Every finding on record at Hospicare & Palliative Care Services of Tompkins County Inc

Based on a review of 13 patient records and interviews with the Director of Patient Services (DPS) and Clinical Team Leader (CTL), it was determined in 5 records (patients # 1, 2, 4 , 7 and 12), the comprehensive assessments failed to identify all of the patient's needs. Evidence as follows: Failure to conduct a comprehensive assessment of the patient has the potential for the development of an incomplete plan of care and unmet patient needs. --- Patient # 4 was admitted to the Hospice on 07/13/22 with a terminal diagnosis of pancreatic cancer and additional diagnoses of abnormal weight loss and age related debility. On 07/13/22 the HN visited the patient for the initial assessment. The HN failed to include a complete assessment of the following: Wound Care The 07/13/22 plan of care included the following: soak feet in warm water, apply bag balm to open areas and cocoa butter to surrounding intact skin, cover open areas with non-adherent pad and wrap feet with rolled gauze. Change daily and as needed (PRN) The HN documented in the initial assessment the patient had peeling skin with an open area to the feet. The HN failed to perform a complete wound assessment that included: wound location/number of woundswound size(s)drainage present including type and amountwound care providedperson responsible for wound careassessment of care giver ability to perform wound care Topical Medication The 07/13/22 plan of care included the following: Triamcinolone Acetonide (steroid ointment) 0.025% apply 2 times per day. The HN assessment failed to assess if the patient was using the medication to treat an active skin condition including a description of the skin rash and areas of involvement. On 02/07/23 the record was reviewed with the DPS and the CTL. They acknowledged the findings, and no additional information was provided. Home VisitPatient #2 was admitted to the Hospice on 12/19/22 with a terminal diagnosis of anorexia and additional diagnoses of chronic kidney disease and hypertension. On 12/19/22, the HN visited the patient for the initial assessment. The HN failed to include a complete assessment of the following: EdemaThe physician documented in the 12/01/22 referral the patient had +2 pitting edema to bilateral lower extremities, and the medication bumetanide (a fluid reducer) dosage was increased. On 12/19/22, the HN documented in the genitourinary system section of the assessment note the patient had compromised cardiovascular status related to hypertension and renal failure. The HN failed to assess the patient for edema, including quantitative baseline measurements if needed, the effectiveness of bumetanide, and interventions such as positioning and elevating extremities. On 02/02/23, the surveyor conducted an observational home visit with the HN. The HN failed to assess the patient for edema, including the effectiveness of bumetanide or other interventions used for edema management. On 02/07/23, the record was reviewed with the DPS and the CTL. They acknowledged the findings, and no additional information was provided. Home Visit Patient # 1 was admitted to the agency on 07/08/22 with a terminal diagnosis of Alzheimers disease and an additional diagnosis of dysphagia (difficulty swallowing). The hospice nurse (HN) failed to perform a comprehensive assessment to adequately identify the patients needs. On 07/08/22 the HN visited the patient for the initial assessment and failed to address the following: Urinary Catheter The 07/08/22 Hospice Plan of Care (POC) included catheterization 2-3 times per day. The HN failed to assess: - how often the patient required catheterization, - who was performing the catheterization with demonstration of ability to competently perform the procedure and follow infection control guidelines, - amount and color of urine obtained, - the size of the catheter used, - and if adequate supplies were available. Medications The 07/08/22 POC included the following oral medications: -Probiotic (bacillus coagulans) 1 capsule 2 times a day. -Lorazepam 0.5mg 1 tablet every 6 hours as needed. -Aspirin81 mg delayed release tablet once a day. -Escitalopram oxalate 5 mg once daily. -Melatonin 1 mg one tablet at bedtime as needed. -Metoprolol succinate extended release (ER) 25mg 0.5mg once a day. -Omeprazole 20mg delayed release capsule once a day. -Doxycycline monohydrate 100mg capsule take 1 tablet 2 times a day. -Haloperidol 2mg/ml oral concentrate 1 milligram every 6 hours as needed for agitation. The HN failed to assess how medication were being administered, including if they were being crushed, determine if the caregiver understood which medications should not be crushed, and offer an alternative form of medications including liquid form if appropriate. On 02/06/23 at 1.p.m the surveyor conducted an observational home visit with the HN. During the visit the caregiver reported she was crushing metoprolol succinate ER tablets to make them easier to swallow. Nutrition The HN failed to assess the patients diet on the POC and what the patients was tolerating. During the 02/06/23 home visit, the caregiver reported the patient was on a soft diet with nectar thick fluids. On 02/07/23 the surveyor reviewed the record with DPS and CTL. They acknowledged the findings an provided no additional information. Patient # 7 was admitted to the agency on 12/17/22 with a terminal diagnosis of congestive heart failure and an additional diagnosis of dysphagia. On 12/17/22 the HN visited the patient and failed to assess the following: Respiratory On 12/17/22 the HN and physician documented in the certification of terminal illness the patient had significant hypoxia with oxygen levels of 70% (normal above 90%) prior to last hospitalization. The 12/17/22 POC included oxygen at 2-4 liters nasal cannula as needed for hypoxia or shortness of breath. The HN failed to assess: -the patient/caregiver understanding of oxygen precautions and maintenance of equipment, including cleaning of filter, changing tubing and refilling humidity bottle with distilled water. Between 12/17/22 and 01/31/23 the HN visited weekly and failed to assess oxygen management in the home. Wound care/skin The POC included wound care to stage 2 pressure ulcers to upper buttocks/coccyx and medial buttocks/gluteal fold as follows: -remove old dressing -clean wounds with wound cleanser and pat dry -apply bag balm to reddened peri-wound areas only, and -cover entire area with sacral optifoam dressing. The SN failed to assess: -the person responsible for providing care - the responsible persons ability to perform ordered care including instruction and return demonstration - compliance with infection control practices. The undated policy titled ";Wound Assessment and Documentation" directs the nurse provide and document patient and caregiver instruction and assessment of compliance with wound care, with identification of who is responsible to provide care. On 02/07/23 the surveyor reviewed the record with DPS and CTL. They acknowledged the findings an provided no additional information.

Based on a review of 13 patient records and interviews with the Director of Patient Services (DPS), and Clinical Team Leader (CTL), it was determined in 3 records (patients # 3, and 9), the updated comprehensive assessments were incomplete and/or failed to include changes in the patient's condition. Evidence as follows: --- Patient # 9 was admitted to the hospice on 11/04/22 with a terminal diagnosis of weight loss and additional diagnoses of dementia and heart failure. The HN failed to perform updated comprehensive assessments of sufficient scope to identify changing needs of the patient. On 01/16/22 and 01/18/22 visited the patient. The HN documented the care giver stated the patient was refusing to take medications. The 11/04/22 plan of care included the following oral medications: Senna 50 mg/8.6 mg 1 tablet 2 times/day as needed (PRN) for constipation, Cordarone (heart medication) 200 mg daily, Lasix (fluid reducer) 40 mg ½ a tablet PRN for edema or shortness of breath, Synthroid (thyroid hormone) 88 mcg 1 tablet daily, Remeron (antidepressant) 30 mg 1 tablet at bedtime, Zofran 4 mg every 8 hours PRN nausea/vomiting, and Seroquel (anti-psychotic) 50 mg 1 tablet 2 times/day. The HN failed to assess which medications the patient was refusing including the patients ability to safely swallow medications and fluids. There was no evidence the HN collaborated with the physician and the interdisciplinary team (IDT) regarding changes in the patient's condition. On 02/07/23 the record was reviewed with the DPS and CTL. They acknowledged the findings, and no additional information was provided. Patient # 3 was admitted to the agency on 01/09/23 with a terminal diagnosis of myelodysplastic syndrome and additional diagnosis of ileostomy secondary to colitis. The HN and the Interdisciplinary Team (IDT) failed to ensure the plan of care reflected the changing needs of the patient. The 01/09/23 plan of care included the patient was to apply Fentanyl patch 12 mcg/hour extended release every 72 hours. On 01/23/23 the HN documented in the communication notes a late entry for a visit on 01/18/23. The note included the patient stated the Fentanyl patch was making him too drowsy and he will not use it. On 01/25/23 the Interdisciplinary Team (IDT) met to review the patient's plan of care. The HN documented in the IDT prep notes the patient was no longer using the Fentanyl patch for pain management due to excessive drowsiness. Additionally, the social worker (SW) prep note included on 01/19/ 23 the patient stated he stopped using the Fentanyl "yesterday" because he didn't like how it made him feel, and concern about his history of addiction. There was no evidence the IDT discussed the patient's decision to stop using the Fentanyl patch and update the plan of care. On 02/06/23 the surveyor completed a home visit with the HN. During the visit, the HN reviewed the patient's medications. The HN asked the patient if he had his Fentanyl patch on. The patient stated he stopped using the Fentanyl patch "a while ago" because it made him feel dizzy and drowsy. The HN and the IDT failed to assess the patients pain management plan and update the plan of care based on the changing needs of the patient. On 02/07/23 the record was reviewed with the DPS and CTL. They acknowledged the findings, and no additional information was provided. Patient #12 was admitted to the Hospice on 09/30/22 with a terminal diagnosis of bladder cancer and additional diagnoses of malnutrition, atrial fibrillation, and post-traumatic stress disorder. The hospice nurse (HN) failed to assess the patient and educate the patient's caregivers. On 10/25/22, orders for wound care were obtained from the patient's primary physician by the HN as follows; - meatus; cleanse the area with wound care spray and gently pat dry. Apply bag balm to affected areas. - coccyx; cleanse the wound with wound care spray, apply bag balm, and cover with Optifoam dressing. On 11/04/22, the HN visited and documented that the "wound to coccyx appears to be healed" and failed to assess the tip of the penis. On 11/10/22, the HN documented that the "wound to coccyx fully healed" and failed to assess the tip of the penis. The HN failed to educate the PCG (and the HA) on the use of and the continuing care of the meatus and whether or not the wound care supplies had been obtained and were available to the PCG. On 02/07/2023, the record was reviewed with the DPS and the CTL. They acknowledged the findings, and no additional information was provided.

Based on a review of patient records and interviews with the Director of Patient Services (DPS) and Clinical Team Leader (CTL), it was determined in 5 of 13 records (patients # 4, 5, 8, 10 and 12), the plan of care failed to address all problems identified during the initial, comprehensive and updated comprehensive assessments. Evidence as follows: --- Patient #12 was admitted to the Hospice on 09/30/22 with a terminal diagnosis of bladder cancer and additional diagnoses of malnutrition, atrial fibrillation, and post-traumatic stress disorder.The hospice nurse (HN) failed to ensure the plan of care reflected the patient's needs. Nutrition The 09/30/22 plan of care included the patient's prime source of nutrition was Ensure liquid dietary supplement. The plan failed to include complete instructions regarding the amount and frequency. Vital Signs The plan of care included an intervention for the Hospice Aide (HA) to report abnormal vital signs to the nurse as needed. The plan of care failed to include an order to take vital signs, including the frequency and parameters for reporting abnormal results. Bowel Management The plan of care included an intervention for the HA to report no bowel movement to the HN.The plan failed to specify the frequency of no bowel movements. On 02/07/23, the record was reviewed with the DPS and CTL. They acknowledged the findings, and no additional information was provided. Patient #8 was admitted to the Hospice on 10/19/20 with a terminal diagnosis of Alzheimer's dementia and an additional diagnosis of age-related physical debility.The HN failed to determine if the medications were safe to crush, notify the physician and obtain orders for crushing the medications.The medication profile included the following: Ibuprofen 200mg 1 - 2 tabs every 6 hours as needed for pain andTylenol 325 mg 1 - 2 tabs every 4 hours as needed for painThe plan of care failed to specify when the patient should take each of the ordered medications, including: - pain levels such as low, moderate, high - when to select 1 tablet or 2 tablets - the maximum daily dose Liquid thickener The plan of care included the following: "Thick-it powder; dissolve small dose orally daily as needed for prevention of aspiration; mix small amount with liquids to desired consistency."The plan failed to include instructions for measuring, and the consistency required. On 02/07/23, the record was reviewed with the DPS and the CTL. They acknowledged the findings, and no additional information was provided. Patient # 10 was admitted to the Hospice on 12/29/22 with a terminal diagnosis of glioblastoma (brain cancer) and additional diagnoses of pulmonary effusion and atrial fibrillation. The Hospice Nurse (HN) failed to ensure the medication profile did not contain duplicate medication and that the patient instructions were clear and easy to follow. On 12/29/02, the HN visited the patient at the assisted living facility (ALF) for the initial comprehensive assessment. Findings included; Constipation The HN documented the patient had a diagnosis of constipation. The note included the patient's bowel status was reported to the ALF supervisor. The ALF supervisor stated Alf staff would administer the laxative. The plan of care included the following medications for bowel management: MiraLAX oral powder for reconstitution; administer 17 gm(s) orally once a day as needed for constipation.Bisacodyl 5 mg delayed-release tablet; take 1 tab(s) once daily as needed for constipation.Docusate sodium 100 mg capsule; take 1 cap(s) 2 times a day as needed for constipation.The plan failed to include the following:the indication for when to use each medication, i.e., Docusate sodium and MiraLAX not indicated for episodic constipationthe interval frequency for administrationthe fluid type and amount for mixing MiraLAX powder Pain The plan of care included the following orders:oxycodone 5 mg/ 325 mg acetaminophen; take 1 tablet every 4 hours as needed for pain (may take after taking Tylenol) MDD 6 tabletsacetaminophen 500mg; take 2 tab(s) every 6 hours as needed for painIbuprofen 200mg tablet; take 1 tab every 6 hours as needed for painThe plan of care failed to include instructions for when to take ibuprofen instead of acetaminophen, the administration time interval between the Tylenol and oxycodone, and clarification of the Tylenol maximum daily dose (MDD). The acetaminophen and oxycodone/acetaminophen, if administered at the dose specified in the plan of care, is 4000 mg which is > the recommended MDD of 3000 mg/day. Nausea The plan of care included the following:Zofran 8 mg tab; take 1 tab every 8 hours as needed for nausea and vomiting r/t malignant neoplasm of the frontal lobe.Prochlorperazine 10 mg tab; take 1 tab every 6 hours as needed for nausea/vomiting.The plan of care failed to clarify how to determine when to use Zofran for nausea and vomiting related to malignant frontal lobe neoplasm as opposed to prochlorperazine for other causes. On 02/07/23, the record was reviewed with the DPS and the CTL. They acknowledged the findings, and no additional information was provided. Patient # 5 was admitted to the Hospice on 02/10/20 with a terminal diagnosis of oxygen-dependent chronic obstructive pulmonary disease (COPD) and an additional diagnosis of Alzheimer's dementia.The hospice nurse (HN) failed to ensure the plan of care accurately reflected the patient's needs. Oxygen therapy The 01/25/23 plan of care included continuous oxygen via nasal cannula at 2-4 liters per minute. The 01/19, 01/20, and 01/26/23 nursing visit notes indicate the oxygen flow was at 4.5 liters per minute. The HN failed to communicate with the physician or the IDT for a titration plan with parameters for increasing oxygen flow to maintain the patient's comfort. Liquid thickener The plan of care included an order for Thick-it powder: "dissolve small dose orally daily as needed for prevention of aspiration; mix small amount with liquids to desired consistency." The plan failed to include instructions for measuring, and the consistency required. On 02/07/23, the record was reviewed with the DPS and the CTL. They acknowledged the findings, and no additional information was provided. Patient # 4 was admitted to the Hospice on 07/13/22 with a terminal diagnosis of pancreatic cancer and additional diagnoses of abnormal weight loss and age related debility. The hospice nurse (HN) failed to ensure the plan of care reflected the patient's needs. Implantable Port On 01/06/23 the SN documented in a prep note the patient's blood was drawn via venipuncture to left arm, and the patient requested future blood draws be done through the port. Neither the 07/13/22 or 01/09/23 plan of care failed to include that the patient had an implantable port including the type, and a plan for how the port would be used or maintained following admission to the Hospice. Edema On 01/05/23 the HN documented in the recertification assessment the patient had bilateral lower extremity edema. On 01/09/23 The physician documented in the plan of care summary the patient's weight increased 13 pounds over the past couple of weeks. The note included it was unclear if this was a true weight gain as opposed to a fluid gain, as the patient's lower extremities had swollen above her knees over the past 2 weeks. The plan of care included the following fluid reducing medications: Bumex 1 mg 2 times/day and Lasix 20 mg daily, and instructions to wrap feet with an ace bandage. The plan of care failed to include a plan for monitoring and symptom management including assessment with parameters for reporting changes to the physician and interventions to alleviate edema such as positioning and elevation of extremities. On 01/25/23 the physician changed the patients Lasix order form 20 mg daily to 20 mg daily if weight goes up by 3 pounds or increased edema. However; there was no update to the plan of care to include a plan to weigh the patient and monitor edema. Topical Medication The 07/13/22 plan of care included the following: Triamcinolone Acetonide (steroid ointment) 0.025% apply 2 times per day. The order failed to include the indication for use and site of application. On 02/07/23 the record was reviewed with the DPS and CTL. They acknowledged the findings, and no additional information was provided.

Based on review of the hospice's Quality Assurance and Performance Improvement (QAPI) Program activities for the past 12 months and interview with the Quality and Education Manager (QEM), it was determined the hospice failed to ensure performance improvement interventions were tracked to ensure development of effective action plans to correct deficient practices such as those identified in the report. Evidence as follows: --- On 02/07/23, the surveyor reviewed the QAPI and governing body meeting minutes for the past 12 months. The agency developed a performance improvement project (PIP) to improve the quality of the aide care plans and aide supervision following the 03/09/20 recertification and 02/01/21 post-certification visit, The PIP concluded on 04/21/22 when the agency had achieved a goal of "> 90% for > than 6 months with supervisory documentation" and "sustained improvement in home health aide care plan interventions." On 02/08/23, the surveyor interviewed the Quality and Education Manager (QEM) via phone, who explained the auditing process. The surveyor requested and reviewed the audit tools provided by the QEM for 14 patients. The audit findings included the only that orientation, supervision, and documentation completed. The tool lacked specificity of the accuracy or completeness of aide care plans or aide supervision by the hospice nurse. There was no evidence the agency continued to monitor the accuracy of the aide care plans or supervisory visits resulting in the deficiencies identified within this report. Failure to ensure that the agency develops a plan of correction and performance improvement program that monitors continued progress to maintain compliance has the potential for unmet patient needs and negative outcomes for the patient population.

Based on a review of 7 patient records, for patients receiving Hospice Aide (HA) services, and interviews with the Director of Patient Services (DPS) and Clinical Team Leader (CTL), it was determined in 4 records, (patients # 4, 8, 10 and 12), the HA care plans failed to include all information necessary for the HA to provide care. Evidence as follows: Failure of the HN to individualize and provide complete instructions to the HA has the potential for unmet patient needs, and possible negative patient outcomes. --- Patient # 4 was admitted to the Hospice on 07/13/22 with a terminal diagnosis of pancreatic cancer and additional diagnoses of abnormal weight loss and age related debility. The hospice nurse (HN) failed to ensure the Hospice Aide (HHA) instructions were complete and met the needs of the patient. The 07/13/22 plan of care included HA service 5 times per week for personal care. On 07/19/22 the HN documented in a supervisory visit note the HA was oriented to the aide care plan. The note included the HA was educated on patient activities of daily living (ADLs) such as bathing and foot care, and was instructed to keep the HN informed of any issues or concerns that occur during the HA visit. On 07/20/22 the HA documented in the visit note the patient's daughter showed the HA how to wrap the patient's feet. The note included the HA applied cocoa butter and gauze wrap to feet. On 07/21/22 the HA documented in the visit note she soaked the patient's feet in Epsom salt, dried the feet and applied cocoa butter and re-wrapped with gauze. The plan of care included the following: soak feet in warm water, apply bag balm to open areas, apply cocoa butter to surrounding intact skin, cover open areas with non-adherent pad and wrap with gauze, change daily and as needed. There was no evidence the HN assessed the patient to determine the wound care was within the HA scope of practice per the New York State Department of Health Home Health Aide Matrix of Permissible and Non-Permissible Activities dated March 2009. The HN failed to: assess the patient to determine the patient was self-directing assess the wound to ensure the wound was stable, not open or drainingassess the availability/willingness/ability of informal care giversdevelop a HA care plan with written instruction for providing foot soak/ wound careeducate the HA on wound careassess the HAs ability to correctly perform foot soak/wound careinclude patient specific signs and symptoms the HA was to observe for and report to HN On 07/07/2023 the record was reviewed with the DPS and the CTL. They acknowledged the findings, and no additional information was provided. Patient # 10 was admitted to the Hospice on 12/29/22 with a terminal diagnosis of glioblastoma (brain cancer) and additional diagnoses of pulmonary effusion and atrial fibrillation. The hospice nurse (HN) failed to ensure the Hospice Aide (HHA) instructions met the patient's needs. At the time of admission, the patient resided in an assisted living facility (ALF). The 12/29/22 Hospice Certification and Plan of Care (POC) included Interdisciplinary Team (IDT) Interventions of; - ALF is responsible for all care, the activity of daily living (ADL's), incontinence care, medication administration, and personal safety of the patient 24 hours/day, 7 days /week. Skilled Nurse (SN) - Initiate referral for HHA to assist with ADLs 3-5 times per month and PRN (as needed). On 01/27/23, the patient was admitted to the Hospice residence from the Hospital Emergency Room after a fall at the ALF. A review of the updated Interdisciplinary Care Plan (ICP) interventions included "Residence HHA - Patient Care, Discipline- Interdisciplinary Team." Tasks 1 through 23 included; activity, diet, intake and output, home management, safety, screening, and hygiene, "SN." Tasks 23-31 continued with teaching interventions, and task 30 was to teach medication management "to include dose, action, side effects administration, and when to notify residence staff. The tasks were all current and assigned to the SN. None to an aide. A review of the "shift running document" of 01/27/23 between 03:00 p.m. through 10:00 p.m. and the communication notes for 01/27/23 indicate the hospice aide (HA) transferred, toileted, repositioned and prepared a snack, meal and fluids for the patient between admission (approximately 03:00 p.m.) and 10:00 p.m. There is no evidence the HA was oriented to a patient-specific aide plan of care prior to performing care. The HN failed to create an aide care plan that was patient-specific, within the scope of the HA, and orient the HA to the plan. On 02/07/2023, the record was reviewed with the DPS and the CTL. They acknowledged the findings, and no additional information was provided. Patient # 12 was admitted to the Hospice on 09/30/22 with a terminal diagnosis of bladder cancer and additional diagnoses of malnutrition, atrial fibrillation, and post-traumatic stress disorder. The hospice nurse (HN) failed to ensure the Hospice Aide (HHA) instructions met the patient's needs. The 09/30/22 plan of care included HA service 5 times per week/4 times per month for personal care. The aide care plan was not updated on 10/25/22 when the patient developed a wound to the coccyx and meatus. - meatus; cleanse the area with wound care spray and gently pat dry. Apply bag balm to affected areas. - coccyx; cleanse the wound with wound care spray, apply bag balm, and cover with Optifoam dressing. The HN failed to update the aide care plan to include instructions to report soiled dressing to the RN or include instructions for soiled dressing management and to provide education for specific care to the meatus.The aide care instructions to report to the RN if the patient had no bowel movement failed to include a parameter or specific amount of time without a bowel movement.The aide care plan included instructions to report abnormal vital signs to the nurse as needed; however, there were no instructions to take vital signs and no parameters defining "abnormal." The aide care plan included the HA may trim or file long or uneven toenails as needed. As identified in the HHA scope of Tasks updated March 2009, page 29, nail care, cutting nails, is only permissible under special circumstances. On 01/07/23, the DPS and the CTL were asked if the Hospice had provided additional training and competency evaluation for finger and toenail cutting and were these criteria considered when developing this aspect of care for the HA. They provided no information. On 02/07/23, the record was reviewed with the DPS and the CTL. They acknowledged the findings, and no additional information was provided. Patient #8 was admitted to the Hospice on 10/19/20 with a terminal diagnosis of Alzheimer's dementia and an additional diagnosis of age-related physical debility. The hospice nurse (HN) failed to ensure the Hospice Aide (HA) had a plan of care and then a plan of care that met the patient's needs. On 03/04/21, the patient's caregiver requested a HA when the patient's mobility deteriorated and required a second assist to transfer. The first plan of care that included aide services was dated 04/17/21. The order read 5 times per week, beginning the week of 04/19/21 and ending the week of 06/15/21.The HA first visited the patient on 03/10/21, and a review of the interdisciplinary team notes revealed the aide care plan was developed and implemented on 06/02/21. The HA failed to ensure an aide care plan was in place between 03/04/21 and 06/02/21. On 02/07/23, the record was reviewed with the DPS and the CTL. They acknowledged the findings, and no additional information was provided.

Based on a review of patient records and interviews with the Director of Patient Services (DPS) and Clinical Team Leader (CTL), it was determined in 5 of 7 records for patients receiving Hospice Aide (HA) service (patients # 4, 5, 6, 8 and 12), the hospice nurse (HN) failed to supervise the HA every 14 days. Evidence as follows: --- Patient # 6 was admitted to the agency on 07/29/21 with a terminal diagnosis of congestive heart failure and additional diagnosis to atrial flutter. The HN failed to perform supervision every 14 days. The 11/15/ 22 Plan of Care included Hospice Aide services 2 times per week for personal care. On 01/03/23 visited the patient and documented HA supervision was performed. The HN visited the patient for re-assessment without supervision 3 times between the dates of 01/04/22 and 01/31/23. The HN failed to perform HA supervision including an assessment of the patient's satisfaction with care and the adequacy of care provided until 01/31/23 (28 days). On 02/07/23 the record was reviewed with the DPS and CTL. They acknowledged the findings, and no additional information was provided. Patient # 4 was admitted to the Hospice on 07/13/22 with a terminal diagnosis of pancreatic cancer and additional diagnoses of abnormal weight loss and age related debility. The HN failed to supervise the HA every 14 days. The 10/11/22 plan of care included HA services 5 times per week for personal care. On 12/19/22 the HN documented in the visit note HA supervision was performed and the next supervision was due on 01/02/23. The HN visited the patient for re-assessment without supervision 4 times between the dates of 12/20/22 and 01/16/23. The HN failed to perform HA supervision including an assessment of the patient's satisfaction with care and the adequacy of care provided until 01/16/23 (28 days). The record was reviewed on 02/07/23 with the DPS and CTL. They acknowledged the findings, and no additional information was provided. Patient # 12 was admitted to the Hospice on 09/30/22 with a terminal diagnosis of bladder cancer and additional diagnoses of malnutrition, atrial fibrillation, and post-traumatic stress disorder. The HN failed to supervise the HA every 14 days. The 09/30/22 plan of care included HA services 5 times per week for personal care.On 11/18/22, the HN documented in the visit note HA supervision was performed, and the next supervision would be completed on 12/02/22. On 11/22/22, the HN visited; no HA supervision was performed. On 11/26/22, the HN visited; no HA supervision was performed. The HN failed to perform HA supervision, including an assessment of the patient's satisfaction with care and the adequacy of care provided until 12/06/22. (18 days). On 02/07/23, the record was reviewed with the DPS and CTL. They acknowledged the findings, and no additional information was provided. Patient #8 was admitted to the Hospice on 10/19/20 with a terminal diagnosis of Alzheimer's dementia and an additional diagnosis of age-related physical debility.The HN failed to supervise the hospice aide every 14 days. On 03/10/21, HA services were initiated. Between the dates of 03/10/21 and 06/2/21, there was no HA care plan with patient-specific care tasks and written instructions for the HA to follow. See L 625. As a result, the HN was not able to assess whether HA services were adequately meeting the needs of the patient. On 02/07/23, the record was reviewed with the DPS and CTL. They acknowledged the findings, and no additional information was provided. Patient # 5 was admitted to the Hospice on 02/10/20 with a terminal diagnosis of oxygen-dependent chronic obstructive pulmonary disease (COPD) and an additional diagnosis of Alzheimer's dementia.The HN failed to supervise the HA every 14 days. The 01/25/23 plan of care included HA services 5 times per week for personal care. On 12/29/22, the HN documented in the visit note HA supervision was performed, and the subsequent supervision was due on 01/12/23. On 01/19/23, the HN visited the patient for the Hospice recertification assessment. There was no evidence the HN completed an evaluation of HA services, including the patient's satisfaction with the care provided, the adequacy of service for meeting the patient's needs, and HA supervision. On 01/26/23, the HN visited for a reassessment and failed to perform supervision. There was no evidence the HN assessed HA services for satisfaction and adequacy of care provided or performed HA supervision until 02/07/23, a gap of 39 days. On 02/06/23, the surveyor requested and reviewed the agency's Hospice Aide Supervision policy dated 04/19/22. The policy included "a registered nurse makes an on-site visit to the patient's home no less frequently than every 14 days to ensure that the services ordered by the IDG and provided by the Hospice aide are meeting the patient's needs." On 02/07/23, the surveyor reviewed the record with the DPS and CTL. They acknowledged the findings, and they provided no additional information.

Based on observation and interview during the Life Safety Code survey conducted on 2/1/23, the facility failed to ensure exit signs were displayed/arranged in accordance with National Fire Protection Association (NFPA) 7.10 requirements for the main corridor of the resident unit. Specifically, there were no approved exit signs readily visible from any direction in the main corridor of the resident unit to indicate where the two remote emergency exits were located (in the meditation room and in the great room). Findings include: --- When observed on 2/1/23 at 12:30 PM, there were no approved exit signs readily visible from any direction in the main corridor of the resident unit to indicate where the two remote emergency exits were located (in the meditation room and in the great room). Specifically, there were no exit signs available in the corridor or in front of the doors leading to the rooms with the emergency exits in them to indicate the direction of the emergency exits from the resident unit When interviewed on 2/1/23 at 12:30 PM, the Director of Buildings and Grounds stated they were told last year by a life safety surveyor the exit in the meditation room had to be labeled and used as a required emergency exit. There have not been any exit signs in the hallway only exit signs at the emergency exits themselves. They were not aware of the code requirements for exit egress signage. When interviewed on 2/1/23 at 12:35 PM, the Director of Admissions stated there had never been exit signs in the corridor of the unit. They were not aware anymore exit signs needed to be installed to show where the exits were. 2012 NFPA 101: 19.2.10.1, 7.10.1.5.110NYCRR 415.29(a)(2), 711.2(a)(1)

Based on observation and interview during the Life Safety Code survey conducted on 2/1/23, the facility failed to ensure hazardous areas were properly maintained for 1 isolated room (the resident common tub room). Specifically, the resident common tub room was used as a storage room and the corridor door was not equipped with a self-closing device while containing combustible storage. Findings include: --- When observed on 2/1/23 at 12:40 PM, the resident common tub room was used as a storage room and the corridor door was not equipped with a self-closing device while containing combustible storage. Specifically, the room was approximately 144 sqft. in size and contained two 4 tier bakers racks with linens and cardboard boxes, there was a lard foam wedge in the tub, and there were multiple cardboard boxes with personal care supplies stored on the floor all around the tub. When interviewed on 2/1/23 at 12:40 PM, the Dir of Admissions stated the room was not used much and was more a storage bathroom. Most of the storage needs to go into closets when they upgrade their sprinkler system. When interviewed on 2/1/23 at 12:40 PM, the Dir of Buildings and Grounds stated they were not aware of the code requirements for storage and hazardous room. 2012 NFPA 101: 19.3.2.1 10NYCRR 415.29(a)(2), 711.2(a)(1)