Every finding on record at Jazmine Enterprises, LLC

It is required that the written Patient Bill of Rights includes the right to have person and property treated with respect by anyone providing services on behalf of the hospice. This standard was not met as evidenced by document review, interview and observation. In 1 of 3 (33%) home visit observations revealed that the agency did not ensure that the patient was properly treated with respect while receiving services on behalf of the hospice. Document 1: Policy No. 9-005 Bill of Rights revision date 10/2024 read in part "1. The Bill of Rights statement defines the right of the patient to: A. Have his or her property and person treated with respect." Document 6: Hospice Admission Booklet revision date 05/2024 page 14 read in part "Privacy and Security-You have the right to" Personal privacy and security during home care visits and to have your property and person treated with respect." Home Visit 1: The patient elected hospice care on 07/19/2024 with a diagnosis of Atherosclerotic Heart Disease. During the home visit on 11/12/2024 with the registered nurse (personnel record 1), the registered nurse was observed performing a complete nursing assessment, peri care, Foley flush, and wound care. Upon entering the patient's room, the patient was found lying in bed with a sweater on with a sheet and blanked draped over her body. The registered nurse began the assessment and obtained vital signs (blood pressure, temperature, respirations, pulse, and oxygen saturation). After the completion of the nursing assessment, the registered nurse removed the sheet and blanket exposing patient's lower body. The patient's lower body remained exposed throughout peri care, Foley flush and wound care to the buttocks. The registered nurse left the bedside to retrieve supplies for wound care and left the patient's lower body exposed. The observation lacked evidence that the registered nurse treated the patient's person with respect and maintained privacy while providing hospice care. The Bill of Rights Policy and Hospice Admission Booklet were reviewed during an interview with the Clinical Director (personnel record 6) on 11/12/2024. The Clinical Director confirmed the policy and stated in part "The nurse thought it was okay as long as the door was shut."

It is required that each patient’s individualized written plan of care includes the drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, interview and observation. In 1 of 14 (7%) clinical records reviewed revealed that the agency did not ensure that the plan of care included the drugs and treatment necessary to meet the needs of the patient. Document 1: Policy No. 9-017 The Plan of Care revision date 10/2019 read in part "The written plan of care will contain, but will not be limited to, S. drugs and treatments." Clinical Record 1: The patient elected hospice care on 07/19/2024 with a diagnosis of Atherosclerotic Heart Disease. During the home visit on 11/12/2024 with the registered nurse (personnel record 1), the registered nurse was observed providing wound care the patient's sacral wound and left posterior thigh wound. The registered nurse cleansed the sacral wound with wound cleanser and applied calmoseptine ointment to the affected area. A review of the plan of care effective 10/17/2024 and updated physician orders through 11/12/2024 revealed that the individualized plan of care did not include the treatment necessary to meet the needs of the patient's sacral wound. The Clinical Director (personnel record 6) confirmed findings and stated in part "The wound care provided is not in the plan of care as it should be."

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions and safe handling of soiled items in the patient’s care environment. This standard was not met as evidenced by document review, interview and observation. In 1 of 3 (33%) home visit observations revealed that the agency did not ensure safe handling of soiled items in the patient's care environment. Document 1: Policy No. 7-001 Infection Control Plan revision date 04/2019 read in part "Personnel will be provided training on the basics of transmission of pathogens to patients and personnel, bloodborne diseases, the use of standard precautions, infectious waste management, and other infection control procedures when their work activities may result in an exposure to blood, other potentially infectious materials, or under circumstances in which differentiation between body fluid types is difficult or impossible." Home Visit 1: The patient elected hospice care on 07/19/2024 with a diagnosis of Atherosclerotic Heart Disease. During the home visit on 11/12/2024 with the registered nurse (personnel record 1), the registered nurse was observed flushing the patient's foley catheter and performing wound care. The registered nurse placed the foley irrigation kit on the clean work surface (plastic barrier) and proceeded to irrigate the patient's foley catheter. After completion of the irrigation, the registered nurse disposed of the foley irrigation supplies, removed gloves, cleansed hands, and placed wound care supplies on the soiled work surface. The observation lacked evidence that the registered nurse followed accepted standards of practice to prevent the transmission of infections and communicable disease as evidenced by placing clean wound care supplies on the soiled work surface. The Alternate Administrator (personnel record 5) confirmed the findings in an interview on 11/12/2024 and stated in part "She knows this, she was just really nervous with the surveyors present."

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed that received wound care revealed that the agency did not ensure that the clinical records included physician orders for the wound care provided. Clinical Record 1: The patient elected hospice care on 07/19/2024 with a diagnosis of Atherosclerotic Heart Disease. During the home visit on 11/12/2024 with the registered nurse (personnel record 1), the registered nurse was observed providing wound care to the patient's sacral wound and left posterior thigh wound. The registered nurse cleansed the sacral wound with wound cleanser and applied calmoseptine ointment to the affected area. The registered nurse cleansed the left posterior thigh wound with wound cleanser and left the area open to air. The nursing clinical note completed on 11/05/2024 included wound assessment and measurements for three wounds (right heel, left posterior thigh, and sacral area) and read in part that "wound care provided as ordered to 3 wounds". A review of the plan of care effective 10/17/2024 and updated physician orders through 11/12/2024 revealed that the clinical record did not contain physician orders for the sacral wound care that was provided during the home visit observation. The Clinical Director (personnel record 6) confirmed findings during a joint record review and interview on 11/12/2024 and stated in part "I don't see an order for the sacral wound care or anything on the care plan." The Medical Director (personnel record 10) confirmed findings during an interview on 11/13/2024, and stated in part "The nurse called me yesterday and I gave her orders for the sacral wound care. They are supposed to call me before providing any wound care."

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies and other alternative treatments that could affect drug therapy. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by as evidenced by clinical record review and interview. 1 of 11 (9%) clinical records reviewed did not include documented evidence that the drug profile was updated with new medication orders received at the time of the comprehensive assessment. Record #37685 was reviewed and identified a comprehensive assessment was completed on 10/11/2021 which revealed “Performed wound care. Patient tolerated well. Instructions given on regular wound/skin care.”. The documentation included a signed physician’s order on 10/11/2021 “Cleanse with wound spray, pat dry with gauze, Irrigate with normal saline. Pat dry with gauze. Apply Medihoney. Cover with Border Gauze 1 x daily and as needed. Hospice SN to perform 1 x a week during SN visit. Facility nurse to perform 6 x a week, in between hospice SN visit.”. There was no evidence of the wound spray, medihoney or normal saline on the medication profile. The Clinical Director was interviewed on 1/20/2022 and stated, “it doesn’t look like they are on the medication profile but should be”.” The Administrator confirmed this finding on 1/20/2022.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, includes all services necessary for the palliation and management of the terminal illness including intervention to manage pain and symptoms and measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. 7 of 11 (63%) clinical records reviewed revealed the hospice did not ensure that the plan of care was individualized, contained measurable outcomes, and reflected problems identified in the comprehensive assessments. Record #73888 was reviewed and identified the plan of care for period 12/15/2021-2/12/2022 revealed pain as a problem with a goal “Patient/caregiver will verbalize understanding of signs/symptoms of pain.” This goal was not individualized or measurable. Record #37685 was reviewed and identified the plan of care for period 1/3/2022-3/3/2022 revealed pain as a problem with a goal “Patient’s pain will remain at comfortable level throughout certification period.” This goal was not individualized or measurable. Record #67712 was reviewed and identified the plan of care for period 12/1/2021-1/29/2022 revealed grief issues as a problem with a goal “Patient/caregiver will achieve optimal grief reaction prior to patient’s death." This goal was not individualized or measurable. Record #43112 was reviewed and identified the plan of care for period 8/6/2021-11/3/2021 revealed grief issues as a problem with a goal “Patient/caregiver will achieve optimal grief reaction prior to patient’s death." This goal was not individualized or measurable. Record #56356 was reviewed and identified the plan of care for period 12/12/2021-2/9/2022 revealed nutrition/hydration as a problem with a goal “Patient will be maintained under aspiration precautions throughout care/certification period." This goal was not individualized or measurable. Record #53925 was reviewed and identified the plan of care for period 11/25/2021-1/23/2022 revealed grief issues as a problem with a goal “Bereavement needs are assessed throughout certification period." This goal was not individualized or measurable. Record #87541 was reviewed and identified the plan of care for period 11/3/2021-1/31/2022 revealed coping as a problem, listing numerous interventions, without any goals. The Director of Operations was interviewed on 1/20/2022 and stated, these are not individualized and measurable. The Administrator confirmed this finding on 1/20/2022.

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by personnel record review, interview, and document review. 1 of 10 (10%) personnel records reviewed revealed the hospice did not ensure that personnel received annual education in infection control consistent with agency policy. Record #87026 (MD): hire date 12/26/2019. Review of the personnel file revealed there was no evidence of annual infection control in-services for 2020 or 2021. Agency policy, “Infection Control Plan Policy No. 7-001”, revised April 2019, stated, “Infection control in-services will be scheduled no less than annually. Attendance will be mandatory and will be documented. Records of in-service attendance will be maintained in the personnel file.”. The Director of Operations was interviewed on 1/20/2022 and stated, there was no documented infection control education for 2021 within the record identified. The Administrator confirmed this finding on 1/20/2022.