Every finding on record at Hospice Care Network

Observed in Individual Tracer. In 3 of 20 patient records reviewed, it was noted that the chaplain assessment was not completed in 5 days from the election of benefits. This was confirmed by the Hospice Leadership. Observed in Record Review. It was noted in a second record, that a Chaplain visit and assessment was not completed in the mandated timeframe of 5days from the election of hospice benefit. This was noted by the Hospice Leadership . Observed in Record Review. It was noted that the spiritual assessment was not completed in the required time frame of 5 days . This was noted by the Hospice Leadership.

Observed in Individual Tracer. In 1 of 20 patient records reviewed, It was noted that the patient's pain reassessment was not completed in the timeframe as prescribed by the organization's policy . The organization's policy entitled Pain Management # 100-603 says that after administration of parenteral pain medications will be assessed at 60 minutes post administration It was noted that in one patient record, the patient at two different times had two documented pain scales of 10 and 8 and was given intravenous opiates. However the documented pain reassessments occurred in 3 hours later, not in 60 minutes as per the policy previously mentioned. This was noted by the Hospice Inn's Leadership .

Observed in Record Review. The organization's Fall Assessment, the MAHC falls risk tool was not appropriate for the pediatric population that the organization served. This was verified by the Hospice Leadership .

Observed in Patient Home. The organization's Hand Hygiene Guidelines Policy - # INF 1109 was not followed. This policy states that no artificial nails are to be used when performing patient care . It was noted on RRHV#1 that the RN had artificial nails. This was confirmed by the hospice leader accompanying the surveyor. Observed in Patient Home. During HV#3 it was noted that the LPN performing abdominal PluerX drainage and dressing change did not maintain sterile technique during the dressing change as he did not don the sterile gloves in the sterile kit correctly , he touched the outside of the glove several times during the donning process of the sterile gloves. Manufacturers guidelines state the draining and the dressing change are sterile processes. This was observed by quality leadership.

Observed in Record Review. In 3 of 12 patient records reviewed, it was noted that the hospice aides were performing tasks or care that were not included on the aide plan of care. In RRHV# 6, the mentioned that she adds thicket to the patient's drinks, and the aide removed oxygen canula for some of the shampooing time, there were no orders or indications for these tasks or care noted on the care plan. On the second patient, it was noted that the aide offered fluids to the patient as well as spoon feeds the patient- neither of these orders or care were included on the aide care plan. Observed in Record Review. On a third patient the aide checked the that she did foot care, offered oral fluids, shave the patient, pulse, temperature and respirations, however these tasks were not on the aide care plan. This was noted by the organization leadership

Observed in Document Review. There was no documentation of the monthly or annual test of the battery powered task light in the generator cabinet and the electrical room. This was confirmed by the facilities staff. Observed in Document Review. The monthly generator test was not being initiated by the automatic transfer switch. This was confirmed by the facilities staff.

Based on patient record review and staff interview, the Agency failed to ensure that the comprehensive assessment identifies the physical, emotional, and spiritual needs related to the terminal illness are addressed in order to promote the hospice patients well-being, comfort, and dignity throughout the dying process. This was evident in one (1) of four (4) patient records reviewed (Patient #4). Failure to ensure the comprehensive assessment identifies the physical, emotional, and spiritual needs related to the terminal illness has the potential for negative patient outcomes. The findings are: --- Patient #4 has a start of care date of 04/20/2024 with diagnoses of Malignant Neoplasm of Pancreas, Secondary Malignant Neoplasm of Right Lung as documented on the "Physician's Plan of Care start date 04/20/2024, end date 07/18/2024". The "Physician's Plan of Care start date 04/20/2024, end date 07/18/2024" documents orders for "Professional Nurse: Registered Nurse 1 -2 x week x 14 weeks (one to two visits a week for fourteen weeks), and PRN 2 (two as needed visits) for change in condition". Registered Nurse to make "assessment visit and admit to Hospice Care". The referral date 04/17/2024 ";History Present Illness" documents the patient "ambulates independently but is weak". The patient also feels she has a "pressure ulcer to the coccyx" but she hasn't looked at the area. The "Admission" comprehensive assessment dated 04/20/24, the Registered Nurse documents "Palliative Performance Scale: 40 % (forty percent) Ambulation: mainly in bed/unable to do most activity -extensive disease/self-care: mainly assistance. Muscular Skeletal signs and symptoms: "painful joints, unsteady gait, weakness. Bathing -supervision, Toileting- Independent". The Registered Nurse documents the assessment of the patient's skin as "Intact, warm", "No immediate need for skin/wound intervention". The Home Health Aide tool assessment tool documents "No" Hospice aide services. A telephone interview was conducted with the Registered Nurse on 06/26/2024 at 10:50 AM. The Registered Nurse stated that the patient has "unsteady gait", cannot recall if saw patient "toileting", did not assess the patient's sacrum. The Registered Nurse further reported that "Physical Therapy and a commode for toileting was not ordered, and Home Health Aide services was offered". The admission comprehensive assessment lacks documented evidence of an accurate patient comprehensive assessment of the terminally ill Hospice patient with unsteady gait, weakness, self-care defects and impaired skin integrity. The Hospice did not ensure an accurate comprehensive assessment to promote the terminally ill patient's well-being, comfort, and dignity throughout the dying process. The survey findings were reviewed on 06/25/2024 at 04:29 PM with the Associate Executive Director for Clinical Operations, Director of Regulatory Affairs, and the Hospice Administrative staff. Interview conducted on 06/26/2024 at 12:08 PM with the Director of Regulatory Affairs, no explanation was provided.

Based on patient record review and staff interview, the Agency failed to ensure the comprehensive assessment takes into consideration the complications and risk factors that affect care planning. This was evident in one (1) of four (4) patient records reviewed (Patient #4). Failure to ensure the comprehensive assessment takes into consideration the complications and risk factors that affect care planning has the potential for negative patient outcomes. The findings are: --- Patient #4 has a start of care date of 04/20/2024 with diagnoses of Malignant Neoplasm of Pancreas, Secondary Malignant Neoplasm of Right Lung as documented on the "Physician's Plan of Care start date 04/20/2024, end date 07/18/2024". The "Physician's Plan of Care start date 04/20/2024, end date 07/18/2024" documents orders for "Professional Nurse: Registered Nurse 1 -2 x week x 14 weeks (one to two visits a week for fourteen weeks), and PRN 2 (two as needed visits) for change in condition". Registered Nurse to make "assessment visit and admit to Hospice Care". The "Admission" comprehensive assessment dated 04/20/24, the Registered Nurse documents "Palliative Performance Scale: 40 % (forty percent) Ambulation: mainly in bed/unable to do most activity -extensive disease/self-care: mainly assistance. Muscular Skeletal signs and symptoms: "painful joints, unsteady gait, weakness. Bathing -supervision, Toileting- Independent". A telephone interview was conducted with the Registered Nurse on 06/26/2024 at 10:50 AM. The Registered Nurse stated that the patient has "unsteady gait", cannot recall if saw patient "toileting", did not assess the patient's sacrum. The Registered Nurse further reported that "Physical Therapy and a commode for toileting was not ordered, and Home Health Aide services was offered". The comprehensive assessment lacks documented evidence of interventions for a Commode to address the patient's unsteady gait, weakness and bathing assistance. The Hospice did not ensure the comprehensive assessment address complications and risk factors that affect care planning. The survey findings were reviewed on 06/25/2024 at 04:29 PM with the Associate Executive Director for Clinical Operations, Director of Regulatory Affairs, and the Hospice Administrative staff. Interview conducted on 06/26/2024 at 12:08 PM with the Director of Regulatory Affairs, no explanation was provided.

Based on patient record review and staff interview, the Agency failed to ensure the comprehensive assessment includes the need for referrals and further evaluation by appropriate health professionals. This was evident in one (1) of four (4) patient records reviewed (Patient #4). Failure to ensure the comprehensive assessment includes the need for referrals and further evaluation by appropriate health professionals has the potential for negative patient outcomes. The findings are: --- Patient #4 has a start of care date of 04/20/2024 with diagnoses of Malignant Neoplasm of Pancreas, Secondary Malignant Neoplasm of Right Lung as documented on the "Physician's Plan of Care start date 04/20/2024, end date 07/18/2024". The "Physician's Plan of Care start date 04/20/2024, end date 07/18/2024" documents orders for "Professional Nurse: Registered Nurse 1 -2 x week x 14 weeks (one to two visits a week for fourteen weeks), and PRN 2 (two as needed visits) for change in condition". Registered Nurse to make "assessment visit and admit to Hospice Care". The "Admission" comprehensive assessment dated 04/20/24, the Registered Nurse documents "Palliative Performance Scale: 40 % (forty percent) Ambulation: mainly in bed/unable to do most activity -extensive disease/self-care: mainly assistance. Muscular Skeletal signs and symptoms: "painful joints, unsteady gait, weakness". The "Comprehensive Visit" notes dated 04/23/24, the Registered Nurse documents " Palliative Performance Scale: 40 % (forty percent) Ambulation: mainly in bed/unable to do most activity/-Extensive disease/self-care: mainly assistance. Muscular Skeletal signs and symptoms: "painful joints, unsteady gait, weakness". The comprehensive assessments lack documented evidence of interventions/referral for Physical Therapy services to address the patient's unsteady gait, weakness, and bathing assistance. The Hospice did not ensure that the comprehensive assessment consider the need for referrals and further evaluation by appropriate health professionals. The survey findings were reviewed on 06/25/2024 at 04:29 PM with the Associate Executive Director for Clinical Operations, Director of Regulatory Affairs, and the Hospice Administrative staff. Interview conducted on 06/26/2024 at 12:08 PM with the Director of Regulatory Affairs, no explanation was provided.

Based on patient record reviews and staff interviews, the Hospice failed to follow individualized Plans of Care and ensure the provision of care in accordance with written patient Plans of Care to address all patient needs. This was evident for three (3) of four (4) clinical records reviewed (Patients #1, #2, and #4). Failure to follow individualized Plans of Care to address all patient needs has the potential for negative patient outcomes. The findings are: --- 3) Patient #4 has a start of care date of 04/20/2024 with diagnoses of Malignant Neoplasm of Pancreas, Secondary Malignant Neoplasm of Right Lung as documented on the "Physician's Plan of Care start date 04/20/2024, end date 07/18/2024". The "Physician's Plan of Care start date 04/20/2024, end date 07/18/2024" documents orders for "Professional Nurse: Registered Nurse 1 -2 x week x 14 weeks (one to two visits a week for fourteen weeks), and PRN 2 (two as needed visits) for change in condition". The "Modified Order" dated 04/23/24 documents an physician's medical treatment order for "Professional Nurse to instruct patient and caregiver to clean wound with soap and water, pat dry and apply thin layer of Zinc Oxide barrier cream daily and as needed". The "Comprehensive Visit" note dated 04/23/24, the Registered Nurse documents that the patient has a wound to the "Coccygeal area (Sacrum) -Pressure Ulcer stage 2", measurement of "0.5-centimeter X 0.5 centimeter, no odor or drainage". There is no documented evidence that the wound care treatment was performed on 04/23/24 as ordered. The ";As Needed (PRN)/Focused Visit" note dated 04/28/24, the Registered Nurse documents "skin/wound intervention - No". There is no documented evidence that the wound care treatment was performed on 04/28/24 as ordered. The "Comprehensive Visit" note dated 05/06/24, the Registered Nurse documents that the patient has a wound to the "Coccygeal area (Sacrum) -Pressure Ulcer stage 2- patient refused assessment this visit". There is no documented evidence of a subsequent Registered Nurse visit was conducted from 05/06/24 until 05/12/24 to perform wound care as ordered. The ";As Needed (PRN)/Focused Visit" note dated 05/12/24, the Registered Nurse documents "skin/wound intervention - No", see wound/ulcer assessment". There is no documented evidence of a wound/ulcer assessment performed on 05/12/24. The clinical record lacks documented evidence of a wound/ulcer assessment performed on 05/12/24 as ordered. The patients clinical record does not document wound care in accordance with the plan of care as established by the physician. The survey findings were reviewed on 06/25/2024 at 04:29 PM with the Associate Executive Director for Clinical Operations, Director of Regulatory Affairs, and the Hospice Administrative staff. Interview conducted on 06/26/2024 at 12:08 PM with the Director of Regulatory Affairs, no explanation was provided. 2) Patient #2 has a start of care date of 05/03/2024 with a diagnosis of Other Specified Disease of Pancreas as documented on the ";Physicians Plan of Care" for the certification period of 05/03/2024 through 07/31/2024. The ";Physicians Plan of Care" for the certification period of 05/03/2024 through 07/31/2024 documents an order for ";Professional Nurse: Registered Nurse (RN) start 05/03/2024, end 07/31/2024, one to two (1-2) times per week for fourteen (14) weeks and two (2) visits as needed (PRN) for symptom management". The ";As Needed (PRN)/Focused Visit" note dated 05/24/2024 was completed by a Licensed Practical Nurse (LPN). The ";As Needed (PRN)/Focused Visit" note dated 05/26/2024 was completed by a Licensed Practical Nurse (LPN). The Plan of Care lacks documented evidence of an order for the Licensed Practical Nurse, visit frequency, and treatments to be provided. The patients clinical record does not document care in accordance with the plan of care as established by the physician. On 06/26/2024 at 4:30 PM, the Associate Executive Director for Clinical Operations and the Director of Regulatory Affairs were interviewed and did not provide an explanation for the findings. 1) Patient #1 has a start of care date of 11/20/2023 with diagnoses that include Alzheimers Disease, Dementia, Psychotic Disturbance, Atrial Fibrillation, Cerebral Infarction, Transient Ischemic Attack, Hyperlipidemia, Anxiety and Depression Disorder as documented on the ";Physicians Plan of Care" for the Certification Period of 11/20/2023 to 02/17/2024. The ";Physicians Plan of Care" for the Certification Period 11/20/2023 to 02/17/2024 documents: ";Admission visit: Registered Nurse to make assessment visit and admit to hospice care". Physician Orders dated 11/28/2023; Professional Nurse: Registered Nurse start 11/28/23 to 02/17/2024, 1 time per week times 12 weeks, 4 as needed visits: pain and symptom management. Social Worker 1-2 visits per month times four months; increased psychosocial crisis. Chaplain1-2 per month times four months, 2 as needed visit; increased spiritual crisis. The record lacked documented evidence of a Physician order from 11/20/23 to 11/28/23 for skilled hospice care and frequency of services to be provided. The ";LPN Observation Visit" note dated 11/21/2023 was completed by a Licensed Practical Nurse (LPN). The ";LPN Observation Visit" note dated 01/04/2024 was completed by a Licensed Practical Nurse (LPN). The Plan of Care lacks documented evidence of an order for the Licensed Practical Nurse, visit frequency, and treatments to be provided. On 06/26/2024 at 12:45 PM, the Associate Executive Director for Clinical Operations and the Director of Regulatory Affairs were interviewed and did not provide an explanation for the findings.

Based on patient record review and staff interview, the Agency failed to develop an individualized plan of care that includes all services necessary for the palliation and management of the terminal illness and related conditions, including interventions to manage pain and symptoms. This was evident in one (1) of four (4) patient records reviewed (Patient #4). Failure to develop an individualized plan of care that includes all services necessary for the palliation and management of the terminal illness and related conditions includes interventions to manage pain and symptoms has the potential for negative patient outcomes. The findings are: --- Patient #4 has a start of care date of 04/20/2024 with diagnoses of Malignant Neoplasm of Pancreas, Secondary Malignant Neoplasm of Right Lung as documented on the "Physician's Plan of Care start date 04/20/2024, end date 07/18/2024". The "Physician's Plan of Care start date 04/20/2024, end date 07/18/2024" documents orders for "Professional Nurse: Registered Nurse 1 -2 x week x 14 weeks (one to two visits a week for fourteen weeks), and PRN 2 (two as needed visits) for change in condition". Medication regimen includes Morphine Sulfate Rapid resolve 5 milligram by oral every 4 hours as needed. Indication -pain, dyspnea. The "Modified Order" dated 04/23/24 documents a physician's medical treatment order for new pain medications to include "Take 30 milliliters (1000 milligram) of Acetaminophen (500 milligram/15 milliters liquid) by mouth every 8 hours as needed for mild to moderate pain", "apply 1 adhesive patch medicated of Lidocaine 4% patch to neck for 12 hours". The "Comprehensive Visit" note dated 05/01/24, the Registered Nurse documents that the patient has "pain to left shoulder: pain level 10: pain effects on quality of life - unable to perform Activities of Daily Living, Anxiety, fearful: Physician notified - no". The "Comprehensive Visit" note dated 05/06/24, the Registered Nurse documents that the patient has "pain to left shoulder: pain level 8: pain effects on quality of life - unable to perform Activities of Daily Living, Anxiety, fearful: Physician notified - no". The clinical record lacks documented evidence that the Physician was notified of the patients high pain level and symptoms. The survey findings were reviewed on 06/25/2024 at 04:29 PM with the Associate Executive Director for Clinical Operations, Director of Regulatory Affairs, and the Hospice Administrative staff. Interview conducted on 06/26/2024 at 12:08 PM with the Director of Regulatory Affairs, no explanation was provided.

Based on patient record review and staff interview, the Agency failed to develop an individualized plan of care that includes all services necessary for the palliation and management of the terminal illness and related conditions, including medical supplies and appliances necessary to meet the needs of the patient. This was evident in one (1) of four (4) patient records reviewed (Patient #4). Failure to develop an individualized plan of care that includes all services necessary for the palliation and management of the terminal illness and related conditions includes medical supplies and appliances necessary to meet the needs of the patient has the potential for negative patient outcomes. The findings are: --- Patient #4 has a start of care date of 04/20/2024 with diagnoses of Malignant Neoplasm of Pancreas, Secondary Malignant Neoplasm of Right Lung as documented on the "Physician's Plan of Care start date 04/20/2024, end date 07/18/2024". The "Physician's Plan of Care start date 04/20/2024, end date 07/18/2024" documents orders for "Professional Nurse: Registered Nurse 1 -2 x week x 14 weeks (one to two visits a week for fourteen weeks), and PRN 2 (two as needed visits) for change in condition". Durable Medical Equipment include a "Cane". The "Admission" comprehensive assessment dated 04/20/24, the Registered Nurse documents "Palliative Performance Scale: 40 % (forty percent) Ambulation: mainly in bed/unable to do most activity -extensive disease/self-care: mainly assistance. Muscular Skeletal signs and symptoms: "painful joints, unsteady gait, weakness". The Plan of Care lacks an order for a Commode to assist the patient with management of the terminal illness and related conditions. The survey findings were reviewed on 06/25/2024 at 04:29 PM with the Associate Executive Director for Clinical Operations, Director of Regulatory Affairs, and the Hospice Administrative staff. Interview conducted on 06/26/2024 at 12:08 PM with the Director of Regulatory Affairs, no explanation was provided.

Based on patient record review and staff interview, the Agency failed to ensure the hospice interdisciplinary group reviews, revises, and documents the individualized plan as frequently as the patient condition requires to ensure that care and services provided are based on all assessments of the patient and family needs. This was evident in one (1) of four (4) patient records reviewed (Patient #4). Failure to ensure the hospice interdisciplinary group reviews, revises, and documents the individualized plan as frequently as the patient condition requires to ensure that care and services provided are based on all assessments of the patient and family needs has the potential for negative patient outcomes. The findings are: --- Patient #4 has a start of care date of 04/20/2024 with diagnoses of Malignant Neoplasm of Pancreas, Secondary Malignant Neoplasm of Right Lung as documented on the "Physician's Plan of Care start date 04/20/2024, end date 07/18/2024". The "Physician's Plan of Care start date 04/20/2024, end date 07/18/2024" documents orders for "Professional Nurse: Registered Nurse 1 -2 x week x 14 weeks (one to two visits a week for fourteen weeks), and PRN 2 (two as needed visits) for change in condition". Registered Nurse to make "assessment visit and admit to Hospice Care". Social Worker/Counselor 1-2 x month x 4 month (one to two visits a month for four months), Chaplain 1-2 x month x 4 months (one to two visits a month for four months). The referral dated 04/17/2024 ";History Present Illness" documents the patient "ambulates independently but is weak". The patient also feels she has a "pressure ulcer to the coccyx" but she hasn't looked at the area. (The patient lives alone). The "Admission" comprehensive assessment dated 04/20/24, the Registered Nurse documents "Palliative Performance Scale: 40 % (forty percent) Ambulation: mainly in bed/unable to do most activity/ -Extensive disease/self-care: mainly assistance. Muscular Skeletal signs and symptoms: "painful joints, unsteady gait, weakness. Bathing -supervision, Toileting- independent". The Registered Nurse documents the assessment of the patient's skin as "Intact, warm", "No immediate need for skin/wound intervention". The Home Health Aide tool assessment tool documents "No" Hospice aide services. The "Comprehensive Visit" notes dated 04/23/24, 05/01/24, and 05/06/24 the Registered Nurse documents " Palliative Performance Scale: 40 % (forty percent) Ambulation: mainly in bed/unable to do most activity/-Eextensive disease/self-care: mainly assistance. Muscular Skeletal signs and symptoms: "painful joints, unsteady gait, weakness". The ";As Needed (PRN)/Focused Visit" note dated 04/28/24, the Registered Nurse documents "Palliative Performance Scale: 30% (thirty percent) Ambulation: Totally bed bund/unable to do any activity/-Extensive disease/total care. Muscular Skeletal signs and symptoms: "painful joints, unsteady gait, weakness". The ";As Needed (PRN)/Focused Visit" note dated 05/12/24, Palliative Performance Scale: 40 % (forty percent) Ambulation: mainly in bed/unable to do most activity/-Extensive disease/self-care: mainly assistance. Muscular Skeletal signs and symptoms: "painful joints, unsteady gait, weakness". There is no documented evidence of a referral for Physical Therapy services to address the patient's unsteady gait, weakness, and bathing assistance. The "Modified Order" dated 04/23/24 documents and physician's medical treatment order for "Professional Nurse to instruct patient and caregiver to clean wound with soap and water, pat dry and apply thin layer of Zinc Oxide barrier cream daily and as needed". There is no documented evidence that the Professional Nurse/Registered Nurse performed wound care treatment to the sacrum on 04/23/24, 04/28/24, and 05/12/24. The "Modified Order" dated 04/25/24 documents an physician's medical treatment order for "Home Health Aide 4-5x week x 13 weeks". The "Activity Sheets" dated 04/26/24 and 04/30/24, 05/09/24, and 05/13/24 documents Home Health Services provided. The "Care Plan" for Home Health Aide services is dated 05/6/24. There is no documented evidence that a Care Plan was established for Home Health Aide services provided 04/26/24, and 04/30/24. There is no documented evidence that a Commode was ordered for the patient based on the comprehensive assessment dated 04/20/24, and comprehensive visits conducted by the Registered Nurse on 04/23/24 - 05/12/24. The ";Durable Medical Equipment/Supply" request for a ";Bedside Commode" is dated 05/12/2024. The "Patient Incident Report" dated 05/12/24 the Registered Nurse documents "patient states she was trying to get to the bathroom and fell, she says it took about one hour for her to get up. Denies hitting head or any injury". The Hospice interventions include patient assessment and transfer to Hospice Inn. The Hospice did not ensure coordination of care and services based on assessment of the terminally ill patient's need for Sacral wound treatment, Physical Therapy services, Home Health Aide services, and appropriate Durable Medical Equipment-Bedside Commode. The survey findings were reviewed on 06/25/2024 at 04:29 PM with the Associate Executive Director for Clinical Operations, Director of Regulatory Affairs, and the Hospice Administrative staff. Interview conducted on 06/26/2024 at 12:08 PM with the Director of Regulatory Affairs, no explanation was provided.

Based on patient record review and staff interview, the Agency failed to provide written care instructions for a hospice aide that are prepared by a registered nurse who is responsible for the supervision of the hospice aide. This was evident in one (1) of four (4) patient records reviewed (Patient #4). Failure to provide written care instructions for a hospice aide that are prepared by a registered nurse who is responsible for the supervision of the hospice aide has the potential for negative patient outcomes. The findings are: --- Patient #4 has a start of care date of 04/20/2024 with diagnoses of Malignant Neoplasm of Pancreas, Secondary Malignant Neoplasm of Right Lung as documented on the "Physician's Plan of Care start date 04/20/2024, end date 07/18/2024". The "Physician's Plan of Care start date 04/20/2024, end date 07/18/2024" documents orders for "Professional Nurse: Registered Nurse 1 -2 x week x 14 weeks (one to two visits a week for fourteen weeks), and PRN 2 (two as needed visits) for change in condition". Registered Nurse to make "assessment visit and admit to Hospice Care". The "Modified Order" dated 04/25/24 documents an physician's medical treatment order for "Home Health Aide 4-5x week x 13 weeks". The ";Care Plan" for Home Health Aide services is dated 05/06/24. The "Activity Sheets" dated 04/26/24 and 04/30/24, 05/09/24, and 05/13/24 documents Home Health Services provided. There is no documented evidence that a written Care Plan was established by the Registered Nurse for Home Health Aide services prior to the provision of care on 04/26/24, and 04/30/24. The survey findings were reviewed on 06/25/2024 at 04:29 PM with the Associate Executive Director for Clinical Operations, Director of Regulatory Affairs, and the Hospice Administrative staff. Interview conducted on 06/26/2024 at 12:08 PM with the Director of Regulatory Affairs, no explanation was provided.

Based on patient record review and staff interview, the Agency failed to ensure the supervising nurse assess an aides ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria. This was evident in one (1) of four (4) patient records reviewed (Patient #4). Failure to ensure the supervising nurse assess an aides ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria has the potential for negative patient outcomes. The findings are: --- Patient #4 has a start of care date of 04/20/2024 with diagnoses of Malignant Neoplasm of Pancreas, Secondary Malignant Neoplasm of Right Lung as documented on the "Physician's Plan of Care start date 04/20/2024, end date 07/18/2024". The "Physician's Plan of Care start date 04/20/2024, end date 07/18/2024" documents orders for "Professional Nurse: Registered Nurse 1 -2 x week x 14 weeks (one to two visits a week for fourteen weeks), and PRN 2 (two as needed visits) for change in condition". Registered Nurse to make "assessment visit and admit to Hospice Care". The "Modified Order" dated 04/25/24 documents a physician's medical treatment order for "Home Health Aide 4-5x week x 13 weeks". Home Health Aide services were provided on 04/26/24 and 04/30/24, 05/09/24, and 05/13/24. The "Progress note dated 05/01/2024 documensts that the patient's care giver requested a "change of aide because patient is unhappy with services, willing to wait for replacement aide". Replacement Home Health Aide services were provided effective 05/09/2024. The Home Health Aide initial supervision is dated 05/13/2024. There is no documented evidence that the Home Health Aide was supervised from 04/26/24 - 05/12/24. The survey findings were reviewed on 06/25/2024 at 04:29 PM with the Associate Executive Director for Clinical Operations, Director of Regulatory Affairs, and the Hospice Administrative staff. Interview conducted on 06/26/2024 at 12:08 PM with the Director of Regulatory Affairs, no explanation was provided.

Observed in Record Review. In 1 of 20 patient records reviewed, it was noted that the organization did not ensure that the plan of care included all required information. For example, during a review of the medical record for RR#6, it was noted that during week 6 of the 1st benefit period, the updated comprehensive assessment identified a change in the patient’s condition related to pain in the left lower extremity. The plan of care was not updated to include a patient specific pain goal and interventions to address the patient’s discomfort related to pain.

Observed in Individual Tracer. During 5 of 5 Individual tracers, the Hospice Surveyor was not able to validate that a plan to provide education regarding procedures to follow if care, treatment, or services are disrupted by a natural disaster or an emergency was established. For example, during a review of the patient education information in the home for HV#1, HV#2, HV#3, HV#4, and HV#5, an individualized disaster/emergency management plan was not identified. This observation was reviewed with the Associate Executive Director - Clinical Operations.

Observed in Building Tour. During the building tour of the Hospice Inpatient Building, it was noted that the fire door undercut was greater that ¾”. This observation was reviewed with the Executive Director and the Facilities Manager. 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. During the review of the above ceiling area of the Hospice Inpatient Building, it was noted that the piping for the automatic sprinkler system was supporting other items – coiled conduits were resting on this piping. This observation was reviewed with the Executive Director and the Facilities Manager. 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.

Based on clinical record review and Home Visit (HV) observation, the Hospice failed to establish an individualized Plan of Care including pain control, wound care treatments, and medications specific to meet the needs of the patient and patient family. This was evident in two (2) of four (4) clinical records reviewed. Patients # 1 and #3. Failure to establish an individualized Plan of Care, has the potential for negative patient outcome. The findings include: --- 2. Patient # 3 has a start of care date of 09/28/2022 with diagnoses of Alzheimer's, Dementia Hypertensive Heart, Chronic Kidney Failure and Heart Failure as documented on the "Physician's Plan of Care" dated 09/28/2022 to 12/26/2022. The "Physician's Plan of Care" (POC) dated 09/28/2022 to 12/26/2022 documents the patient's "Nutritional/Diet order - NPO (Nothing Per Oral)". The POC documents an order for the patients medications include "Citalopram 20 mg (milligram) by oral 1 x day, Gabapentin 300 mg by oral 2 x day, Melatonin 10 mg by oral at bedtime as needed, Prochlorperazine Maleate 10 mg by mouth every 12 hours as needed, Quetiapine 50 mg tablet by oral 2 x day, Senna -S 8.6mg-50 mg tablet take 2 tablets by mouth at bedtime as needed, Trazadone 50 mg tablet by oral at bedtime as needed, Tylenol Extra strength 500 mg tablet by oral every 6 hours as needed". The "RN (Registered Nurse) Admission Assessment" dated 09/28/200, the RN documents: "swallowing assessment: NPO, aspiration precautions, impaired chewing skills, Dysphagia". The Hospice failed to establish an individualized Plan of Care to meet the patient specific medication regimen with a prescribed order and assessment for Nothing Per Oral. The survey findings were reviewed with the Director of Regulatory Affairs (DRA) on 11/01/2022 at 01:15 PM. The DRA was interviewed on 11/2/2022 at 10:15 AM, no explanation was provided. 1. Patient #1 has a Start of Care date of 10/07/2022 with the following diagnoses "Unspecified Malignant Neoplasm of Brain, Unspecified Atrial Fibrillation" as documented in the "Physicians Plan of Care" dated 10/07/2022 to 01/04/2023. The Physicians Plan of Care dated 10/07/2022 to 01/04/2023 documents: Admission visit order: RN (registered nurse) to make assessment visit and admit to Hospice Care. The clinical record documents visits completed by RN on: 10/8/2022, 10/09/2022, 10/10/2022, 10/11/2022, 10/12/2022, 10/13/2022, 10/14/2022, and 10/15/2022; and by the SW (Social Worker) 10/10/2022 and 10/12/2022. The plan of care lacks an order for the additional frequency of services for the RN and SW. On 11/02/2022 at 2:53pm, the Director of Clinical Services and the Director of Regulatory Affairs were interviewed and did not provide an explanation for the findings.

Based on home visit observation, record review and interview, the Hospice failed to ensure that the Plan of Care include all necessary wound care treatments for the terminally ill patient. This was evident in one (1) of two (2) clinical records reviewed. (Patient #1). Failure to ensure that the Plan of Care includes all wound care treatments, has the potential for negative patient outcome. The findings are: --- 1. Patient #1 has a Start of Care date of 10/07/2022 with the following diagnoses "Unspecified Malignant Neoplasm of Brain, Unspecified Atrial Fibrillation" documented in the Physicians Plan of Care dated 10/07/2022 to 01/04/2023. The Physicians Plan of Care dated 10/07/2022 to 01/04/2023 documents: Admission visit order: RN (registered nurse) to make assessment visit and admit to Hospice Care. The "Physician Order Activity Detail Report" documents: 10/08/2022 Collagenase Clostridium Histolyticum 250 unit/gram topical ointment, SIG (let it be labeled): apply by topical route to the affected area once daily. New order. The clinical record documents wound assessment on 10/07/2022 by RN: 1. Pressure Ulcer Site: Sacrum, Stage: Unstageable, Length: 11.5 cm, Width: 9 cm, Depth: 0 cm, Appearance: Necrotic, Color: Black. 2. Pressure Ulcer Site: Right Hip, Stage: Unstageable, Length: 5 cm, Width: 1 cm, Depth: 0 cm, Appearance: Dry, Color: Black. 3. Pressure Ulcer Site: Left Elbow, Stage: 1, Length: 1 cm, Width: 1 cm, Depth: 0 cm, Appearance: Dry, Color: Red. 4. Pressure Ulcer Site: Right Elbow, Stage: II, Length: 0.5 cm, Width: 0.5 cm, Depth: 0 cm, Appearance: Dry, Color: Pink. 5. Pressure Ulcer Site: Left Hip, Stage: 1, Length: 0.2 cm, Width: 0.2 cm, Depth: 0 cm, Appearance: Dry, Color: Pink. 6. Pressure Ulcer Site: Left Heel, Stage: 1, Length: 2 cm, Width: 2 cm, Depth: 0 cm, Appearance: Dry, Color: Pink. 7. Pressure Ulcer Site: Right Heel, Stage: 1, Length: 2 cm, Width: 2 cm, Depth: 0 cm, Appearance: Dry, Color: Pink. 8. Bilateral Bunion with Redness. The Hospice Plan of Care lacks documented evidence of an order for the wound care treatment to the left elbow, left hip, left heel, right heel, and bilateral bunion performed by the RN on 10/7/2022; and for the wound care treatment to the right hip and right elbow performed by the RN on 10/7/2022 to 10/10/11. The clinical record lacks documented evidence of which treatment for the wound is being provided: site of the wound to be treated with Collagenase on 10/08/2022. On 11/02/2022 at 2:53pm, the Director of Clinical Services and the Director of Regulatory Affairs were interviewed and did not provide an explanation for the findings.

Based on clinical record review and staff interview, the Hospice failed to ensure that the Interdisciplinary Group (IDG) maintain responsibility in the coordination and supervision of all services provided at the Inpatient Unit (IPU). This was evident in two (2) of two (2) patients receiving IPU services. (Patients #1 and #3). Failure for the IDG to maintain responsibility and supervision of all services provided at the IPU has the potential for negative patient outcome. --- 2) Patient # 3 has a start of care date of 09/28/2022 with diagnoses of Alzheimer's, Dementia Hypertensive heart Chronic Kidney Failure and Heart Failure as documented on the "Physician's Plan of Care" dated 09/28/2022 to 12/26/2022. The "Physician's Plan of Care" (POC) dated 09/28/2022 to 12/26/2022 documents the patient's "Nutritional/Diet order - NPO (Nothing Per Oral)". The "RN (Registered Nurse) Admission Assessment" dated 09/28/200, the RN documents: "swallowing assessment: NPO, aspiration precautions, impaired chewing skills, Dysphagia". The "RN New Focus Assessment" note dated 10/01/2022, the RN documents the patient is "Neurological assessment - Dysphagia, and Nutrition assessment - NPO". The "IDG Report" dated 10/05/2022 meeting note documents " PCG (Primary Care Giver) reports no PO medications or intake since 09/22". The IDG list of prescribed medications include medications given via oral route: "Citalopram 20 mg (milligram) by oral 1 x day, Gabapentin 300 mg by oral 2 x day, Melatonin 10 mg by oral at bedtime as needed, Prochlorperazine Maleate 10 mg by mouth every 12 hours as needed, Quetiapine 50 mg tablet by oral 2 x day, Senna -S 8.6mg-50 mg tablet take 2 tablets by mouth at bedtime as needed, Trazadone 50 mg tablet by oral at bedtime as needed, Tylenol Extra strength 500 mg tablet by oral every 6 as needed". The IDG Report dated 10/05/2022, "Plan of Care -Problem" lacks documented evidence of a discussion of the patient's Dysphagia, NPO status, and alternative route of medication administration other than oral. The IDG failed to maintain responsibility and supervision of the patient's medication management to include alterative measures for medication administration for a Hospice terminally ill patient that has continous assessment of Dysphagia, and prescribed order for NPO. The survey findings were reviewed with the Director of Regulatory Affairs (DRA) on 11/01/2022 at 01:15 PM. The DRA was interviewed on 11/2/2022 at 10:15 AM, no explanation was provided. 1. Patient #1 has a Start of Care date of 10/07/2022 with the following diagnoses "Unspecified Malignant Neoplasm of Brain, Unspecified Atrial Fibrillation" documented in the Physicians Plan of Care dated 10/07/2022 to 01/04/2023. The Physician Order Activity Detail Report (nursing home – NH) documents the following orders: 10/08/2022 Collagenase Clostridium Histolyticum 250 unit/gram topical ointment, SIG (let it be labeled) apply by topical route to the affected area once daily. New order. 10/11/2022 Santyl 250 unit/gram topical ointment SIG: apply 2 grams by topical route once daily Cleanse sacrum with normal saline pat dry and apply thin layer of Santyl and cover with dry dressing. New order. 10/11/2022 Collagenase Clostridium Histolyticum 250 unit/gram topical ointment. Discontinue. 10/11/2022 Santyl 250 unit/gram topical ointment SIG: apply 2 grams by topical route once daily Cleanse right hip with normal saline pat dry and apply thin layer of Santyl and cover with dry dressing. New order. 10/11/2022 Silver Sulfadiazine 1% topical cream SIG: apply by topical route once daily Cleanse right elbow with normal saline pat dry and apply Silvadene and cover with dry dressing. New order. The clinical record documents wound assessment dated 10/07/2022 performed by the RN: 1. Pressure Ulcer Site: Sacrum, Stage: Unstageable, Length: 11.5 cm, Width: 9 cm, Depth: 0 cm, Appearance: Necrotic, Color: Black. 2. Pressure Ulcer Site: Right Hip, Stage: Unstageable, Length: 5 cm, Width: 1 cm, Depth: 0 cm, Appearance: Dry, Color: Black. 3. Pressure Ulcer Site: Left Elbow, Stage: 1, Length: 1 cm, Width: 1 cm, Depth: 0 cm, Appearance: Dry, Color: Red. 4. Pressure Ulcer Site: Right Elbow, Stage: II, Length: 0.5 cm, Width: 0.5 cm, Depth: 0 cm, Appearance: Dry, Color: Pink. 5. Pressure Ulcer Site: Left Hip, Stage: 1, Length: 0.2 cm, Width: 0.2 cm, Depth: 0 cm, Appearance: Dry, Color: Pink. 6. Pressure Ulcer Site: Left Heel, Stage: 1, Length: 2 cm, Width: 2 cm, Depth: 0 cm, Appearance: Dry, Color: Pink. 7. Pressure Ulcer Site: Right Heel, Stage: 1, Length: 2 cm, Width: 2 cm, Depth: 0 cm, Appearance: Dry, Color: Pink. 8. Bilateral Bunion with Redness. The clinical record documents wound assessment dated 10/14/2022 performed by the wound Doctor: 1. Pressure Ulcer Site: sacrum, Stage: Unstageable, Length: 19 cm, Width: 12 cm, Depth: 0 cm, Appearance: Necrotic, Color: Black. 2. Pressure Ulcer Site: Right Hip, Stage: Unstageable, Length: 5 cm, Width: 1 cm, Depth: 0 cm, Appearance: Dry, Color: Black. The clinical record documents wound assessment dated 10/26/2022 performed by wound Doctor: 1. Pressure Ulcer Site: sacral, Stage: IV, Length: 10 cm, Width: 12 cm, Depth: 2 cm, Tunnelling: No, Undermining: Yes, Appearance: Necrotic, Color: Black. The IDG (Interdisciplinary Group) reports dated 10/11/2022 and 10/18/2022 documents: Skin S&S (signs and symptoms): no significant findings. The IDG meeting dates of 10/11/2022 and 10/18/2022 lack documented evidence of the discussion, intervention, and goals of the sacral, right hip, left elbow, right elbow, left hip, left heel, right heel and bilateral bunion wounds. The IDG failed to maintain responsibility and supervision of the patient's wound progression for a Hospice terminally ill patient. On 11/02/2022 at 2:53pm, the Director of Clinical Services and the Director of Regulatory Affairs were interviewed and did not provide an explanation for the findings.