Every finding on record at Hot Springs Health Program, Inc

Based on clinical record review and staff interview, the agency failed to complete a psychosocial assessment within 5 days of the initial assessment for 4 of 11 patients (#6, 7, 8 and 11). Findings include: 1. Patient #6 was admitted on 1/26/22 with a diagnosis of Alzheimer's disease. The Plan of Care for 1/26/22-4/25/22 included orders for skilled nursing 2 times per week for 1 week, then weekly for 8 weeks. The Initial Assessment was conducted on 1/26/22 by RN #1. There was no evidence of a psychosocial assessment. There were no orders for chaplain or medical social work services. An interview with the agency director on 2/10/22 at 1:00 p.m. revealed the patient had refused chaplain services and no medical social worker was available. The interview also confirmed there was no psychosocial assessment. 2. Patient #7 was admitted on 10/28/21 with diagnoses of lower abdominal pain unspecified, gastro-esophageal reflux, and hypertensive chronic kidney disease. The Plan of Care for 10/28/21-1/25/22 included orders for skilled nursing 2 times per week for 6 weeks; and Chaplain services one time on 11/1/21. There was a verbal order for a medical social worker on 11/5/21. The initial assessment was conducted by RN #2 on 10/28/21. There was no evidence of a psychosocial assessment within 5 days. The MSW conducted a visit on 11/5/21 (eight days after the initial assessment). An interview with the agency director on 2/10/22 at 1:05 p.m. confirmed there was no psychosocial assessment. 3. Patient #8 was admitted on 11/11/21 with interstitial pulmonary disease. The Plan of Care for 11/11/21-2/8/22 included orders for skilled nursing visits 2 times per week for 1 week, then weekly for 11 weeks; and chaplain visit on 11/15/21. The initial assessment was conducted on 11/11/21 by RN #1. There was no evidence of a psychosocial assessment. In an interview with the agency director on 2/10/22 at 1:30 p.m., it was stated, "I think the social worker was out at that time." It was confirmed there was no psychosocial assessment. 4. Patient #11 was admitted on 12/18/21 with Lewy body dementia. The Plan of Care of 12/18/21-3/17/22 did not include frequency for visits. The Initial Assessment was conducted on 12/18/21 by RN #2. There was no evidence of a psychosocial assessment. An interview with the agency director on 2/10/22 at 1:05 p.m. revealed the agency did not have medical social worker services available and the RN had not completed the psychosocial assessments with the initial assessments.

Based on clinical record review and staff interview the agency failed to have medications and treatments in place for symptom manage for 5 of 11 patients (#7, 8, 9, 11, and 10). Findings include: 1. Patient #7 was admitted on 10/28/21 with diagnoses of lower abdominal pain unspecified, gastro-esophageal reflux, and hypertensive chronic kidney disease. The Plan of Care [POC] for 10/28/21-1/25/22 included orders for skilled nursing [SN] 2 times per week for 6 weeks. The RN conducted a prn [as needed] visit on 12/23/21. The visit noted stated, "SN received call for _____ Retirement report pain not controlled. MAR [medication administration record] incorrect and did not have Morphine for break through pain on MAR and could not give anything else to relieved pain reported at 10/10 [sic] ...MAR printed from facility and was found to be incorrect. Facility had MAR signed by _____ RN [hospice RN] as current medication list however was found to not be correct [sic]. SN discontinued Amlodipine, Isosorbide, Eliquis, scheduled Tylenol. Corrected Cyclobenzaprine to 1 tab twice a day and 1 tab prn in addition if needed for pain and muscle spasms. Also corrected: Ativan as scheduled for 0.5 mg twice a day and prn 0.5 mg every 4 hours as needed. Added Morphine Sulfate-100 mg/5 ml to give 0.25 ml every hour for breakthrough pain. SN stayed with patient until order could be written to correct facility MAR ..." The POC for 10/28/21-1/25/22 included orders for Morphine Sulfate 5 mg every 1 hours as needed for severe pain (0.25 ml of 100 mg/ml). An interview with the agency director on 2/10/22 at 1:25 p.m. revealed the MAR was not correct. 2A. Patient #8 was admitted on 11/11/21 with interstitial pulmonary disease. The Plan of Care for 11/11/21-2/8/22 included orders for skilled nursing visits 2 times per week for 1 week, then weekly for 11 weeks. The Initial Assessment was conducted by RN #1 on 11/11/21. The note stated, "Pt [patient] takes muscle relaxer for pain control. Her pain is not controlled in her back. She is allergic to lots of narcotics. Pt requests to try "pain patch." ...SN will send message to Dr. ____." The SN note for 11/16/21 stated, "Pt [patient] takes muscle relaxers for pain control. Her pain is not controlled in her back. SN requested Fentanyl patch and pt placed a patch this AM during SN visit ..." An interview with the agency director on 2/10/22 at 1:30 p.m. revealed the nurse notified the physician of the request for Fentanyl patch on 11/12/21 and the physician ordered the medication on 11/12/21. There was no evidence of notification to the patient that Fentanyl was ordered and no reason why the medication was not started until 11/16/21. 2B. On 11/28/21, patient #8 "called SN's cell phone to talk about ...her medications. She reports to SN that she feels she may be "over medicated with the Fentanyl." She is wanting to know if she can only put on ½ of the Fentanyl patch. SN agreed and reports she will call and check on her tomorrow." On 11/30/21, RN #1 visited the patient. The note stated, "Pt has talked with SN over the weekend and was wondering about using half the patch as there was a "score in the patch." Pt had ½ the patch on today. She removed the patient and requests to stay off the patch until a small dose is available ...SN called ___ in the office to see about dose decrease of Fentanyl." There was no evidence the RN had notified the physician of the patient feeling over-medicated after the call on 11/28/21 until the visit on 11/30/21. In an interview with the agency director on 2/10/22 at 1:45 p.m., it was confirmed there was no follow-up regarding the Fentanyl until 11/30/21. 3. Patient #9 was admitted on 7/22/21 with a diagnosis of lung cancer. The Plan of Care for 10/20/21-1/17/22 included orders for skilled nursing (SN) for 2 times per week for 1 week, then weekly for 10 weeks. The RN note on 10/20/21 stated, "SN visit as pt [patient] is having anxiety/eating problems/changed pain medications/flu vaccine". The was no gastrointestinal assessment included on this visit note. On 10/25/21, a case communication note stated, "SN received call from pt's spouse, _____, stating pt's chronic pain has not improved. Also, beginning this a.m. pt started having acute rt [right] lower abdominal pain. Pain has moved across lower abdomen and is 10/10 [10 out of 10 on pain scale]. Per pt, last BM [bowel movement] was 2 days ago, and that the acute abdominal pain may/could be gas related ..." The note revealed the physician was notified of the pain and increase the Fentanyl patch. On 10/27/21, the RN documents, "Pt continues to have rt sided pain. SN requested to add Morphine to regimen for pain control." The RN notes abdominal tenderness and distention upon assessment with last bowel movement on 10/25/21." On 11/1/21, a communication note stated, "Pt called SN yesterday to report pain was more controlled the "lump on rt side of abdomen" is now gone [no documentation of "lump" on previous visit]. Pt feels as though it was gas. Pt is having increased constipation though. Taking Colace 3 tabs daily. SN recommended prune juice with warm water ..." A communication note on 11/3/21 stated, "[wife] reports pt has still not had a BM. It's been 9 days ...Pt has been taking Colace 3 pills daily, he has tried prune juice and butter x 3 days and Metamucil. No BM. Pt is in no discomfort and denies feeling constipated. SN sent Dr. ___ at text with info for suggestions. SN received text back from Dr. ____ @ 4:05 PM for pt to try Miralax. Can use up to QID [four times per day]. On 11/4/21, the RN visited the patient. There was no evidence that bowel sounds were assessed. The last bowel movement was noted to be 10/27/21 (inconsistent with previous note of 9 days since last bowel movement). The note stated, "Pt needed visit today as pt has been having trouble with constipation ...Pt is taking Colace 3 tabs daily and has added prune juice with warm butter. Still not working, but SN talked with Dr. ____ via text and can add Miralax up to 4 times daily ..." On 11/10/21, the RN conducted a visit. There was no gastrointestinal assessment documented. The Visit Summary stated, "Pt has had trouble with constipation since increasing meds and not eating any solid foods and cutting Boost to 1-2 daily. Pt is taking Colace 3 tabs daily and has added prune juice with warm butter. Still not working, but SN talked with Dr. ____ via text and pt can add Miralax PRN up to 4 times daily." On 11/17/21, patient's wife declined visit. There was no evidence the RN assessed the bowel status. On the RN visit on 11/24/21 the last bowel movement was documented on 11/22/21. The patient was noted to have abdominal distention. There was no evidence that bowel sounds were assessed. The note stated, "Pt has had constipation since increasing pain meds and not eating any solid foods. [Wife] reports he might drink 1/2 -1 Boost daily now. Pt is taking Colace 3 tabs daily and has added prune juice with warm butter and Miralax PRN up to 4 times daily." On 12/1/21, the RN documented the last bowel movement of 11/30/21. An interview with the agency director on 2/10/22 at 1:55 p.m. revealed there were standing orders for a bowel protocol that should have began after 3 days of no bowel movement. 4. Patient #11 was admitted on 12/18/21 with Lewy body dementia. The Plan of Care of 12/18/21-3/17/22 did not include frequency for visits. The Initial Assessment was conducted on 12/18/21 by RN #2. The visit note stated, "Pressure ulcer stage 2 to sacrum ...No wound assess [sic] or wound care today, not due until Monday under current treatment in facility." The POC did not include any wound care orders. An interview with the agency director on 2/10/21 revealed the hospice POC should include wound care orders and the POC failed to include wound care orders. 6. Patient #10 has a Start of care (SOC) date of 10/29/2021, with a diagnosis of Hypertensive heart disease with heart failure. The Plan of Care for 10/29/21- 01/20/2022 included orders for skilled nurse (SN) visits starting with 2 times per week for 6 weeks and 6 PRN (as needed) visits. The visit frequency changed as of 12/13/2021 with visits of 1 time per week for 6 weeks and 6 PRN visits. Clinical documentation from the SN on 01/15/2022, stated she made a phone call to the patient's spouse in which he reported that he had started giving "Morphine 0.5 ml about every 5 hours." He also reported that the patient was "sleeping more ... only ate 2 bites of yogurt this morning." The nurse documented she had "changed status to imminent today (nearing end of life)." The SN did not make a nursing visit to assess possible imminent status or the need for medication adjustments. The nurse visit notes on 01/19/2022 stated the patient's spouse "is administering Morphine every 4-5 hours, Pt does "yell out" when touched ...does not appear to have pain, again only when touched." The nurse stated "pt {sic} yells out when touched." There was no evidence that medications were changed to address pain management. In a staff interview with Agency Director on 02/10/2022 at 3:43 p.m., it was determined the plan of care for pain management had not been addressed.

Based on policy review, clinical record review, and staff interview, the agency failed to update the chaplain's plan of care at least every 15 days for 4 of 11 patient's that received chaplain services (#1, 2, 7, and 8). Findings include: A policy, Hospice Interdisciplinary Team (IDT) revised 9/2013, was provided by the agency director on 2/10/22 at 4:20 p.m. The policy stated, "The IDT evaluates the patient's response every 15 days or more often if the patient's condition warrants for change in the psychosocial status, patient's home environment, or change in prognosis ...The patient's identifying data and plan of care review is documented on the Interdisciplinary Team Summary form by the nurse case manager as well as other Hospice IDT members ...Hospice team interventions and plan of care changes are addressed at the IDt [sic] meeting with the original Summary form filed in the patient's chart and a copy mailed to the attending physician." 1. Patient #1 was admitted on 3/11/21 with a diagnosis of acute and chronic respiratory failure with hypercapnia (excessive carbon dioxide in the blood). The Plan of Care (POC) for 1/5/22-3/5/22 included orders for chaplain services 1 time for 1 day on 1/11/22. There were also verbal orders for chaplain services: • 1/21/22 one time • 1/25/22 one time • 1/31/22 one time The Interdisciplinary Team (IDT) Meetings were held on 1/18/22 and 2/1/22. The IDT Meeting notes failed to include an update to chaplain's POC. 2. Patient #2 was admitted on 11/17/21 with a diagnosis of chronic systolic heart failure. The Plan of Care (POC) for 1/16/22-3/16/22 included orders for chaplain services 1 time for 1 day on 1/11/22. The Interdisciplinary Team (IDT) Meeting note for 1/18/22 stated, "Chaplain visited last week." The IDT Meeting notes failed to include an update to the chaplain's POC. The IDT Meeting note on 2/1/22 stated, "Chaplain has seen pt [patient] once and will see PRN [as needed]." There was no update to the POC stating the prn indication for further visits. 3. Patient #7 was admitted on 10/28/21 with diagnoses of lower abdominal pain unspecified, gastro-esophageal reflux, and hypertensive chronic kidney disease. The Plan of Care for 10/28/21-1/25/22 included orders for chaplain services 1 time for 1 day on 11/1/21. There were also verbal orders for chaplain services: • 11/12/21 one time • 11/15/21 one time • 11/22/21 one time • 11/29/21 one time • 12/6/21 one time • 12/10/21 one time • 12/13/21 one time • 12/14/21 one time • 12/20/21 one time • 12/28/21 one time • 1/4/22 one time The Interdisciplinary Team (IDT) Meetings were held on 11/9/21, 11/23/21, 12/7/21, 12/21/21, and 1/4/22. The IDT Meeting notes failed to include an update to chaplain's POC. 4. Patient #8 was admitted on 11/11/21 with interstitial pulmonary disease. The Plan of Care for 11/11/21-2/8/22 included orders for skilled nursing visits 2 times per week for 1 week, then weekly for 11 weeks; and chaplain to visit on 11/15/21. There were also verbal orders for chaplain services: • 11/15/21 • 11/23/21 • 12/3/21 • 12/13/21 • 1/7/22 • 1/13/22 The Interdisciplinary Team (IDT) Meetings were held on 11/23/21, 12/7/21, 12/21/21, and 1/4/22. The IDT Meeting notes failed to include an update to chaplain's POC.

Based on clinical record review and staff interview the nurse failed to conduct assessments related to a change for 2 of 11 patients (#8 and 10); and to assess a wound in 1 of 2 patient's with a wound (#11). Findings include: 1. Patient #8 was admitted on 11/11/21 with interstitial pulmonary disease. The Plan of Care for 11/11/21-2/8/22 included orders for skilled nursing visits 2 times per week for 1 week, then weekly for 11 weeks. The visit note for 11/24/21 by RN #1 stated, "Pt [patient] has also called SN on Monday ti [sic] report that she may be coming down with bronchitis. SN requested Prednisone and Z Pack as she reports this is what usual makes her feel better." There was no evidence the RN assessed the patient prior to the request for prednisone or antibiotic. There was no evidence of breath sounds on the 11/24/21 visit. An interview with the agency director on 2/10/22 ay 1:30 p.m. revealed the agency's expectation was that the patient should have been assessed by the nurse. 2. Patient #11 was admitted on 12/18/21 with Lewy body dementia. The Plan of Care for 12/18/21-3/17/22 did not include frequency for visits. The Initial Assessment was conducted on 12/18/21 by RN #2. The visit note stated, "Pressure ulcer stage 2 to sacrum ...No wound assess [sic] or wound care today, not due until Monday under current treatment in facility." On 12/21/21, RN #1 visited the patient. The visit note stated, "Pt has stage 2 on coccyx area that facility changes dressing 3 times weekly and PRN." There was no evidence the nurse assessed the wound. On 12/23/21, there was no documentation related the wound. An interview with the agency director on 2/10/22 at 2:10 p.m. confirmed the hospice nurse should assess wounds on all patients. 3. Patient #10 has a Start of care (SOC) date of 10/29/2021, with a diagnosis of Hypertensive heart disease with heart failure. The Plan of Care for 10/29/21- 01/20/2022 included orders for skilled nurse (SN) visits starting with 2 times per week for 6 weeks and 6 PRN (as needed) visits. The visit frequency changed as of 12/13/2021 with visits of 1 time per week for 6 weeks and 6 PRN visits. Clinical documentation from the SN on 01/15/2022, stated she made a phone call to the patient's spouse in which he reported that he had started giving "Morphine 0.5 ml about every 5 hours." He also reported that the patient was "sleeping more ... only ate 2 bites of yogurt this morning." The nurse documented she had "changed status to imminent today (nearing end of life)." The SN did not make a nursing visit to assess possible imminent status or the need for medication adjustments. On 01/17/2022 the nurse documented she would contact the patient's spouse "tomorrow" (01/18/2022). There was no evidence the nurse made contact on 01/18/2022. There was no nursing visit made until 01/19/2022 after making patient imminent on 01/15/2022.

Based on clinical record review and staff interview, the agency failed to provide social work services for 3 of 3 patients that agreed to medical social work services (#2, 8, and 11). Findings include: 1. Patient #2 was admitted on 11/17/21 with a diagnosis of chronic systolic heart failure. The Initial Assessment conducted on 11/17/21 stated, "Pt [patient] is open to Chaplain, CNA [hospice aide] and MSW [medical social worker]. 2. Patient #8 was admitted on 11/11/21 with interstitial pulmonary disease. The initial assessment conducted on 11/11/21 stated, "Pt [patient] is also open to visits from Chaplin [sic] and MSW [medical social worker]. 3. Patient #11 was admitted on 12/18/21 with Lewy body dementia. The Initial Assessment was conducted on 12/18/21 by RN #2. The note stated, "Wife does request chaplain and MSW [medical social worker] ..." An interview with the Human Resource Director on 2/10/22 at 3:45 p.m. revealed the medical social worker was on an extended leave with last day worked on 11/11/21. The agency had not been unsuccessful with recruitment and hiring a medical social worker.

Based on policy review, clinical record review, and staff interview, the agency failed to include all orders in the clinical record for 4 of 11 patients (#1, 2,7, and 6); to include indications and/or routes for prn (as needed) medications for 8 of 11 patients (#2, 4, 6, 7, 8, 3, 6, and 10). Findings include: A policy, Physician Orders revised 12/2008, was provided by the agency director on 2/10/22 at 4:20 p.m. The policy stated, "Orders from a physician or other person authorized by law to prescribe treatments are required for _____ (agency name) to administer pharmaceuticals or medical treatments ...All original signed orders from pharmaceuticals and medical treatments are incorporated in the patient's medical record." 1. Patient #1 was admitted on 3/11/21 with a diagnosis of acute and chronic respiratory failure with hypercapnia (excessive carbon dioxide in the blood). The Plan of Care (POC) for 1/5/22-3/5/22 included orders for skilled nursing 1 time for 1 week, then 2 times per week for 8 weeks. The skilled nurse note for 1/21/22 stated, "Patient has been on antibiotic, for assumed pneumonia for two days, so far." In an interview with the agency director on 2/10/22 at 12:15 it was confirmed there was no order for an antibiotic in the hospice record. 2A. Patient #2 was admitted on 11/17/21 with a diagnosis of chronic systolic heart failure. The Plan (POC) for 1/16/22-3/16/22 included orders skilled nursing (SN) weekly for 9 weeks. Metoprolol Succinate 25 mg twice daily for blood pressure was also on the POC. The skilled nursing visit note on 1/20/22 identified a blood pressure (BP) of 168/60. On the 1/26/22 the SN noted a blood pressure of 172/62. The note also stated, "VS [vital signs] are WNL [within normal limits], except BP, it continues to creep up and he is having more headaches. SN talked with Dr. ______ about increase in BP meds ..." The SN note on 2/2/22 noted the BP to be 182/62. The visit note stated, "VS are WNL except BP continue to trend up. Dr. _______ gave order to increase Metoprolol from 25 mg to 50 mg BID [twice daily]." An interview with the agency director on 2/10/22 at 12:35 p.m. revealed the Metoprolol was increased on 1/31/22. The agency director confirmed there were no orders for the increase in Metoprolol in the hospice clinical record. 2B. On 2/2/22 SN visit note, the nurse stated, "HGB [hemoglobin] drawn today following up with last CBC [complete blood count] in office prior to Hospice admission." There was no evidence of an order for a HGB in the hospice record. The agency director confirmed there were no orders for the HGB in the hospice clinical record. 2C. The Plan of Care for 1/16/22-3/16/22 included the following prn (as needed) medication with no indication for when it should be given: • Zofran ODT 4 mg every day oral as needed • Nitroglycerin 0.4 mg every 4 hours sublingual as needed • Ativan 0.5 mg every day oral as needed • Singular 10 mg every day oral as needed • Albuterol Sulfate every 6 hours inhalation as needed • Pataday every day ophthalmic as needed (1 drop of 0.1%) • Mupirocin twice a day external as needed An interview with the agency director on 2/10/22 at 12:35 p.m. revealed all prn medication should have had an indication for use. 3. Patient #4 was admitted on 10/27/21 with diagnoses of chronic obstructive pulmonary disease (COPD-lung disease) and abnormal weight loss. The Plan of Care (POC) for 1/25/22-4/24/22 included the following prn (as needed) medication with no indication for when it should be given: • Colace 100 mg every day oral as needed (1 capsule of 100 mg) • Mirtazapine 15 mg bedtime oral as needed (1 tablet of 15 mg) • Nystatin four times a day mouth/throat as needed (1 ml of 10,000 unit/ml) 1 teaspoon swish and swallow QID (four times per day) • ProAir HFA every 4 hours inhalation as needed (2 puffs of 108 (90 Base) mcg/act) An interview with the agency director on 2/10/22 at 12:35 p.m. revealed all prn medication should have had an indication for use. 4. Patient #6 was admitted on 1/26/22 with a diagnosis of Alzheimer's disease. The Plan of Care for 1/26/22-4/25/22 included the following prn (as needed) medication with no indication for when it should be given: • Tramadol Hcl 50 mg every 6-8 hours oral as needed (1 tablet of 50 mg) • Morphine Sulfate (concentrate) 20 mg every 1 hour oral as needed • Lorazepam 0.5 mg every 4 hours oral as needed (0.5-1 table of 1 mg) • Oxygen 2-3 l/min as needed (no route of administration listed) An interview with the agency director on 2/10/22 at 12:35 p.m. revealed all prn medication should have had an indication for use. 5A. Patient #7 was admitted on 10/28/21 with diagnoses of lower abdominal pain unspecified, gastro-esophageal reflux, and hypertensive chronic kidney disease. The Plan of Care for 10/28/21-1/25/22 included orders for skilled nursing 2 times per week for 6 weeks. RN #2 visited on 11/4/21. The note stated, "COVID lab administered [sic] per MD [medical doctor] order ..." There was no evidence of an order for a COVID test. An interview with the agency director on 2/10/22 at 1:05 p.m. revealed the hospice agency had the ability to communicate with the medical director through a separate system. It was confirmed the physician order was in the separate system by was not incorporated into the hospice clinical record. 5B. The Plan of Care (POC) for 10/28/21-1/25/22 included the following prn (as needed) medication with the incorrect route of administration of how it should be given: • Atropine sulfate 4 drops ophthalmic solution 4 drops every two hours ophthalmic for excess secretions An interview with the agency director on 2/10/22 at 1:05 p.m. revealed the Atropine sulfate should have been ordered sublingual (under the tongue). 6A. Patient #8 was admitted on 11/11/21 with interstitial pulmonary disease. The Plan of Care for 11/11/21-2/8/22 included orders for skilled nursing visits 2 times per week for 1 week, then weekly for 11 weeks. The Plan of Care included the following prn (as needed) medication with no indication for when it should be given: • Advil 400 mg twice a day oral as need (2 tablets of 200 mg) • Transdermal scopolamine (1.5 mg) transdermal as needed • Ativan every 6 hours oral as needed (0.5-1 tablet on 1 mg) • Ambien 5 mg bedtime oral as needed (1 tablet of 5 mg) An interview with the agency director on 2/10/22 at 12:35 p.m. revealed all prn medication should have had an indication for use. 7. Patient #3 was admitted on 06/08/2021 with diagnosis of Chronic Obstructive Pulmonary disease. The order for nursing visits were 1 time per week for 8 weeks with 6 PRN (visits). The Plan of Care (POC) for 02/03/2022 to 04/03/2022 included the following PRN (as needed) medications with no indication for use: • Lorazepam 1 mg every 6 hours(s) oral as needed (1 tablet of 1 mg) • Morphine Sulfate (concentrate) .25mg {sic} every 1 hour(s) oral as needed • Promethazine HCL 25mg every 4 hour(s) rectal as needed (1 suppository of 25mg) • Atropine Sulfate (Ophth) {sic} every 2 hour(s) ophthalmic as needed (4 drops(s) of 1 %) 8A. Patient #6 had a start of care (SOC) date of 08/04/2021 with a diagnosis of Malignant neoplasm unspecified, ovary. The Plan of Care (POC) for 01/31/2022 - 03/31/2022 included orders for skilled nursing visits of 1 time per week for 9 weeks and 6 PRN (as needed) for coping and symptom management. The POC also included orders for Coreg (a blood pressure medication) 25mg twice a day oral (1 tablet of 25 mg) based on BP reading. The medication order was missing blood pressure parameters. In an interview with the Agency Director on 02/10/2022 at 4:25 p.m., it was confirmed the medication order was missing blood pressure parameters. 8B. The POC for patient # 6 for 01/31/2022 to 03/31/2022 included orders for skilled nursing visits for 1 time per week for 9 weeks and 6 PRN. The POC included the following PRN (as needed) medications with no indication for use: • Miralax every day oral as need (no dose) • Lorazepam every 6 hour(s) oral as needed (1 tablet of 1 mg) • Zofran ODT 8 mg every 6 hour(s) oral as needed (1 tablet disintegrating of 8 mg) • Phenergan 25 mg every 8 hour(s) oral as needed (1 tablet of 25mg) • Lidocaine every 12 hour(s) external as needed (1 patch of 5%) 9. Patient # 10 was admitted on 10/29/2021 with a diagnosis of Hypertensive heart disease with heart failure. The Plan of Care for 10/29/2021 to 01/20/2022 included skilled nursing visits for 2 times per week for 6 weeks with 6 PRN visits. The POC included the following PRN (as needed) medications with no indication for use: • Hydrocodone/Acetaminophen every 4-6 hour(s) oral as needed (1 tablet of 7.5mg- 325mg) • Miralax every day oral as needed (no dose) An interview with the Agency Director on 02/10/22 at 4:10p.m, confirmed these medications did not have indications for use.

Based on personnel record review and staff interview, the agency failed to ensure all personnel requirements were met for 4 of 4 personnel records reviewed (#1, 2, 3, and 4). Findings include: 1. Employee #1 was hired on 7/19/21 as the chaplain. A review of the personnel file on 2/10/22 revealed there was no competency completed upon hire. The review also revealed the employee completed the screening tool for tuberculosis (TB). but did not have a TB test. An interview with the agency director on 2/10/22 at approximately 11:00 a.m. confirmed there were no competencies completed. An interview with the Human Resource Director on 2/10/22 at approximately 11:00 a.m. revealed the agency did not do TB tests on employees, only the screening. 2. Employee #2 was hired on 5/5/20 as a medical social worker. There was no evidence of Hepatitis B vaccination status or declination. There was no evidence of a performance evaluation since hire. There was no evidence of a competency evaluation. An interview with the Human Resource Director on 2/10/21 at approximately 11:00 a.m. confirmed there was no Hepatitis B vaccination status or declination. The HR Director stated the employee confirmed she had had the Hepatitis B vaccination series but had not provided the agency a copy or signed a declination. An interview with the agency director on 2/10/22 at approximately 11:00 a.m. confirmed there was no performance evaluation completed. 3. Employee #3 was hired on 7/11/18 as a registered nurse. There was no Hospice RN signed job description. The most recent signed job description was for a Home Health Case Manager on 9/24/19. There was no evidence of a performance review since hire. There was no evidence of a competency evaluation. An interview with the Human Resource Director on 2/10/21 at approximately 11:00 a.m. confirmed there was no hospice RN job description, no performance evaluation completed, and no competency for hospice RN completed. 4. Employee #4 was hired on 11/9/10 as a hospice aide. The last performance evaluation was completed on 10/15/19. An interview with the agency director on 2/10/22 at approximately 11:00 a.m. confirmed that was the most recent performance evaluation.