Every finding on record at Hospice by the Sea, Inc.

Observed in Tracer Activities. In one of four bereavement records reviewed, the organization had not identified the two young children of the patient as potential bereaved during the admission assessment and, therefore, had not completed bereavement assessments for them upon admission. The operations excellence nurse confirmed this observation.

Observed in Record Review. In one of four bereavement records reviewed, the operations excellence nurse confirmed that the IDG notes did not identify the bereaved or a handoff to the bereavement team upon death.

Observed in Tracer Activities. In one of four bereavement records reviewed, the operations excellence nurse and grief care manager confirmed that the first bereavement phone call did not occur within four weeks of death as stated in the bereavement plan of care. Observed in Tracer Activities. In one of four bereavement records reviewed, the operations excellence nurse confirmed that the notes and continued plan of care for the bereaved was missing from the social worker's bereavement visit on 6/1/23. There was no further documentation after that date.

Observed in Individual Tracer. During HV5 the Hospice nurse surveyor noted that the organization did not follow accepted standards of practice in infection control. During the bed bath, the aide competed peri care and did not change the water, washcloths or gloves before proceeding to the legs. This was validated in a discussion with and observation by OPEX Specialist.

Observed in Tracer Activities. During a tour of John Knox IPU, the unit manager confirmed that one of the ready-to-use oxygen concentrators in the supply room was past due for the annual maintenance. The tag showed that the maintenance was due 2/2025.

Observed in Building Tour. The door pair marked as an EXIT in the Long Term Care unit adjacent to the John Knox Inpatient Hospice Unit was equipped with delayed egress door hardware; however, there was no PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS sign on the door adjacent to the releasing device as required by NFPA 101-2012, 7.2.1.6.1.1(4). This exit served as one of the two required exits from the hospice unit. This was verified by the Facilities Director. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. A door pair marked as an EXIT at the end of the corridor by staff lounge 133 in the John Knox Inpatient Unit had a sign on the door that stated Staff Only thereby confusing the direction of egress. This was verified by the Facilities Director. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. Two 95-gallon red biohazardous waste containers were stored in a corridor closet by patient room 711. This closet was NOT protected as a hazardous area as the sliding doors to this closet were NOT self-closing or positive latching. This was verified by the Facilities Director. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. An open 1-inch conduit that penetrated the smoke barrier wall above the ceiling in the corridor by mechanical room 102 was NOT sealed. This was verified by the Facilities Director. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.

Observed in Building Tour. Three (3) electrical outlets within 5 feet of the sink in Nutrition Room 131C at the John Knox Inpatient Unit were NOT a ground-fault circuit interrupter (GFCI) protected circuit. This was verified by the Facilities Director. Observed in Building Tour. Five (5) unsecured oxygen H cylinders were observed outside in the oxygen manifold area. A securing chain was present, but was NOT in use. This was verified by the Facilities Director. Observed in Building Tour. Two (2) electrical outlets within 4 feet of the sink in the Medication room were NOT a ground-fault circuit interrupter (GFCI) protected circuit. This was verified by the Facilities Director.

Observed in Tracer Activities. During the tour of John Knox IPU, the unit manager confirmed that three of the ten room refrigerators had temperatures out of range during the last 37 days. Specifically, there were between five and ten days for each of those refrigerators that were out of range with no action documented. Observed in Tracer Activities. During the tour of the IPU in Boca, the Hospice Nurse surveyor noted that in the family room the refrigerator for family and guest use did not have a temperature documented on April 12. This was validated in a discussion with and observation by the OPEX Specialist.

Based on record review and interview, the Hospice failed to ensure the continuous assessment of each patient's and family's needs and implementation of the Interdisciplinary Plan of Care for 2 of 3 sampled patients as evidenced by the lack of written documentation of the weekly Skilled Nurses visits, as per the patients' Plan of Care (Patient #1 and #2). The findings included: --- 1) Review of Patient #1s clinical record documented an admission to Hospice care on 05/08/24. Review of the physician's order dated 05/09/24 documents a SN (Skilled Nurse) visits weekly for 8 weeks effective 05/12/24. Review of the patients record reveals no evidence of documentation of the physician's ordered weekly Skilled Nurse's visit for the week of May 12th through 18th; the week of May 26th through June 1st; the week of June 9th through June 15th and the week of June 23rd through June 29th. Review of Patient #1s Plan of Care (POC) dated 06/26/24 documents a physician's order for a Skilled Nurse visit weekly for 8 weeks, effective 07/07/24. Review of the patients record reveals no evidence of documentation of the physician's ordered weekly Skilled Nurse's visit for the week of July 14th through July 20th and the week of July 28th through August 3rd. Review of Patient #1s "Coordination Notes" reveals a lack of written documentation regarding these multiple "missed" Skilled Nurse visits. On 08/28/24 at 9:10 AM, a side-by-side review of Patient #1s clinical record was conducted with the Compliance Resource Nurse (CRN). who confirmed Patient #1s missed visits, and the review of the patients "Coordination Notes" reveal no evidence of documentation of an explanation regarding the patients missed visits. On 08/28/24 at 10:00 AM, a joint interview was conducted the Corporate Compliance Officer (CCO) and the CRN; the CCO was apprised of Patient #1s missed Skilled Nurse visits; the CCO stated the way the "system" works is that whenever there is a visit, it populates to the calendar, when a scheduled visit is missed, it is removed from the calendar because it was not completed; the CCO stated that a missed visit is either documented on the "Coordination Notes" or the "Missed Visit Report;" a "missed visit ";extra context is needed to be written on the "Coordination Notes; the CCO was apprised of the lack of written documentation related to the missed visits under the "Coordination Notes" section; a side-by-side report of patients missed visits provided by the CCO was reviewed by the CRN; the report reveals reasons (codes) for missed visits as scheduling conflict, duplicate visit and/or caregiver or patient request day outside of the "Medicare week;" the CRN was asked to explain the report codes and the CRN asked to discuss it with the RN/Case Manager. On 08/28/24 at 10:35 AM, an interview via a telephone conference call was conducted with Staff A, Registered Nurse (RN) Case Manager (CM), Staff B, Team Manager and the CRN; Staff A stated Patient #1 was very difficult to get in touch with, (they) never got an answer when calling the patient, and never received a call back from the patient; Staff A stated for missed visits, she will have to write a narrative but uses the "missed visit template" (report) to avoid a writing repetition; Staff A, and Staff B were apprised that the patients "Coordination Notes" section lacks written documentation of the reason for Patient #1s multiple missed Skilled Nurse visits; Staff B, Manager stated it would be nice to have another nurse, ";unfortunately we dont have an extra nurse" and added that they have to triage the patient and sometimes the visit has to be moved; they cant always "cover" the patients visits; Staff B stated most of the patients must have a visit once a week, and sometimes not everybody can be seen, ";unfortunately"; Staff B stated her manager was aware of that; Staff B stated that patients do request not to be seen and that she encourages the nurses to document missed visits and added that she understands the records reviewed do not reflect that; she has addressed that with the nurses and the nurses are "working on that." 2) Review of Patient #2s clinical record documented an admission to Hospice care on 02/08/24. The physician's order dated 02/27/24 documents SN (Skilled Nurse) visits weekly for 10 weeks effective 02/25/24. Review reveals the patients record lacked written documentation of a weekly Skilled Nurse visit for the week of March10th through 16th and the week of April 14th through 20th. Review of Patient #2s POC (Plan Of Care) certification period from 05/08/24 to 08/05/24 documents a physician's order for a Skilled Nurse visit weekly for 13 weeks, effective 05/08/24. Review reveals the patients record lacked written documentation of a weekly Skilled Nurse visit for the week of May 19th through 25th the week of June 2nd through 8th and the week of June 16th through 22nd. On 08/28/24 at 9:45 AM, a side-by-side review of Patient #2s clinical record was conducted with the Compliance Resource Nurse (CRN) who confirmed Patient #2s missed visits documentation. Review of the patients "Coordination Notes" lacks written documentation with an explanation regarding the patients missed visits. On 08/28/24 at 10:00 AM, a joint interview was conducted the Corporate Compliance Officer (CCO) and the CRN; the CCO was apprised of Patient #2s missed Skilled Nurse visits; the CCO stated the way the "system" works is that whenever there is a visit, it populates to the calendar, when a scheduled visit is missed, it is removed from the calendar because it was not completed; the CCO stated that a missed visit is either documented on the "Coordination Notes" or the "Missed Visit Report;" a "missed visit ";extra context is needed to be written on the "Coordination Notes; the CCO was apprised of the lack of written documentation related to the missed visits under the "Coordination Notes" section; a side-by-side report of patients missed visits provided by the CCO was reviewed by the CRN; the report reveals reasons (codes) for missed visits as scheduling conflict, duplicate visit and/or caregiver or patient request day outside of the "Medicare week;" the CRN was asked to explain the report codes and the CRN asked to discuss it with the RN/Case Manager. On 08/28/24 at 10:35 AM, an interview via a telephone conference call was conducted with Staff A, Registered Nurse (RN) Case Manager (CM), Staff B, Team Manager and the CRN; Staff A stated for missed visits, she will have to write a narrative but uses the "missed visit template" (report) to avoid a writing repetition; Staff A, and Staff B were apprised that the patients "Coordination Notes" section lacks written documentation of the reason for Patient #2s multiple missed Skilled Nurse visits; Staff B, Manager stated it would be nice to have another nurse, ";unfortunately we dont have an extra nurse" and added that they have to triage the patient and sometimes the visit has to be moved; they cant always "cover" the patients visits; Staff B stated most of the patients must have a visit once a week, and sometimes not everybody can be seen, ";unfortunately"; Staff B stated her manager was aware of that; Staff B stated that patients do request not to be seen and that she encourages the nurses to document missed visits and added that she understands the records reviewed do not reflect that; she has addressed that with the nurses and the nurses are "working on that."

Based on review of the Hospice's Policies, record review and interview, the Hospice failed to follow the physician's Plan of Care for 2 of 3 sampled patients (Patient #1 and #2). The findings included: --- 1) Review of the Hospice's Policy titled, ";Plan of Care- Chapter 8 Provision of Care" revised on 03/2023 documents, ";...hospice in collaboration with the patient and family, develops an interdisciplinary plan of care (POC)...the initial POC is established before services are provided... team members shall document the patient/family agreement with the POC..." Review of the Hospice's Policy titled, ";Interdisciplinary Plan of Care- Chapter 8 Provision of Care" revised on 03/2023 documents, ";The POC is developed to address the immediate needs identified in initial assessment and established before care, treatment and services are provided...the interdisciplinary team collaborates with the patient, family, physician...in developing a comprehensive plan of care that includes the following: a statement of the scope and frequency of services needed to meet the patients and familys needs..." Review of Patient #1s clinical record documents an admission to Hospice care on 05/08/24 and a physician's order, dated 05/09/24 documents a SN (Skilled Nurse) visit weekly for 8 weeks effective 05/12/24. Review of Patient #1s clinical record reveals the following completed Skilled Nurse visits on: 05/09/24, 05/23/24, 06/07/24, a Skilled Nurse "Recertification" visit on 06/20/24 with a subsequent Skilled Nurse visit on 07/02/24. Review reveals a lack of weekly Skilled Nurse visits, as per the physician's order, dated 05/09/24. Further review reveals the lack of a Skilled Nurse visit for the week of May 12th through 18th; the week of May 26th through June 1st; the week of June 9th through June 15th; and the week of June 23rd through June 29th. Review of Patient #1s POC, dated 06/26/24 documents a physician's order for a Skilled Nurse visit weekly for 8 weeks effective 07/07/24. Review of Patient #1s clinical record reveals the following Skilled Nurse visits on 07/11/24, 07/22/24, 08/05/24 and 08/13/24. Further review reveals a lack of weekly Skilled Nurse visits as per the physician's order dated 06/26/24 and the patient did not have a Skilled Nurse visit the week of July 14th through July 20th; and the week of July 28th through August 3rd. On 08/28/24 at 9:10 AM, a side-by-side review of Patient #1s clinical record was conducted with the Compliance Resource Nurse (CRN); the CRN confirmed Patient #1s physicians' orders for a weekly Skilled Nurse visit was not done as ordered. On 08/28/24 at 10:00 AM, a joint interview was conducted the Corporate Compliance Officer (CCO) and the CRN; the CCO was apprised of the Skilled Nurse visits not being completed as per the physicians order. On 08/28/24 at 10:35 AM, an interview via a telephone conference call was conducted with Staff A, Registered Nurse (RN) Case Manager (CM), Staff B, Team Manager and the CRN; Staff A stated Patient #1 was very difficult to get in touch with, never got an answer when calling the patient, never received a call back from the patient; Staff A, and Staff B were apprised that the patients "Coordination Notes" section lacks written evidence of the reason for Patient #1s multiple missed Skilled Nurse visits; Staff B stated it would l nice to have another nurse, ";unfortunately we dont have an extra nurse" and added that they have to triage the patient and sometimes the visits have to be moved; they cant always cover the patients visits; Staff B stated most of the patients must have a visit once a week, and sometimes not everybody can be seen, ";unfortunately" and Staff B stated her manager was aware of that. 2) Review of Patient #2s clinical record documented an admission to Hospice care on 02/08/24 and the physician's order, dated 02/27/24 documents a SN (Skilled Nurse) visits weekly for 10 weeks effective 02/25/24.Review of Patient #2s clinical record reveals the following completed Skilled Nurse visits on, 02/28/24, 03/07/24, 03/18/24, and 04/09/24. Further review reveals a lack of weekly Skilled Nurse visits as per the physician's order, dated 02/25/24. Continued review reveals the patient did not have a Skilled Nurse visit the week of March10th through March 16th and the week of April 14th through April 20th. Review of Patient #2s POC (Plan Of Care) certification period from 05/08/24 to 08/05/24 documents a physician's order for a Skilled Nurse visit weekly for 13 weeks, effective 05/08/24. Review of Patient #2s clinical record reveals the following completed Skilled Nurse visits on 05/09/24, 05/17/24, 05/30/24, 06/11/24, 06/24/24 and 07/03/24. Review reveals a lack of weekly Skilled Nurse visits as per the physician's order, effective on 05/08/24. Continued review reveals the patient did not have a Skilled Nurse visit the week of May 19th through 25th, the week of June 2nd through 8th, and the week of June 16th through 22nd. On 08/28/24 at 9:45 AM, a side-by-side review of Patient #2s clinical record was conducted with the Compliance Resource Nurse (CRN) who confirmed that Patient #2s physician's orders for a Skilled Nurse weekly visit was not done as ordered.

Based on record review, interview, and review of the Hospice's Policy, the Hospice provider failed to ensure documented coordination of services for 1 of 3 sampled patients as evidenced by Patient #1's record lacking documented communication and coordination of services related to the provision of Patient #1's "Yellow Copy DNR" (Do Not Resuscitate) order, reason for delay and late provision of a requested Lidocaine (Anesthetic) patch, and attempt and or return of a telephone call by the Hospice's staff to the patient's spouse (Patient #1). The findings included: Review of the Hospice's Policy titled, "Do Not Resuscitate Order (DNR)" revised 7/2021 documented, "... III Once the form has been signed by the patient and/or legal representative, send to physician for signature. A. A DNR is not legally valid until it is signed by the patient and/or legal representative, physician, and printed on yellow paper." Further review reveals no evidence of documentation of how this policy addresses how the DNR yellow copy is provided back to the patient. Review of the "Standard Work" process for the Communication Center, dated 03/08/2018, documents an explanation of the processes related to incoming calls; this process documented, " Step 15 Document the call and update the Call Status and Save. Enter the reason for call, interventions, and resolution in coordination note. Call status will reflect whether call is resolved or further action required. If caller is requesting to speak with a team member, check scheduling console to ensure that person is working. Email requested team member and the team admin if working. If not working, inform caller team member is not working, but an email will be sent and will return their call when they return." Review of the record revealed Patient #1 was admitted to the Hospice provider on 07/25/22 to received Hospice services in the home. Review of the "Admission Coordination Note," dated 07/25/22 documented Patient #1 as a "DNR." Review of a "narrative note," dated 07/26/22 by Staff A, a Medical Social Worker (MSW) documented, "The patient is a DNR. Document requires the physician's signature." During a telephone interview on 09/14/22 at 3:08 PM, Staff A, the MSW, recalled Patient #1; when asked the process for obtaining a DNR, the MSW explained the admission nurse explains and offers the DNR paperwork, and it is filled out and signed by the patient and or family; the MSW further explained that when the physician visits the patient, the physician can sign the DNR form, or staff can take the DNR paperwork to the physician for signature and the MSW further stated if the patient was transitioning or imminent, they would execute the DNR more quickly. Review of the record revealed Staff B, a Registered Nurse (RN), made a home visit to Patient #1 on 07/26/22, the day after admission. Review of the "narrative note" by Staff B lacked any documentation as to the status of the DNR for the physician's signature and or return of the paperwork to the home. During a telephone interview on 09/14/22 at 3:32 PM, Staff B stated she recalled Patient #1; when asked the process for obtaining a DNR, Staff B stated she would explain the DNR to the patient and or family first, would then have the patient and or family read and sign the DNR paperwork, and then have the physician sign the DNR; the RN explained she would either take the DNR paperwork to the physician and or office for signature, and then either take a yellow copy to the home or have the office scan it to the patient or family; when asked if she was aware of the status of the DNR paperwork when she visited Patient #1 on 07/26/22, the RN stated the spouse had told her the admission nurse had taken the DNR paperwork the previous day to obtain a physician's signature; the RN stated she was unsure as to the status until a few days later when she was on the telephone with the spouse who stated he was still waiting for the yellow copy DNR and the RN did not recall what was done about the DNR paperwork. During an interview on 09/14/22 at 4:00 PM, when asked the process of obtaining a DNR, the Corporate Compliance Officer explained it is signed by the family and then the physician, but it may take a day or two as the physicians are out in the field; the Corporate Compliance Officer agreed the record lacked documented evidence the printed yellow copy of the DNR for Patient #1 had been delivered back to the patient's home. During an interview on 09/14/22 at 4:10 PM, the Vice President (VP) of Clinical Operations was asked the process for getting the yellow copy DNR order back to the patient; the VP of Clinical Operations explained the standard protocol is for the nurse or the social worker to take the yellow copy DNR back to the patient's home; the VP of Clinical Operations stated it would be unusual for the office to scan or e-mail it to the patient or family as most do not have the yellow paper or the ability to print; when asked if there would be documented evidence the yellow copy DNR was returned to a family, the VP of Clinical Operations stated there generally would not be documentation of this as it is a standard practice. During an interview on 09/14/22 at 4:55 PM, Staff C, a staff physician explained after a documented conversation with the patient and or family regarding a DNR status, a team member would have the family sign the DNR order, take it back to the office for physician signature, and then return it to the family; the physician stated they try to get it back to the patient's home within a day, or sooner if the patient is imminent. Review of a Triage Coordination Note dated 07/26/22 at 8:37 AM documented a call was received from Patient #1's spouse requesting a Lidocaine patch due to pain to the left hip when sleeping on that affected side. Further review of the record lacked any evidence of coordinated care related to the provision of the Lidocaine patch, except for a physician's order dated 07/28/22 at 7:26 PM. During a telephone interview on 09/14/22 at 3:32 PM, Staff A, the RN who made a home visit for Patient #1 on 07/26/22, was asked if she was aware of the requested Lidocaine patch from a Triage call earlier on 07/26/22; the RN explained that a couple of days after that 07/26/22 visit a manager asked her to follow up with the patch and the RN stated she obtained a physician's order at that point. During an interview on 09/14/22 at 4:00 PM, the Corporate Compliance Officer was unsure as to the reason for the delay in discussing the need for the Lidocaine patch and or the delay in obtaining an order for the patch but agreed there was no evidence of coordination of care related to the requested Lidocaine patch. Review of the "Coordination Notes" revealed the spouse of Patient #1 had requested a call back from the Team Nurse on 07/27/22 at 3:27 PM and again at 7:49 PM, as per Triage notes. A subsequent Triage Note, dated 07/28/22 at 4:58 PM documented the spouse of Patient #1 had "just missed call from Team Manager." Further review of the record lacked any documented evidence of attempted calls to the patient's spouse or any communication with the spouse by a Team Nurse from the request on 07/27/22 at 3:27 PM until over 24 hours later on 07/28/22 at 4:58 PM. During an interview on 09/14/22 at 4:00 PM, the Corporate Compliance Officer agreed with the lack of a documented return call.

Observed in Individual Tracer. In 20 of 20 patient records reviewed, Confirmed by the Senior Director. Documentation of IDG had not documented the progression to goals. Example: Documentation had documented the current status of the patient but had not addressed goals and their progression of those goals.

Observed in Individual Tracer. In 19 of 20 patient records reviewed, Confirmed by the Senior Director. The plan of care had not reflected patient and family goals and interventions based on the patient assessment . The goals had not been measurable. Example: During review of HOSrr#7 there had not been documented goals and interventions within the poc when subsequent visits had been completed. HOSrr#1, HOSv#1, HOSrr#2,HOSrr#3,HOSrr#4. all goals documented had not been measurable: Example: HOSrr#2 had documented 1. that the patient /caregiver would understand the bowel protocol. 2. patient would understand the prevention of bleeding.

Observed in Individual Tracer. In 2 of 20 patient records reviewed, Confirmed by the Senior Director. The plan of care or updated plan of care had not documented all treatments provided to the patient. Example: During review of HOSrr#1 the nursing note had stated that the caregiver had been instructed on foley catheter irrigation per a verbal order, however the treatment had not been documented within the plan of care. During review of HOS#7 the plan of care had not been updated to include the treatment for s sacral wound and had not included the need for oxygen.

Observed in Building Tour. Confirmed by the Maintenance Manager. During the Building tour three penetrations had been observed in mechanical room at Boca Care Center. These had been corrected on site. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. Confirmed by the Maintenance Manager. There had been 1 fire door that had not closed completely when tested. This had been corrected on site. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.