in Patient Home. In 3 of 3 home visits conducted, During RRHV# 1, RRHV# 2, and RRHV# 3's home observation it was noted the organization had not ensured it implemented prevention and control activities when cleaning and performing disinfection of medical supplies and devices. For example: during RRHV# 1's home observation the registered nurse (RN) was observed cleaning the vital sign equipment with Good and Clean Disinfecting Wipes and immediately placed the vital sign equipment into the bag without allowing any wet time. Review of the manufacturers IFU revealed the Good and Clean Disinfecting Wipes are for hard surfaces in the home and the wet time was four minutes. During RRHV# 2's home observation the RN was observed cleaning the vital sign equipment with alcohol pads and placed the vital sign equipment immediately into the nurse bag without any wet time. During RRHV# 3' home observation the RN was observed cleaning the vital sign equipment with wipes from an unmarked baggie and placed the vital sign equipment immediately into the nurse bag. This was observed, discussed, and validated with the Branch Manager. Observed in Patient Home. In 3 of 3 home visits conducted, During RRHV# 1, RRHV# 2, and RRHV# 3's home observation it was noted the organization had not ensured it implemented the infection prevention and control activities per organization policies Hand Hygiene and Bag Technique IC-60, that included hand hygiene prior to putting on gloves, after removing gloves, and prior to entering the nurse bag. For example: during RRHV# 1's home observation the registered nurse was observed cleaning RRHV# 1's bowel movement then removed the right glove and with the right hand opened a cabinet and grabbed the moisture barrier for the coccyx area with out performing hand hygiene after removing the right glove. The RN was observed next putting on a new glove on the right hand without performing hand hygiene and continued to clean RRHV# 1. In addition, the RN was observed cleaning the vital sign equipment and placing the equipment into the nurse bag without performing hand hygiene. During RRHV# 2's home observation the RN was observed cleaning the vital sign equipment and placing it into the nurse bag without performing hand hygiene prior to placing the vital sign equipment into the nurse bag. During RRHV# 3's home observation the RN was observed performing wound care then removing gloves without performing hand hygiene and then touching supplies and putting on new gloves without performing hand hygiene. In addition, the RN cleaned the vital sign equipment and placed it immediately into the nurse bag without performing hand hygiene prior to placing the equipment in the nurse bag. This was observed, discussed, and validated with the Branch Manager.

Observed in Record Review. In 1 of 7 patient records reviewed with Hospice aide, During RRHV# 1's patient record review it was noted the organization had not ensured registered nurse prepared complete written patient care instructions for the hospice aide. For example: review of RRHV# 1's patient record revealed RRHV# 1 was assessed with two Stage II pressure ulcers to the left foot with wound dressings approximately 21 days after start of care. Review of RRHV# 1's patient written instructions revealed the task of a bed bath with no documentation of an update to the patient written instructions that included the dressings to the left foot. This was reviewed, discussed, and validated with the Branch Manager.

Observed in Patient Home. In 2 of 3 home visits conducted, During RRHV# 2 and RRHV# 3's patient records review it was noted the organization has not ensured the patient records contained information that reflected the patient's care, treatment, or services. For example: during RRHV# 2's home observation the registered nurse (RN) completed a medication review with RRHV# 2's family representative and it was noted RRHV# 2 had not used the Fluorouracil ointment for approximately the last five months and instead was using Eucerin lotion. Review of the organization's medication profile revealed Fluorouracil ointment as an active medication. During RRHV# 3's home observation the RN completed a medication review with RRHV# 3's spouse and it was noted RRHV# 3 was receiving levothyroxine at 50 mcg daily with the last refill approximately a month prior to the surveyor home visit. Review of the organization's medication profile revealed no documentation of levothyroxine. This was observed, discussed, and validated with the RN and the Branch Manager.

Observed in Record Review. In 10 of 10 patient records reviewed, During RRHV# 1, RRHV# 2, RRHV# 3, RRNHV# 1, RRNHV# 2, RRNHV# 3, RRNHV# 4, RRNHV# 5, RRNHV# 6, and RRNHV# 7's patient record review it was noted the organization had not ensured all entries in to the patient record were appropriately authenticated with currently accepted standards of practice and organization policy Verification of Physician Licensure & Orders - PC25 that included The individual receiving the order must record and sign it immediately and have the prescribing person sign it in accordance with state and federal regulations... For example: review of the patients' records revealed the Medical Director's verbal order for the Initial Certificate of Terminal Illness (CTI) with documentation of verbal order date. Further review of the CTI revealed the signature line Verbal Certification taken by with the documentation of the signature of the Branch Manager. However, the verbal certification was not taken by the Branch Manager it was taken by the registered nurse (RN) that completed the start of care comprehensive assessment and medication reconciliation with the Medical Director. This was discussed with the Branch Manager that validated the RN that received the verbal order does not sign the initial CTI. This was reviewed, discussed, and validated with the Branch Director

Observed in Record Review. In 2 of 2 patient records reviewed with recertification, During RRHV# 2 and RRHV# 3's patient records review it was noted the organization had not ensured it maintained accurate patient records. For example: review of RRHV# 2's recertification Certificate of Terminal Illness (CTI) revealed the Medical Director signature dated 13 days prior to the new certification. Further review of the recertification revealed a verbal order signature by the Branch Manager dated 13 days after the Medical Director signature. Further review of RRHV# 2's patient record revealed a subsequent recertification CTI signed by the Medical Director three days prior to the new certification period. Further review of the subsequent recertification CTI revealed a verbal order signed by the Branch Manager dated three days after the Medical Director signature. Review of RRHV# 3's recertification CTI revealed the Medical Director signature dated approximately eight days prior to the new certification period. Further review of the recertification CTI revealed a verbal order signed by the Branch Manager dated eight days after the Medical Director signature. Further review of RRHV# 3's patient record revealed a subsequent recertification CTI with the Medical Director signature dated approximately 14 days prior to the new certification period. Further review of the subsequent recertification CTI revealed a verbal order signed by the Branch Manager 12 days after the Medical Director signature. This was reviewed, discussed, and validate with the Branch Manager.

Observed in Patient Home. In 1 of 1 home visits conducted in a nursing facility, During RRHV# 1's home observation it was noted the organization had not ensured it provided the Nursing Facility the patient's initial Certificate of Terminal Illness. For example: review of RRHV# 1's nursing facility chart/binder revealed a blank initial CTI with no documentation from the Medical Director or signature. Review of RRHV# 1's plan of care revealed RRHV# 1 was admitted to hospice 48 days prior to the surveyor home observation. This was reviewed, discussed, and validated with the Branch Director.

Based on record review and interview, the hospice failed to provide documentation of a notice of rights and responsibilities in advance of furnishing care to the patient and/or patient representative for 1 of 10 patient charts reviewed. (Patient 1) --- The findings include: On 05/02/23 at 8:40 AM, review of Patient #1's chart revealed the patient was transferred from a hospice to this hospice on 05/26/22. Review of the patient's chart revealed Patient #1s start of care (SOC) was 05/27/22. Review of the patient's chart revealed there was no documentation of a signed notice of rights in advance of care. During an interview on 05/05/23 at 10:29 AM, the Branch Director stated, ";The patient was a transfer to us from the other (sister) hospice company. We were told we didnt need to do new paperwork for the transfer."

Based on patient record reviews and interview, the hospice failed to provide documentation of an initial assessment completed by a Registered Nurse (RN) within 48 hours of an election of notice for 1 of 10 patient charts reviewed. (Patient #1) --- The findings include: On 05/02/23 at 8:40 AM, of Patient # 1 revealed the patient was transferred from another hospice on 05/26/22. Review of the patient's chart revealed the Start of Care (SOC) was 05/27/22. There was no documentation of an initial assessment by the Registered Nurse (RN) or a notice of election prior to hospice services being provided by the hospice. During an interview on 05/05/23 at 10:29 AM, the Branch Director stated, ";The patient was a transfer to us from the other (sister) hospice company. We were told we didnt need to do new paperwork for the transfer."

Based on interview, record review and review of facility policy and procedure, the hospice facility failed to ensure the interdisciplinary team (IDT) completed a comprehensive assessment within 5 days of notice of election for 7 of 10 patient charts reviewed. (P 1, 2, 3, 4, 7, 8 and 10). --- On 5/2/23, at 12:00 PM Patient #2's record was reviewed. Patient #2 was admitted to the hospice on 12/28/21 with a diagnosis of Senile Degeneration of the Brain. There was no documented evidence the hospice Interdisciplinary Group (IDG) core members completed a comprehensive assessment and collaborated in the formulation of the initial plan of care within five days of admission. On 5/4/23, at 2:30 PM, an interview was conducted with the Branch Director/Administrator (BD/Admin). During a concurrent review of Patient #2's record, the BD/Admin was unable to provide any documented evidence the IDG core members collaborated in the formulation of the comprehensive assessment and the initial plan of care for Patient #2 within five days of admission, On 5/2/23, at 3:25 PM, Patient #4's record was reviewed. Patient #4 was admitted to the hospice on 2/3/23 with a diagnosis of Chronic Systolic Heart Failure. There was no documented evidence the hospice IDG core members completed a comprehensive assessment and collaborated in the formulation of the initial plan of care within five days of admission. On 5/4/23, at 8:42 AM, an interview was conducted with the BD/Admin. During a concurrent review of Patient #4's record, the BD/Admin was unable to provide any documented evidence the core IDG members collaborated in the formulation of the comprehensive assessment and the initial plan of care for Patient #4 within five days of admission On 5/4/23, at 10:56 AM, Patient #10's record was reviewed. Patient #10 was admitted to the hospice on 3/2/23 with a diagnosis of Chronic Obstructive Pulmonary Disease (lung disease). There was no documented evidence the hospice IDG core members completed a comprehensive assessment and collaborated in the formulation of the initial plan of care within five days of admission. On 5/4/23, at 1:20 PM an interview was conducted with the BD/Admin. During a concurrent review of Patient #10's record, the BD/Admin was unable to provide any documented evidence the core IDG members collaborated in the formulation of the comprehensive assessment and the initial plan of care for Patient #10 within five days of admission. On 5/4/23, the hospice's policy titled, "Plan of Care," dated 4/2022 was reviewed. The policy indicated, "...The comprehensive assessment will be completed by the IDG/IDT no later than five calendar days after the election of hospice care in consultation with the Attending Physician (if any)... The findings include: Record review on 05/02/23 at 8:40 AM of P 1 revealed P 1 was discharged from hospice on 05/26/22 due to discharge/transfer to hospice. Review of the chart revealed P 1s start of care (SOC) documented as 05/27/22. Review of the chart revealed no documented IDT comprehensive assessment within 5 days of SOC. During an interview on 05/05/23 at 10:29 AM the Branch Director stated, ";The patient was a transfer to us from the other (sister) hospice of Myrtle Beach. We were told we didnt have to do any new documentation for them (the patients) since they were transferring to us". Record review on 05/02/23 at 9:25 AM of P 3 revealed P 3 was admitted to the hospice on 09/21/22 for hypertensive heart disease. Review of the chart revealed no IDT comprehensive assessment within 5 days of admission. The first IDT meeting for the patient was on 09/28/22, 7 days after the NOE. During an interview on 05/05/23 at 1:02 PM, the Branch Director verified the findings. Record review on 05/04/23 at 9:20 AM of P 7 revealed P 7 was admitted to the hospice on 10/13/22 for End Stage Renal Disease (ESRD). Review of the chart revealed no IDT comprehensive assessment within 5 days of admission. The first IDT meeting for the patient was on 10/26/22, 13 days after the NOE. During an interview on 05/05/23 at 12:37 PM, the Branch Director verified the findings. Record review on 05/04/23 at 10:00 AM of P 8 revealed P 8 was admitted to the hospice on 03/03/23 for Carcinoma of the liver. Review of the chart revealed no IDT comprehensive assessment within 5 days of admission. The first IDT meeting for the patient was on 03/15/23, 12 days after the NOE. During an interview on 05/05/23 at 11:29 AM, the Branch Director verified the findings.

Based on patient record reviews, interviews, and review of the hospice policy and procedure, the hospice failed to ensure reconciliation of the patient's hospice medication profile with the assisted living facility's medication administration record (MAR) for 1 of 1 patient in a nursing care facility (Patient 9) and failed to reconcile the hospice's medication profile for the patient's actual medications in the patient's home that the patient takes for 2 of 2 home visits. (Patient 1 and 2) --- On 5/2/23, at 8:00 AM, a home visit was conducted to Patient #2 with Registered Nurse (RN) #1. Patient #2 was admitted to the hospice on 12/28/21 with a diagnosis of Senile Degeneration of the Brain. At 9:05 AM, RN #1 was observed reconciling Patient #2's medications with the plan of care medication profile. There were discrepancies between the medication profile and the medications in the home. A medication bottle of Atorvastatin 40 mg tablets with a pharmacy fill date of 10/14/22 indicated to take one tablet every night. The family member caregiver (FMCG) stated she/he was instructed by the physician to give the patient one-half tablet/20 mg every night. The hospice medication profile indicated Atorvastatin 10 mg one tablet every night. A medication bottle of olanzapine 10 mg daily with a pharmacy fill date of 4/26/23 indicated one tablet daily. The FMCG stated this was the second bottle filled by the pharmacy since the physician changed the dose The hospice medication list indicated olanzapine 5 mg one tablet daily. During a concurrent interview with RN #1, she confirmed the findings. On 5/2/23, at 2:00 PM, Patient #15's record was reviewed. Patient #15 was admitted to the hospice on 10/7/22 with a diagnosis of Sepsis. The Nurses Admission Visit Note dated 10/7/22 indicated the medication Fentanyl was increased to 75 mcg and morphine sulfate was ordered by intravenous push (IVP). Patient #15's Client Medication Report was reviewed. Morphine sulfate IVP was not on the list and Fentanyl was indicated as 50 mcg, not 75 mcg. Additionally, there were no physician's prescription orders for morphine sulfate IVP or Fentanyl 75 mcg in Patient #15's hospice record. On 5/4/23, at 3:15 PM the Branch Director/Administrator (BD/Admin) was interviewed. During a concurrent review of Patient #15's record, the BD/Admin confirmed morphine sulfate IVP and fentanyl 75 mcg were not on Patient #15's medication profile and there were no physician's orders in the hospice record for these medications. On 5/4/23, the hospice's policy titled, "Medication List and Monitoring," dated 4/2022 was reviewed. The policy indicated, "...'Prescription' means an order obtained from a physician or other authorized licensed independent practitioners...Medication monitoring will include appropriate date/information to develop an accurate patient medication history and a current, complete medication profile. This data will be available to all Hospice staff involved in the patient care...The Hospice will maintain a current, accurate Medication Profile...Changes in the medication regimen will be documented in the medical record either on the medication profile or on a verbal order... The findings include: Observation on 05/02/23 at 4:50 PM of P 1s home medications revealed P 1 was not taking Senna laxative 8.6 mg (milligram) tablet compared to the hospices MAR. During an interview on 05/05/23 at 10:29 AM with Branch Director stated, ";The family doesnt always tell us when they stop taking medicines". Observation on 05/03/23 at 11:25 AM of P 9s facility MAR revealed ";Apply Medihoney ointment to left heel 2 times per day every 12 hours as needed for wound healing" when compared to the hospice facility MAR. During an interview on 05/05/23 at 10:59 AM, the Branch Director stated, ";The nurse will get that corrected". Facility policy, entitled ";Medication List and Monitoring" revealed, ";I. The Hospice will maintain a current, accurate Medication Profile of all prescription, over-the-counter (OTC), sample and investigational medications, herbal and home remedies taken by the patient, alternative treatments that could affect drug therapy, and drug therapy currently associated with laboratory testing...".

Based on patient record reviews, interviews, and the hospice policy, the hospice failed to ensure initial bereavement risk assessments were completed for 3 of 15 patient records reviewed. (Patient 1, 5 and 15) --- On 5/2/23, at 2:00 PM, Patient #15's record was reviewed. Patient #15 was admitted to the hospice on 10/7/22 with a diagnosis of Sepsis. There was no documented evidence an initial bereavement risk assessment was conducted. On 5/4/23, at 3:15 PM, an interview was conducted with the Branch Director/Administrator (BD/Admin). During a concurrent review of Patient #15's record, the BD/Admin confirmed there was documented evidence an initial bereavement risk assessment was conducted for patient #15. The hospice's policy titled, "Bereavement," dated 4/2022 was reviewed on 5/4/23. The policy indicated, "...The Hospice will perform an initial bereavement assessment of the needs of the patient's family and other care individuals...as part of the Initial Comprehensive Assessment which shall not exceed no later than five calendar days after the election of the Hospice benefit..." The findings include: Record review on 05/02/23 at 8:40 AM of P 1 revealed P 1 was discharged from hospice on 05/26/22 due to discharge/transferred to hospice. Review of the chart revealed P 1s start of care (SOC) documented as 05/27/22. Further review revealed no initial bereavement assessment within 5 days of the documented SOC for the patient. During an interview on 05/05/23 at 10:29 AM with the Branch Director stated, ";The patient was a transfer to us from the other (sister) hospice of myrtle Beach. We were told we didnt have to do any new documentation for them (the patients) since they were transferring to us". Record review on 05/03/23 at 8:30 AM of P 5 revealed P 5 was admitted to the hospice on 10/25/22 for Parkinsons Disease. Review of the chart revealed no initial bereavement assessment within 5 days of P 5s admission. During an interview on 05/05/23 at 9:52 AM with the Branch Director, verified the findings.

Based on interview, record review and review of facility policy and procedure, the hospice facility failed to ensure an initial plan of care (POC) was conducted for 1 of 10 patient charts reviewed. (Patient 1). --- Review on 05/02/23 at 8:40 AM of Patient 1's chart revealed a start of care (SOC) documented as 05/27/22. There was no initial plan of care (POC) developed for the patient. During an interview on 05/05/23 at 10:29 AM, the Branch Director stated, ";The patient was a transfer to us from the other (sister) hospice of Myrtle Beach. We were told we didnt have to do any new documentation for the patients since they were transferring to us." Hospice policy, entitled, ";Plan of Care", revealed, ";Information will be gathered from the initial assessment and be used by the Hospice to develop the Initial Plan of Care (IPOC)/Physician Orders and to provide care and services to treat a patients and patients familys immediate care and support needs...".

Based on record reviews, interviews, and review of hospice policy and procedure, the hospice failed to ensure the Interdisciplinary Team (IDT) documented as needed (prn) orders specific to meet the patient needs for 1 of 1 patient charts reviewed. (Patient 8) --- The findings include: On 05/04/23 at 10:00 AM, review of Patient 8's chart revealed the patient was admitted on 03/03/23 for Carcinoma of the Liver. Review of certification period dated 03/03/23 to 05/31/23 revealed the Interdisciplinary team had not assigned prn orders for the certification period. Review of Skilled Nurse (SN) visits showed the SN conducted a PRN visit on 03/18/23 and 04/27/23.. During an interview on 05/05/23 at 11:29 AM, the Branch Director stated, ";The nurse puts in the prn visits on her calendar so he/she will have it. It (the order) populates from his/her start of care (SOC) order". Hospice policy, entitled, "IDG Roles and Responsibilities", revealed, "The IDG/IDT, in collaboration with the Attending Physician (if any) will prepare a written POC for each patient and family, which specifies the care and services necessary to meet the patient and/or family's specific needs identified in the Comprehensive Assessment, as those needs relate to the terminal illness and related conditions...".

Based on record reviews and interview, the hospice failed to ensure the Skilled Nurses (SN), Master of Social Worker (MSW), and Chaplain completed home visits per the ordered frequency on the patient's plan of care for 7 of 10 patient charts reviewed. (Patient 1, 3, 5, 6, 7, 8, and 9) --- The findings include: On 05/02/23 at 8:40 AM , review of Patient 1's chart revealed the start of care was dated 05/27/22 for Alzheimers Disease. Review of certification period dated 02/26/23 to 04/26/23 revealed the SN visit frequency was 1 time a week for 7 weeks, 3 times a week for 1 week, and 1 time a week for 1 week. Review of the SN visits revealed 2 missed visits the week of April 16. During an interview on 05/05/23 at 10:29 AM, the Branch Director verified the findings. On 05/02/23 at 9:25 AM, review of Patient 3's chart revealed Patient 3 was admitted on 09/21/22 for Hypertensive heart disease. Review of the certification period dated 09/21/22 to 11/19/22 revealed the Chaplain visit frequency was 1 time a week for 1 week, 3 times a week every 12 weeks for 12 weeks, and then changed on 10/23/22 to 1 time a week for 2 weeks and 1 time a week every 2 weeks for 2 weeks. Review of the Chaplain visits revealed 2 missed visits the week of 10/02/22 and 1 missed visit the week of 10/30/22. During an interview on 05/05/23 at 1:02 PM, the Branch Director verified the findings. On 05/03/23 at 8:30 AM, review of Patient 5's chart revealed Patient 5 was admitted on 10/25/22 for Parkinsons Disease. Review of the certification period dated 01/23/23 to 04/22/23, the MSW visit frequency was 1 time a week for 1 week and Chaplain visit frequency was 1 time a week for 1 week. Review of the MSW and Chaplain visits revealed one MSW and one Chaplain missed visit the week of 02/05/23. During an interview on 05/05/23 at 9:52 AM, the Branch Director verified the findings. On 05/03/23 at 12:15 PM, review of Patient 6's chart revealed Patient 6 was admitted on 10/24/22 for Carcinoma of the Rectum. Review of the certification period dated 10/24/22 to 01/21/23 revealed the SN visit frequency was 1 time a week for 12 weeks, and the MSW visit frequency was 1 time a week for 1 week, 1 time a week every 2 weeks for 2 weeks, 1 time a week every 4 weeks for 8 weeks. Review of the MSW visits revealed one missed visit the week of 11/06/22 and 12/18/22 and one missed visit for the SN for the week of 11/20/22 and 12/04/22. During an interview on 05/05/23 at 12:52 PM, the Branch Director verified the findings. On 05/04/23 at 9:20 AM, review of Patient 7's chart revealed Patient 7 was admitted on 10/13/22 for End Stage Renal Disease (ESRD). Review of the certification period dated 01/11/23 to 04/10/23 revealed the SN visit frequency was 1 time a week for 11 weeks, and the MSW visit frequency 1 time a week for 1 week, and the Chaplain visit frequency 1 time a week for 1 week and 1 time a week every 2 weeks for 8 weeks. Review of SN visits revealed one missed visit the week of 01/11/23, and the MSW had one missed visit the week of 02/05/23, one Chaplain missed visit for the week of 02/05/23 and 3/05/23. During an interview on 05/05/23 at 12:37 PM, the Branch Director verified the findings. On 05/04/23 at 10:00 AM, review of Patient 8's chart revealed Patient 8 was admitted on 03/03/23 for Carcinoma of the Liver. Review of the certification period dated 03/03/3 to 05/31/23 revealed SN visit 2 times a week for 1 week, 1 time a week for 1 week, 2 times a week for 1 week, and 1 time a week for 1week. Review of SN visits revealed one missed visit the week of 04/16/22. During an interview on 05/05/23 at 11:29 AM, the Branch Director verified the findings. On 05/04/23 at 8:36 AM, review of Patient 9's chart revealed Patient 9 was admitted on 03/08/21 for Alzheimers disease. Review of the certification period dated 12/28/22 to 02/25/23, the SN visit frequency was 2 times a week for 1 week, 1 time a week for 4 weeks and 3 times a week for 1 week and the MSW visit frequency was 2 times a week for 1 week. Review of SN visits revealed 2 missed visits the week of 12/28/22 and 02/19/23 and 1 missed MSW visit the week of 01/08/23. During an interview on 05/05/23 at 10:59 AM, the Branch Director verified the findings.

Based on record reviews and interview, the hospice failed to provide ongoing sharing of information between all disciplines providing care and services for patients in all settings whether provided directly or under arrangement for 1 of 17 patient chart reviews. (Patient 9) --- On 05/03/23 at 11:15 AM to 11:40 AM review of Patient 9s (facility) hospice chart revealed there were no current interdisciplinary comprehensive assessment and plan of care update report since 10/26/22 and 11/09/22 respectively, no physician certification and recertification documentation, and no documentation of hospice and/or attending physician orders. During an interview on 05/05/23 at 10:59 AM, the Branch Director verified the findings.

Based on observations, interviews, and review of the hospice policy, the hospice failed to ensure outdated and opened supplies were not immediately available for patient use. --- On 5/1/23, at 12:15 PM, an inspection of the hospice's patient supply room was conducted with Scheduler #1. The following supplies were found: One box of Coloplast Urostomy pouches (for urine collection) expired 2/13/23, and one package of 200, 4 x 4 gauze pads was open and one-fourth gone. In a concurrent interview with Scheduler #1, she/he confirmed the findings. The hospice's policy titled, "Infection Control and Prevention," dated 4/2022, was reviewed. The policy indicated, "...Supply packaging will remain intact while stored. If outer package is damaged or opened, supply will be removed and discarded...Supplies will be checked for expiration date prior to use. If outdated, the supplies will be immediately removed from stock and discarded..." Observation on 05/01/23 at 12:20 PM of the hospice supply room revealed (94) bacitracin zinc ointments expired 03/23 and (1) 7-inch small bore extension set with microclave clamp expired 04/01/23. During an interview on 05/01/23 at 12:38 PM, Scheduler 1 verified the findings. Observations in P 1s home on 05/02/23 from 04:30 PM to 4:55 PM revealed Certified Nursing Assistant (CNA) 3 obtained a protective barrier from an outside area of his/her nursing bag and placed it on P 1s bed to place his/her nursing bag. Post usage of the protective barrier protective used on P 1s bed, CNA3 folded up the protective barrier and placed it bag on the side of the nursing bag where it was originally obtained from. During an interview on 05/05/23 at 10:29 AM, the Branch Director stated, ";Staff is to designate what is the dirty side of their nursing bag". Facility policy, entitled ";Bag Technique" revealed, ";L. If paper towels/newspapers/trash bags, etc are used as a protective barrier for bag placement in the patients home, they will be properly disposed". Observation in P 9s (facility) home on 05/03/23 from 10:37 AM to 11:09 AM revealed CNA 2 with dirty gloves donned post changing P 9s brief and transferring him/her back to a wheelchair with gait belt donned, removed the gait belt from around P 9s waist and returned it to his/her nursing bag without disinfection. CNA 2 then discarded all dirty supplies, removed dirty gloves and donned clean gloves without hand hygiene. During an interview on 05/05/23 at 11:17 AM the Branch Director stated, ";We are to perform hand hygiene before touching the patient and after glove changing".

Based on record review, interview, and review of hospice policy and procedure, the hospice failed to ensure bereavement services were available to the family up to one year post patient death based on the bereavement plan of care for 1 of 3 deceased patients. (Patient 12) --- The findings include: On 05/04/23 at 10:05 AM, review of P 12s chart revealed the patient expired on 08/20/22. Review of the patients bereavement plan of care revealed there was no documentation that the patient's plan of care was completed based on services and frequencies outlined in the plan of care. During an interview on 05/05/23 at 11:41 AM, the Branch Director verified the findings.

Based on observations, record review, and interview, the hospice failed to update the Aide Plan of Care for one of three patients observed during home visits. (Patient 2). --- On 5/2/23 at 8:00 AM, a home visit accompanied by Certified Nurse Assistant #1 (CNA #1) to Patient #2's home revealed CNA #1 assisting Patient 2 to take a shower bath, but observations showed the patient's hair was not shampooed. Registered Nurse #1 (RN #1) arrived while the patient was showering. Concurrently, Patient #2's "Aide Care Plan Report," for the benefit period 4/22/23 to 6/20/23 revealed, "SHAMPOO...EVERY VISIT...BATHING - TUB BATH...EVERY VISIT...". After completing Patient #2's personal care, CNA #1 stated he/she always gives the patient a shower and washes the patient's once a week because that's what the patient wants and "because his hair is dry already." CNA #1 reviewed his/her care plan assignment on the tablet and stated it reads, "tub bath" and "shampoo every visit." RN #1 stated when the patient was first admitted in 2021, the patient was not able to shower. CNA #1 and RN #1 confirmed the Aide Care Plan had not been updated regarding the patient's bath method. . Hospice policy, titled, "Implementing Care & Treatment", dated 4/2022, reads,"To ensure patient care and treatment are provided as identified in the care planning process...The Hospice RN...will oversee the assignment of a Hospice Aide (HA) to a particular patient...to meet identified patient's needs as identified in the POC (plan of care)...the HA will be provided with written instructions for patient care prepared by an RN...".

Based on patient record reviews and interview, the hospice failed to ensure the patient charts contained physician orders for 1 of 10 patient charts reviewed. (Patient 14) --- On 5/2/23, at 2:00 PM, Patient #15's record was reviewed. Patient #15 was admitted to the hospice on 10/7/22 with a diagnosis of Sepsis while a patient in a local hospital. The record did not include a physician's order for General Inpatient Level of Care (GIP LOC). Continued review of Patient #15's record was conducted on 5/2/23 at 2:00 PM. The Nurses Admission Visit Note dated 10/7/22 indicated the medication Fentanyl was increased to 75 mcg and morphine sulfate was ordered by intravenous push (IVP). There were no physician's orders for morphine sulfate IVP or Fentanyl 75 mcg in Patient #15's hospice record. On 5/4/23, at 3:15 PM the Branch Director/Administrator (BD/Admin) was interviewed. During a concurrent review of Patient #15's record, the BD/Admin confirmed there were no physician's orders in the hospice record for these medications. The BD/Admin stated Patient #15 was admitted on GIP LOC. The BD/Admin was unable to find a physician's order for Hospice GIP LOC for Patient #15. The findings include: Record review on 05/04/23 at 10:00 AM of P 8 revealed P 8 was admitted to the hospice on 03/03/23 for Carcinoma of the Liver. Review of certification period 03/03/23 to 05/31/23 revealed SN as needed visits (prn) on 03/18/23 and 04/27/23 with no physician orders for the visits. During an interview on 05/05/23 at 11:29 AM, the Branch Director stated, ";The nurse puts in the prn visits on her calendar so he/she will have it. It (the order) populates from his/her start of care (SOC) order". Record review on 05/04/23 at 10:54 AM of P 14 revealed P 14 was discharged from hospice by the agency on 08/04/22 due to the patient seeking aggressive treatment at a hospital. Further review of the chart revealed no physician order to discharge the patient. During an interview on 05/05/23 at 11:50 AM, the Branch Director stated, ";The nursing note is the discharge order for the patient".