Every finding on record at If Hospice Opco LLC

Based on IDG observation and staff interviews, it was determined the hospice failed to ensure the IDG included all disciplines, specifically, a chaplain or counselor. This failure had the potential to interfere with the quality of patient care and not meet all patient needs. Findings include: --- Surveyors attended and observed the IDG meeting on 2/05/25 beginning at 8:30 AM. In attendance were the Medical Director, Social Worker, DON and RN case manager. There was no Chaplain present. The DON was interviewed on 2/05/25 at 2:30 PM. When asked if the hospice had a chaplain, she stated they did not. When asked how long they have been without a chaplain, she stated it had been about 6 months. The Administrator was interviewed on 2/05/25 at 2:45 PM. He was asked if they were currently searching for a chaplain. He stated they were not. The hospice agency did not have the ability to provide spiritual support to its patients and had the potential to affect all patients.

Based on direct observation, staff interview, and hospice policy and procedures, it was determined the hospice failed to ensure proper infection control was maintained during 2 of 3 observational patient visits (Patients #2, Patient #3) conducted by surveyors. This had the potential to affect all hospice patients should proper infection control methods not be maintained. Findings include: --- A hospice policy titled "Hand Hygiene, Ref #4006" was reviewed. The policy stated: "All staff will use the hand-hygiene techniques, as set forth in the following procedure. The CDC has recommended guidelines on when to use...after coming in contact with patient's intact skin, i.e., taking a patient's blood pressure, pulse...always after removing gloves." This policy was not followed. A hospice policy titled "Hospice Aide Bag, Ref #4016" was reviewed. The policy stated: "After hand cleansing, the supplies and/or equipment needed for the visit will be removed from the bag...when the visit is completed, reusable equipment will be cleaned, hands will be cleansed, and equipment and supplies will be returned to the bag." This policy was not followed. A hospice policy titled "Nursing Bag, Ref #4015" was reviewed. The policy stated: "the bag should be placed on a barrier...after hand cleansing, all the clean supplies and equipment needed for the visit are removed from the bag...when the visit is completed...reusable equipment is cleaned using alcohol...hands are washed prior to returning clean equipment and supplies to the bag." This policy was not followed. Examples include: 1.An HHA observation visit was conducted on 2/05/25, beginning at 11:30 AM with Patient #2. Patient #2 was an 87 year old male on hospice services with a terminal diagnosis of congestive heart failure. The HHA was observed to take the patient's blood pressure, pulse, and oxygen saturation. The HHA then returned the used equipment of blood pressure cuff and pulse oximeter to her aide bag without cleaning the equipment or her hands. The HHA then assisted Patient #2 to the bathroom, donned gloves, and assisted patient to prepare for the shower. The HHA did not use hand sanitizer prior to donning gloves. The HHA was interviewed on 2/05/25, at 12:30 PM, after the observation visit. She confirmed she did not follow hand hygiene policy. She confirmed she neglected to perform proper hand hygiene before donning gloves and did not clean her equipment after use on patient. 2. An RN observation visit was conducted on 2/05/25, beginning at 1:00 PM with Patient #3. Patient #3 was an 82 year old male on hospice services with a terminal diagnosis of lung cancer. The RN was observed to remove a blood pressure cuff and pulse oximeter from her jacket pocket and take the vital signs of Patient #3. The RN then placed the used blood pressure cuff and pulse oximeter back into her jacket pocket. She then removed a stethoscope from around her neck and proceeded to listen to patient #3's lung sounds. The RN then placed the stethoscope around her neck again. The RN did not carry a nursing bag into the patient home and did not clean her equipment after use. The RN was interviewed on 2/05/25, at 1:45 PM, after the observation visit. The RN stated she did not like to bring her nursing bag into the patient home if it was not needed. The RN stated she cleans the used equipment in her pocket when she returns to her vehicle. When asked if she considered her jacket pockets to be a clean area, she agreed they were not. The DON was interviewed on 2/05/25, beginning at 4:00 PM. The observation findings were reviewed with her. The DON confirmed the HHA and the RN did not follow the hospice policies for bag technique and hand hygiene. Infection control policies were not followed.

Based on Hospice Policy, IDG observation and staff interviews, it was determined the hospice failed to ensure the spiritual needs of patient were being assessed or met. This failure had the potential to interfere with the quality of patient care and not meet all patient needs. Findings include: --- A hospice policy titled "Spiritual Care Services, Ref #9112" was reviewed. The policy stated, "Hospice provides spiritual support in keeping with the patient's belief system and practice and as developed by the interdisciplinary team's plan of care...The Hospice Chaplain/Spiritual Care Coordinator provides direct support and coordinates spiritual care...The Chaplain provides spiritual services or coordinates a referral." This policy was not followed. The DON was interviewed on 2/05/25 at 2:30 PM. When asked if the hospice had a chaplain, she stated they did not. When asked how long they have been without a chaplain, she stated it had been about 6 months. The Administrator was interviewed on 2/05/25 at 2:45 PM. He was asked if they were currently searching for a chaplain. He stated they were not. The hospice did not follow follow their policy of providing patient spiritual support via Hospice Chaplain/Spiritual Care Coordinator which had the potential to affect all patients.

Based on record review and interview, the agency failed to review and update a current and comprehensive Emergency Preparedness program. Failure to meet this standard had the potential to hinder agency response during an emergency which requires coordination and cooperation with local resources available. This deficient practice had the potential to affect all patients on services during an emergency. The agency's EP plan and any other EP documentation was requested at the entrance interview. A binder and a policy, "Emergency Management Program," updated April 2019 was provided. The Administrator was interviewed on 2/16/22, beginning at 9:10 AM. She confirmed she was the agency's Emergency Management Program Manager and the Emergency Program had not been updated since April 2019. The agency failed to review and update an EP plan biennially.

Based on record review and interview, the agency failed to review and update a current and comprehensive Emergency Preparedness program. Failure to meet this standard had the potential to hinder agency response during an emergency which requires coordination and cooperation with local resources available. This deficient practice had the potential to affect all patients on services during an emergency. The agency's EP plan and any other EP documentation was requested at the entrance interview. A binder and a policy, "Emergency Management Program," updated April 2019 was provided. The Emergency Management Program policy identified that communication was a critical area of emergency response and stated, "shall be managed in order to assess the Hospice's needs and prepare staff to respond to incidents." The binder included undated and incomplete lists of various EMS resources, medical facilities, and utilities. There was no documentation of an overall communication plan that had been reviewed and updated biennially. The Administrator was interviewed on 2/16/22, beginning at 9:10 AM. She confirmed she was the agency's Emergency Management Program Manager. She stated the agency's communication plan was to contact appropriate resources depending on the area and emergency but confirmed there was no documentation of a communication plan. The agency failed to develop and maintain an EP communication plan.

Based on review of policy, medical records, and staff interview, it was determined the hospice failed to include all patients' needs in the POC as identified in the comprehensive assessment for 1 of 13 patients (Patient #8) whose records were reviewed. This resulted in an incomplete POC. Findings include: A hospice policy titled "Plan of Care," undated, stated, "Using the date obtained during the initial and ongoing Hospice assessments, the interdisciplinary team members develop a list of patient problems and needs with corresponding goals, interventions and anticipated target dates for reaching those goals." This policy was not followed. An example includes: Patient #8 was an 84 year old male admitted to the hospice on 12/28/21 with a primary diagnosis of senile degeneration of the brain. He received SN, MSW, and aide services. His record for the certification period 12/28/21 to 3/27/22 was reviewed. Patient #8's record contained an RN admission visit note dated 12/28/21. The note stated, "he has been losing weight since his fall in July. Pt has lost approx. [approximately] 15 pounds since July. His appetite has been poor and has had some episodes of dysphagia." Additionally, the note indicated Patient #8 had poor hydration. Patient #8's POC did not include interventions to address his altered nutritional status. The Administrator was interviewed on 2/17/22 beginning at 10:08 AM. She confirmed Patient #8's POC did not contain goals and interventions to address his altered nutritional status. She confirmed there should have been interventions and goals related to his altered nutritional status in the POC. The hospice failed to include all patients' needs in the POC as identified in the comprehensive assessment.

Based on review of medical records, healthcare guidelines, and staff interview, it was determined the hospice failed to identify duplicate drug therapy in the comprehensive assessment for 2 of 13 patients (Patients #2 and #6) whose records were reviewed. This resulted in multiple medications being ordered for the same reason, without direction on the order in which to take medications. Findings include: According to Stanford Healthcare, accessed 2/23/22, "Therapeutic duplication is the practice of prescribing multiple medications for the same indication or purpose without a clear distinction of when one agent should be administered over another. For example, prescribing both ibuprofen and acetaminophen for PRN mild pain, or prescribing both Zofran [ondansetron] and Compazine [prochlorperazine] for PRN nausea and vomiting. Why is this a patient safety concern? Therapeutic duplication may lead to an unintended overdose of medication, as well as potential adverse drug reactions." 1. Patient #2 was a 45 year old female admitted to the hospice on 1/18/22 with a primary diagnosis of breast cancer. An additional diagnosis included anxiety. She received SN and MSW services. Her record for the certification period 1/18/22 to 4/17/22 was reviewed. Patient #2's medication list included the following as needed medications for pain: - acetaminophen-hydrocodone 325 mg - 5 mg: take 1-2 tablets every 4-6 hours - acetaminophen-hydrocodone 325 mg - 7.5 mg: take 1 tablet every 6 hours Patient #2's record included the following as needed medications for nausea: - ondansetron 8 mg: take 1 tablet every 8 hours - prochlorperazine 10 mg: take 1 tablet every 6 hours - promethazine 25 mg: take 1 tablet every 6-8 hours Patient #2's POC did not include when to give as needed medications when there were multiple medications ordered for the same indication. 2. Patient #6 was a 65 year old female admitted to the hospice on 2/04/22 with a primary diagnosis of rectal cancer. She received SN and MSW services. Her record for the certification period 2/04/22 to 5/04/22 was reviewed. Patient #6's medication list included the following as needed medications for pain: - hydromorphone 1 mg/mL: take 7 mL every 2-4 hours - morphine 20 mg/mL: take 2 mL every 1 hour Patient #6's POC did not include when to give which as needed medication when there were multiple medications ordered for the same indication. The administrator was interviewed on 2/17/22 beginning at 10:08 AM, and Patient #2 and #6's records were reviewed in her presence. She confirmed there were no instructions on which medications to take first when there were multiple medications ordered for the same indication. The hospice failed to ensure duplicate drug therapy was identified in the comprehensive assessment.

Based on review of medical records and staff interview, it was determined the hospice failed to ensure care and services were provided in accordance with the POC for 3 of 13 patients (Patient #5, #8, and #11) whose records were reviewed. This resulted in orders not being provided as specified in the POC. Findings include: 1. Patient #8 was an 84 year old male admitted to the hospice on 12/28/21 with a primary diagnosis of senile degeneration of the brain. He received SN, MSW, and aide services. His record for the certification period 12/28/21 to 3/27/22 was reviewed. Patient #8's record included a POC which included the "Hospice Aide Care Plan" dated 12/29/21. The hospice aide care plan included, "Check weight weekly." Patient #8's record included 17 aide visit notes between 12/29/21 and 2/14/22. None of the 17 aide visit notes documented Patient #8's weight. There was no documentation a weight for Patient #8 was performed during any of the aide visits. The Administrator was interviewed on 2/17/22 beginning at 10:08 AM. She confirmed there was no documentation the aides performed a weight for Patient #8 on any of the 17 aide visits. The hospice failed to ensure care and services were provided in accordance with the POC. 2. Patient #5 was a 95 year old female admitted to the hospice on 9/28/21 with a primary diagnosis of nutritional deficiency. She received SN, MSW, and aide services. Her record for the certification periods 9/28/21 to 12/26/21 and 12/27/21 to 2/24/22 was reviewed. Patient #5's record included a POC which included the "Hospice Aide Care Plan" dated 9/29/21. The hospice aide care plan included, "Check weight weekly," and "Empty colostomy and record size of stool every visit." Patient #5's record included 7 aide visit notes between 12/17/21 and 1/03/22. None of the 7 aide visit notes documented Patient #5's weight or stool size. The Administrator was interviewed on 2/17/22 beginning at 8:40 AM. She confirmed there was no documentation of a weight or stool size for Patient #5 on any of the 7 aide visits. The hospice failed to ensure care and services were provided in accordance with the POC. 3. Patient #11 was a 63 year old male admitted to the hospice on 11/09/21 with a primary diagnosis of striatonigral degeneration. He received SN, MSW, and aide services. His record for the certification period of 2/07/22 to 5/07/22 was reviewed. Patient #11's record included a POC which included the "Hospice Aide Care Plan" dated 9/29/21. The hospice aide care plan included, "Empty catheter and record output every visit." Patient #11's record included 5 aide visit notes between 12/20/21 and 1/12/22. None of the 5 aide visit notes documented Patient #11's catheter output. The Administrator was interviewed on 2/17/22 beginning at 8:40 AM. She confirmed there was no documentation of catheter output for Patient #11 on any of the 5 aide visits. The hospice failed to ensure care and services were provided in accordance with the POC.

Based on review of policy, medical records, and staff interview, it was determined the hospice failed to ensure POCs contained all services necessary for the management of the terminal illness and related conditions for 3 of 13 patients (Patients #1, #9, and #12) whose records were reviewed. This resulted in POCs not containing specific orders for cares of problems identified by hospice staff. Findings include: An hospice policy titled "Wound Care Policy," revised 1/10/21 stated, "For skilled nursing care to be reasonable and necessary to treat a wound, the size, depth, nature of drainage ..., and condition and appearance of the skin surrounding the wound must be documented in the clinical findings so that an assessment of the need for skilled nursing care can be made ...The plan of care must contain the specific instructions for the treatment of the wound." This policy was not followed. Examples include: 1. Patient #1 was a 56 year old male admitted to the hospice on 1/27/22 with a primary diagnosis of hepatic failure. He received SN, MSW, and aide services. His record for the certification period 1/27/22 to 4/26/22 was reviewed. a. Patient #1's record included an RN visit note dated 1/28/22. This visit note included a narrative which stated, "Pt has wound on right hip. No dressing on wound when nurse arrived. Wound cleaned with saline, patted dry bacitracin applied and wound covered with foam dressing. Pt states it hurts to lay on that side." Patient #1's record did not include a full assessment of the wound including measurements. Patient #1's record also did not contain orders for what specific wound care should have been applied to his wound. b. Patient #1's record included a PRN RN note dated 1/30/22 with the comment, "PRN visit to check pts [patient's] abdominal drain site." The narrative portion of the note stated, "dressing on pts abdomen was off prior to arrival. Area was cleaned with iodine and redressed." Patient #1's record did not include orders for what specific wound care should have been applied to his abdominal drain. c. Patient #1's record included an LPN note dated 2/11/22. The note indicated the LPN drained Patient #1's abdomen using his abdominal drain. The note stated, "1000 ml drained using sterile technique, catheter patent and flowed freely. No concerns. New sterile drsg [dressing] placed, secured w/ [with] tegaderm. Drain site red and slightly swollen." Patient #1's record did not include orders for what specific wound care should have been applied to his abdominal drain. Patient #1's record did not include orders to assess and drain his abdomen using his abdominal drain. Without an order, it was unclear how the LPN determined Patient #1's abdomen should have been drained. The Administrator was interviewed on 2/17/22 at 10:08 AM. She confirmed Patient #1's hip wound did not have wound care orders. She confirmed the wound should have been assessed and should have orders for which specific wound care should have been applied. The Administrator confirmed there were no orders for wound care and assessment of Patient #1's abdominal drain. She confirmed there was no order to drain Patient #1's abdomen including when it should have been drained. She confirmed these orders should have been in place. 2. Patient #12 was a 62 year old female admitted to the hospice on 12/28/21 with a primary diagnosis of COPD. She received SN, MSW, and aide services. Her record for the certification period 12/28/21 to 3/27/22 was reviewed. Patient #12's record included an RN visit note dated 12/30/21. The note stated, "abdomen dressing changed." Patient #12's record did not include wound care orders for dressing changes to her abdomen. It was not documented what was used for wound care on Patient #12's abdomen. The Administrator was interviewed on 2/17/22 beginning at 10:08 AM. Orders for wound care of Patient #12's abdominal dressing were requested during the interview, but were not provided prior to survey exit. The hospice failed to ensure POCs contained all services necessary for the management of the terminal illness and related conditions. 3. Patient #9 was a 93 year old male admitted to the hospice on 1/02/22 with a primary diagnosis of dementia. He received SN, MSW, and aide services. His record for the certification period 1/02/22 to 4/02/22 was reviewed. a. Patient #1's record included an RN visit note dated 1/05/22 that stated, "RN: location wrist. Patient has skin tear, sustained during fall down dghtrs [sic] stairs, removed tegaderm to assess. Visible drainage yellow noted. Cleaned with NS. Applied bacitracin and island dressing." Patient #1's record did not include orders for what specific wound care should have been applied this wound. b. Patient #1's record included an RN visit note dated 1/18/22 which identified a wound on his left wrist and stated, "RN: measuring 1cm x 2.4cm. minimal drainage SS. Cleansed area with normal saline. Applied bacitracin and covered with island dressing." Patient #1's record did not include orders for what specific wound care should have been applied this wound. The Administrator was interviewed on 2/17/22 at 8:40 AM. She confirmed Patient #1's left wrist wound did not have wound care orders. She confirmed these orders should have been in place. The hospice failed to ensure POCs contained all services necessary for the management of the terminal illness and related conditions.

Based on review of policy, medical records, and staff interview, it was determined the hospice failed to ensure POCs contained all medications necessary for treatment for 1 of 13 patients (Patient #7) whose records were reviewed. This resulted in incomplete medication lists. Findings include: A hospice policy titled "Medication Reconciliation / Verification," undated, stated, "Medications that must be reconciled include: over-the counter drugs ... respiratory therapy-related medications." This policy was not followed. An example includes: Patient #7 was a 91 year old female admitted to the hospice on 5/12/21 with a primary diagnosis of heart failure. She received SN services. Her record for the certification period 1/07/22 to 3/07/22 was reviewed. Patient #7's record included an RN visit note dated 2/14/22. The narrative portion of the note stated, "[family member name] reports that he is giving her a nebulizer tax [sic] 1-2 daily," and, "[family member name] also report that Bengay is helping with neck pain." Patient #7's medication record was reviewed. It did not include nebulizer treatments or Bengay. The Administrator was interviewed on 2/17/22 beginning at 10:08 AM. She confirmed that Patient #7's nebulizer treatment and Bengay were not on her medication list. The hospice failed to ensure POCs contained all medications.

Based on policy review, medical record review, observation, agency volunteer documentation, and staff interview, it was determined the hospice failed to ensure all hospice staff screened patients prior to completing home visits for 13 of 13 patients (#'s 1-13) whose records were reviewed and 2 of 3 patients (#4 and #8) whose home visits were observed by surveyors. This created the potential for signs and symptoms of COVID-19 to go unreported to hospice staff. Findings include: A CMS memorandum titled "Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) by Hospice Agencies," released 3/09/20 stated, "hospice agencies should be monitoring the health status of patients, residents, visitors, volunteers, and staff under their care setting for signs or symptoms of COVID-19." A hospice policy titled "Solace Healthcare Covid-19 Plan," updated 7/30/21, stated, "When making home visits all staff will identify risks of COVID-19 infection." This policy was not followed. Examples include: 1. Patients were not observed to be screened prior to home visits. a. Patient #8 was an 84 year old male admitted to the hospice on 12/28/21 with a primary diagnosis of senile degeneration of the brain. He received SN, MSW, and aide services. His record for the certification period 12/28/21 to 3/27/22 was reviewed. An SN visit to Patient #8's residence was observed by the surveyor on 2/15/22 beginning at 12:00 PM. The Nurse did not screen Patient #8 or his wife for signs and symptoms of COVID-19. The Nurse was interviewed after the visit on 2/15/22 at 12:33 PM. She stated all staff were to screen patients for signs and symptoms of COVID-19. When asked if she screened Patient #8 and his wife for signs and symptoms of COVID-19, she stated she took vital signs, and that was what the hospice was looking for. b. Patient #4 was an 68 year old female admitted to the hospice on 2/11/22 with a primary diagnosis of Alzheimer's disease. She received SN, MSW, and aide services. Her record for the certification period 2/11/22 to 5/12/22 was reviewed. An MSW visit to Patient #4's residence was observed by the surveyor on 2/14/22 beginning at 4:00 PM. The MSW did not screen Patient #4 or her spouse for signs and symptoms of COVID-19. The MSW was interviewed after the visit on 2/14/22. She stated that she did not know what the agency's policy or expectation was for screening of patients, family, or caregivers for signs and symptoms of COVID-19. She stated that she did not screen patients or family in the home for signs or symptoms of COVID-19 prior to or during visits. 2. The hospice failed to maintain documentation of COVID-19 screening in patient records. Thirteen patient records were reviewed for evidence of COVID-19 screening. The following certification periods were reviewed. a. Patient #1: 1/27/22 to 4/26/22 b. Patient #2: 1/18/22 to 4/17/22 c. Patient #3: 11/12/21 to 1/10/22 d. Patient #4: 2/11/22 to 5/12/22 e. Patient #5: 12/27/21 to 2/24/22 f. Patient #6: 2/04/22 to 5/04/22 g. Patient #7: 1/07/22 to 3/07/22 h. Patient #8: 12/28/21 to 3/27/22 i. Patient #9: 1/02/22 to 4/05/22 j. Patient #10: 5/20/21 to 8/17/21 k. Patient #11: 11/09/21 to 2/06/22 l. Patient #12: 12/28/21 to 3/27/22 m. Patient #13: 1/11/22 to 4/10/22 Patients #1-13's records did not contain documentation of COVID-19 screening for all visits and from all disciplines for the certification periods reviewed. It could not be determined Patients #1-13 were screened for signs and symptoms of COVID-19 prior to all home visits made by hospice staff. The Administrator was interviewed on 2/17/22 beginning at 8:40 AM, and Patients #1-13's records were reviewed in her presence. She confirmed the missing COVID-19 screenings. 3. The Volunteer services coordinator, an MSW, was interviewed on 2/17/22, beginning at 9:45 AM and volunteer personnel records and volunteer visit notes were reviewed in her presence. The MSW confirmed there was no documentation that volunteers received education about the prevention and transmission of of COVID-19 and volunteers were not expected to screen patients or family before or during a visit. The MSW confirmed there had been at least 33 home visits by volunteers from 10/01/21 to 1/31/22. The hospice failed to ensure all staff screened patients at every visit for signs and symptoms of COVID-19.

Based on review of patient medical records and staff interview, it was determined the agency failed to ensure aide care followed the written plan of care for 1 of 13 patients (Patient #11) who received aide services and whose records were reviewed. This resulted in care being provided beyond the scope of RN written approval and had the potential to interfere with quality, consistency, and coordination of patient care. Findings include: Aide documentation of tasks completed were not included on the written aide care plan. Examples include: Patient #11 was an 63 year old male admitted to the hospice on 11/09/21 with a primary diagnosis of striatonigral degeneration. He received SN, MSW, and aide services. His record for the certification periods of 11/09/21 to 2/06/22 was reviewed. a. A Hospice Aide Visit, dated 12/20/21, stated, "Aid [sic] put lotion on patients back." The visit note also documented vital signs. The aide care plan did not include these tasks. b. A Hospice Aide Visit, dated 12/29/21, stated, "Aide washed patietns [sic] hair..." The visit note also documented vital signs. The aide care plan did not include these tasks. c. A Hospice Aide Visit, dated 1/03/22, stated, "Aide did peri cares and washed patients hair." The aide care plan did not include these tasks. d. A Hospice Aide Visit, dated 1/10/22, stated, "Peri cares and hair washed..." The aide care plan did not include these tasks. e. A Hospice Aide Visit, dated 1/12/22, stated, "Aide assisted patient with oral cares. Aide gave patient a bed bath peri cares and hair washed..." The aide care plan did not include these tasks. The Administrator was interviewed on 2/17/22 at 8:40 AM. She confirmed Patient #11's aide documentation included tasks that were not delegated by an RN as directed on the aide care plan. The hospice aide provided services that were not included on the POC.