Every finding on record at Hospice of the Chesapeake, Inc.

Observed in Record Review. In 14 of 22 active patient records reviewed, the organization failed to conduct and document a patient specific comprehensive assessment and reassessment that addressed the adequacy of the environment. In records RRNH#3 and RRNHV#10 assessments were not completed as required by policy 2-076 entitled Basic Home Safety. This RFI was reviewed and verified with the Director of Support Services and QAPI Coordinator.

Observed in Record Review. In 1 of 22 active patient records reviewed, the organization failed to ensure that the initial comprehensive assessment was completed within five days of the election of the hospice benefit. In record RRNHV#6 the bereavement assessment was documented seven days after the start of care date. This RFI was reviewed and verified with the Director of Support Services and QAPI Coordinator.

Observed in Record Review. it was noted by the nurse surveyor that the IDG meeting notes did not reflect progress toward goals nor updates to the plan of care. For RRHV#2, the patient had multiple falls, one of which resulted in the patient receiving staples in the back of his head. Nothing was noted in the IDG notes regarding the occurrences. For RRHV#3, the patient had an arterial ankle wound. There was nothing reflected in the IDG notes regarding the condition of the wound or that the patient also developed cellulitis and was put on an Antibiotic. Findings were verified by the Director of Operations. Observed in Record Review. In 22 of 22 patient records reviewed, where the interdisciplinary group met two or more times the organization failed to update the comprehensive assessment to reflect changes that occurred since the initial assessment. For example, in records RRNHV#1 through RRNHV#14 the interdisciplinary group did not consistently document patient decline, progress towards goals, and plans for the next two weeks. For example, in record RRNHV#3 clinical documentation identified that the patient fell twice in three days. In record RRNHV#5 the patient was started on an antibiotic for a dental infection and had also had a fall. In record RRNHV#6 a nurse documented that the husband was exhausted, and caregivers were threatening to leave. In record RRNHV#11 a nurse documented that the patient returned from hospital after having a nasogastric tube placed. The plans of care were not revised, nor were these identified problems addressed in interdisciplinary group notes. This RFI was reviewed and verified with the Director of Support Services and QAPI Coordinator.

Observed in Record Review. In 22 of 22 active patient records reviewed, the organization failed to ensure that plan of care goals identified requirements for completion. For example: patient will maintain optimal mobility; patient will remain safe in environment; desired nutrition/hydration needs will be met; oral comfort/hygiene will be maintained; patient/caregiver will verbalize/demonstrate effective adjustment techniques and support network; In addition, most goals that were written when the patient was admitted as long ago as six months were not resolved because the completion target was consistently changed to the date of the next interdisciplinary meeting two weeks later. the organization failed to assess patient needs and provide education and training on the storage handling, and access to medical gases. This RFI was reviewed and verified with the Director of Support Services and QAPI Coordinator. Observed in Record Review. the nurse surveyor noted that the goals were not consistently measurable. For RRHHV#1, RRHH#2, RRHV#3, RRHV#4, RRHV#5, and RRHV#6 goals were not measurable with time frames all at the end of the certification period. For example, there were no goals for wound care progression. Findings were discussed with the Director of Operations

Observed in Record Review. , it was noted by the nurse surveyor that medication orders were not clear or complete. For RRHV#1, the order for a Fentanyl Patch100mg/hr, one patch every 3 days, said to remove old patch before applying new patch but did not contain any further instructions regarding the patch application. Additionally, the patient had orders for Morphine concentrate, Acetaminophen, and oxycodone with no indication of when to take which medication. For RRHV#2, the order read Donepezil 10mg tab, 20mg every evening, with no instruction to take 2 tablets. The order for Polyethylene glycol 3350 17 gm/dose oral powder did not include instructions to mix in liquid. For RRHV#3, the oxygen order was for Oxygen 2 – 4 liters by nasal canula continuously. Findings were verified by the Director of Operations Observed in Record Review. In 7 of 22 active patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including medications and treatment necessary to meet the patient’s needs. For example, in record of RRNHV#5 the medication list included Clindamycin 300 mg four times a day for 10 days. The order was not provided by the hospice medical director. Rather, it was written by a nurse practitioner at the skilled nursing facility. In record RRNHV#6 an order was written for Nystatin 100,000 units/gram topical powder, apply twice a day to rash, but did not specify a location. Five days later the same order was written with new directions to apply under the breast. In record RRNHV#11 a nurse documented that the patient returned from hospital with a nasogastric tube and was receiving Pediasure 150 mls at 9.6 mls/hour by pump. There were no orders for the tube, pump, or enteral feeding. And in record RRNHV#14 a nurse documented in the initial comprehensive assessment that the patient had a large tumor on the lip that made eating difficult. There were no orders for nutritional support. This RFI was reviewed and verified with the Director of Support Services and QAPI Coordinator.

Observed in Patient Home. In 1 of 6 home visits conducted, it was observed by the nurse surveyor that the nurse did not clean her equipment per agency policy. For RRHV#2 the cleaned her equipment (BP cuff, stethoscope, pulse oximeter) with alcohol wipes and immediately dropped them into her bag without allowing them to dry per the recommended product dry time of one minute. For RRHV#3, The skilled nurse after using her wrist BP cuff on the patient put it in her pocket without cleaning and after use put her stethoscope around her neck. Finding was verified by the Director of Operations who was present during the home visit. Observed in Pharmacy. In 2 of 6 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned. For example, during RRHV#2 the registered nurse took the patient’s vital signs, assessed his lungs, abdomen and feet, then donned gloves to check the healing of his head wound all without hand sanitizing. Additionally, she went in and out of her nursing bag several times without sanitizing her hands during the patient visit. During RRHV#3, the skilled nurse did not hand sanitize before or after the patient assessment or at any time during the visit after touching items in the room such as the oxygen concentrator or furniture. Findings were verified by the Director of Operations who was present on the home visits.

Observed in Patient Home. In 3 of 5 patients receiving hospice aide services, it was noted by the nurse surveyor that hospice aide care plans were not complete or updated. For RRHV#2 the hospice aide care plan did not give instructions regarding when to notify the nurse, the patient was reportedly having problems with constipation. Additionally, the hospice aide care plan was not updated to reflect a patient fall that resulted in patient getting 7 staples to the back of his head. The hospice aide was to shampoo the patient every visit. For RRHV#3, the hospice aide care plan was not updated to reflect what to do regarding a dressing on the patient’s ankle. For RRHV#6, the hospice aide care did not give instructions regarding when to notify the nurse. Additionally, the patient was on continuous oxygen and there were not any instructions of what the aide was to do with the oxygen while giving the patient a bed bath. All findings were verified by the Director of Operations

Observed in Record Review. In 1 of 3 live discharge records reviewed, the organization did not provide the reason for the patient’s discharge, a summary of treatment, symptoms and pain management, current plan of care and orders and other documentation to assist in continuity of care. The Summary of Care document in RRDC#2 did not include this information. This RFI was reviewed and verified with the Director of Support Services and QAPI Coordinator.

Observed in Building Tour. In the pharmacy/medication room, the IPU manager and nurse confirmed that a controlled substance discrepancy that occurred last month did not have the expected documentation of an investigation or resolution of the discrepancy.

Observed in Record Review. the organization failed to assess patient needs and provide education and training on the storage handling, and access to medical gases. In records RRHV#1, RRHV#3, RRHV#4, and RRHV#6 where oxygen was present, the safety assessment documented in the initial comprehensive assessment did not include whether there were smoking materials, other fire safety risks in the home, or risks to neighboring residences and buildings. As a result, there was no documentation of oxygen safety education having been provided to the patient, family, or caregiver. Finding was verified by the Director of Operations Observed in Patient Home. In 2 of 6 home visits conducted, it was noted by the nurse surveyor that for RRHV#1 there were two backup E-tanks that were standing up in the middle of the back bedroom, unsecured. They were laid down flat on the floor by the Social Worker prior to leaving the patient’s home. For RRHV#3, the oxygen concentrator in the patient’s skilled facility room was partially covered with the room’s dividing curtain and shoved under the overbed table, and the plug was half hanging out of the outlet. Additionally, the plug for the oxygen concentrator was not plugged into a red plug (in case of power failure). The skilled nurse did push the plug securely into the wall and did move the curtain and pull out the oxygen concentrator. Findings were verified by the Director of Operations who was present during the home visit. Observed in Record Review. In 8 of 22 active patient records reviewed, the organization failed to assess patient needs and provide education and training on the storage handling, and access to medical gases. In records RRNHV#2, RRNHV#6, RRNHV#7, RRNHV#13 where oxygen was present, the safety assessment documented in the initial comprehensive assessment did not include whether there were smoking materials, other fire safety risks in the home, or risks to neighboring residences and buildings. As a result, there was no documentation of oxygen safety education having been provided to the patient, family, or caregiver. This RFI was reviewed and verified with the Director of Support Services and QAPI Coordinator.

Observed in Building Tour. During the building tour, the maintenance manager and IPU manager confirmed that there were 2 freestanding, unsecured oxygen tanks in the oxygen storage room.

Observed in Building Tour. During the building tour, the maintenance manager and IPU manager confirmed penetrations in the ceiling as follows: two penetrations in the IT room and three in the mechanical control room. 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 building tour, the maintenance manager and IPU manager confirmed that the magnetic releasing device was missing from on the fire-rated doors into the south wing. It had been propped open using cardboard. 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 building tour, the maintenance manager and IPU manager confirmed that the escutcheon plate on the sprinkler head in the bathroom of room 10 had fallen below ceiling level. 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 Record Review. In 1 of 7 patient records reviewed, the plan of care did not include interventions to manage symptoms. In RR #2, the surveyor noted the patient was identified as having edema; however, the plan of care did not include interventions to address this identified need. This was confirmed with the director of quality and compliance.

Observed in Record Review. In 1 of 7 patient records reviewed, the plan of care did not include drugs and treatment necessary to meet the needs of the patient. In RR #2, the surveyor noted the plan of care included three as needed drugs for constipation: senna, miralax and lactulose; however, the plan of care did not include specify instructions as to when to take each medication. This was confirmed with the director of quality and compliance.

Observed in Record Review. In 1 of 7 patient records reviewed, the patient record did not contain all clinical information. In RR #2, the surveyor noted the patient declined visits the fourth week of service for the aide and the nurse; however, there was no documentation in the clinical record at the time of survey of the missed visits. This was confirmed with the director of quality and compliance.

Observed in Building Tour. The surveyor noted the organization's emergency power system did not have a remote manual stop station. This was confirmed with the Director of Quality and Compliance.

Observed in HR File Review. In 2 of 13 HR files reviewed, did not provide initial training in emergency preparedness policies and procedures. In HR #1 and HR #2, the volunteer did not receive emergency preparedness training as part of initial orientation. This was confirmed with Volunteer Manager.

Observed in Record Review. In 1 of 20 patient records reviewed, the surveyor observed that the patient/family had elected to receive a copy of the Notification of Hospice Non-Covered Items, Services, and Drugs. The copy provided to the family on admission only had Coumadin list as a non-covered drug. During the first Interdisciplinary Team (IDT) meeting, the physician noted that Coumadin and Aspirin were not covered by Hospice. An Addendum to the Notification, was not provided in writing to the family within three (3) days of the changes as required by Medicare. This observation was discussed with the Director of Clinical Services.

Observed in Record Review. In 19 of 20 patient records reviewed, the organization did not inform the patient in writing of their financial responsibility.In all records reviewed where the patient was a medicare beneficiary the surveyor noted the organization did not provide an estimated dollar amount for the patient's responsibility. This was confirmed with the Director of Education. Observed in Record Review. In 1 of 20 patient records reviewed, the surveyor observed that the organization did not provide the patient or family member a written copy of the Patient Notification Of Hospice Non-Covered Items, Services And Drugs, as requested by the patient's family member. This observation was discussed and verified with the Director of Clinical Services.

Observed in Record Review. In 3 of 20 patient records reviewed, the hospice did not respect the patient's right to choose his or her attending physician.In HV #5, the surveyor noted the patient chose their primary physician to be the attending hospice physician. The nurse documented unable to reach Dr. Beard and unable to leave message with office. Family will report HOC admission. Primary team to follow up. The organization then documented that documents were faxed to the primary MD without response. There was then documentation that a change of physician to the hospice medical director was initiated with a completed form of the change document; however, there was no documentation the patient was made aware of the change in attending physician as required by organization policy/standard of work. This was confirmed with the director of education. Observed in Record Review. During active patient record review #3, the surveyor observed that the patient and family had requested to be followed by their personal physician as the attending physician. The organization attempted to contact the physician and when the attending physician did not return calls, the organization, changes the patient to being followed by Hospice MD without documentation of family or patient being notified. Additionally, during active record review #6, there was no documented notification to family with agency was unable to reach attending physician and patient's attending physician was changed to a hospice physician. These observations were discussed and verified with the Director of Education.

Observed in Record Review. In 1 of 20 patient records reviewed, the organization did not conduct a patient-specific comprehensive assessment. In RR #11, the surveyor noted the patient's pressure ulcer sacral wound was not measured on admission as part of the comprehensive assessment as required by the organization policy. This was confirmed with the director of nursing.

Observed in Record Review. In 1 of 20 patient records reviewed, the hospice did not perform an initial bereavement assessment of the needs of the patient's family and other individuals. In HV #4, the surveyor noted the hospice did not perform a bereavement risk assessment as part of the comprehensive assessment. This was confirmed with the director of education.

Observed in Record Review. In 7 of 20 patient records reviewed, the plan of care was not based on the patient's goals and the time frames, settings and services required to meet those goals.In HV #4, the surveyor noted the plan of care included the following non-measurable goals: patient maintains adequate airway and respiratory function within limits of disease process. Respiratory symptoms will be minimized to promote comfort: mom will verbalize comfort level of 8/10 during SN visits. This was confirmed with the director of education.In HV #5, the surveyor noted the pain goals did not include a time frame. In addition, the plan of care included the following non-measurable goal: patient maintains adequate airway and respiratory function within limits of disease process. Patient/caregiver have an understanding of the effect of the disease process and the medications on bowel function. This was confirmed with the director of education.In RR #8, the surveyor noted the plan of care included the following non-measurable goals: Patient determines optimum nutrition within disease limits. Pain and symptoms managed to optimum level of comfort. This was confirmed with the director of education.In RR #13, the surveyor noted the plan of care goals for pain did not include time frames. In addition, the plan of care pain goal indicated control to patient's desire; however, it did not specify the patient's specific desired level. This was confirmed with the director of education. Observed in Record Review. - the surveyor observed that the plan of care goals, did not include the patient’s goals and the time frames, settings, and services required to meet those goals. The written plans of care did not For example, during review of the plan of care for home visit #1 not all goals had timeframes, for example patient/caregiver/family verbalize understanding of hospice philosophy and team roles. patient/caregiver/family demonstrate compliance with catheter care.For home visit #2, there goals did not address catheter careFor home visit #3 there were no goals or interventions addressing constipation and patient's need for enemas once or twice a week.

Observed in Record Review. In 6 of 20 patient records reviewed, the plan of care did not include interventions to manage pain and symptoms. In HV #4, the surveyor noted the patient had a secondary diagnosis of epilepsy; however, the plan of care did not include interventions to address seizures. In addition, the patient was identified at high risk for skin breakdown; however, the plan of care did not include any interventions. This was confirmed with the director of education. In HV #5, the surveyor noted the patient was identified as having constipation, diarrhea, edema, dysphagia and at risk for falls; however, the plan of care did not address these identified needs. This was confirmed with the director of education. In RR #8, the surveyor noted the patient was identified as having anxiety, edema, and at risk for falls; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the director of education. In RR #9, the surveyor noted the plan of care included goals for COVID 19; however, there were no interventions to reach those goals. In addition, the patient was identified as having pain anxiety, agitation, shortness of breath and at risk for falls; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the director of education. In RR #12, the surveyor noted the patient was identified as having constipation and edema; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the director of education. In RR #13, the surveyor noted the patient was identified at risk for falling; however, the plan of care did not include interventions to address this identified need. This was confirmed with the director of education.

Observed in Record Review. In 1 of 20 patient records reviewed, the plan of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care. In RR #9, the surveyor noted the skilled nurse documented the family request of anointing of the sick; however, the plan of care did not include interventions to ensure the coordination of care to facilitate this request. This was confirmed with the director of education.

Observed in Record Review. In 8 of 20 patient records reviewed, the plan of care did not include drugs and treatments necessary to meet the needs of the patient.In GIP #1, the surveyor noted the plan of care indicated diet as tolerated; however, did not specify the type of diet. In addition, the initial plan of care did not specify the site care for the nephrostomy tube or the flushing to be performed. The plan of care also included the following intervention: may insert foley catheter size 12 - 18 5 -30 cc balloon or alternate size PRN for incontinence, patient comfort, or retention. This was confirmed with the director of education.In HV #4, the surveyor noted the plan of care included duplicate entries for melatonin of different concentrations indicating that one would be discontinued when it ran out. In addition, the plan of care included an order for amoxicillin on the plan of care which indicated it was to be discontinued after Wednesday dose; however, this was from the previous admission. This was confirmed with the director of education. In HV #5 and RR #8, the surveyor noted the plan of care indicated diet as tolerated; however the plan of care did not specify the type of diet and the patient had a secondary diagnosis of dysphagia. This was confirmed with the director of education. In RR #8, the surveyor noted the patient was identified as having g-tube; however, the plan of care did not include interventions to address g-tube care or flushing. In addition, the surveyor noted an 18 French foley catheter was in place; however, there was no order for the foley catheter to be inserted. This was confirmed with the director of education.This was confirmed with the director of education.In RR #9, the surveyor noted the plan of care included standing orders that were not appropriate for the identified patient needs. For example, the plan of care indicated up as tolerated; however, the patient was bed bound. The plan included tube feedings may continue:; however, patient did not have a tube feeding. Third example, the plan of care included may insert SQ button and/or peripheral IV if needed; however, there was no indication provided. Fourth example, the plan of care indicated drain care per HOC protocol; however, the patient did not have drain. Fifth example, the plan of care included may insert urinary catheter for retention/comfort/skin protection; however, the order did not specify the size of the foley catheter or the balloon. Sixth example, the plan of care included may discontinue wound measurements at nurse discretion; however, the patient did not have a wound. Seventh example, the plan of care indicated wound dressing changes per product recommendation per type of wound; however, the order was not specific and the patient did not have a wound. Eighth example, the plan of care indicated oxygen via nasal cannula or venti-mask or 100% NRB oxygen at 10 liter/minute or high flow nasal cannula at 15 liters per minute; however, this was not based on patient identified need at the time of the initial comprehensive assessment. Ninth example, the plan of care included tracheostomy suctioning; however, the patient did not have a tracheostomy. In addition, the surveyor noted the nurse inserted an 18 french foley catheter without obtaining an order prior to insertion. This was confirmed with the director of education.In RR #11, the surveyor noted the patient was identified as having a stage 2 pressure ulcer; however, the plan of care did not include interventions to address this identified need. This was confirmed with the director of education. Observed in Record Review. During record review for home visit #2, the surveyor observed that the plan of care did not include patient or family goals and interventions based on the problem identified in updated assessments. There was no goal related to urinary incontinence. The nurse documented use of condom catheter due to urinary incontinence, however, this intervention was not listed on the plan of care reviewed by the Interdisciplinary team. This observation was reviewed and discussed with the Director of Clinical Services.

Observed in Record Review. In 3 of 20 patient records reviewed, the organization did not ensure that the care and services were provided in accordance with the plan of care. In HV #5, the surveyor noted the aide visit frequency was three times per week; however, only one visit was made the first week of service. This was confirmed with the director of education. In RR #11, the surveyor noted the plan of care visit frequency for skilled nursing was 1 - 2 x's per week; however, there was no visit made the third week of service. This was confirmed with the director of education. In RR #12, the surveyor noted the plan of care visit frequency for skilled nursing was 1 week 2; however, the skilled nurse made 2 visits the second week of service. This was confirmed with the director of education.

Observed in Individual Tracer. In 4 of 5 home visits conducted, the organization did not use standard precautions to reduce the risk of infection.In HV #5, the surveyor noted the nurse did not perform hand hygiene after glove removal. This was confirmed with the director of clinical services. Observed in Individual Tracer. the surveyor observed that the staff did not follow the agency policy for Hand Hygiene. Observed during home visit #1, the clinician double gloved and did not perform hand hygiene after removing the wound dressing. Observed during home visit #2, the clinician double gloved to give the patient a bath. The clinician did not change gloves after performing perineal care. Additionally, the clinician did not have a face shield as required by agency policy. The Hospice Clinical Manager gave the clinician a face shield. The clinician stated she last wore her face shield on Monday, but disposed of it due to scratches. Observed during home visit #3, the clinician removed gloves multiple times and did not perform hand hygiene in between glove changes. These observations were discussed and verified with Hospice Clinical Manager. Observed in Individual Tracer. In 1 of 5 tracers conducted, the surveyor observed that the organization did not implement infection prevention and control activities when cleaning and performing disinfection of medical supplies and devices Observed in home visit #3 the clinician did not use an approved disinfectant for cleaning equipment . The clinician was using Benzethonium Chloride to clean the BP cuff, thermometer and stethoscope, which is a hand sanitizer, not a disinfectant. This observation was verified and discussed with the Clinical Manager.

Observed in Record Review. In 3 of 20 patient records reviewed, the registered nurse did not prepare written patient care instructions for the hospice aide. In HV #5, RR #10 and RR #12, the surveyor noted the patient was at risk for falls; however, the aide plan of care did not include fall precautions. This was confirmed with the director of education.

Observed in Record Review. In 1 of 10 patient records reviewed, the hospice aide did not provide services that were ordered in the aide plan of care. In HV #5, the surveyor noted the current aide plan of care indicated bed bath; however, the patient reported the aide cleaned her up as she sat on the bedside commode on visits which was confirmed by the patient's daughter. This was confirmed with the director of education.

Observed in Record Review. In 1 of 10 patient records reviewed, the registered nurse did not perform an on-site visit to the patient's home to address the quality of care and services provided by the hospice aide. In RR #10, the surveyor noted the aide plan of care included the application optifoam to bilateral heel wounds; however, the aide was not assessed to be competent to perform this care by the registered nurse. This was confirmed with the director of education.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.100 and 418.104, 418.52, 418.56.

Observed in Record Review. In HV #5, the surveyor noted the clinical record included a secondary diagnosis of diabetes mellitus type 2; however, the nurse documented in the comprehensive assessment and the second visit note that the patient was not diabetic. This was confirmed with the director of education.In RR #11, the surveyor noted the aide plan of care indicated a shower or bed bath twice weekly and the visit schedule was twice weekly; however, the aide documented shower/bed bath not due on a visit note. This was inaccurate documentation. This was confirmed with the director of education. Observed in Record Review. In 3 of 20 patient records reviewed, the surveyor observed that the clinical record did not contain correct clinical information. This was observed during record review for HV#1, the first Interdisciplinary t (IDT)team note had incorrect patient information in the narrative. The note had the following inaccuracies: stated the patient was 70 years old with the primary diagnosis Hepatic failure when patient was actually 88 years old and the admitting diagnosis on the intake sheet and the Certificate of Terminal Illness stated the diagnosis was Cerebral Vascular Accident. This observation was discussed and verified with the Director of Clinical Services.

Observed in Record Review. In 2 of 20 patient records reviewed, the patient record did not contain all clinical information. In HV #5, the surveyor noted the first interdisciplinary group meeting was not documented although the patient was discussed. This was confirmed with the director of education. In RR #8, the surveyor noted documentation of a foley catheter 18 French in place; however, there was no documentation as to when the catheter was inserted. This was confirmed with the director of education.

Observed in Record Review. In 2 of 20 patient records reviewed, all entries were not appropriately authenticated. In GIP #1 and RR #9, the surveyor noted the aide did not sign any of the aide notes in the inpatient unit. The notes were signed by the supervising RN. In discussion with agency leadership, the form did not have a placeholder for the aide's signature for the inpatient unit. This was confirmed with the Director of Education.

Observed in Record Review. In 1 of 3 discharged records reviewed, the hospice did not provide the receiving facility with a copy of the hospice discharge summary. In RR #8, the surveyor noted the patient was transferred to the hospital after revoking hospice; however, the hospice did not provide the hospital with a copy of the discharge summary. This was confirmed with the director of education.

Observed in Individual Tracer. In GIP #1, the surveyor observed a nurse come into the medication room to witness hydromorphone waste. The nurse entered the waste into the medication dispensing system and then left the medication room without witnessing the administering nurse actually waste the medication. This was confirmed with the Director of Quality and Compliance.

Observed in Record Review. In 5 of 5 home visits conducted, the hospice did not provide the patient with a written individualized emergency management plan. In all home visits conducted, the surveyors noted the organization did not provide the patient with a written individualized emergency management plan. In discussion with the director of quality and compliance the organization did have a process to provide the patients with an individualized written emergency management plan. This was confirmed with the director of quality and compliance.

Observed in Building Tour. The surveyor noted that all fire extinguishers in the patient hallways were located in clinical nooks that were not visible from the hallway. There was not signage in the hallway to indicate their location. This was confirmed with the Director of Quality and Compliance. 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. The surveyor noted the label on the fire door frame was painted over. This was confirmed with the Director of Quality and Compliance. 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.