Every finding on record at Hospice of Jefferson County, Inc.

Based on record review, observation, and interview during the Life Safety Code recertification survey conducted 3/22/2024 - 3/26/2024, the facility did not ensure that the two-hour fire-rated building separation barrier was maintained for 1 of 1 building separation barriers (healthcare to business occupancy separation barrier). Specifically, the healthcare to business occupancy separation barrier double doors did not latch as required. --- The facilitys floor plan identified the double doors in the hallway between the bathrooms and the toilets as part of the two-hour occupancy separation barrier. During an observation on 3/22/2024 at 12:07 PM, the set of fire doors in the main hallway between the bathrooms and the toilets did not latch. The top latch could not reach the catch plate and the doors were unable to latch properly. The doors and frame were properly rated as part of the 2-hour occupancy separation barrier. During an interview on 3/26/2024 at 9:40 AM, the Administrator stated they were aware of the requirement that building separation barrier doors were required to latch, but they were not aware until identified by the surveyor that the doors were unable to latch properly. 2012 NFPA 101 19.1.3.5 10NYCRR 415.29(a)(2), 711.2(a)(1)

Based on observation and interview during the Life Safety Code Survey conducted on 3/22/2024 - 3/26/2024, the facility did not properly maintain 2 of 7 exit doors and 1 isolated pair of hazardous area doors (exit from family room, double door exit across from laundry, and the utility closet in the conference room). Specifically, the exterior exit from the family room, the double door exit across from laundry, and the double door utility closet in the conference room were not self-closing, as required. --- During an observation on 3/22/2024 at 11:38 AM, the double door exit across from the laundry was not self-closing. The doors were tested multiple times, but they did not close as required and remained ajar. During an observation on 3/22/2024 at 12:02 PM, the family room had a door marked by an exit sign. The door was very difficult to open and did not close as required. The door stopped short when tested and was unable to be closed completely from the inside. The door caught the ground and remained open approximately 1 inch. During an observation on 3/22/2024 at 12:50 PM, the utility closet in the conference room had double doors that were not self-closing. This hazardous area was approximately 150 square feet and contained a fuel-fired heater (red switch on wall labeled for gas shut off), two electrical panels, and various storage items that consisted of totes and cardboard boxes. During an interview on 3/26/2024 at 9:40 AM, the Administrator stated they were aware of the requirements, but not aware these areas were not properly self-closing until they were identified during survey. 2012 NFPA 101: 19.2.2.2.7, 7.2.1.8.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Based on observation, record review, and interview conducted during the Life Safety Code survey on 3/22/2024 - 3/26/2024, the facility did not ensure all emergency exit exterior discharges were maintained with a level hard-packed all-weather travel surface to the public way for 1 of 5 emergency exits (solarium vestibule exit). Specifically, the exterior emergency exit discharge pathway from the solarium vestibule was not maintained as a hard-packed all-weather level walking surface for approximately 15 feet to the public way. --- The facilitys ";Evacuation Map" highlighted the solarium vestibule exit as an emergency exit to the outside. Th During an observation on 3/22/2024 at 11:23 AM, the resident hallway entered a vestibule to the solarium with a door marked exit to the left, and the solarium to the right. That exited to an approximately 4-foot by 4-foot concrete pad surrounded by gravel and grass for approximately 15 feet to a paved pathway. During an interview on 3/26/2024 at 9:40 AM, the Administrator stated they were not aware that exit required a hard-packed all-weather surface because there was another exit from the Solarium. They were not aware that exit was highlighted on their evacuation map. They stated the gravel and grass was not hard-packed all-weather terrain. 2012 NFPA 101 19.2.7, 7.7, 7.1.7 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Based on observation, record review, and interview during the Life Safety Code recertification survey conducted 3/22/2024 - 3/26/2024, the facility did not ensure that hazardous areas were maintained for 3 isolated locations (utility room by the nurses station, Heating Ventilation and Air Conditioning (HVAC) room, and the laundry room). Specifically, the fire-rated door to utility room by the nurses station could not latch properly; there were multiple unsealed penetrations in the Heating Ventilation and Air Conditioning Room, and the left door to the laundry room was not fire-rated and self-closing, as required. --- During an observation on 3/22/2024 at 11:35 AM, the fire-rated door to the utility room adjacent to the nurses station could not latch properly. The utility room was approximately 100 square feet in area and contained heating and air conditioning equipment. The door and frame had tape covering the latch and catch plate which prevented the door from latching. During an observation on 3/22/2024 at 11:40 AM, the laundry room had two doors. The left door was not self-closing and was not fire-rated. During an observation on 3/22/2024 at 11:51 AM, the Heating Ventilation and Air Conditioning (HVAC) room contained multiple unsealed penetrations. A 6-inch water line had a half inch gap around it through the wall, (2) 1-inch lines have small gaps around them through the wall, the smoke detector on the ceiling had a small gap around it through the ceiling, and a 4-inch conduit contained an unsealed bundle of wires that penetrated the wall. During an interview on 3/26/2024 at 9:40 AM, the Administrator stated they were aware of the requirements, but not aware these areas were not properly self-closing, fire-rated, or contained unsealed penetrations until they were identified during survey. They were not sure why the utility room door had the latch taped but stated that should not be like that. 2012 NFPA 101 19.3.2.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Based on record review, observation, and interview conducted during the Life Safety Code survey 3/22/2024 - 3/26/2024, the facility did not ensure cooking facilities were maintained in accordance with National Fire Protection Association (NFPA) 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations for 1 of 1 kitchen hood fire suppression systems within the main kitchen. Specifically, the main kitchen's fire suppression system lacked semi-annual inspections in 2022 and 2023. --- The facilitys documented inspections of the main kitchens fire suppression system were dated 12/3/2021, 8/10/2023, and 2/14/2024. No other documentation was available. During an observation on 3/22/2024 at 11:58 AM, there was a semi-annual inspection tag affixed to the fire suppression systems pull station dated February 2024. During an interview on 3/26/2024 at 9:40 AM, the Administrator stated they were not able to locate any additional documentation for the main kitchen fire suppression system. They were not at the facility prior to August of 2023. They stated they were aware of the requirements, but not aware the previous inspections had been missed in 2022 and not completed semi-annually. 2012 NFPA 101 19.3.2.5.1 2011 NFPA 96 10.2.6, 11.2.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Based on record review and interview during the Life Safety Code recertification survey conducted 3/22/2024 - 3/26/2024, the facility did not maintain the fire alarm system in accordance with the requirements of National Fire Protection Association (NFPA) 72 for 1 of 1 building fire alarm systems. Specifically, the fire alarm system was not inspected annually in 2022, as required. --- The facility's full fire alarm system inspection reports were dated 1/27/2021 and 7/17/2023. No other fire alarm inspection documentation was provided. During an interview on 3/26/2024 at 9:40 AM, the Administrator stated they were not able to locate any additional documentation for the fire alarm inspections and that was missed in 2022. They stated they were aware of the requirements, but not aware the previous inspection had been missed in 2022, because they did not start at the facility until August 2023. 2012 NFPA 101: 19.3.4.1, 9.6.1.5 10NYCRR 415.29(a)(2), 711.2(a)(1)

Based on record review and interview during the Life Safety Code survey conducted 3/22/2024 - 3/26/2024, the facility did not ensure 1 of 1 automatic sprinkler systems were maintained. Specifically, outdated dry quick response sprinkler heads were under the driveway portico. --- The facilitys sprinkler inspection reports documented the following: - on 2/10/2022 – notes dry heads will be 10 years old in 2021 - on 5/26/22 – notes dry heads will be 10 years old in 2021 - on 8/30/22 – notes dry heads will be 10 years old in 2021 - on 11/30/22 – notes dry heads will be 10 years old in 2021 - on 2/23/23 – notes dry heads will be 10 years old in 2021 - on 5/24/23 - notes dry heads will be 10 years old in 2021; also checked ";no" on page one and listed under deficiencies, recommendation to pull and test 1 or 2. - on 8/17/23 – notes dry heads will be 10 years old in 2021; also checked ";no" on page one and listed under deficiencies, recommendation to pull and test 1 or 2. - on 11/1/23 – not sure date on dry heads in Portico sheer. Recommendation- should have one or two pulled and tested. - on 2/14/24 – not sure date on dry heads in Portico sheer. Recommendation- should have one or two pulled and tested. The Administrator provided documentation from their sprinkler vendor after an incident in 2022 that set off a sprinkler in the exterior canopy. The invoice dated 8/31/2022 documented on 7/22/2022, the dry head had been taken out and plugged off and the system was back in service, a new dry head. No additional documentation was available. During an interview on 3/26/2024 at 9:40 AM, the Administrator stated they were not able to locate any additional documentation for the dry sprinkler heads. They stated they had heard of an event where the sprinklers under the portico accidentally went off due to the exhaust from a truck parked underneath, but they were not sure what had happened. They stated they were not aware that those sprinklers under the portico were documented as more than ten years old on multiple years of inspection reports, but they would review those more closely moving forward. 2012 NFPA 101: 19.3.5.1, 9.7.5 2011 NFPA 25 10NYCRR 415.29(a)(2), 711.2(a)(1)

Based on record review and interview during the Life Safety Code survey conducted 3/22/2024 - 3/26/2024, the facility did not ensure fire drills were completed as required in 2022. Specifically, only 1 of 3 required quarterly fire drills were completed in the fourth quarter of 2022. --- The facility fire drill reports from the fourth quarter of 2022 were dated and timed 12/20/2022 at 6:30 AM. The facility did not have documentation for any other fire drills during the fourth quarter of 2022. During an interview on 3/26/2024 at 9:40 AM, the Administrator stated they were not able to locate any additional documentation for the fire drills that were missed in 2022. They stated they were aware of the requirements, that drills were to occur quarterly during each shift, but not aware the previous drills had been missed in 2022, because they did not start at the facility until August 2023. 2012 NFPA 101: 19.7.1, 4.7.4 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Based on review of clinical records and interviews with the Administrator and Director of Patient Care, it was determined in 5 of 17 records (patients #1, 2, 3, 6, and 10), the comprehensive assessments were incomplete and failed to identify all of the patient's needs. Evidence was 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. Home Visit 1.Patient #3 was admitted to the hospice on 03/14/24 with a terminal diagnosis of Alzheimers disease and additional diagnoses of stage 4 sacral pressure ulcer, cirrhosis of the liver, thrombocytopenia, coronary artery disease, hypertension, hyperlipidemia, and benign prostatic hyperplasia. On 03/14/24 the hospice nurse visited the patient for the initial assessment and failed to perform a complete skin assessment. The 03/14/24 Physicians Plan of Care included an order for weekly and as needed care to a skin tear to the right upper arm to include cleansing with normal saline, patting dry, and covering with a foam dressing. Care could be performed by the spouse/caregiver or hospice nurse. On 03/14/24 there was no evidence that the hospice nurse assessed the right upper arm for a skin tear and/or dressing covering the area or reviewed the ordered care with the caregiver. On 03/18/24 and 03/19/24 the hospice nurse visited the patient and failed to assess the wound. On 03/21/24 at 2:00 p.m. the surveyor reviewed the record with the Administrator, Director of Patient Services, and clinical manager. They acknowledged the findings and provided no additional information. 2.Patient #5 was admitted to the hospice on 02/02/24 with a terminal diagnosis of emphysema and additional diagnoses of chronic respiratory failure, coronary artery disease, hypertension, and hyperlipidemia. On 02/02/24 the hospice nurse visited the patient for the initial assessment and failed to perform a complete assessment of: -The 02/02/24 ";Physicians Plan of Care" included aspirin (blood thinner) 81 mg daily. The hospice nurse failed to assess the patient/caregiver knowledge of bleeding precautions. -On 02/02/24 the hospice nurse documented the caregiver continues to monitor the patients blood pressure. There was no evidence the registered nurse assessed the caregivers ability to use the blood pressure equipment. On 03/21/24 at 2:00 p.m. the surveyor reviewed the record with the Administrator, Director of Patient Services, and clinical manager. They acknowledged the findings and provided no additional information. 3.Patient #10 was admitted to the hospice on 03/08/24 with a terminal diagnosis of metastatic breast cancer and additional diagnoses of secondary neoplasm to the bone, neoplastic anemia, pathological spine fracture, rib fracture, hypertension, and hypothyroidism. On 03/08/24 the hospice nurse visited the patient for the initial assessment and documented a left breast wound measuring 6.5 cm X 6.5 cm involving the areola and nipple with moderate bloody drainage. There was no evidence the hospice nurse assessed the caregivers ability to perform wound care. The 03/08/24 Physicians Plan of Care included weekly and as needed wound care (left breast open lesion) that could be performed by the caregiver or hospice nurse to include washing with normal saline or mild soap and water, rinsing and patting dry, applying a non-adherent dressing, and securing in place with paper tape or bra. On 03/25/24 at 2:00 p.m. the surveyor reviewed the record with the Administrator, Director of Patient Services, and clinical manager. They acknowledged the findings and provided no additional information. Home Visit 2. Patient #2 was admitted to the hospice on 02/21/24 with terminal diagnoses of amyotrophic lateral sclerosis, and additional diagnoses of atrial fibrillation, and pulmonary fibrosis. On 02/21/24 the hospice nurse visited the patient for the initial comprehensive assessment and documented the patient had a 16 Foley French catheter draining tea color urine and the patient had no signs or symptoms of infection. The hospice nurse failed to assess the date the catheter was last changed. Plan of care documentation included a plan to instruct in cather care and irrigation procedures with instruction provided related to catheter care, maintenance and when to notify the nurse. The 02/21/24 Physicians Plan of Care orders included orders to irrigate the catheter with 30-60 cc of normal saline as needed for sediment, blockage, hematuria or to maintain patency. The irrigation was to be performed by the family, caregiver, or nurse. There was no evidence the hospice nurse assessed the family/caregiver ability to irrigate the catheter or provide catheter care. On 03/21/24 at 1 p.m. the surveyor conducted an on observational visit with the case manager conducting a routine visit. The surveyor interviewed the patients caregiver after the nurse had completed their visit and left the home. The surveyor asked how the caregiver is managing the patient's catheter. They had stated it was draining and the licensed practical nurse changes the drainage bag. The surveyor asked, has the catheter required irrigation? the caregiver stated" I dont do anything with internal treatments but can empty the bag when its full of urine. "; On 03/21/24 at 2 p.m. the surveyor reviewed the record with the Administrator, Director of Patient Care, and clinical manager. The acknowledged the findings and provided no additional information. 1. Patient #1 was admitted to the hospice on 08/08/23 with a terminal diagnosis of Alzheimers disease and additional diagnoses of neurogenic bladder requiring self-catheterization and history of urinary tract infections. Straight Catheterization Management The 08/08/23 plan of care included the following order for straight catheterization – ";patient, caregiver, or nurse may perform routine straight catheterization frequency: 3x a day and as needed." On 08/08/23 the hospice nurse visited the patient for the initial comprehensive assessment and documented the patent ";straight catheterizes self 2-3x daily." There was no evidence the hospice nurse assessed the patient and/or caregiver ability to perform straight catheterization. On 03/25/24 at 2 p.m. the record was reviewed with the Administrator, Director of Patient Services, and clinical manager. They acknowledged the findings and provided no additional information. 2. Patient #6 was admitted to the hospice on 01/15/24 with a terminal diagnosis of lung cancer and an additional diagnosis of dysphagia (difficulty swallowing). Feeding Tube Management The 01/15/24 plan of care included the following orders: Nutrition/diet: enteral (feeding tube) feeding of choice, frequency as desired. Feeding tube flush: flush gastrostomy tube (G-tube) with 30-60 milliliters (ml) of free water twice a day to maintain tube patency and before and after medication administration and/or tube feeding. Flush may be performed by patient, caregivers, or Hospice nurse. Feeding Tube Residual: check for residual prior to each feeding. If greater than >250 ml hold feeding. Notify Hospice RN prior to next feeding. Residual check may be performed by patient, caregivers or Hospice Nurse. On 1/15/24 the hospice nurse visited the patient for the initial comprehensive assessment and documented patient ";takes most nutrition orally but does administer tube feeding of his choice (varies) every few days. Flushes G-tube twice a day to maintain patency. The patient is completely independent with G-tube care. Reports lack of appetite and decline in intake." There is no evidence the hospice nurse: - assessed patient or caregiver ability to administer tube feeding, flush G-tube, and check residual - perform a complete nutrition assessment including amount and frequency of tube feedings, amount of residuals, and amount/frequency of oral intake. On 03/21/24 the record was reviewed with the Administrator, Director of Patient Services, and clinical manager. They acknowledged the findings and provided no additional information.

Based on clinical record reviews and interviews with the Administrator and Director of Patient Care, it was determined in 3 of 17 records (patients #1, 5 and 22), plans of care failed to address all problems identified during the initial, comprehensive and updated comprehensive assessments. This was evidenced by: --- Failure to develop a complete plan of care that addresses the patient's needs has the potential for unmet patient needs and negative outcomes. Patient #1 was admitted to the hospice on 08/08/23 with a terminal diagnosis Alzheimers disease and additional diagnoses of neurogenic bladder requiring self-catheterization and history of urinary tract infections. The 05/25/23 hospital discharge instructions included the following allergies to medications: sulfadiazine, amiodarone, atorvastatin, Aricept, and rivastigmine. On 08/08/2023 the hospice nurse visited the patient for the comprehensive admission without documentation to support allergies were assessed. The 08/08/23 Physician's Plan of Care stated ";allergies: unknown." The hospice nurse failed to ensure the plan of care addressed the patient's medication allergies. On 03/25/24 at 2 p.m. the record was reviewed with the Administrator, Director of Patient Services, and clinical manager. They acknowledged the findings and provided no additional information. 1.Patient #5 was admitted to the hospice on 02/02/24 with a terminal diagnosis of emphysema and additional diagnoses of chronic respiratory failure, atherosclerotic heart disease, coronary artery disease, hypertension, and hyperlipidemia. Blood Pressure Monitoring On 02/02/24 the hospice nurse visited the patient for the initial assessment and documented the caregiver was monitoring the patients blood pressure and was instructed to report any low or high readings to the hospice team. The 02/02/24 Plan of Care failed to include a plan for monitoring blood pressure including who would be checking the blood pressure, how often it should be checked, and specific parameters for reporting. Diuretic Use On 02/02/24 the hospice nurse documented the patient had 2+ pitting edema to feet and ankles managed with furosemide and elevation. The 02/02/24 Physicians Plan of Care included furosemide (diuretic) 40 mg daily as needed for fluid imbalance. The plan of care failed to specify how to determine when the medication would be indicated. On 03/21/24 at 2:00 p.m. the surveyor reviewed the record with the Administrator, Director of Patient Services, and clinical manager. They acknowledged the findings and provided no additional information. 2. Patient #10 was admitted to the hospice on 03/08/24 with a terminal diagnosis of metastatic breast cancer and additional diagnoses of secondary neoplasm to the bone, neoplastic anemia, pathological spine fracture, rib fracture, hypertension, and hypothyroidism. On 03/19/24 the hospice nurse documented ";heating pad helps" in the visit narrative next to pain. There was no evidence the hospice nurse updated the plan of care and/or received a modified order to include the use of heat including location, frequency, and duration of application. On 03/25/24 at 2:00 p.m. the surveyor reviewed the record with the Administrator, Director of Patient Services, and clinical manager. They acknowledged the findings and provided no additional information. 3.Patient #22 was admitted to home hospice on 10/17/23 and then transferred to the hospice residence on 10/19/23 with a terminal diagnosis of amyloidosis (buildup of proteins in the organs) and additional diagnoses of cerebral amyloid angiopathy (buildup of proteins in the brains arteries), subarachnoid hemorrhage (brain bleeding) epilepsy, atherosclerotic heart disease, coronary artery disease, hypertension, transient ischemic attack (small stroke), and gastro-esophageal reflux disease. The 09/07/23 hospital referral information listed an allergy to chocolate flavor with the reaction of facial rash. The 09/15/23 primary care physician visit note listed allergies to aspirin and Plavix. The 01/15/24 Physicians Plan of Care failed to include the allergies and listed allergies as unknown. The 02/29/24 IDG Report/Plan of Care documented discussion of ongoing back pain improved with massage, muscle rub, moist heat, cold, and ibuprofen. The IDG Report/Plan of Care failed to include instructions for the use of moist heat and cold including location, frequency and duration. On 03/25/24 at 2:00 p.m. the surveyor reviewed the record with the Administrator, Director of Patient Services, and clinical manager. They acknowledged the findings and provided no additional information.

Based on a review of patient records, observational home visits, a review of the agency's policies and procedures and interviews with the Administrator and Director of Patient Care, it was determined on 2 of 4 observational home visits (patients #1 and 3), hospice staff failed to adhere to accepted standards and practices to prevent transmission of infection. Evidence as follows: --- Failure to follow accepted standards of practice for infection control has the potential of increased transmission of infections and communicable diseases. Home visit Patient #1 was admitted to the hospice on 08/08/23 with a terminal diagnosis of Alzheimers disease and additional diagnoses of neurogenic bladder requiring self-catheterization and history of urinary tract infections. Agency staff failed to follow agency policy for infection control. On 03/20/24 the surveyor completed an observational home visit with the hospice nurse who performed a comprehensive assessment and licensed practical nurse who performed home health aide services and wound care. Bag technique The surveyor observed the hospice nurse enter the home and place the nursing bag directly on a fabric chair. The hospice nurse failed to perform hand hygiene after touching the patient's personal item and prior to entering the bag to obtain equipment, contaminating the contents of the bag. The agency's 10/17/22 Bag Technique policy directed the clinician to place the bag on a barrier and perform hand hygiene as needed including after contact with the patient items and prior to entering the nursing bag. Wound Care During the home visit the surveyor observed the licensed practical nurse perform bathing and wound care to the left leg. The nurse arranged supplies on the bottom shelf of a cart used for bathing without placing a barrier on the shelf and failed to change gloves or perform hand hygiene prior to or following performing wound care. The agency's 01/16/24 Wound Care policy directed the clinician to assemble dressing supplies on a protective barrier and performing hand hygiene and applying gloves before providing a dressing change, following removal of a soiled dressing after removing gloves, and following the dressing change after supplies are discarded and gloves are removed. On 03/25/24 at 2 p.m. the record was reviewed with the Administrator, Director of Patient Services, and clinical manager. They acknowledged the findings and provided no additional information. Home Visit 1.Patient #3 was admitted to the hospice on 03/14/24 with a terminal diagnosis of Alzheimers disease and additional diagnoses of stage 4 sacral pressure ulcer, cirrhosis of the liver, thrombocytopenia, coronary artery disease, hypertension, hyperlipidemia, and benign prostatic hyperplasia. The licensed practical nurse failed to follow accepted standards of infection control practices. The 03/19/24 orders included daily and as needed wound care and eye wash orders, which could be performed by the spouse/caregiver or hospice nurse as follows: -Wound care to stage 4 sacral pressure ulcer: gently cleanse wound bed with Vashe and gauze pad. Apply skin prep to surrounding skin. Cut a piece of Calcium Alginate to fit inside wound bed and place inside wound without touching surrounding skin. Cover with a gauze pad and foam dressing. -Eye wash: place a few drops of Johnsons baby shampoo into a cup of warm water. Dip a cotton ball or gauze pad or washcloth into the solution. With eyes closed, gently wipe across one eyelid and across lashes. Rinse well and repeat with a clean cotton ball, gauze, or washcloth to the other eye. On 03/21/24 at 11:00 a.m. the surveyor completed an observational home visit with the licensed practical nurse and observed the following: Bag Technique Upon entering the living room, the nurse placed their nursing bag directly on a wooden chair. No bag barrier was used. The 10/17/2022 agency Bag Technique policy directed the clinician to place the nursing bag on a barrier. Wound Care The surveyor observed the following during wound and eye care: -The nurse donned clean gloves, placed a barrier at the top of the patients bed, and placed the dressing/wound care supplies on the barrier. -The nurse repositioned the patient onto their side and removed the soiled dressing -Without donning new gloves and performing hand hygiene, the nurse proceeded to clean the wound and placed the Calcium Alginate inside the wound. -The nurse was then observed removing one soiled glove then entering their nursing bag with the ungloved hand and touching the bag with the soiled gloved hand. -After removing an item from the nursing bag, the nurse donned a clean glove to the ungloved hand and proceeded to finish the dressing change. -The patient was repositioned onto their back and the nurse removed their soiled gloves. -Without performing hand hygiene, the nurse donned clean gloves and performed the eye wash. -When finished, the nurse removed their soiled gloves and discarded the eye wash solution. -No hand hygiene was performed. The 11/02/23 agency Hand Hygiene policy directs clinicians to perform hand hygiene when visibly soiled, before touching a patient/resident, before performing clean/aseptic procedures, before moving to a clean body site from a contaminated body site, after performing tasks that involve risk of exposure to body fluids, after touching a resident, before and after wearing gloves. On 03/21/24 at 2:00 p.m. the surveyor reviewed the record with the Administrator, Director of Patient Services, and clinical manager. They acknowledged the findings and provided no additional information.

Based on a review of clinical records for 7 patients receiving hospice aide services and interviews with the Administrator and Director of Patient Care, it was determined in 2 of 7 records (patients #11 and 21) aide written instructions were incomplete and/or inaccurate. Evidence as follows: --- Patient #11 was admitted to the agency on 12/02/23 with a terminal diagnosis of Alzheimer's disease and additional diagnoses of depression, coronary artery disease and arthritis. On 12/01/23 the hospice nurse visited the patient for the initial assessment and documented the caregiver reported seizure like activity where the patient goes rigid and unresponsive and is lethargic following episodes. The nurse documented a plan to monitor for seizure activity. The 12/01/23 medications included Ativan 2 mg under the tongue every 15 minutes for seizures up to 8 mg total dosage. The 12/07/23 interdisciplinary team meeting notes included the patient was at risk for seizures and had possible seizure activity around 6 months prior to admission. On 12/15/23 the hospice nurse visited and documented the last seizure was around 6 months ago. The 02/23/24 licensed practical nurse/aide care plan failed to include instructions for seizure precautions including signs and symptoms to report. On 03/21/24 at 2 p.m. the record was reviewed with the Administrator and Director of Patient Care. They acknowledged the finding and provided no additional information. Patient #21 was admitted to the hospice on 07/06/23 with a terminal diagnosis of peripheral vascular disease and additional diagnoses of type 2 diabetes, pulmonary hypertension, and chronic atrial fibrillation. The patient was in the hospice residence. The 03/02/24 physician's plan of care included Eliquis (anticoagulant) 2.5 mg twice daily. The 03/06/24 licensed practical nurse/aide care plan failed to include bleeding precautions and included instructions to shave the patient using an electric and a straight razor. On 03/21/24 at 2 p.m. the record was review with the Administrator, Director of Patient Care and Residence Nurse Manager. They acknowledged the finding and provided no additional information. Failure of the hospice to ensure aide plans of care are available and include specific assignments and instructions necessary to provide care has the potential for unmet patient needs and possible negative patient outcomes. 1. Home Visit Patient #3 was admitted to the hospice on 03/14/24 with terminal diagnoses of Alzheimers and dementia and additional diagnoses of a stage 4 pressure ulcer (sacral area), cirrhosis, thrombocytopenia, atherosclerotic heart disease, coronary artery disease, hypertension, hyperlipidemia, and benign prostatic hyperplasia. The registered nurse failed to ensure the licensed practical nurse plan of care included all the necessary information to provide safe care to the patient. The 03/14/23 ";Physicians Plan of Care" included a co-existing diagnosis of thrombocytopenia (low platelet count which increases bleeding risk). The 03/14/24 ";LPN POC" (plan of care) failed to include bleeding precautions. Failure to ensure aide plans of care include specific instructions necessary to provide care has the potential for unmet patient needs and possible negative patient outcomes. 2. Patient #22 was admitted to home hospice on 10/17/23 and then transferred to the hospice residence on 10/19/23 with terminal diagnoses of amyloidosis (buildup of proteins in the organs), cerebral amyloid angiopathy (buildup of proteins in the brains arteries), subarachnoid hemorrhage (brain bleeding) and additional diagnoses of epilepsy, atherosclerotic heart disease, coronary artery disease, hypertension, transient ischemic attack (small stroke), and gastro-esophageal reflux disease. The registered nurse failed to ensure the licensed practical nurse plan of care included all the necessary information to provide safe care to the patient. In the 02/29/24 IDG Report/Plan of Care, back pain is described as ongoing but improved with massage, muscle rub, moist heat, cold, and ibuprofen. In the 03/08/24 ";LPN POC" (plan of care) the registered nurse documented in the pain narrative that the patient has occasional back pain and headaches and to monitor and report any uncontrolled pain to the registered nurse. The ";LPN POC" failed to include the use of massage, moist heat, and cold including location, frequency, and duration. Failure to ensure aide plans of care include specific instructions necessary to provide care has the potential for unmet patient needs and possible negative patient outcomes. Patient #20 was admitted to the hospice at the residence on 02/15/24 with terminal diagnosis of bile duct carcinoma and additional diagnosis of rectal cancer. On 02/17/24 @ 0745 on 02/17/24 an ice pack was applied to knee due to reported pain, however, LPN plan of care did not include ice pack for pain management nor was the plan of care updated to reflect use of ice pack. The hospice nurse failed to update plan of care to include use of ice. On 03/21/24 the above record was reviewed with the Administrator, Director of Patient Services, and clinical manager. They acknowledged the findings and provided no additional information.

Based on 4 record reviews of patient's who reside in the hospice residence and staff interviews, it was determined for one (1) patient (patient # 5) the agency failed to ensure that the patient received effective pain and symptom management resulting in a significant change in condition and hospitalization. Evidence was as follows: Patient # 5 was admitted to the hospice residence on 06/18/21 with a terminal diagnosis of cirrhosis of the liver with portal hypertension, and additional diagnoses of coronary artery disease, congestive heart failure, hypertension, and chronic kidney disease. The 09/02/21 interdisciplinary group (IDG) report included documentation of discussion of the patient's symptoms including intermittent paranoia and hallucinations, itching of the skin, pain to feet and legs, and ascites with abdominal girth measurement of 159 cm (62.2 inches) on 08/24/21. The patient had multiple medications ordered for symptom management and behavior management including: - quetiapine 50 mg twice daily for neurological imbalance - Trazadone 100 mg at bedtime for sleep - Ativan 1 mg three times a day for anxiety, agitation - dexamethasone 8 mg daily for restlessness, itching - Zofran 4 mg every 4 hours as needed (PRN) for nausea - hydroxyzine 50 mg every 6 hours PRN for itching - Lactulose 10 grams/15 ml every 48 hours for neurological imbalance - Neurontin 300 mg at bedtime for pain - midodrine 15 mg three times daily for orthostatic hypotension - torsemide (diuretic) 20 mg daily for fluid imbalance - spironolactone (diuretic)100 mg daily for fluid imbalance - morphine solution 0.25 to 1 ml, initial dose 0.25 ml every 2 hours PRN for pain or difficulty breathing - hyoscyamine 0.125 mg sublingual every four hours PRN for terminal secretions On 09/15/21, the day shift the hospice RN failed to provide any personal care or medications ordered and necessary to control patient's symptoms of paranoia and hallucinations for an entire 8 hour shift, resulting in the patient developing symptoms of extreme distress and psychosis. On 09/15/21, the day shift hospice RN documented between 7:00 am and 2 pm that the patient was asleep and it was unsafe to administer any medications to the patient. This resulted in the patient not receiving the eight (8) medications scheduled at 8 am the medications included: - quetiapine - an anti-psychotic drug used to decrease hallucinations ordered 2 times a day - dexamethasone for restlessness ordered once a day - midodrine used to treat low blood pressure ordered 3 times a day - nicotine patch to be changed once a day for 14 days - spirolactone a diuretic ordered once a day to treat edema for people with cirrhosis of the liver - Tamsulosin ordered twice a day to relax the muscles of the prostate and bladder - torsemide a second water pill ordered once a day to treat edema The medication administration progress note indicates "not administered" for these 8 am medications as patient asleep [patient lethargic]. The RN also failed to perform a bed bath using Selsun Blue body wash ordered daily which may have made the patient less lethargic and encouraged him to take the scheduled medications. At 12:00 pm the patient had midodrine and Tamsulosin ordered that were not administered for the reason [excessive lethargy] At 2:00 pm the RN documented lorazepam 1 mg ordered 3 times a day not administered again for excessive lethargy. At 4:00 pm the next shift began work and the licensed practical nurse (LPN) documented administration of the patient's midodrine, and the following medication needed for symptom management: - 4:45 pm - morphine 20 mg/1 ml patient states he is in a lot of pain. - 4:46 pm - Haloperidol 0.5 mg as needed for comfort - 5:32 pm - morphine .25 ml 1 time dose per the RN from day shift. for no reason - 6:00 pm - morphine 20 mg/1 ml given to patient for pain - 8:50 pm - morphine 20 mg/1 ml given to patient for comfort also given at that time was Haloperidol .5 mg At an undisclosed time, the evening LPN documented in the narrative note patient resting in bed, patient responds to verbal cues and wanted to talk to someone, the LPN documented that she listened for a while then had a volunteer come and sit with the patient who was alert and talking for over 2 hours. At 10:05 pm, the LPN documented the patient's call light was sounding and when she entered the patient's room the call bell was on the floor and pulled out of the wall. The LPN plugged the cord back into the wall the patient grabbed the her arm and started "yelling/growling and jerking me back and forth". A second LPN came into the room while the patient still had the LPN's arm, when the first LPN turned to look at the doorway, the patient kicked her in the head. The second LPN was able to distract the patient, and the first LPN was able to get to safety. The second LPN attempted to calm the patient and asked what the patient would like them (the hospice) to do? The patient yelled "Kill her Kill her". After a few other clear words the patient's speech became gibberish, but he continued to yell and throw objects at the door. Sometime between 10:05 pm and 11:00 pm the on-call RN arrived to assess the patient situation and give direction to the LPN. The LPN was directed to continue to provide as needed medications for symptom management of pain and behavior. At 11:45 pm the night shift LPN arrived and continued to administer as needed medications for symptom management, and documented with the assistance of the on-call RN the patient was settled in bed for the night. On 09/16/21 from 12:00 am to 6:15 am, the LPN documented providing the patient with as needed medication. At 4:25 am the LPN documented the patient was displaying the same growling and yelling behaviors so he was medicated as ordered with some relief At 6:15 am the patient was resting comfortably in bed. No agitation noted. On 09/16/21, at 8:00 am the patient became agitated, combative, got out of bed, started banging on the door of the room swearing and yelling. The RN on duty called the ambulance, and specifically "pushed the panic button" which brings the police department to the residence. The patient was transported to the hospital. On 10/06/21 at 9:30 am the surveyor interviewed the LPN assigned to the patient on the evening shift. The LPN stated the shift prior the RN did not medicate the patient at all and prior to that staff had been medicating the patient regularly to keep the patient at a therapeutic level. On 10/06/21 at 3:15 pm the surveyor interviewed the day shift RN assigned to provide care on 09/15/21. The RN stated that the patient was sleeping and not arousable and there was no way to give medications. The HN stated catheter care was provided. The RN provided no further explanation of the lack of care. On 10/14/21 at 8:30 am the surveyor interviewed an individual who was present in the hospice residence on 09/15/21 who stated they overheard the day shift RN state "I didn't touch him all, it was almost negligence." Failure to ensure that the patient's right to receive effective pain and symptom management for conditions related to the terminal illness resulted in the inability to control behaviors and manage symptoms.

Based on record review and interviews with the Chief Executive Officer (CEO), Director of Patient Care (DPC), Hospice Residence Manager (RNNM) and nursing staff it was determined the hospice failed to maintain accurate records and investigate discrepancies of controlled drugs for 1 of 4 patients (Patient # 7 ) in the hospice residence. Evidence was as follows: On 10/04/21 the surveyor requested any incident reports from the hospice including medication errors from the CEO. A folder was provided with two fall reports. On 10/06/21 at 8:35 AM, the surveyor interviewed the residence RNNM regarding controlled drug records, viewed the locked cabinets, and reviewed the count sheets and related forms. The RNNM stated each patient in the residence had their own supply of medications and controlled drugs were locked in narcotic cabinets. There were two cabinets, one for each side of the unit. Staff members counted all medications and signed off at the end of each shift prior to handing off the keys and leaving the building. The RNNM stated everything was disposed of when the patient died. Patient # 7 was admitted to the hospice on 02/26/21 with a terminal diagnosis of endometrial cancer, and was transferred to the hospice residence on 09/21/21. The September 2021 Controlled Medication Inventory included documentation of the patient's medications brought in from home and included Ativan 0.5 mg tablets with a count of 17 tablets on 09/21/21. The next entry on the form was on 09/24/21 with 4 tablets administered and 13 tablets remaining. On 09/29/21 the quantity remaining was 12 and a notation on the form indicating the original count was incorrect and there were 12 tablets remaining. This entry was initialed by the RNNM and DPC. The September 2021 Shift Count of Ativan 0.5 mg showed a count of 13 tablets from 09/24/21 11 PM to 7 AM shift to 09/29/21 on the 3-11 PM when the count was 12 tablets. A review of patient # 7's record showed the last time the patient had received Ativan was on 09/24/21 at 10:40 PM when 2 mg (4 tablets) were administered for an active seizure. On 10/06/21 at 3:15 PM the surveyor interviewed the RNNM who stated when the medication was discovered missing she reported it to the DPC and the resource nurse as she had never had a discrepancy come up before. They went through the record and no Ativan had been given, they then interviewed the family and came to the conclusion the count had been incorrect when the medication was brought in from the patient's home. On 10/07/21 at 10:00 AM, during record reviews the DPC stated when the Ativan count was discovered to be wrong, an investigation was done and it was determined the medication was counted wrong when it was brought in by the family. When asked why all the staff members had counted the same incorrect number of pills for 5 days prior, the DPC did not have an answer and agreed she did not know what had happened to the pill. There was no written investigation provided prior to leaving the facility. On 10/12/21 the DPC emailed a medication incident and discrepancy investigation report dated 10/11/21. This report stated the lorazepam (Ativan) count was lacking one pill, no doses had been given to the patient during the previous shift and it was later noted that one of the nurses found a pill on the counter that was identified to be lorazepam. The report included an email from this nurse dated 10/04/21, 5 days after the pill came up missing. On 10/13/21 at 8:28 AM, the surveyor interviewed the staff member who discovered the pill who stated the medication was thought to be dropped from another patient who staff had destroyed medications after the patient's death. When asked about destruction of medications, the staff member stated the policy was that a registered nurse and another nurse were supposed to count and dispose of medications, however on the off shifts it may be licensed practical nurses who do this. She said she did not think the medication had belonged to Patient #7 as it was 5 days since the medication came up missing and the counter had been cleaned and floor swept. The LPN stated this was reported to the DPC and RNNM. On 10/14/21 at 8:30 AM, the nurse who counted the medications at the beginning of the day shift on 09/29/21 stated the Ativan tablets were counted with the night nurse and there were 13 tablets in the vial. The nurse was asked by the RNNM who was also working the shift to count for both sides of the floor which was not the usual practice and stated the RNNM gave medications to the patient and this nurse did not enter the cabinet during the shift. The nurse stated when the shift ended the keys were handed off to the RNNM without counting, and later the nurse received a call from the RNNM asking what happened to the other Ativan. On 10/21/21 at 10:19 AM, the surveyors interviewed the CEO, DPC and RNNM on site and reviewed additional information. The DPC stated policies and procedures for narcotics had not been reviewed or updated since 2012-2018 depending on the policy and the DPC was actively working on updating them. The DPC stated she was aware of the need to track medications, ensure variances are investigated, and the need to report them and the facility had not been compliant with regulations. The RNNM submitted a copy of the Medication Variance Tracking Form form for the dates of 05/15/21 to present. The form included several entries for Roxanol (morphine liquid) with excesses or shortfalls of up to 6.5 ml. The form included prescription numbers instead of medical record numbers as directed on the form, making tracking very difficult. The DPC stated the form needed to be updated and the process changed. Failure to ensure agency procedures are followed and are consistent with state and federal requirements has the potential for medication diversion and possible patient harm.