Every finding on record at Intermountain Hospice

Based on interview, record review, and facility policy review, the agency failed to ensure two of 14 sampled patients (Patient 10, and Patient 11), were assessed by a Registered Nurse (RN) within 48-hours of their referral for hospice (end of life care) services, or on the start of care date ordered by the physician and did not notify the physician when there was a delayed in their start of care. --- Findings:A review of the agency’s policy dated, 11/2018, titled, “Assessment of the Hospice Patient,” indicated an initial assessment to determine the patient’s immediate care and support needs is conducted by the hospice nurse within 48 hours of the patient’s election of hospice care. An initial assessment visit is made earlier than 48 hours if requested by the patient, family, and/or if the patient’s needs warrant it.A review of the agency’s policy dated and approved 3/26/25, titled, “Admission to Hospice-Referrals and Process,” indicated the hospice nurse (RN) will be responsible for implementing this procedure with the patient and caregiver/family. This initial assessment will take place within 48 hours of receipt of signed certification. During a review of Patient 11’s clinical record, Patient 11 was admitted to the hospice agency on 3/14/24 with diagnoses that included malignant neoplasm of upper lobe (cancerous tumor in the top portion of the lung), Chronic Obstructive Pulmonary Disease (COPD, a progressive lung disease that causes inflammation and shortness of breath), chronic kidney disease (slow, progressive damaged kidneys that cannot filter wastes from the blood as needed), and atrial fibrillation (irregular and fast heart beat). During a review of Patient 11's clinical record, a document dated 3/13/24, titled, “Referral,” indicated Patient 11 scheduled start of care (SOC) date was 3/13/24 for hospice services. During a review of Patient 11’s clinical record, a document titled, “Hospice Plan of Care,” was dated 3/14/25, one day later than than the physician had ordered hospice services. During a concurrent interview and record review on 4/9/25 at 3:45 pm, Registered Nurse A confirmed the SOC date for Patient 11 was one day late, and there was no update to the physician for the delay for hospice services ordered. During an interview on 4/9/25 at 3:55 pm, the Chief Clinical Officer (CCO) confirmed the SOC was late for Patient 11, and the physician was not updated for the delay in hospice services. CCO stated, “I confirm if the physician orders a specific date for the SOC, we need to complete the initial visit on the ordered date or update the physician if this order for hospice services cannot be met on time.”        During a review of Patient 10’s clinical record, the record indicated Patient 10 was admitted to the hospice agency on 12/10/24 with diagnoses that included malignant neoplasm (cancerous tumor) of the brain.Patient 10's clinical record included a referral for services on 11/22/24, and the first start of care skilled nursing visit was documented on 12/10/24 for hospice services. The referral indicated Skilled Nursing (SN), Medical Social Worker (MSW) and a Chaplin were to be assessed and evaluated for services.  During an interview and review of Patient 10’s clinical record, there was no Physicians Plan of Care, (orders found) only a referral for the hospice services.During an interview and record review on 4/10/25 at 9:30 am with Registered Nurse (RN) B she confirmed there was no initial Physicians Plan of Care found for the services provided.  There was two SN visits, one prn (as needed) and one Social Worker (MSW) visit for the four days Patient 10 was receiving hospice services.

Based on interview, record review, and facility's policy review, the agency failed to complete an initial bereavement risk assessment for one of 14 sampled patients (Patient 1).  This failure resulted in not identifying family bereavement needs for Patient 1 while on hospice (end of life care) services. --- Findings:A review of the agency’s policy dated 2/7/2018, titled, “Bereavement Program Hospice,” indicated the Hospice has a comprehensive bereavement program that includes assessing and care planning bereavement needs. Hospice patients and significant family members and caregivers are assessed for grief and bereavement needs. The bereavement program includes mailings, and tracking. Bereavement risk factors and needs of family members, care givers, and significant others are identified and documented by the Bereavement Coordinator in collaboration with other team members. Each person designated to receive bereavement services is categorized according to the level of risk for complicated grief reactions and receives appropriate interventions according to needs identified. The three levels of bereavement risk are determined as followed: High, Moderate and Low risk.  Findings:A review of Patient 1's clinical record indicated she was originally admitted to the hospice agency on 7/24/24 and then had a resumption of care (continuation of needed services after 90 days) on 10/25/24 through to 12/20/24. Patient 1's diagnoses included end stage renal (kidney) disease and diabetes (high levels of sugar in the bloodstream).Patient 1 had physicians orders for MSW services for one time a month for four months (1m4m) and four prn (as needed) to start 10/22/24 during the resumption of care.A record review and interview was conducted on 4/8/25 at 4 pm with Registered Nurse (RN) A.  RN A refereed to the initial "Medical Social Worker Visit Note" dated 7/24/24. Under Bereavement Status and risk assessment the document indicated there was no risk assessment completed by the Social Worker (SW).  Under the narrative section the SW documented that Patient 1 was a widow, lived alone and had no caregiver. The assessment identified that Patient 1 would be talking to her family about her services.During a concurrent interview with the Social Worker (SW) on 4/8/24 at 4:10 pm she stated she was the Bereavement Coordinator. SW stated she did not complete a Bereavement Risk Assessment on Patient 1 because there was no caregivers. She confirmed she later found out Patient 1 had sons and did not attempt to contact them. A review of a "Bereavement Program" policy and procedure dated 2/7/18 indicated the agency has a comprehensive bereavement program that includes assessing and care planning anticipated bereavement needs for hospice patients and significant family members. Bereavement risk factors and needs of the family members, caregivers and significant others are identified and documented as low, moderate or a high risk. Each level of risk factor would identify the support and actions of the agency. There was no bereavement risk assessment, risk factor or care plan implemented for Patient 1.

Based on interview, record review, and facility's policy review, the agency failed to complete an initial assessment, Plan of Care (POC, a detailed guide for the patient’s end of life care, outlining specific needs and services provided to ensure comfort and quality of life that includes physician orders) for two out of 14 sampled patients (Patient 7, and Patient 10).  This failure could result in changes to care without physician's knowledge or approval, and specific needs of the patients not identified with no needed interventions implemented needed for quality care which could lead to negative clinical outcomes. --- Findings: A review of the agency’s policy dated, 2/7/2018, titled, “Plan of Care,” indicated the POC specifies the care and services necessary to meet the needs of the patient and caregiver as identified in the initial, comprehensive, and updated assessments of the patient. Each patient and his or her primary caregiver receive education and training from the hospice as appropriate to their responsibilities for the care and services provided in the POC. This policy also indicated the patient’s POC includes all services necessary for the palliative and management of the terminal illness and related conditions. The POC must include but is not limited to interventions to manage pain and symptoms, a detailed statement of the scope and frequency necessary to meet the specific patient and family needs.A review of the agency’s policy dated, 11/2018, titled, “Assessment of the Hospice Patient,” indicated an initial assessment to determine the patient’s immediate care and support needs is conducted by the hospice nurse within 48 hours of the patient’s election of hospice care. An initial assessment visit is made earlier than 48 hours if requested by the patient, family, and/or if the patient’s needs warrant it.A review of the agency’s policy dated and approved 3/26/25, titled, “Admission to Hospice-Referrals and Process,” indicated the hospice nurse (RN) will be responsible for implementing this procedure with the patient and caregiver/family. This initial assessment will take place within 48 hours of receipt of signed certification. During a review of Patient 7’s clinical record, Patient 7 was admitted to the hospice agency on 2/28/25 with diagnoses that included brain cancer, malignant neoplasms of the lungs, (lung cancer) and encephalopathy (the brain is not working properly due to an infection or disease). During an interview on 4/9/25 at 2:20 pm, the social worker confirmed she could not find a POC for Patient 7 admitted to the agency on 2/28/25 in the clinical record or the hard copy of the medical record. During a concurrent interview and record review on 4/10/25 at 9:50 am, Registered Nurse (RN) A confirmed there was no initial assessment, plan of care for Patient 7 admitted on 2/28/25. RN stated, “I have looked in the hard copy chart as well, there is no POC for Patient 7.          During a review of Patient 10’s clinical record, the record indicated Patient 10 was admitted to the hospice agency on 12/10/24 with diagnoses that included malignant neoplasm (cancerous tumor) of the brain.Patient 10's clinical record included a referral for services on 11/22/24, and the first start of care skilled nursing visit was documented on 12/10/24 for hospice services. During an interview and review of Patient 10’s clinical record, there was no Physicians Plan of Care (orders) found. There was only a referral for the hospice services which included instructions for Skilled Nursing (SN) , and Medical Social Worker (MSW) to assess and evaluate for services.During a interview and record review on 4/10/25 at 9:30 am with Registered Nurse (RN) B she confirmed there was no initial Physicians Plan of Care found for the services provided. There was two SN visits, one prn (as needed) and one Social Worker (SW) visits for the four days Patient 10 was receiving hospice services.

Based on interview, record review, and facility's policy review, the agency failed to individualize the Plan of Care (POC) for 4 out of 14 sampled patients when: 1. Patient 2 did not have a Skilled Nursing (SN) frequency for visits needed.2. Patient 4 had no specific orders, interventions or goals for the disease processes.3. Patient 11 had no SN orders or treatments, interventions or goals listed on the POC. 4. Patient 13 had no specific wound care instructions on the POC. These failures resulted in no physician oversight of frequency, education of specific problems not provided, the potential for specific needs to not be identified, and the potential for poor symptom management leading to negative clinical outcomes. --- Findings: 1. A review of the agency’s policy dated, 2/7/2018, titled, “Plan of Care (POC),” indicated that the POC specifies the care and services necessary to meet the needs of the patient and caregiver as identified in the initial, comprehensive, and updated assessments of the patient. Each patient and his or her primary caregiver receive education and training from the hospice as appropriate to their responsibilities for the care and services provided in the POC. This policy also indicated the patient’s POC includes all services necessary for the palliative and management of the terminal illness and related conditions. The POC must include but is not limited to interventions to manage pain and symptoms, a detailed statement of the scope and frequency necessary to meet the specific patient and family needs. Patient 2's clinical record was reviewed. Patient 2 was admitted to the hospice  agency on 11/9/23, with diagnoses that included malignant neoplasm of the breast (breast cancer), high blood pressure, end stage kidney disease (gradual loss of kidney function) and depression. During a review, of Patient 2’s clinical record, a document dated 11/9/23, titled, “Hospice Plan of Care,” indicated there was no SN frequency listed for the POC signed by the physician on 11/30/23. During a concurrent interview, and record review, on 4/8/25 at 3:40 pm, Registered Nurse (A) confirmed, that Patient 2 had no SN frequency for the visits listed on the POC as required for physician oversight and scheduling. 2. Patient 4's clinical record was reviewed. Patient 4 was admitted to the hospice agency on 3/13/25, with diagnoses that included metastatic biliary tract (cancer has spread from the original site of the gall bladder and bile ducts), malignant neoplasm of ampulla Vater (a rare cancer that develops in the small opening in the first part of the small intestine where the pancreas and bile ducts join) and agranulocytosis (serious condition when the body does not produce enough white blood cells to fight infection). During a review, of Patient 4’s clinical record, a document dated 3/13/25, titled, “Hospice Plan of Care,” indicated there were no specific interventions for education on three separate disease processes not explained on the POC signed by the physician on 3/21/25. During a concurrent interview, and record review, on 4/9/25 at 9:30 am, RN A confirmed Patient 4’s POC did not contain specific interventions to educate on the specific disease processes for Patient 4 and caregivers to understand. RN A confirmed that this POC was not specific to Patient 4’s needs. 3. Patient 11's clinical record was reviewed. Patient 11 was admitted to the hospice agency on 3/14/24, with diagnoses that included malignant neoplasm of upper lobe (cancerous tumor in the top portion of the lung), Chronic Obstructive Pulmonary Disease (COPD, a progressive lung disease that causes shortness of breath), chronic kidney disease (progressive damaged kidneys), and atrial fibrillation (irregular heart beat).  During a review, of Patient 11’s clinical record, a document dated 3/14/25, titled, “Hospice Plan of Care,” indicated there were no SN interventions or goals listed at all on this POC.  During a concurrent interview, and record review, on 4/9/25 at 3:35 pm, RN A confirmed, that Patient 11’s POC did not contain any SN interventions or goals on the POC signed by the physician on 3/25/25.  4. Patient 13's clinical record was reviewed. Patient 13 was admitted to the hospice  agency on 7/5/24, with diagnoses that included chronic kidney disease  (gradual loss of kidney function), pneumonia (infection of the lungs), phlebitis (inflammation of the vein), and depression. During a review, of Patient 13’s clinical record, a document dated 7/5/24, titled, “Hospice Plan of Care,” indicated that there were no specific SN interventions or goals for wound care, pneumonia, depression and urinary tract infections.   During a concurrent interview, and record review, on 4/9/25 at 3:35 pm, RN A confirmed, that Patient 13’s POC did not contain any specific, individualized SN interventions or goals on the POC signed by the physician on 3/25/25. During an interview, on 4/9/25 at 4:50 pm, the Chief Clinical Officer (CCO) confirmed the POCs were not individualized for Patients 2, 4, 11, and Patient 13.

Based on interview, and record review, the agency failed to ensure plans of care contained orders for PRN (as needed) visits, with appropriate indications to justify the desired proposed visits for various disciplines for 12 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 8, 9, 11, 12, 13, and Patient 14).  This failure could result in unnecessary or inappropriate visits by the agency, which could lead to fraudulent billing practices. --- Based on interview and record review twelve of fourteen sampled patients plan of care (POC, physicians orders ) failed to contain an indication to support  the  PRN (as needed ) visit completed (Patient  1, 2, 3, 4, 5, 6, 8, 9, 11, 12, 13 and 14).Theses failed actions had the potential for unauthorized visits, and services to occur.Findings:During a clinical record review of all fourteen sampled patients (1-11) it was noted that their POC's failed to have a documented frequency, and indications to support the PRN visits.During an interview and record review of all the fourteen sampled Patients with the Registered Nurse (RN) A and B ) on 4/10/24 at 9:50 am acknowledged that all of the fourteen sampled Patients POC did not contain a frequency, or indication for their on call (PRN) visits.According to the Medicare Benefit Policy Manuel 30.2.3-Specificity of Orders (Rev. 10438, Issued: 11-06-20, Effective 03-01-20, Implementation: 01-11-21).The order of the plan of care must indicate the type of services to be provided to the patient, both with respect to the professional who will provide them and the nature of the individual services as well as the frequency of the services.All orders for services to be furnished "as needed, "or "PRN," must be accompanied by a description of the patients medical signs and symptoms that would occasion a visit and a specific limit on the number of those visits to be made under the order before an additional physician or allowed practitioner order would have to be obtained.    Findings:A review of the agency’s policy dated, 2/7/2018, titled, “Plan of Care,” indicated the patient’s POC includes all services necessary for the palliative and management of the terminal illness and related conditions. The POC must include but is not limited to interventions to manage pain and symptoms, a detailed statement of the scope and frequency necessary to meet the specific patient and family needs. The number of as needed (prn) visits should be specified with possible reasons a prn visit may be necessary.During the survey, from 4/8/25 through 4/10/25, 14 patient records, which included the plans of care, were reviewed.  It was noted that 12 of the 14 clinical records (Patients 1, 2, 3, 4, 5, 6, 8, 9, 11, 12, 13 and 14) had plans of care that included prn visits for various disciplines that did not include any indication to explain why the visits were needed. There were two clinical records with no POC for Patient 7 and Patient 10. During an interview on 4/9/25 at 4:50, the Chief Clinical Officer (CCO) confirmed the above findings and stated that the agency previously had not included any indications with their prn visits but would start doing so moving forward.During a telephone interview on 4/10/25 at 11:40 am, the Hospice Manager (HM) confirmed the prn orders for all the POCs were not patient specific for indications for use. HM stated, “I know moving forward and we will make sure each prn has a specific indication for use.”

Based on interview, record review, and policy review the agency failed to have an effective clinical management to provide oversight of staff to establish and implement all policies, to ensure the agency provided care and services within the acceptable standards of practice when the agency failed to: 1. Ensure the Hospice Manager (HM) Registered Nurse was trained and verbalized the federal and state regulations for the Hospice Agency. 2. Ensure there were skills competency check lists for all current RNs providing direct care for symptom management. 3. Ensure there were Home Health Aide (HHA) supervisory visits every 14 days.4. Ensure all Plans of Care (POC)s had frequencies, interventions, and goals. 5. Ensure there was a wound measurement policy and process for any altered skin integrity or the potential for any wounds. Refer to L535.6. Ensure there were medication reconciliation policies and added to the POC.  Refer to L549. 7. Ensure all medication errors, and unusual occurrences are reported as indicated. 8. Ensure the Certification of Terminal Illness was signed before the initial assessment for hospice services. Refer to L667.These failures had the potential to lead to poor case management, and negative clinical outcomes. --- 1. A review of a document not dated, titled, “Job Description, Hospice Manager,” indicated under specific competencies the HM operates hospice in accordance with federal, state, and professional standards and regulations, maintaining licenses and certifications…Oversees day to day operations, keep policies and procedures current to fulfill the program objectives, and oversees scheduling, supervision and ongoing education for HHA and other staff members.   During a telephone interview on 4/10/25 at 11:45 am, the HM stated, “I confirm I was not trained on the federal and state regulations, I do not know the regulations. I was just thrown into this position, I was never checked off as a RN, only as a Licensed Vocational Nurse (LVN).” 2. During a phone interview on 4/10/25 at 11:45 am, the HM stated, “I confirm I do not have any skill competency check lists for the current staff, the old list was outdated, and I have not made a new one. I have been on visits with the staff, but there is no official check off list for competencies.” 3. During a review of the agency’s policy dated 2/20/2020, titled, “Hospice Aide Supervision,” indicated Hospice Aides are supervised by a Registered Nurse (RN) in a manner and frequency that assures the safety of patients, and the quality of aide services provided. A RN makes an on-site visit to the patient’s home no less frequently than every 14 days to ensure that the services ordered by the Interdisciplinary Team or Group (IDT, a group of professionals involved in the coordination of care that brings together knowledge from different disciplines to help people receive the care they need) and provided by the aide are meeting the patient’s needs. The Hospice Aide need not be present.During a phone interview on 4/10/25 at 11:45 am, the HM stated, “I did not know the HHA needed to be supervised every 14 days, I thought it was every 60 days like the LVNs. I will know moving forward.” 4. A review of the agency’s policy dated, 2/7/2018, titled, “Plan of Care,” indicated the POC specifies the care and services necessary to meet the needs of the patient and caregiver as identified in the initial, comprehensive, and updated assessments of the patient. Each patient and his or her primary caregiver receive education and training from the hospice as appropriate to their responsibilities for the care and services provided in the POC. This policy also indicated the patient’s POC includes all services necessary for the palliative and management of the terminal illness and related conditions. The POC must include but is not limited to interventions to manage pain and symptoms, a detailed statement of the scope and frequency necessary to meet the specific patient and family needs.During a phone interview on 4/10/25 at 11:45 am, HM confirmed she had never been taught specifically how to develop a plan of care for hospice patients. 7. During an interview on 4/8/25 at 4:40 pm, the Chief Commercial Officer (CCO) confirmed he did not report a medication error for Patient 2. CCO stated, “I was going to check with Quality Assurance to see how they are reported, and with any unusual occurrences.”During an interview on 4/10/25 at 12:30 pm, the Quality Assurance Officer (QA) confirmed the new HM is still learning and they will provide additional training to make sure the POCs are complete, and all federal and state regulations are taught. QA stated, “The HM wants to learn, but there is a lot to learn in this job, we will make sure it happens.”

Based on interview, record review, and agency's policy review, the agency failed to ensure two of 14 sampled patients (Patient 4, and Patient 7) had an initial certification of terminal illness signed by the physician before admission to the hospice agency.  This failure had the potential to not identify all current patient needs to develop the plan of care for each patient at the time of admission to the hospice agency, and has poses the risks of inappropriate patient's being admitted into hospice care. --- Findings: During a review, of the agency’s policy dated 2/16/23, titled, “Certification of Terminal Illness Hospice,” it indicated that it is the policy of this specific hospice agency to utilize the initial fax or electronic medical record Certification and Plan of Care (POC) for Medicare/Medi-Cal Hospice benefit requirements of original certification of Hospice Benefit patients. The medical director, or physician designee reviews the clinical information for each hospice (end of life care) patient and provides written certification that is anticipated that the life expectancy is six months or less if the illness runs its normal course. Subsequent recertification will utilize the Physician’s Certification of Terminal Illness signed by the Medical Director.  Patient 4's clinical record was reviewed. Patient 4 was admitted to the hospice agency on 3/13/25, with diagnoses that included metastatic biliary tract (cancer has spread from the original site of the gall bladder and bile ducts), malignant neoplasm of ampulla Vater (a rare cancer that develops in the small opening in the first part of the small intestine where the pancreas and bile ducts join), and agranulocytosis (serious condition when the body does not produce enough white blood cells to fight infection).  During a concurrent interview, and record review, on 4/9/25 at 9:05 am, Registered Nurse (RN) A confirmed, that there was no initial certification of terminal illness in the clinical record for Patient 4 signed by the physician.   During an interview, on 4/9/25 at 9:19 am, the Social Worker confirmed there was no signed certification of terminal illness signed in the hard chart for Patient 4. Patient 7's clinical record was reviewed.  Patient 7 was admitted to the hospice agency on 2/28/25, with diagnoses that included brain cancer, malignant neoplasms of the lungs, (lung cancer) and encephalopathy (the brain is not working properly due to an infection or disease). During a concurrent interview, and record review, on 4/9/25 at 2:40 pm, RN A confirmed, that there was no initial certification of terminal illness in the clinical record for Patient 7 signed by the physician, and Patient 7 was discharged on 3/3/25. During an interview, on 4/9/25 at 2:45 pm, RN A confirmed, that there was no signed certification of terminal illness signed in the hard chart for Patient 7.

Based on interview, record review, and agency's policy review, the agency failed to identify, document safety interventions, and education for in-home oxygen therapy use for one out of 14 sampled patients (Patient 5). This failure resulted in Patient 5 sustaining an injury which required a visit to the hospital to be treated, and could have resulted in serious adverse consequences. --- Findings: A review, of the agency’s policy dated, 2/7/2018, titled, “Plan of Care (POC),” indicated that the POC specifies the care and services necessary to meet the needs of the patient and caregiver as identified in the initial, comprehensive, and updated assessments of the patient. Each patient and his or her primary caregiver receive education and training from the hospice as appropriate to their responsibilities for the care and services provided in the POC. This policy also indicated the patient’s POC includes all services necessary for the palliative and management of the terminal illness and related conditions. The POC must include but is not limited to interventions to manage pain and symptoms, a detailed statement of the scope and frequency necessary to meet the specific patient and family needs. Patient 5's clinical record was reviewed. Patient 5 was admitted to the hospice  agency on 10/3/24, with diagnoses that included malignant neoplasm of the left lower lung (lung cancer), Chronic Obstructive Pulmonary Disease (COPD, a progressive lung disease that causes shortness of breath), and anxiety (feelings of worry, nervousness, or uneasiness), insomnia (difficulty falling asleep or staying asleep), history of nicotine dependency, and the supplemental in-home oxygen therapy. During a review, of Patient 5’s clinical record, a document dated 10/3/24, titled “Hospice Plan of Care,” indicated there were no specific oxygen precautions, or education listed under safety. During a concurrent interview, and record review, on 4/9/25 at 9:10 am, Registered Nurse (RN) A confirmed, that there were no safety measures for oxygen on the first plan of care dated 10/3/24. RN A confirmed, that Patient 5, and the family needed an oxygen sign at the home for safety, and additional education regarding oxygen safety.  RN A reported that Patient 5 had to gone to the Emergency Room two times since his admission related to accidents surrounding his oxygen treatment. RN A stated that they did not know that he was still smoking while on ordered oxygen.  During an interview, on 4/9/25 at 10:40 am, RN A confirmed, that Patient 5 needed additional education for oxygen safety, and smoking which had the potential for serious injury for Patient 5, and the family living in the home. RN A stated, “I will further educate him on oxygen safety during  every visit from now on."

Based on interview, and record review, eleven of 11 sampled patients plans of care (POC, physicians orders) failed to contain a frequency, and indication to support the PRN (as needed) visits completed. These failed actions had the potential for unauthorized visits, and services to occur. Findings: During a clinical record review, of all eleven sampled patients (Patients 1-11), it was noted that their POC's failed to have a documented frequency, and indications to support the PRN visits. During an interview, and record review, of all eleven sampled patients with the Hospice Manager (HM) on 6/29/22 at 4:30 pm, she acknowledged that all eleven patients POC's did not contain a frequency, or indication for their on call (PRN visits). The HM explained that all patients orders are originally ordered 1-2 times weekly, and PRN until they are changed by the physician. The HM acknowledged that the agency frequently has to make PRN visits for many reasons, including pain and symptom management. According to the Medicare Benefit Policy Manual 30.2.3 - Specificity of Orders (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01-11-21). The orders on the plan of care must indicate the type of services to be provided to the patient, both with respect to the professional who will provide them and the nature of the individual services, as well as the frequency of the services. All orders for services to be furnished "as needed," or "PRN," must be accompanied by a description of the patient's medical signs and symptoms that would occasion a visit and a specific limit on the number of those visits to be made under the order before an additional physician or allowed practitioner order would have to be obtained.

Based on interview, and record review, the facility failed to follow the plan of care (physician orders) for two of eleven patients (Patients 6, and 8) when two scheduled Home Hospice Aide (HHA) visits, and one Social Work (SW) visit were not made for Patient 6, and four HHA visits were not made for Patient 8. This failure had the potential for Patients 6, and 8 to not receive necessary care and treatments that could lead to a negative clinical outcomes. Findings: 1. A review of the clinical record indicated that Patient 6 was admitted on 7/9/21, with a diagnosis of heart disease. A review of the plan of care for Patient 6 indicated that the HHA was to visit the patient once or twice a week, and the SW was to visit once a month. A review of the visits scheduled for Patient 6 indicated that no HHA visit was made during the week of 7/18/21, or the week of 8/15/21. No SW visits were made during August 2021. Patient 6's clinical record indicated no documentation regarding any missed visits. During an interview, on 6/29/22 at 4:25 pm, the Hospice Manager (HM) stated that missed visits should be documented and marked "declined." The HM confirmed that Patient 6 did not receive HHA visits during the weeks of 7/18/21, or 8/15/21, and that these missed visits were not documented. During an interview, on 6/29/22 at 4:35 pm, SW confirmed that she made no visits to Patient 6 during August 2021, and the missed visit were not documented. 2. A review of the clinical record indicated that Patient 8 was admitted on 12/3/21, with a diagnosis of lung cancer. A review of the plan of care for Patient 8 indicated that the HHA was to visit once or twice a week. A review of the visit schedule for Patient 8 indicated that no HHA visits were made from 12/11/21 through 1/13/22. Patient 8's clinical record contained no documentation regarding any missed visits. During an interview, on 6/29/22 at 4:40 pm, the HM confirmed that no HHA visits were made to Patient 8 between 12/11/21, and 1/13/22, and there was no documentation of this. During an interview, on 6/30/22 at 10:45 am, the Chief Operations Officer (COO), stated that the facility did not have a policy regarding missed visits. The COO confirmed staff should document any missed visits in the clinical record, and that not documenting a missed visit did not follow their facility expectations.

Based on observation, interview, and record review, the facility failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions when the Licensed Nurse (LN) did not follow proper bag and barrier technique during two out of two observed home visits (Patients 1 and 2). This failure had the potential to contribute to the spread of disease among patients and staff when equipment and supplies are potentially cross contaminated leading to negative clinical outcomes. Findings: A review of a facility policy titled, "Infection Control - Bag Technique," approved 8/16/17, indicated that nurses are required to have a home care bag. The staff are required to maintain their bags with equipment and clean supplies at all times, and that equipment shared between patients must be cleaned with disinfectant after each use and before supplies are returned to the bag. The policy additionally directed staff upon arrival to the patient's home, the bag would be placed on a clean surface utilizing newspaper, paper towels, or other barrier. The policy instructs the bag could be placed on a door nob if no barrier was available. 1. A review of the clinical record indicated that Patient 1 was admitted to the agency on 5/17/22, with a diagnosis of colon cancer. During an observation, of a home visit on 6/27/22 at 2:55 pm, LN A assessed Patient 1's pedal edema (foot swelling). Patient 1 placed her right foot on LN A's lap, with the blood pressure cuff resting beneath the foot. LN A removed the shoe and sock, and assessed the edema with bare hands. Then, LN A replaced the shoe and sock, and without sanitizing her hands, proceeded to measure vital signs using her stethoscope, blood pressure cuff, and oximeter. When finished, LN A replaced the stethoscope and oximeter around her neck and the blood pressure cuff in her pocket without sanitizing the equipment, or her own hands. LN A did not have a nursing bag to carry her equipment. During an interview, on 6/28/22 at 3:45 pm, LN A (also the Hospice Manager)confirmed she should have followed the agency bag technique to prevent the spread of infection, and promote the practice of standard precautions (infection control practices, that must be used at all times for all patients in all situations). 2. A review of the clinical record indicated that Patient 2 was admitted to the agency on 6/17/22, with diagnoses that included chronic pulmonary (lung) disease, and dependant on oxygen use. During a visit to Patient 2's home with the Hospice Manager (HM) on 6/28/22 at 5 pm, HM failed to use a barrier for her bag, and hung her bag on Patient 2's walker. On 6/29/22 at 11:15 am, HM was interviewed. HM acknowledged she hung her bag on Patient 2's walker and not a door knob. HM acknowledged that she should have used a barrier and placed her visit bag on it, and and not the patients personal walker.

Based on interview, and record review, six of 11 sampled patients plans of care (physicians orders) failed to be appropriately authenticated (signed by the physician), in accordance with hospice policy, and currently accepted standards of practice. This action has the potential for unauthorized medications, treatments, and services to be provided to patients which could lead to potential fraud, and negative clinical outcomes. Findings: During the clinical record review, Patients 4, 5, 6, 7, 9, and 11, indicated that their initial plan of care after their admission to the agency was not signed by the attending physician, or the Medical Director. Seven patients POC's had a hand written, "cc," documented where the physician, or the Medical Director were directed to sign. Patient 4 was admitted to the agency on 5/17/21, with diagnoses that included heart failure. Patient 5 was admitted to the agency on 7/6/21, with diagnoses that included cancer of the pancreas. Patient 6 was admitted to the agency on 7/9/21, with diagnoses that included heart disease. Patient 7 was admitted to the agency on 7/29/21, with diagnoses that included Alzheimer's disease (a progressive brain disease that effects memory, speech and mobility). Patient 9 was admitted to the agency on 1/27/22, with diagnoses that included cancer of the pancreas. Patient 10 was admitted to the agency on 5/24/22, with diagnoses that included lung cancer. Patient 11 was admitted to the agency on 5/20/22, with diagnoses that included cancer. During an interview, and record review, with the Hospice Manager (HM) on 6/29/22 at 5:35 pm, she stated that the "cc," stood for conference call. She stated the agency does not use electronic signatures. The HM acknowledged the above patients plans of care were not signed by the physician, or the Medical Director. On 6/30/22 at 9:30 am, the agency's Medical Director (MD) was interviewed. He stated it was the policy not to meet in person due to the COVID-19 (a serious respiratory virus). He stated on a weekly basis that he is available to sign patient's plans of care, and he can not answer why they were not forwarded to him for his signature (authorization). The MD stated it was a standard of practice to have physicians orders signed timely. A review of an undated agency policy titled, "Hospice: Medication - Orders," indicated that a copy of telephone/verbal orders are sent to the ordering physician for a signature, and should be signed within 30-days.

Based on observation, interview, and posted facility license review, the hospice agency failed to operate and furnish services in compliance with all applicable Federal, State, and local laws and regulations, when the hospice agency had moved and had not notified appropriate State agencies of their new address, in order to update their license in a timely manner (greater than four years). This action had the potential for misguided notifications, and failure to receive important State and Federal compliance updates to be received and acted upon. Findings: On 6/27/22 at 12 pm, the survey team attempted to find the hospice agency located at the address listed on their current license (on the hospital's main campus). At this time the Chief Operations Officer (CCO) was identified in the parking lot, and stated that the agency had moved from the hospital campus down the road into town. The CCO provided the team with the agency's current physical address. The address provided was not the current address on listed on their most currently issued license. During an interview, on 6/29/22 at 9:20 am, the Hospice Manager acknowledged that the posted agency license does not have the correct address listed. On 6/29/22 at 10:30 am, the Chief Executive Officer (CEO) reported that the hospice agency had moved to its current location from the hospital campus on 4/1/2018. The CEO was unaware if the appropriate State agencies had been notified their new address.

Based on interview, and record review, the facility failed to: 1. Establish a contingency plan (such as weekly testing or the use of additional personal protective equipment (PPE) for staff who have exemptions from the COVID-19 (a serious respiratory virus) vaccine, and 2. Establish a process for tracking and documenting the COVID-19 vaccination status of the volunteers. These failures had the potential to contribute to the spread of COVID-19 among patients and staff, which could lead to negative clinical outcomes. Findings: 1. A review of a facility document titled, "Immunization Program, Employee", approved on 3/28/22, indicated that no contingency plan was specified for unvaccinated staff. During an interview, on 6/28/22 at 2:45 pm, the Hospice Manager (HM) stated the facility expects unvaccinated staff to test weekly, and wear an N-95 respirator when visiting patients. The HM confirmed that this expectation is not included in the facility policy. 2. A review of the facility's staff COVID-19 vaccination log, indicated that the four volunteers were not included on the log, only the paid staff. During an interview, on 6/28/22 at 3:35 pm, the Human Resources Assistant (HRA) stated that she maintained the staff COVID-19 vaccination log for paid employees only, not the volunteers. During an interview, on 6/29/22 at 9:40 am, the Volunteer Coordinator (VC) stated that she did not track the COVID-19 vaccination status of volunteers. During an interview, on 6/29/22 at 10:20 am, the Hospital Foundation Director (HFD) confirmed that they have not tracked the COVID-19 vaccination status of their volunteers, and that they would need to revise their policy and procedures.