Every finding on record at International Tutoring Services, LLC

Upon patient record review 1 of 27 records (Patient #20) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #20: The patient was admitted on 8/9/24. The record indicated that the spiritual assessment was completed on 8/15/24.

Upon patient record review 1 of 27 records (Patient #11) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #11: There was not evidence of a spiritual assessment

Upon patient record review, 4 of 27 records (Patient #8,#9,#12,#13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #8: Upon patient visit, Lorazepam was listed on the medication profile at the ALF but was not included on the hospice medication profile. Corrected on site. In addition, Acetaminophen rectal suppository and Bisacodyl were on the Hospice medication profile but not the facility MAR. Corrected on site Patient #9: Upon patient visit, Ascorbic Acid was listed on the medication profile at the SNF but was not included on the hospice medication profile. Corrected on site. In addition, Acetaminophen suppository was on the Hospice medication profile but not the facility MAR. Corrected on site. Patient #12: Upon patient visit, medications in the home included Tums and Esomeprazole. The caregiver indicated that the patient was taking both of these medications. There was not evidence that they were on the hospice medication profile. In addition, upon patient record review the medication profile contained Coricidin chest congestion cough 10mg-200mg cap as needed per instructions. Corrected on site. Patient #13: Upon patient visit, the medication profile included Docusate Sodium, Gabapentin, Mirtazapine, Oxygen and Zonisamide. A medication reconciliation and comparison could not be completed as the bottles from these medications could not be found. There was a monthly pill planner in the home and on most days, the compartments from 9/1/24 to current still contained the medications for that particular day.

Upon patient record review, 4 of 27 records (Patient #11,#13,#17,#20) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #11: The patient was admitted on 1/20/24 and the record indicated that the bereavement assessment was completed on 2/8/24. Patient #13: The record indicated that the patient's wife lived with him and was the primary caregiver. There was not evidence of an initial bereavement assessment on the wife (only the son and God-daughter). Patient #17: The patient was admitted on 2/9/24 and the record indicated that the bereavement assessment was completed on 2/20/24. Patient #20: The record indicated that the patient lived with her spouse. There was not evidence that a bereavement risk assessment was completed on the spouse (Only completed on the daughter).

Upon patient record review, 2 of 27 records (Patient #5,#14) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #5,#14: The initial visit frequency for both the social worker and the spiritual care counselor was 1 prn with no indication of a scheduled frequency.

Upon patient record review, 5 of 27 records (Patient #7,#8,#9,#12,#13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #7: The certification of terminal illness indicated that the patient had/used an in and out urinary catheter. Nurse documentation indicated he had urinary retention and used it. There was not evidence of an order for catheter usage including how frequently and under what conditions to use the catheter. Corrected on site. Patient #8: Lorazepam was listed on the medication profile at the ALF. There was not evidence of an order for Lorazepam on the hospice record. Corrected on site. Patient #9: Ascorbic Acid was listed on the medication profile at the SNF. There was not evidence of an order for Ascorbic Acid on the hospice record. Corrected on site. Patient #12: The record contained an order for Coricidin chest congestion cough 10mg-200mg cap as needed per instructions. Corrected on site. In addition, medications in the home included Tums and Esomeprazole. The caregiver indicated that the patient was taking both of these medications. There was not evidence of an order. Corrected on site Patient #13: During an observed home visit, the nurse and patient were discussing that the nurse advised the patient to take Imodium for his complaint of diarrhea. There was not evidence of an order

Upon client record review, 4 of 27 records (Patient #1,#8,#13, #15) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The initial plan of care indicated for a volunteer evaluation. There was not evidence that this was performed. Patient #8: The visit frequency for the spiritual care counselor for the benefit period starting 6/18/24 was 1m1, 2m2, 1m1. The record indicated only 1 visit during the month of July. Patient #13: The nurse recommended Imodium on 8/30/24 due to the patients complaints of diarrhea, yet the record indicated that the patient remained on docusate sodium, 1 capsule BID. There was instruction provided with no order. Patient #15: The visit frequency for the social worker was 1m1, 2m2, 1m1 effective 6/24/24. The record indicated visits were conducted on 6/26/24, 7/10/24, 8/13/24 and 9/5/24.

Upon patient record review, 2 of 27 records (Patient #8,#12) did not have evidence that Social work services are based on the patient's psychosocial assessment and the patient/family's needs and acceptance of these services. Patient #8: The initial bereavement risk assessment which the RN conducted on the daughter dated 5/3/34 (admission), indicated that she was a high risk with a score of 10. Factors leading to this included but were not limited to a dependent relationship, family conflict, multiple loses and unresolved issues with the patient. There was not evidence of any follow-up regarding this assessment. Patient #12: The initial bereavement risk assessment which the RN conducted on the son was indicated as high risk with a score of 11. There was not evidence of any follow-up regarding this assessment.

Upon patient record review 1 of 27 (Patient #13) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #13: The aide visit frequency was 4x/week. For the week of 8/18/24-8/24/24, the record indicated only 3 visits. For the week of 8/25/24-8/31/24, the record indicted only 2 visits. For the week of 9/1/24-9/7/24, there was not evidence of a visit by the aide.

Upon personnel record review, 1 of 16 records (Personnel #14) did not have evidence in the hospice aide personnel file that a registered nurse made an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. The supervising nurse must assess an aide's ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include all required content. Personnel #14: There was not evidence that the following tasks were return demonstrated on a patient or pseudo-patient at the annual on-site visit: • Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. (42 CFR 418.76(b)(3)(i)) • Reading and recording temperature, pulse, and respiration (42 CFR 418.76(b)(3)(iii)) • Safe transfer techniques and ambulation. (42 CFR 418.76(b)(3)(ix)) • Normal range of motion and positioning (42 CFR 418.76(b)(3)(x)) • Appropriate and safe techniques in personal hygiene and grooming that include-(42 CFR 418.76(b)(3)(xi)) • Bed bath • Sponge, tub, and shower bath • Shampoo, sink, tub, and bed • Nail and skin care • Oral hygiene • Toileting and elimination

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The volunteer percentage of usage for the year 2023 was reported as 3.98%.

Upon patient client record review, 1 of 27 records (Patient #21) did not evidence that each patient record contains all physician orders. Patient #21: The patient was discharged for cause. There was not evidence of a physician order from the medical director to discharge the patient.

Upon patient client record review, 4 of 27 records (Patient #1,#2,#7,#15) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #1: The patient was admitted 7/19/24 and was a Full Code at that time. On 8/25/24, the patient signed an OOHDNR for a no code. All IDG plans of care from admission listed the patient as a NO code. Patient #2: The legal admission document which had a question, "Does the patient have an Advance Directive or not" was not completed. Neither checkbox was filled, both were left blank. Patient #7: The patient was admitted on 3/21/24 and was a Full Code. The OOHDNR was obtained on 7/10/24. The IDG plan of care updates listed the patient as a DNR from admission. Patient #15: The patient was admitted 6/24/24 and was a Full Code at that time. On 8/25/24, the patient signed an OOHDNR for a no code. All IDG plans of care from admission listed the patient as a NO code.

Upon client record review, 2 of 27 records (Patient #21,#23) did not have evidence that the discharge summary includes all required information. Patient #21, #23: There was not evidence of a summary of the patient's stay, including treatments, symptoms and pain management.

Upon client record review, 1 of 27 records (Patient #10) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #10: The visit frequency for the spiritual care counselor was for an evaluation and then 2m2, 1m1 effective 8/12/24. The patient was admitted on 8/12/24. The evaluation was conducted on 8/12/24 with no evidence of further visits.

Upon client record review, 1 of 27 records (Patient #14) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #14: The record indicated an order dated 8/13/24, wound care to MASD sacral area. Clean with wound cleanser. Apply collagen sheet. Cover with bordered gauze. Wound care to be provided by facility nurse or hospice nurse. There was not evidence that specifically identify which provider (nursing facility or hospice) is responsible for performing the wound care. Corrected on site.

Upon patient record review, 2 of 8 (Patients #2,#8) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient 2: The medical record contained documentation of a phone call to triage 9/1/23 identifying patient was having increased agitation and the facility stated medications ordered a week ago had not been delivered and were not available for administration. Triage recommended visit to be made but there was no evidence of a visit completed. Patient 8: The medical record contained a PRN nursing visit 1/3/23 for reported combativeness. An order for Benedryl topical gel was previously ordered to a local pharmacy 1/2/23. The local pharmacy did not have the medication available. The agency did not utilize an immediate delivery option in response to PRN visit for combativeness, instead a nurse documented that follow up would be made with the pharmacy the next day. Additional nurse documentation 1/4/24 identified the pharmacy still did not have medication and was expecting delivery that night. There was no further documentation to verify medication was received.

Upon patient record review, 1 of 8 (Patient #2) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 2: The medical record contained documentation of a phone call to triage 9/1/23 identifying patient was having increased agitation and the facility stated medications ordered a week ago had not been delivered and were not available for administration. Ativan and Tramadol ordered 8/23/23 was the medication referenced. The agency did not utilize an immediate delivery option in response to report increase in agitation, instead a nurse documented medications to be delivered in the morning. There was no evidence of a nursing visit completed per triage recommendation.

Based on record review and interview, the hospice failed to maintain a system of communication in accordance with its own policies that provided ongoing sharing of information with other non-hospice providers that furnished services unrelated to the terminal diagnosis in 1 (#2) of 3 patient records reviewed of patients that resided at Skilled Facility X. The failure placed the patients at risk for inappropriate care and negative outcomes. --- The agency had a policy titled "Provision of Care to Residents of SNF/NF, ICF/IDD or ALF," labeled Policy No. 4-038 with a revised date of 11/2020. The policy read in part: "Purpose to ensure the coordination of care provided to residents of Skilled Nursing Facilities/Nursing Facilities (SNF/NF), Intermediate Care Facilities/Individuals with Intellectual Disabilities (ICF/IID), or Assisted Living Facilities (ALF). Policy Core Services including physician, nursing, social work, counselors, medical supplies, durable medical equipment and drugs related to the terminal illness will be directly provided by hospice. Other services may be provided. A designated interdisciplinary group member is responsible for the coordination of services...Procedures...5. The hospice will designate a member of each interdisciplinary group that is responsible for a patient who is a resident of the skilled nursing facility...The designated member is responsible for: a. Providing overall coordination of hospice care of the resident with the facility representatives..." The agency used an electronic medical record system. Patient #2: Record review of Patient #2's record revealed Plans of Care dated 5/18/2023, 6/1/2023, 6/15/2023, 6/29/2023, 7/13/2023, and 7/27/2023. The Plans of Care indicated that Patient #2 was admitted to the agency's services on 9/17/2021. The Plans of Care listed Alzheimer's Disease (brain disorder that slowly destroys memory and thinking skills, and the ability to carry out the simplest tasks) with Early Onset as the terminal diagnosis. Patient #2's record indicated that Patient #2 resided at Skilled Facility X. Licensed Vocational Nurse C conducted a skilled nurse visit on 5/22/2023. Licensed Vocational Nurse C documented the visit on an agency document titled "Visit Note Report." Licensed Vocational Nurse C documented that Patient #2's right hand at the thumb joint was slightly swollen and warm. Licensed Vocational Nurse C notified Physician Z. Physician Z ordered Ibuprofen (a nonsteroidal anti-inflammatory drug used for inflammation) 400 milligrams 4 times each day for 14 days. Licensed Vocational Nurse C hand wrote the order for Ibuprofen 400 Milligrams by mouth 4 times a day for 14 days and gave the order to a nurse that worked at Skilled Facility X. Licensed Vocational Nurse C documented the order for Ibuprofen in the hospice's record as follows: Ibuprofen 400 milligrams, start date 5/22/2023 and end date 6/4/2023, 4 times daily by mouth. Registered Nurse D conducted skilled nurse visits on 6/7/2023, 6/21/2023 - Comprehensive Assessment, 6/21/2023, 6/28/2023, 7/5/2023, 7/12/2023, 7/12/2023, 7/20/2023, 7/27/2023, and 7/31/2023 - post hospital. Registered Nurse D did not indicate that Ibuprofen was ordered to be continued past the ordered end date of 6/4/2023. Licensed Vocational Nurse C conducted skilled nurse visits on 6/5/2023, 6/19/2023, 6/26/2023, 7/3/2023, 7/10/2023, and 7/17/2023. Licensed Vocational Nurse C did not indicate that Ibuprofen was ordered to be continued past the ordered end date of 6/4/2023. The hospice had Interdisciplinary Team meetings on 6/15/2023, 6/29/2023, 7/13/2023, and 7/27/2023. The Plans of Care did not include Ibuprofen. The Medication Administration Record from Skilled Facility X indicated that Patient #2 was administered Ibuprofen from 5/22/2023 through 7/29/2023. Patient #2 was hospitalized 7/24/2023 to 7/26/2023 and returned to Skilled Facility X on 7/26/2023. The Ibuprofen was restarted at Skilled Facility X with one dose given on 7/26/2023 and three doses given on 7/27/2023. Patient #2 was sent to the hospital on 7/27/2023 and returned to the facility on 7/31/2023. The Medication administration record indicated that on 7/31/2023 that Ibuprofen was refused by Patient #2's family member. Patient #2 was hospitalized on 7/24/2023 for gastrointestinal bleeding. Patient #2 returned from the hospital to Skilled Facility X on 7/26/2023. Patient #2 returned to the hospital on 7/27/2023 for gastrointestinal bleeding. Patient #2 returned from the hospital to Skilled Facility X on 7/31/2023. Patient #2 received blood transfusions while hospitalized. On 8/1/2023 a care plan meeting was conducted between Patient #2's family, Skilled Facility X's staff, and the hospice's staff, Registered Nurse D, Registered Nurse E, and Social Worker F. Registered Nurse D documented that miscommunication regarding prior Ibuprofen order and Patient's #2's recent hospitalizations related to gastrointestinal bleeding were discussed. Registered Nurse D documented that a nurse at Skilled Facility X failed to enter a stop date for the Ibuprofen and Patient #2 had received Ibuprofen since 5/22/2023. During an interview on 9/7/2023 at 1:40 p.m. with Licensed Vocational Nurse C, the surveyor discussed Patient #2 and the Ibuprofen that was ordered on 5/22/2023. Licensed Vocational Nurse C informed the surveyor that the Ibuprofen was ordered due to swelling to the wrist, that the order was for 14 days, the order was written and given to the facility nurse, the hospice staff cannot write orders in the facility chart, that Licensed Vocational Nurse C does not conduct comprehensive assessments, and asked the facility nurse about medications or would look at the medication administration record. Licensed Vocational Nurse C stated that since the issue with the Ibuprofen, "I ask the facility nurse to print off the medication administration record." During an interview on 9/7/2023 at 1:54 p.m. with Registered Nurse D, the surveyor discussed Patient #2 and the Ibuprofen that was ordered on 5/22/2023. Registered Nurse D informed the surveyor that the Ibuprofen was ordered for two weeks. Registered Nurse D informed the surveyor that Registered Nurse D coordinated the nursing facility and checked with staff for any updates and medications. Registered Nurse D informed the surveyor that Registered Nurse D mainly asked the nurse about medications and had not asked the facility to print a medication administration record. Registered Nurse D stated that Registered Nurse D would stand with the facility nurse and verbally compare medications. Registered Nurse D and Licensed Vocational Nurse C failed to maintain ongoing communication with the nursing staff at Skilled Nursing Facility X. Patient #2 continued to be given Ibuprofen through 7/29/2023, almost two months after the stop date for the Ibuprofen. On 8/1/2023, a care plan meeting was conducted with Patient #2s family, Skilled Facility X staff, and hospice staff when it was discovered that the Ibuprofen was not stopped on 6/4/2023. Nursing 2015 Drug Handbook. Wolters Kluwer. Pages 721 - 725. 2015. "Ibuprofen...Indications and Dosages Rheumatoid arthritis, osteoarthritis, arthritis Adults: 300 to 800 milligrams by mouth, three or four times a day...Adverse Reactions...Hematologic...prolonged bleeding time...Black Box Warning...Use cautiously in elderly patients...Black Box Warning...non-steroidal anti-inflammatory agents cause an increased risk of serious gastrointestinal bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. Elderly patients are at greater risk..."

Upon patient record review, 1 of 5 (Patient #3) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. Patient #3 - The record indicated the patient had a primary terminal diagnosis of neoplasm of upper left bronchus. The physician CTI narrative indicated the patient has frequent episodes of dyspnea and has oxygen 2-4L NC PRN for respiratory comfort. There is no evidence in the plan of care of a respiratory problem with individualized goals and interventions. Corrected on Site

Upon patient record review 1 of 5 (Patient #5) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the interdisciplinary group and included in the plan of care Patient #5 - The record indicated on the initial plan of care an aide visit frequency order for 5x/week. There was no evidence in the record of a 5th visit or a missed visit report for weeks of 9/26 and 10/3. Corrected on Site.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence that when the patient/family selected the option to receive the Patient Notification of Hospice Non-Covered Items, Services and Drugs that it was provided. Patient #5 - The patient elected to receive the Patient Notification of Hospice Non-Covered Items, Services and Drugs form. There was no evidence in the record that it was given to the patient/family. Corrected on Site

Upon patient record review, 1 of 2 applicable (Patient #1) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #1 - The record indicated the social worker visit frequency to be weekly. Documentation revealed in the 9/30/21 social worker visit note that she was going to decrease visits to 2 times/month. The next visit was 10/19/21 but there was no evidence of an order to decrease the visit to 2 times/month. Corrected on Site