Every finding on record at Hospice & Palliative Care of Chenango County Inc.

Based on a review of 4 patient records with delayed or no admission, and interviews with the Executive Director, Director of Patient Programs, and Clinical Officer, it was determined the family of 1 patient (patient #4) expressed concerns/complaints to agency staff and the the Hospice failed to identify it as a complaint and complete a complaint investigation.Evidence as follows: --- Patient #4 was referred to the agency on 04/01/25 with a terminal diagnosis of gastrointestinal stromal tumor of the small intestine. The Hospice failed to investigate complaints made to the Hospice.The Hospice’s complaint policy reviewed 07/2024 included: - Complaints/concerns brought to the direct attention of any Hospice employee or volunteer are addressed immediately whenever possible and brought to the Director of Patient Family Services and or Executive Director. - All complaints are documented in a complaint log no more than 5 business days from the date the complaint was first received. - An Investigation is conducted by appropriate personnel of all written or verbal complaints received by the Hospice.The Hospice’s Admission Policy revised 07/2024, included:  - Once admission is approved by the Medical Director, a phone call to arrange an initial interview with the patient and caregivers will be made by an RN/SW, or designee, within 48 hours of the referral whenever possible.On 04/01/25, the agency received a referral from the patient’s physician that included a recent history and physical, medication list, imaging reports and lab results; the referral also included “ASAP” (as soon as possible). Per date stamp the referral was faxed to the Hospice on 04/01/25 at 11:25 a.m. The patient’s record included documentation for the patient as follows:  - skilled nursing to assess and evaluate; start date 04/01/25   - Medical Social Worker to assess and evaluate; start date 04/01/25  On 04/17/25 at 8:48 a.m., the Director of Patient Programs documented a late entry:  - “04/03/25, Director of Patient Programs: records received 04/03/25, request to MD to review for appropriateness.” On 04/17/25 at 8:50 a.m., the Director of Patient Programs documented a late entry: "04/04/25, Director of Patient Programs, per Hospice MD, patient is appropriate for Hospice with dx (diagnosis) gastrointestinal stromal tumor of small intestine. Returned call to [spouse] left VM." (voice message)On 04/09/25 at 4:24 p.m., the Director of Patient Programs documented a late entry: “04/06/25 writer called [spouse] to review the Hospice referral. Patient is appropriate for Hospice. Wife requests Tuesday 04/08/25 at 1 p.m. for admission to Hospice. DME (durable medical equipment) ordered for delivery Monday 04/07/25 as per patient caregiver request."On 04/17/25 at 11:43 a.m., the surveyor interviewed the Director of Patient Programs who stated:- they had called the patient’s spouse on Friday the 4th and left a voicemail.- they were “admin on-call” Saturday, 04/05/25 and had received a call from the on-call RN who had reported the patient’s family was upset and had made a complaint when they learned the patient would not be admitted that day. The Director of Patient Programs stated that they called the family that afternoon.On 04/17/25 at 12:30 p.m., the surveyor interviewed Executive Director who stated on 04/05/25 they received a call from the Director of Patient Programs (on call administrator) who reported the on-call nurse had received a call from the family of a patient who had not yet been admitted requesting admission for their family member. The Executive Director said per the Director of Patient Programs the family was upset and the Executing Director requested the Director of Patient Programs call the family back.  The surveyor requested the Executive Director provide the agency’s phone logs or electronic verification of when the Director of Patient Programs had phoned the patient. On 04/17/25 at 1:08 p.m., the Executive Director provided a screen shot of one phone call made to the patient on 04/07/25 at 11:11 a.m. and stated there were no more calls found. The surveyor interviewed the Executive Director and inquired what the process was for Hospice physician record review and approval of admission, and also sought clarification regarding whether the records were received on 04/01 or 04/03/25. The Executive Director explained the process, which included a “group chat” of agency personnel and scrolled back through the group chat to show the surveyor the screen dated 04/03/25 at 7:53 a.m. that read “[patient’s name] yes.” According to the Director, the Hospice physician had reviewed the records and approved of the patient for admission at that time.On 04/22/25, the surveyor conducted a follow-up interview with the Executive Director and determined the group chat included the entire "IDG" (interdisciplinary group) and “basically the whole organization.”On 04/17/25, at 1:38 p.m. the surveyor interviewed the patient’s spouse via phone. who stated: - they made a call to the Hospice on Thursday 4/3/25 since they hadn’t heard from the Hospice  - the Hospice told them they had received the referral but were still waiting for the doctor’s progress notes - the Hospice told them they would get back to the later that afternoon (04/03) or Friday (04/04) - the first call they received from the Hospice was on Monday, 04/07/25 to schedule the admission visit for the following day, at 11:00 a.m.On 04/17/25, at 2:57 p.m. the surveyor interviewed a family member of the patient via phone who reported the same information as the spouse.Both the family member and spouse stated they were requesting admission as the patient was increasingly restless, anxious, confused, and in a significant amount of pain.The family member stated on 04/05/25, a call was placed to the Hospice, and they were patched through to the on-call registered nurse (RN). They requested the on-call nurse come out and admit the patient due to the rapid decline in the patient’s condition and inability of the spouse and family to manage the patient’s pain and restlessness. The family member stated the RN said, “that’s not how it works, you have to wait until Monday.” They then requested to speak to a supervisor and were told by the RN they could talk to them on Monday, and they told the RN they were upset and would be making a complaint. The spouse stated that during the call on 04/07/25 the Hospice staff: - said the patient couldn’t be admitted Monday because the admitting nurse had the day off - asked if they needed oxygen and/or a hospital bed. The spouse stated that they responded that they did need a hospital bed, but didn’t know if the patient needed oxygenThe spouse stated a hospital bed was delivered Monday.  On 04/18/25 at 9:50 a.m., the surveyor interviewed the Clinical Officer who stated:  - they were ill and out of work 04/04, 04/07, and 04/08/25  - they were “on triage call” over the weekend of 04/05 and 04/06/25  - the family member was upset when informed admission could not happen Saturday the 5th, and asked to speak to a supervisor   - they informed the family member they couldn’t speak to anyone else until Monday and at that time, the family member became more upsetOn 04/08/25 at 7:28 a.m., the on-call RN documented:  - 6:30 a.m., telephone call from family member stating patient passed at 5:55 a.m. Patient currently is not a Hospice patient. Writer advised to call 911 to pronounce the patients passing. Funeral home was also called and advised the same. - The patient’s spouse had some concerns about the process of admission and did not want to talk at this time. On 04/17/25 at 9:13 a.m., the surveyor had requested the Hospice Complaint Log since 01/01/25 and complaint policy. The Executive Director provided the Concerns/Grievances policy and 2 complaints. Neither complaint was from the family or spouse of patient #4.On 04/17/25 at 12:30 p.m., the Executive Director was asked why the complaint wasn’t in the complaint log. The Executive Director stated when they spoke to the Director of Patient Programs on Saturday the 5th, they didn’t consider it a complaint. The Executive Director was then asked if they had seen the notes written by the on-call nurse and they stated they had, but didn’t consider it a complaint because they didn’t consider them a patient.The Hospice failed to: - Identify the issues/concerns expressed by the patient's family as a complaint.  - Follow Hospice policy and immediately address the complaint brought to the attention of the Clinical Officer, Director of Patient Programs, Executive Director and the contracted on-call RN. - Investigate the complaint to determine whether there were any issues or systems problems resulting in. or as a result of, delayed admission.Failure to ensure that the agency investigates complaints and resolves issues has the potential for unmet patient needs.

Based on a review of medical records, staffing schedules, policies, and interviews with the Executive Director, Director of Patient Programs, and Clinical Officer, the Hospice failed to ensure patients routinely have access to nursing services 24 hours a day.Evidence as follows: --- Patient #4 was referred to the agency on 04/01/25 with a terminal diagnosis of gastrointestinal stromal tumor of the small intestine. The agency failed to admit the patient timely after the Hospice physician approved the patient. On 04/03/25, the Hospice received a call from the patient’s spouse requesting the patient be admitted to the Hospice due to the rapid decline of the patient which included increases in restless, anxiety, pain and the inability of the family to manage these symptoms.On 04/05/25 at 11:36 a.m., the patient’s family member called the Hospice and spoke to the on-call registered nurse (RN). They requested the patient be admitted for the reason above and when they learned the patient wouldn’t be admitted, informed the RN they wished to speak to "higher-up" to voice concern about the delay, and they would be making a complaint.On 04/17/25 at 9:10 a.m., the surveyor received the employee roster, and at 10:30 a.m. requested the registered nurse (RN) schedules for the period of 04/01-04/09/25.The employee roster included the following nurses: - Clinical officer RN, full time - Quality Assurance (QA) RN, from remote location - RN, part time - Licensed practical nurses, 2 full timeOn 04/17/25 at 11:43 a.m. the surveyor interviewed the Director of Patient Programs who stated admissions were not usually done on the weekend due to the difficulties getting “comfort packs and DME” (medications and equipment).A review of the RN schedule for 04/04/25 determined: - the part time RN was on duty 8:30 a.m.-2 p.m. - the Clinical Officer was on duty 8:30 a.m.-4:30 p.m. and on-call 4:30 p.m.-8:30 a.m. - the QA RN was on duty for “nursing triage” 8:30 a.m.-4:30 p.m.A review of the RN schedule for 04/05 and 04/06/25 determined: - the Clinical Officer was on-call 24 hours 8:30 a.m. 04/05 to 04/06/25 4 p.m. - an LPN was on call 4:30 p.m. 04/06 – 8:30 a.m. 04/07/25 - a contracted RN was on duty 4:30 p.m. 04/06 to 8:30 a.m. 04/07/25On 04/17/25 at 12:30 p.m. the surveyor interviewed the Executive Director and asked about RN coverage. The Executive Director stated: - they were short RNs but had hired a new RN that was to start soon after recovery from an injury - they had contracted with another Hospice to cover the “on-call” gaps - The Clinical Officer was on vacation this week (04/14-04/18/25)During the interview with the Executive Director, the surveyor asked why the patient hadn’t been admitted on Friday, Saturday, or Sunday. The Executive Director stated the RNs schedule was full on Friday, and they don’t usually admit on the weekends.On 04/18/25 at 9:10 a.m., the surveyor interviewed the on-call RN from 04/05/25 via phone who stated, “I was out sick on Friday the 4th, Monday the 7th, and Tuesday the 8th, but I took call over the weekend,” (April 5th and 6th).On 04/22/25 at 10:36 a.m., the surveyor conducted a follow-up phone interview with the Executive Director who stated: - the contracted on-call RN does not perform visits to patients - the QA on-call RN does not perform visits to patients The Hospice failed to ensure RN services were available: - between 2 p.m. 04/04/25 and 8:30 a.m. 04/07/25 - during the week the Clinical Officer was on vacation, 04/14-04/17/25 from 2 p.m.-8:30 a.m.Failure to ensure nursing services are available 24/7 may result in the Hospice's inability to provide admission, and pain and symptom management, in a timely fashion; and may result in negative patient outcomes.

Based on review of personnel records, hospice policies and procedures, and interviews with the Administrator and Director of Nursing (DON), it was determined for 6 of 10 employees (employees #1, 2, 3, 4, 6, and 10) the agency did not comply with emergency preparedness (EP) training requirements for orientation of new staff and training for all employees. Evidence as follows: --- The following employees had no evidence of EP training in personnel records: 1. Employee #10 hired by the hospice on 01/15/21 as a contract employee. 2. Employee #2 hired by the hospice on 05/27/23. 3. Employee #3 hired by the hospice on 08/08/20. 4. Employee #6 hired by the hospice on 07/01/21. 5. Employee #1 hired by the hospice on 10/19/21. The following employee had no evidence of EP training within the last 2 years: 6. Employee #4 hired by the hospice on 05/15/17. On 10/06/23 at 11:15 a.m. the above findings were reviewed with the Administrator and DON. No additional information was provided. Failure to ensure all employees are adequately trained in EP policies and procedures has the potential for unmet patient needs and possible negative patient outcomes.

Based on record reviews and interviews with the Administrator and Director of Nursing, it was determined for 4 of 14 patients (patients #2, 3, 6, and 10) the comprehensive assessment was not of sufficient scope to identify the needs of the patient. Evidence as follows: --- Patient # 6 was admitted to the hospice on 05/19/23 with a terminal diagnosis of pancreatic cancer, and additional diagnoses of polyneuropathy, type 2 diabetes, obstructive sleep apnea and gastroesophageal reflux. The hospice failed to ensure assessments were complete. On 05/19/23 the HN visited the patient for the initial assessment and failed to assess the following: Diabetes The 05/19/23-08/16/23 Hospice Plan of Care included Humalog Kwik Pen 27 units injected three times per day before meals as needed for hyperglycemia based on a sliding scale (SS) with 27 units max. The HN documented the patient had type 2 diabetes treated with insulin and blood glucose monitoring before meals. There was no assessment of recent readings, documentation of a reading during the visit, if there were any high or low readings and if the patient was using the sliding scale correctly. There was no evidence the HN assessed the patient/caregiver performing testing and insulin administration to determine competence. On 05/30/23 the HN documented the patient reported blood sugars had increased since Decadron (steroid) had been added, and the patient was no longer monitoring diet as closely. There were no details regarding specific readings, times and use of sliding scale. Pain The pain assessment was incomplete. The HN documented the patient had abdominal pain, current pain was 2 out of 10, worst pain was 7 and best 2 and the patient was using narcotic analgesics for pain relief. The HN failed to assess the amount, frequency, and dosage the patient was taking. On 10/05/23 at 1 p.m. the surveyor reviewed the record with the Administrator and DON. They acknowledged the findings, and no additional information was provided. Patient #10 was admitted to the hospice on 06/14/23 with a terminal diagnosis of amyotrophic lateral sclerosis (ALS) and additional diagnoses of chronic back pain and cervical myofascial pain syndrome. The hospice failed to ensure assessments were complete. On 06/14/23 the HN visited the patient for the initial assessment which was incomplete in the following areas: Respiratory The 06/14/23-09/11/23 Hospice POC included Albuterol Inhaler and the HN documented no respiratory problems and clear/diminished breath sounds and failed to assess what respiratory symptoms the patient experienced, how often the inhaler was used and effectiveness of the treatment. Pain The HN documented the patient had a current pain level of 9 out of 10, with 10 being the worst pain and 8 the best and a goal of 3. Pain interfered severely with function, mood/emotion and sleep activities. Pain was managed with narcotic analgesics. The HN failed to assess what the patient was taking, how often and any other methods used to manage pain. Skin The POC included Betamethasone 0.05% topical two times a day failed to include a location of application. The HN documented no skin issues and failed to assess the area of skin the ointment was used. On 10/05/23 at 1 p.m. the surveyor reviewed the record with the Administrator and DON. They acknowledged the findings, and no additional information was provided. Patient #3 was admitted to the hospice on 09/06/23 with a terminal diagnosis of respiratory failure with hypoxia, and additional diagnoses of chronic obstructive pulmonary disease (COPD) and left breast cancer. The hospice failed to ensure assessments were complete. The 09/06/23 POC included an albuterol inhaler 90 mcg/inhalation 2 puffs every 6 hours as needed for dyspnea, albuterol-ipratropium 2.5 mg-0.5mg/3 ml by nebulizer 4 times a day and Symbicort 160mcg-4.5 mcg 2 puffs 2 times daily. On 09/06/23 the hospice nurse (HN) visited the patient for the initial comprehensive assessment and failed to assess use of the frequency the albuterol inhaler was required and effectiveness. On 10/05/23 at 1 p.m. the surveyor reviewed the record with the Administrator and DON. They acknowledged the findings, and no additional information was provided. Patient #2 was admitted to the hospice on 09/06/23 with a terminal diagnosis of malignant neuroendocrine tumors and tumors of the liver. Additional diagnoses include insulin-dependent type 2 diabetes, hypertension, low back pain, and depression. The hospice failed to ensure the comprehensive assessments were complete. On 09/06/23, the hospice nurse (HN) visited the patient for the initial comprehensive assessment and documented the patient used a "DEXCOM G6 sensor to monitor BS" (blood sugar, or glucose), and the patient was independent and competent to change the sensor as needed per order. The HN also documented the glucose monitoring frequency was "as needed," the patient was able to self-test, and the blood sugar results were within the expected/normal range. The 09/06/23 - 12/04/23 Hospice Plan of Care included the following orders: - insulin aspart flexpen 100 units/ml inject 3 times a day per sliding scale 141-180 4 units, 181-220 6 units, 221-260 8 units... - insulin glargine 100 units/ml inject 20 units at bedtime The HN failed to assess: - if the patient has required the sliding scale - demonstration of competency of patient/patient caregiver (PCG) with sliding scale use, continuous/ glucometer testing, and self-injection On 09/20/23, the HN visited and documented the blood sugar results within the expected/normal range, and the patient was able to self-test. On 10/04/23, the surveyor conducted an observational home visit. The patient was not wearing a continuous glucose sensor during the visit. The patient stated assistance was required from the PCG to apply the new sensor, stating I'm over 80 and not quite a technical wiz, and also stated the PCG was managing the diabetes. The PCG stated, "I'm a diabetic, so I know how to do it. it was not possible to follow the sliding scale due to the small meals throughout the day as opposed to the sliding scale set up for 3 meals per day. I look at the numbers and give none or an appropriate amount. Even the nighttime amount has to be cut down, or the morning numbers are too low." HN documented that the range of glucose readings from the 10/04/23 visit was 140 - 400, which was within the expected normal range, and the physician was notified. The narrative note included "writer to follow up with patients primary care physician about patients decreased intake, compliance with sliding scale and parameters." No evidence of new insulin orders was noted. The HN failed to accurately assess the patient's competency to manage diabetic testing and medication self-administration. On 10/05/23 at 1 p.m. the surveyor reviewed the record with the Administrator and DON. They acknowledged the findings, and no additional information was provided.

Based on a review of 14 clinical records and interviews with the Administrator and Director of Nursing (DON), it was determined in 2 records (patients #7 and 8), the updated comprehensive assessments were incomplete and/or failed to include changes in the patient's condition. Evidence as follows: --- Patient #8 was admitted to the hospice on 08/18/23 with a terminal diagnosis of Alzheimers dementia and additional diagnoses of hypertension, hypothyroidism and incontinence. The hospice failed to ensure the comprehensive assessment was updated following an injury. On 08/18/23 the hospice nurse (HN) visited the patient for the initial comprehensive assessment and documented the patient was unable to communicate, required a mechanical (Hoyer) lift for transfers, and was incontinent of bladder and bowel. On 08/21/23 the hospice social worker (SW) visited for the initial assessment and documented the patient had 24 hour per day/7 days per week hired caregivers. On 08/25/23 the licensed practical nurse (LPN) visited the patient to provide personal care and documented the patient had dried blood to the right side of the mouth from a small laceration to the bottom lip. There was no further assessment or investigation regarding how the injury occurred and if education was needed to prevent further injury. The HN next visited on 09/07/23 and there was no mention of the previously documented injury. On 10/05/23 at 1 p.m. the surveyor reviewed the record with the Administrator and DON. They acknowledged the findings, and no additional information was provided. Patient #7 was admitted to the Hospice on 04/25/22 with a terminal diagnosis of lung cancer and additional diagnoses of atrial fibrillation, dysphagia, and weakness. The HN failed to assess the patient's neck tumor and notify the physician when it opened and began draining. On 08/30/23, the HN visited and completed an assessment, noting the skin was "CDI" (clean, dry, and intact). On 09/05/23, the licensed practical nurse (LPN) visited for a routine visit to set up the weekly pill box and to reorder medications. The LPN noted the "growth" on the patient's neck had an "open area," and the "RN" was aware, naming the HN by name. On 09/19/23, the LPN visited again to set up the weekly pill box and noted "growth on pt neck has gotten bigger," and again, the "RN" was aware, naming the HN by name. On 09/21/23, the Social Worker (SW) visited and found the patient not feeling well, with increased pain throughout the head and neck. The SW noted the patient's neck mass looked different; the patient was holding a towel against it and documented the mass was draining, and pain meds weren't helping. The SW documented calling to inform the HN of the patient's symptoms during the visit. The HN failed to assess the patient's wound when initially notified on 09/05/23 and again on 09/19/23 when notified the mass and drainage had worsened. On 09/22/23, the HN visited and assessed the patient when the mass, drainage, and pain had worsened 18 days later. On 10/04/23, the findings were reviewed with the Administrator and Director of Nursing, who acknowledged the findings and offered no further information.

Based on a review of clinical records, and interviews with the Administrator and Director of Nursing (DON), it was determined in 5 of 14 clinical records (patients #2, 3, 4, 6, and 10) the plans of care were incomplete and failed to reflect all of the patient's needs. Evidence as follows: --- 1. Patient # 6 was admitted to the hospice on 05/19/23 with a terminal diagnosis of pancreatic cancer, and additional diagnoses of polyneuropathy, type 2 diabetes, obstructive sleep apnea and gastroesophageal reflux. The hospice failed to ensure the interdisciplinary POC included all pertinent interventions to manage symptoms. On 05/19/23 the HN visited the patient for the initial assessment and documented the patient had type 2 diabetes treated with insulin and blood glucose monitoring before meals. The 05/19/23-08/16/23 Hospice Plan of Care included Humalog KwikPen 27 units injected three times per day before meals as needed for hyperglycemia based on sliding scale (SS) with 27 units maximum. There were no further details regarding the scale. The POC failed to include diabetic precautions and parameters to report to the primary care provider (PCP). On 05/30/23 the HN documented the patient reported blood sugars had increased since Decadron (steroid) had been added, and no longer monitoring diet as closely. The HN documented a plan to follow up with the PCP for a new sliding scale. There was no further update of the POC. On 09/12/23 the HN visited the patient and documented a new pressure ulcer to the coccyx the HN cleansed the area, applied betadine and a foam patch applied. The 10/03/23 IDG care plan failed to include skin problems or interventions. On 10/05/23 at 1 p.m. the surveyor reviewed the record with the Administrator and DON. They acknowledged the findings, and no additional information was provided. 2. Patient #3 was admitted to the hospice on 09/06/23 with a terminal diagnosis of respiratory failure with hypoxia, and additional diagnoses of chronic obstructive pulmonary disease (COPD) and left breast cancer. The hospice failed to ensure the interdisciplinary plan of care (POC) included all pertinent interventions to manage symptoms. On 09/06/23 the hospice nurse (HN) visited the patient for the initial comprehensive assessment and noted the following: BiPAP The patient was using BiPAP at night. The 09/08/23 medical director note included the patient was BiPAP dependent in the hospital and still required BiPAP support and had frequent hypoxic episodes. BiPAP was not on the interdisciplinary group (IDG) POC as of 10/02/23. Bowel Regimen The HN noted instruction was given regarding bowel regimen and to begin using, however, the HN did not specify specific interventions implemented and the POC did not include any active medications for management of bowels. On 10/05/23 at 1 p.m. the surveyor reviewed the record with the Administrator and DON. They acknowledged the findings, and no additional information was provided. 3. Patient #4 was admitted to the hospice on 09/05/23 with a terminal diagnosis of dysarthria following cerebral infarction and additional diagnoses of weakness, dysphagia, contractures, failure to thrive and peripheral vascular disease. The hospice failed to ensure the POC included all pertinent interventions to manage symptoms. The 08/29/23 referral information included a 07/25/23 physician note the patient had contractions of all extremities, was nonverbal, had difficulty swallowing and had a diet of pureed food and honey thickened liquids. On 09/05/23 the HN visited the patient and documented the diet was ";pureed, Ensure" and appetite was poor. The HN documented the patient was instructed regarding CVA. In the note at the end of the assessment the HN documented the caregiver reported the patient was eating a pureed diet and pudding thick liquids. The 09/05/23-12/03/23 Hospice Plan of Care included ";ensure, pureed diet" and failed to include thickening of liquids. The 09/15/23 and 09/29/23 IDG meeting reports failed to specify the modification of thickening of fluids in the IDG care plan. On 10/05/23 at 1 p.m. the surveyor reviewed the record with the Administrator and DON. They acknowledged the findings, and no additional information was provided. 4. Patient #10 was admitted to the hospice on 06/14/23 with a terminal diagnosis of amyotrophic lateral sclerosis (ALS) and additional diagnoses of chronic back pain and cervical myofascial pain syndrome. The hospice failed to ensure the POC included all pertinent interventions to manage symptoms. The 06/14/23-09/11/23 Hospice Plan of Care was incomplete as follows: The respiratory medication Albuteral 2 puffs prn failed to include a frequency for use. Betamethasone 0.05% topical two times a day failed to include a location of application. On 10/05/23 at 1 p.m. the surveyor reviewed the record with the Administrator and DON. They acknowledged the findings, and no additional information was provided. Patient #2 was admitted to the hospice on 09/06/23 with terminal diagnoses of malignant neuroendocrine tumors and tumors of the liver. Additional diagnoses include insulin-dependent type 2 diabetes, hypertension, low back pain, and depression. The hospice failed to ensure the interdisciplinary POC included all pertinent interventions to manage symptoms. On 09/06/23, the HN visited the patient for the initial assessment and documented the patient had type 2 diabetes treated with insulin and blood glucose monitoring. The Hospice nurse (HN) documented the testing frequency was "as needed." The 09/06/23-12/04/23 Hospice Plan of Care (POC) included the following orders: - insulin aspart flexpen 100 units/ml inject 3 times a day per sliding scale 141-180 4 units, 181-220 6 units, 221-260 8 units... - insulin glargine 100 units/ml inject 20 units at bedtime The POC failed to include blood glucose frequency of 3 times per day that matched the insulin sliding scale and not "as needed." On 10/05/23 at 1 p.m., the surveyor reviewed the record with the Administrator and DON. They acknowledged the findings, and no additional information was provided.

Based on clinical record reviews and interviews with the Administrator and Director of Nursing (DON), it was determined in 3 of 14 records (patients #1, 2, and 6) plans of care were not reviewed and updated. Evidence as follows: --- Home Visit (HV)1. Patient #2 was admitted to the hospice on 09/06/23 with a terminal diagnosis of malignant neuroendocrine tumors and tumors of the liver. Additional diagnoses included insulin-dependent type 2 diabetes, hypertension, low back pain, and depression. The hospice failed to review and update the plan of care when a patient was injured and required first aid and wound care. On 09/21/23, the hospice nurse (HN) performed a routine visit. During the visit, the patient was injured while playing with the dog. The HN documented the skin tear was cleaned up, and a bandage was applied. On 10/03/23, the surveyor conducted an observational home visit. During the visit, the surveyor asked the patient about the dog scratch wound. The patient displayed a 2-3 cm scab surrounded by a ring of red skin around the area and described the care given. The patient stated the nurse cleaned it, then applied some salve and bandaged it. The surveyor asked the patient and caregiver (PCG) if the HN had provided instruction on care of the wound or asked if the patient needed wound care supplies; they replied they didn't recall.There was no evidence the HN notified the physician, obtained wound care orders, provided the patient and PCG instruction, or ensured wound care supplies were available. On 10/05/23 at 1 p.m. the surveyor reviewed the record with the Administrator and DON. They acknowledged the findings, and no additional information was provided. Home Visit (HV) 2. Patient #1 was admitted to the hospice on 02/13/23 with a terminal diagnosis of chronic obstructive lung disease with additional diagnoses of pressure ulcer of the toe, peripheral vascular disease, atrial fibrillation, and acquired absence of left toes. The hospice failed to ensure the comprehensive assessment was updated following surgical debridement of the toe ulcer. On 10/03/23, the surveyor conducted an observational home visit with the hospice nurse, the patient's caregiver (PCG), and the patient. The HN performed wound care to the left toe with a normal saline wash, betadine swab, mupirocin (an antibacterial ointment), and Allevyn cover. The PCG provided the mupirocin to the HN during the wound care. A review of the 09/15/23 and 09/29/23 interdisciplinary group meeting minutes included the wound care orders for the L great toe initiated 08/12/23 as follows: - Cleanse with NS. Apply betadine. Dress with foam padding. Dressing changes to be completed daily by RN/PCGA review of the 09/21/23 podiatrist notes include the following: - following debridement, the area (L great toe) was redressed with mupirocin ointment and dressing The physician's notes did not include new wound care orders. The HN failed to contact the podiatrist to obtain updated post-debridement/osteomyelitis wound care orders and update the plan of care. On 10/05/23 at 1 p.m. the surveyor reviewed the record with the Administrator and DON. They acknowledged the findings, and no additional information was provided. Patient # 6 was admitted to the hospice on 05/19/23 with a terminal diagnosis of pancreatic cancer, and additional diagnoses of polyneuropathy, type 2 diabetes, obstructive sleep apnea and gastroesophageal reflux. The hospice failed to update the interdisciplinary POC. On 09/12/23 the HN visited the patient and documented a new pressure ulcer to the coccyx the HN cleansed the area, applied betadine and a foam patch applied. The 09/29/23 IDG meeting notes included under current orders an entry for the HN to visit every 5-7 days and as needed for wound care, however, failed to include details regarding wound care and there were no changes to the IDG POC to include skin problems or interventions. On 10/05/23 at 1 p.m. the surveyor reviewed the record with the Administrator and DON. They acknowledged the findings, and no additional information was provided.

Based on a review of the hospice's Quality Assurance and Performance Improvement (QAPI) Program and activities for the past 12 months and an interview with the hospice Administrator, the hospice failed to ensure Performance Improvement Projects (PIP) were developed and initiated, completed, and tracked to improve hospice organizational operations. Failure to develop PIPs and track their effectiveness has the potential to result in negative patient outcomes and adversely affect hospice operations. Evidence as follows: --- On 10/02/23, the surveyor requested the QAPI meeting minutes for the past 12 months. On 10/05/23, the minutes were reviewed and included no evidence of performance improvement projects (PIPs). On 10/05/23, the Administrator was interviewed about the lack of PIPs discussed within the quarterly QAPI meeting minutes. The Administrator replied there were no PIPs this past year; they have only been doing survey preparedness. The Administrator and Director of Nursing (DON) were interviewed and asked to discuss the record auditing. The surveyor requested record audits for the patients in the survey sample. The Administrator replied there were no audits available; they had incorporated record auditing within the interdisciplinary group meetings. The DON explained as the group discussed the patient, the record was reviewed for all needed parts and assessed for thoroughness. Missing items were noted, and case managers were contacted for correction. The surveyor requested the QAPI policy and was provided with "Quality Assessment and Performance Improvement Plan Activities 2023." The Plan included: - Performance Improvement activities and Projects (PIPs) are reflective of the organization's identified needs, areas of weakness, and past performance of service and operation. Activities that are selected: - focus on high-risk - consider incidence - prevalence and severity of these areas and, - affect palliative outcomes - patient safety - quality of care. The Plan also included processes for measuring, analyzing, and tracking quality indicators, including adverse patient events. The QAPI program failed to self-identify through auditing some of the deficiencies idendified within this survey. The hospice failed to develop, implement, and evaluate PIPs as well as measure its success and track performance to ensure improvements are sustained. On 10/06/23 at 1:00 p.m., findings were reviewed with the Administrator, who offered no additional information.

Based on clinical record review, interviews with the Director of Patient and Family Services (DPFS) and the hospice nurse (HN), it was determined in 1 of 3 records (Patient # 1), the hospice nurse failed to conduct a comprehensive assessment including a complete review of the patient's medications. Evidence as follows: 1. Patient # 1 was admitted to the Hospice on 09/10/21 with a terminal diagnosis of malignant neoplasm of the colon. The hospice nurse (HN) failed to perform a complete medication assessment to determine if medications were available to alleviate symptoms should they occur. On 09/10/21, the HN documented in the initial comprehensive assessment "all medications reviewed from discharge summary." The HN failed to assess and document: - names of the medications the patient was currently taking - the medications available in the home - the current drug therapy ordered and it's effectiveness - the presence of any side effects - actual or potential drug interactions - duplicate drug therapy On 10/22/21, the above findings were reviewed with the DPFS, who acknowledged the findings and provided no additional information. Failure to ensure that a comprehensive assessment of the patient's medication was completed has the potential for unmet patient needs.

Based on clinical record reviews and interviews with the hospice nurse and Director of Patient and Family Services (DPFS), it was determined in 1 of 3 clinical records (patient # 1), the hospice nurse failed to provide adequate nursing assessments to meet the changing needs of the patient. Evidence as follows: 1. Patient # 1 was admitted to the Hospice on 09/10/21 with a terminal diagnosis of malignant neoplasm of the colon. The hospice nurse failed to assess and document the patient's non-terminal diagnoses, which may impact the caregiver's ability to provide safe and effective care to the patient. When changes in the patient's condition were reported to the agency, the hospice staff failed to provide adequate assessments and symptom management. - On 09/10/21 at 11:30 am, the case manager (CM) visited the patient and documented in the initial comprehensive assessment the patient had severe cognitive deficits, was alert, confused all of the time, and was unable to follow commands. The patient was disoriented and had changes in memory, both short and long-term. Required total care for ambulating, maximum assistance with taking medications, bathing, grooming, and transferring. The case manager was at the home when the patient arrived from the hospital and documented Medivan employee and nurse transferred the patient to a wheelchair at admission. - The CM failed to assess the patient's medication regimen or identify the medications available in the home. The visit summary included a notation that Tramadol was in use as needed for pain and "wishes no morphine at this time." (it was unclear if the patient or the caregiver declined morphine use.) - On 09/11/21 at 12:06 am, the patient's caregiver (PCG) called the agency to report that the patient was hallucinating. This was recorded in the on-call log from the answering service. - The on-call nurse documented in the patient record a return call to the PCG regarding the report of the patient hallucinating. The nurse began to ask questions about the patient's condition and, "right away the daughter became very agitated and screaming over the phone." The HN documented the PCG did not want to answer questions and the nurse couldn't give recommendations without asking questions because the patient was just admitted yesterday; it was the middle of the night, and there was no comfort kit (medications for symptom management) available at the home yet. The PCG continued to yell, remained upset, and hung up the phone. On 10/21/21 at 10:46 am, the surveyor interviewed the on-call nurse who stated the PCG "was frantic, didn't know what to do, her father was agitated, they had no comfort pack yet. She got upset, then hung up the phone." The on-call nurse stated, she did not offer a visit because there were no medications there yet, and she feared for her safety. She stated she reported the call to her supervisor, the DPFS, immediately after the call. - On 09/11/21 at 03:43 pm, the PCG called the agency again to discuss the patient's personality change and had questions regarding medication, as documented in the on-call log. - The on-call nurse for Saturday 09/11/21 was the hospice nurse who admitted the patient and would be the case manager for the patient. The CM returned the call and documented "PCG reports last evening the patient was agitated, chanting and had personality changes, she gave Tramadol, and the patient became calm and restful, seems more confused." The CM reviewed medication. The CM failed to document what medications were reviewed, offer an in-home visit to assess the patient's current condition, notify the physician regarding the previous night's agitation and failed to obtain medication necessary to alleviate symptoms should they recur. On 10/21/21, at 11:31 am the CM was interviewed and stated the call from the PCG was very civil, like the admission visit, and the conversation was discussed afterward with the DPFS. The CM did not indicate why a visit wasn't conducted. - On 09/12/21 at 02:47 am, the PCG called the agency again and the on-call log included the patient fell. - The CM, who was on-call, returned the call to the PCG and offered to visit. The PCG declined the visit and stated she already called the ambulance. The CM could not determine any further details regarding the fall. - During the interview on 10/21/21 at 11:31 am, the surveyor asked the CM why she had not obtained an order from the primary physician for medications typically in the comfort pack to have on hand over the weekend if the patient became agitated. The CM reported the patient "had no history of agitation", and the patient didn't want morphine. When asked if they had discussed any other medications in the comfort pack, such as Ativan, she stated, "we didn't discuss Ativan." The CM failed to visit the patient on 09/11/21 in the afternoon when the PCG called to report the events from the early morning hours, including agitation, personality changes, and chanting, and failed to recognize that the caregiver needed education regarding interventions to manage the new onset of symptoms which resulted in a patient fall with injury. On 10/22/21, the record was reviewed with the DPFS. She acknowledged the findings, and no additional information was provided. Failure to ensure that the nursing needs of the patient are adequately assessed, and symptoms managed, has the potential for unmet patient needs.

Based on a review of the hospice's current contracts and interview with the Director of Patient and Family Services (DPFS), the Governing Authority failed to ensure drugs and biologicals are routinely available to patients on 24-hour a day basis. Findings: During an interview on 10/22/21, the DPFS stated the hospice holds one current pharmaceutical contract. The contract does not include a provision to ensure medication are available on a 24 hour a day basis. The DPFS stated there were no 24-hour pharmacies available to obtain medications within a reasonable proximity. Failure to ensure patients routinely have access to drugs and biologicals 24 hours a day has the potential to result in the hospice's inability to provide pain and symptom management in a timely fashion resulting in negative patient outcomes.