Every finding on record at Kare-In-Home Hospice of Mobile,LLC

Based on medical record (MR) review, agency policies and procedures, and interviews with staff it was determined the agency failed to ensure the physician ordered visit frequency was followed for each discipline. This deficient practice affected four of 14 MR reviewed including Home Visit (HV) # 3, MR # 1, MR # 2, MR # 6, and had the potential to affect all patients admitted to this hospice. Findings include: Agency Policy: Plan of Care (Hospice) Policy Number: 4-060.1 Revised: 12/2024 ...Policy: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the Hospice program. The Care provided to the patient must be in accordance with the plan of care... Procedure: ...4. The plan of care will identify the patient's needs and services to meet those needs...It must state, in detail, the scope and frequency of services to meet the patient's and family/caregiver's needs... 14. Care provided to the patient will be in accordance with the plan of care. Agency Policy: Missed Visits Policy Number: 4-038.1 Revised: 12/2024 Purpose: To ensure that missed visits are documented and does not affect the quality of patient care. Policy: Missed visits will be communicated to the Clinical Care Manager and the patient's physician. The missed visit will be rescheduled for the same week if possible. Missed visits will be documented in the clinical record. Procedure: ...2. If a visit is missed and not rescheduled the clinician will: a. Notify the physician ... of the missed visit and reason for the missed visit... c. If an aide visit is missed the aide will contact the case manager or Clinical Care Manager and the manager/supervisor will take appropriate measures... --- 4. MR # 6 was admitted to the agency on 2/10/25 with a terminal diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery. Review of the physician's order dated 3/10/25 revealed an order for SN two visits per week for four weeks and one visit per week for one week, effective week of 3/9/25 due to decline and increased educational needs. Review of the SN Visit Report Notes for the week of 3/9/25 revealed the SN performed one visit this week and not the two visits as ordered. There was no documentation of a physician order to omit the SN visit. Review of the IDG Summary Report dated 3/12/25 revealed no documentation the missed visit was discussed with the physician. An interview was conducted on 3/20/25 at 1:04 PM with EI # 1, who confirmed the agency failed to ensure the SN visit frequency was followed. 1. HV # 3 was admitted on 9/9/24 and recertified for hospice care from 12/8/24 to 3/7/25 with a terminal diagnosis of Atherosclerotic Heart Disease. Review of the Hospice Recertification and Plan of Care (POC) dated 12/8/24 revealed physician's orders for Skilled Nurse (SN) two visits per week for 13 weeks. Review of the SN Visit Report Notes for the week of 12/22/24 through 12/28/24 revealed one of the two physician ordered SN visits were completed. There was no documentation of a physician order to omit the SN visit. Review of the IDG (Interdisciplinary Group) Summary Report dated 12/26/24 revealed no documentation the missed visit was discussed with the physician. An interview was conducted on 3/20/25 at 11:50 AM with Employee Identifier (EI) # 3, Vice President of Operations, who confirmed the agency failed to ensure the SN visit frequency was followed. 2. MR # 1 was admitted 11/8/24 and recertified for Hospice care from 2/6/25 to 5/6/25 with a terminal diagnosis of Acute Myeloblastic Leukemia. Review of the Hospice Recertification and POC dated 2/6/25 revealed physician's orders for Hospice Aide (HA) one visit per week for one week, three visits per week for 12 weeks, then one visit per week for one week. Review of the HA Visit Notes from 2/16/25 through 2/22/25 revealed two of three of the HA visits were completed.There was no documentation of a physician's order to omit the visit. Review of the IDG Summary Report dated 2/27/25 revealed no documentation the physician was notified of the missed visit. An interview was conducted on 3/20/25 at 12:10 PM with EI # 1, Branch Director, who confirmed the agency failed to ensure the visit frequency for the HA was followed. 3. MR # 2 was admitted on 11/1/24 and recertified for hospice care from 1/30/25 to 4/29/25 with a terminal diagnosis of Occlusion and Stenosis of Bilateral Carotid Arteries. Review of the Hospice Recertification and POC dated 1/30/25 revealed physician's orders for SN one visit per week for one week, two visits per week for 12 weeks, then one visit per week for one week. Review of the SN Visit Notes from 2/9/25 through 3/1/25 revealed one of the two ordered SN visits were completed in each of the three weeks. There was no documentation of a physician's order to decrease the SN visits during those three weeks and no documentation the physician was notified of the missed visits.In an email received on 3/20/25 at 4:02 PM, EI # 3 confirmed the agency failed to ensure the visit frequency for the SN was followed.

Based on review of employee files, agency policy, and interview with staff it was determined the agency failed to ensure vaccinations against bloodborne pathogens were offered to each employee. This affected one of six employee files reviewed including Employee Identifier (EI) # 7, Registered Nurse, and had the potential of affect all employees. Agency Policy: Bloodborne Pathogens and Hepatitis B Exposure Control Plan Policy Number: 6-029.1 Revised: 12/2024 Purpose: To provide guidelines to reduce the risk of occupational exposure to bloodborne pathogens, including Hepatitis B (HPV). ...Procedure: 1.1. The organization shall ensure that the exposure control plan is made accessible to employees. ...3. Information will be provided to new direct care employees upon hire regarding the risks of exposure... 4. Determination of the new direct care employee's current HBV vaccination will be completed in the pre-employment health assessment. 5. The vaccine and vaccination will be offered free of charge within ten (10) days of employment... 7. An employee who has not been previously been vaccinated and who declines administration of the HBV vaccine is required to sign a declination statement... --- 1. A review of six employee personnel files including health information was conducted on 3/20/25. EI # 7 was hired as a full time RN on 4/15/24. There was no documentation EI # 7 was offered or received the Hepatitis B vaccine and no documentation the employee declined the vaccination. An interview was conducted on 3/20/25 at 1:00 PM with EI # 1, Branch Director, who confirmed the agency failed to ensure each employee was offered vaccinations against bloodborne pathogens.

Based on medical record (MR) review, agency policy and procedure, and interview with staff it was determined the agency failed to ensure the Aide Care Plan was updated to include all instructions for the Hospice Aide (HA).This affected one of 12 patients receiving HA services including MR # 9 and had the potential to affect all patients receiving HA services. Agency Policy: Aide Care/ServicesPolicy Number: 4-031.1Revised: 12/2024Purpose: To define the process for the development and use of an aide care plan.Policy: Each patient receiving aide services will have an individualized care plan developed by an appropriate professional and used to direct the care performed by the assigned aide.Procedure: ...1. The aide care plan will be individualized to the specific patient and may include: ...H. Specific procedure to be performed...3. The Case Manager, or other appropriately skilled professional, will review changes to the aide care plan with the assigned aide, as appropriate... --- MR # 9 was admitted 5/3/24 with a terminal diagnosis of Congestive Heart Failure. Review of the Hospice Certification and Plan of Care dated 5/3/24 revealed physician's orders for Skilled Nurse (SN) two visits per week for nine weeks then one visit per week for one week and HA three visits per week for eight weeks then one visit per week for one week. Review of the physician's order dated 5/20/24 revealed orders for Zinc Oxide, a skin barrier cream, to be applied to blanchable area of redness to buttocks during perineal care daily. Review of the Aide Care Plan Report dated 5/5/24 revealed instructions for the HA to provide perineal care to MR # 9 every visit. There was no documentation the Aide Care Plan Report was updated to include the application of the barrier cream during perineal care.Review of the HA Visit Note Reports dated 5/20/24 through 7/1/24 revealed no documentation Zinc Oxide was applied to the buttocks during perineal care. An interview was conducted on 3/20/25 at 12:00 PM with Employee Identifier # 1, Branch Director, who confirmed the agency failed to update the Aide Care Plan with the new physician's order.

Based on review of personnel files, agency policy and procedure, and interview with staff, it was determined the agency failed to ensure the competency of each employee was assessed annually. This deficient practice affected one of six personnel files reviewed including Employee Identifier (EI) # 6, Hospice Aide (HA), and had the potential to affect each patient admitted to this agency. Findings include: Agency Policy: Competency ProgramPolicy Number: 7-029.1Revised: 12/2024Purpose: To ensure that the competence of clinical organization employees is assessed, maintained, and improved on a continuing basis. Policy: ...Employees will demonstrate knowledge and proficiency of skills appropriate to their assigned responsibilities, including an ability to perform specified duties determined by the organization...Procedure: ...3. The organization will clearly identify and define the skills, which are essential to observe for the determination of competence, for each job category. In the identification of core competence, the essential skills will be demonstrated upon hire and annually thereafter... --- 1. EI # 6, was hired as a full time HA on 2/1/21.A review of EI # 6's personnel file revealed the last competency evaluation was conducted on 5/2/21. An interview was conducted on 3/20/25 at 1:00 PM with EI # 1, Branch Director, who confirmed the skills competency was not evaluated for each employee annually per agency policy.

Based on review of agency policy and procedure, medical record (MR) review and interviews with the staff it was determined the agency failed to ensure an accurate, up to date medication profile, including oxygen and medication changes was maintianed for each patient. This did affect 2 of 7 patients with oxygen including Home Visit (HV) # 2 and MR # 6 and had the potential to negatively affect all patients requiring oxygen served by the agency. Findings include: Policy: Medication Profile Policy number: PC.M60 Effective 10.1.17 Policy: A patient-specific medication profile is maintained for each patient and reviewed, at a minimum, every fifteen days. Procedures: 1. When a patient is admitted to hospice, a medication profile is initiated to document all of the patient's prescriptions. 2. The patient's medication profile is reviewed by the IDG (Interdisciplinary Group) ... 4. The patient's medication profile review includes, but is not limited to: a. Determining accuracy and completeness of the profile; c. Ensuring appropriateness of the medication, the dose, route of administration and dosage schedule; d. Ensuring that the prescribed medications are safe ..... 1. HV # 2 was admitted on 3/18/22 with diagnoses including Dementia with Lewy Bodies and Alzheimer's Disease Early Onset. Review of the physician order dated 4/07/22, revealed "O2 (oxygen) concentrator and portable tank." The order did not include the flow rate, route of administration and frequency. Review of the medication profile dated 4/18/22, revealed no oxygen listed. An interview conducted 4/21/22 at 1:40 PM with Employee Identifier (EI) # 1, Branch Director, who confirmed the staff failed to update the medication profile to include the oxygen. 2. MR # 6 was admitted to the agency on 3/30/22 with an admitting diagnosis of Senile Degeneration of Brain, Not Elsewhere Classified. Review of the Hospice Certification and Plan of Care dated 3/30/22 revealed the skilled nurse (SN) frequency of visits to be conducted were 2wk13 (2 times a week for 13 week), 1wk1 (1 time a week for 1 week). Review of the skilled nurse visit (SNV) notes dated 4/6/22, 4/8/22, 4/11/22, 4/14/22 and 4/18/22 revealed under the respiratory section of the visit note the patient was on 2-4 L (liters) by NC (nasal cannula) PRN (as needed). Review of the medication profile with a print date of 4/20/22 revealed no Oxygen was added to ensure the medication profile was updated. Review of the physician order dated 4/2/22 revealed an order to discontinue Seroquel and add Haldol 5 mg (milligrams) 1 PO (by mouth) every 4 hrs (hours) PRN for agitation. Review of the medication profile with a print date of 4/20/22 revealed the Seroquel remained on the medication profile as an active medication and Haldol was not added per the physician orders. An interview was conducted on 4/21/22 at 12:45 PM with EI # 2, Director of Quality and Education, who confirmed the medication profile should have been updated to reflect the discontinuation of Seroquel and the addition of Haldol and the Oxygen at 2-4 L.

Based on review of medical records (MR), Interdisciplinary Group (IDG) meeting documentation and staff interview, the hospice failed to assure patient's changes from the comprehensive assessment in 1 of 1 record reviewed for a hospice patient who tested positive for COVID-19 were reviewed and documented. This affected MR # 3 and had the potential to negatively affect all patients served by the hospice. Findings include: 1. MR # 3 was admitted to the hospice on 1/22/22 with the terminal diagnosis of Metastatic Colorectal Cancer. Review of the 1/27/22 Hospice Aide Visit documentation revealed the patient has been tested for COVID this morning, no result yet. Review of the 1/28/22 RN (Registered Nurse) Hospice Subsequent Visit documentation revealed the patient is in quarantine due to exposure to COVID positive family members, patient tested on Thursday but has not received results yet. Review of the Hospice IDG Comprehensive Assessment (CA) and Plan of Care (POC) Update Report dated 1/28/22 failed to reveal documentation of the patient's COVID-19 exposure, COVID-19 positive family members, and pending COVID test results. There was no documentation the IDG discussed/reviewed MR # 3's COVID-19 exposure and addressed/considered changes in the POC due to the terminal illness and COVID exposure. Review of the 2/1/22 RN Hospice Subsequent Visit documentation revealed the patient is in quarantine due to COVID-19 with positive COVID-19 test results yesterday, and patient appears asymptomatic at this time. Review of the next Hospice IDG CA and POC Update Report dated 2/11/22 failed to reveal documentation for MR # 3's positive COVID-19 test results on 1/31/22 which were a change in MR # 3's medical condition over the past 15 days. There was no documentation the IDG discussed MR # 3's COVID status/postive test result and used the information update in care planning. In an interview on 4/21/22 at 1:00 PM, Employee Identifier # 2, Director of Quality and Education stated there was a verbal discussion on 1/28/22 and 2/11/22 and no documentation MR # 3's COVID exposure/pending test results and positive test results were discussed and used for care planning during the IDG on 1/28/22 and 2/11/22.

Based on Medical Record (MR) review, Agency Policy and Procedure, and interviews, it was determined the agency failed to ensure care was coordinated Interdisciplinary Group (IDG). This deficient practice affected 1 of 11 MR reviewed including MR # 2, and had the potential to negatively affect all patients admitted to this hospice. Findings include: Agency Policy: Coordination of Service Policy Number: PC.C45 Date Effective: 10.1.2017 Policy: The IDG (Interdisciplinary Group) ensures that there is a coordinated and effective ongoing sharing of information amongst and between all disciplines, ... Procedures: ... 2. An assigned hospice RN (Registered Nurse) coordinates the patient's plan of care and facilitates the ongoing sharing of information... 4. All members of the IDG ... document problems, interventions, goals, observations, and outcomes based on the assessed and reassessed needs of the patient/family... 1. MR # 2 was admitted to the agency on 2/9/22 with diagnoses including Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure. Review of the Hospice Certification and Plan of Care dated 2/9/22 revealed orders of: SN (Skilled Nurse) 2 x a week x 13 weeks, MSW (Master of Social Work) 1 x a month, and Chaplain 1 x a month. Review of the Visit Note Report (VNR) dated 3/18/22 revealed the MSW documented "Cg (caregiver) has requested a sitter for errands. MSW will assist...There is a concern for cg burnout. Cg does not have stable support. MSW will continue to evaluate and support family". There was no documentation provided of follow up by MSW. Review of the VNR dated 3/21/22 revealed the Chaplin documented MR # 2 "making inquiry, needing possible sitter service...". Review of the next IDG Plan of Care Update Report revealed no documentation of the MSW or Chaplain notified the IDG of MR # 2's request and need for sitter services. In an interview conducted on 4/21/22 at 12:20 PM, Employee Identifier (EI) # 2, Director of Quality and Education, confirmed care was not coordinated and patient needs were not communicated with the IDG.

Based on observations, Agency Policy and Procedure, and interviews, it was determined the agency failed to ensure staff followed it's own policy for infection prevention. This deficient practice affected 1 of 3 Home Visits (HV) including HV # 1, and had the potential to negatively affect all patients admitted to this hospice. Findings include: Agency Policy: Infection Control - Hand Hygiene Policy Number: PC.I25 Date Effective: 10.1.2017 Policy: Kare-In-Home Hospice follows hand hygiene guidelines recommended by the Centers for Disease Control and the World Health Organization. Procedures: 1. Hospice staff must wash hands: a. before touching a patient b. before performing clean/aseptic procedures c. after performing tasks that involve risk of exposure to body fluids d after touching a patient e. before and after wearing gloves f. after any activity involving physical contact with a patient's immediate environment. 1. HV # 1 was admitted to the agency on 11/01/2019 and recertified for hospice care from 2/18/22 to 4/18/22 and 4/19/22 to 6/17/22 with diagnoses including Corticobasil Degeneration and Dementia. A HV was conducted on 4/19/22 to observe care provided by Employee Identifier (EI) # 3, Certified Nursing Assistant (CNA). During observation of the bed bath, EI # 3 turned HV # 1 to the left side, removed the soiled adult diaper with gloves on, cleaned the perineal area with wipes, then disposed of the diaper. EI # 3 then continued with bed bath, while still wearing the same gloves used to removed the soiled diaper then washed the back and legs, applied lotion to the back, changed linens, and gown. EI # 3 failed to remove gloves and perform hand hygiene after contact with body fluids. In interview conducted on 4/19/22 at 1:20 PM with EI # 3 after the visit, EI # 3 confirmed he/she failed to change gloves and perform hand hygiene after changing soiled diaper. In an interview conducted on 4/21/22 at 12:07 PM, EI # 2, Director of Quality and Education, confirmed agency policy was not followed for hand hygiene.

Based on review of medical records (MR), agency policies and procedures and interviews with the staff it was determined the agency failed to ensure the Hospice Aide (HA) followed the written Plan of Care (POC) for each patient. This affected 3 of 8 MR's reviewed with hospice aides and did affect MR # 6, MR # 3, MR # 2, and had the potential to negatively affect all patients served by the hospice with hospice aides. Findings include: Agency Policy: Hospice Aide Assignments and Duties Policy Number: PC.H20 Effective Date: 10.1.2017 Policy: Hospice Aides are assigned to specific patients by a hospice RN (Registered Nurse) and follow written patient care instructions in providing care to assigned patients. Procedures: 2. A hospice aide provides services that are: a. ordered by the interdisciplinary group b. included in the plan of care 3. The duties of the hospice aide may include, but are not limited to the following: a. hand-on personal care b. simple procedures as an extension of therapy or nursing services c. assistance in ambulation or exercise... Agency Policy: Hospice Aide Services Policy Number PC.H25 Effective Date: 10.1.2017 Policy: Individuals who currently meet personnel requirements specified in hospice regulations and who have successfully completed a competency evaluation program as required by regulations, provided hospice aide services under the supervision of a hospice registered nurse. Procedures: 2. Hospice aide services are assigned based on the comprehensive assessment and reassessment of the patient's personal care needs and ability to perform activities of daily living. 3. The hospice RN develops a written hospice aide plan of care that provides instructions to the hospice aide of the patient-specific care to be provided. 4. The hospice aide's services are ordered by the IDG (interdisciplinary group), included in the patient's plan of care and are consistent with the hospice aide's training. 1. MR # 6 was admitted to the agency on 3/30/22 with an admitting diagnosis of Senile Degeneration of Brain, Not Elsewhere Classified. Review of the Hospice Certification and Plan of Care dated 3/30/22 revealed the hospice aide frequency of visits to be conducted were 3wk1 (3 times a week for 1 week), 5wk12 (5 times a week for 12 weeks), and 1wk1 (1 time a week for 1 week. Review of the Aide Care Plan Report dated 3/30/22 revealed the following tasks to be performed: Shampoo every other visit. Review of the aide visit note dated 3/30/22 the aide failed shampoo the patient's hair. The aide documented not required this visit. There was no documentation by the aide if the patient was asked if he/she wanted his/her hair shampooed this visit. Review of the aide visit note dated 3/31/22 revealed the aide failed to shampoo and documented not required this visit. Review of the aide visit notes dated 4/4/22, 4/5/22, 4/6/22, and 4/7/22 revealed the aide failed to shampoo the patient's hair every other visit per the Aide Care Plan Report. Review of the aide visit note dated 4/18/22 the aide documented he/she provided a linen change and shaved the patient. Review of the aide plan of care dated 3/30/22 revealed the linen change and shaving the patient was not included in the assignment. Further review of the aide plan of care revealed no documentation the plan of care was updated by the RN to include linen change and shaving. An interview was conducted on 4/21/22 at 12:45 PM with Employee Identifier (EI) # 2, Director of Quality and Education, who confirmed the aide failed to follow the plan of care and perform the shampooing of the patient's hair every other visit as ordered and performed the linen change and shaving of the patient prior to the tasks being assigned. 2. MR # 3 was admitted to the hospice on 1/22/22 with the terminal diagnosis of Metastatic Colorectal Cancer. Review of the Aide Care Plan Report dated 1/21/22 revealed HA services were ordered 2wk12, 1wk1, the tasks below were ordered and included: Stand-by Assistance with Ambulation-every visit Assist to Toilet-every visit Assist with Feeding, Assist with meal prep (preparation)-every visit Bathing (Tub bath/Shower) Assist with Set up, and provide stand by assist- every visit Shampoo Assist when he/she will allow-every visit Skin care-apply moisturizer to arms-every visit Shaving-every visit Oral care-provide assistance when needed-every visit Dressing-every visit Empty trash-every visit Empty urinal-every visit Change linens-weekly Review of the 1/25/22 HA Visit Note Report revealed the following tasks were not provided due to patient preference, task already completed and/or not required this visit: Assist with feeding, Bathing, Shampoo, Skin care, Shaving, Oral care, Nail care, Dressing, Empty trash, Empty urinal, Change linens. Review of the 1/27/22 HA Visit Note Report revealed the following tasks were not provided due to patient preference and/or task already completed: Assist to Toilet, Assist with feeding, Bathing, Shampoo, Skin care, Shaving, Oral care, Nail care, Dressing, Empty trash, Empty urinal, Change linens. Review of the 2/1/22 HA Visit Note Report revealed the following tasks were not provided due to patient preference and/or task already completed: Assist to Toilet, Assist with feeding, Bathing, Shampoo, Oral care, Nail care, Dressing, Empty trash, Empty urinal, Change linens. Review of the 2/3/22 HA Visit Note Report revealed the following tasks were not provided due to patient preference, task already completed and/or not required this visit: Assist to Toilet, Assist with feeding, Bathing, Shampoo, Skin care, Shaving, Oral care, Nail care, Dressing, Empty trash, Empty urinal, Change linens. Review of the 2/9/22 HA Visit Note Report revealed the following tasks were not provided due to patient preference and/or task already completed: Assist to Toilet, Assist with feeding, Bathing, Shampoo, Skin care, Shaving, Oral care, Nail care, Dressing, Empty trash, Empty urinal, Change linens. Review of the 2/10/22 HA Visit Note Report revealed the following tasks were not provided due to patient preference, task already completed and/or not required this visit: Assist to Toilet, Assist with feeding, Bathing, Shampoo, Skin care, Shaving, Oral care, Nail care, Dressing, Empty trash, Empty urinal, Change linens. Review of the 2/15/22 HA Visit Note Report revealed the following tasks were not provided due to patient preference, task already completed or not required this visit: Assist to Toilet, Assist with feeding, Bathing, Shampoo, Skin care, Shaving, Oral care, Nail care, Dressing, Empty urinal, Change linens. Review of the 2/17/22 HA Visit Note Report revealed the following tasks were not provided due to patient preference, task already completed or not required this visit: Assist with feeding, Bathing, Shampoo, Skin care, Shaving, Oral care, Nail care, Dressing, Empty urinal, Change linens. MR review revealed a physician order dated 2/17/22 to decrease HA visits to 1 time a week. Review of the 2/22/22 HA Visit Note Report revealed the following tasks were not provided due to patient preference, task already completed and/or not required this visit: Assist to Toilet, Assist with feeding, Bathing, Shampoo, Nail care, Dressing, Empty urinal, Change linens. Review of the 3/1/22 HA Visit Note Report revealed the following tasks were not provided due to patient preference, task already completed and/or not required this visit: Assist to Toilet, Assist with feeding, Bathing, Shampoo, Skin care, Shaving, Oral care, Nail care, Dressing, Empty urinal, Change linens. Review of the 3/8/22 HA Visit Note Report revealed the following tasks were not provided due to patient preference, task already completed or not required this visit: Assist to Toilet, Assist with feeding, Bathing, Shampoo, Oral care, Nail care, Dressing, Empty trash, Empty urinal, Change linens. Review of the 3/15/22 HA Visit Note Report revealed the following tasks were not provided due to patient preference, task already completed and/or not required this visit: Assist to Toilet, Assist with feeding, Bathing, Shampoo, Skin care, Shaving, Oral care, Dressing, Empty urinal, Change linens. Review of the 3/22/22 HA Visit Note Report revealed the following tasks were not provided due to patient preference, task already completed and/or not required this visit: Assist to Toilet, Assist with feeding, Bathing, Shampoo, Oral care, Nail care, Dressing, Empty urinal, Change linens. Review of the 3/29/22 HA Visit Note Report revealed the following tasks were not provided due to patient preference, task already completed and/or not required this visit: Assist to Toilet, Assist with feeding, Bathing, Shampoo, Skin care, Shaving, Oral care, Nail care, Dressing, Empty urinal, Change linens. Review of the 4/5/22 HA Visit Note Report revealed the following tasks were not provided due to patient preference, task already completed and/or not required this visit: Assist to Toilet, Assist with feeding, Bathing, Shampoo, Oral care, Nail care, Dressing, Empty urinal, Change linens. Review of the 4/12/22 HA Visit Note Report revealed the following tasks were not provided due to patient preference, task already completed and/or not required this visit: Assist with feeding, Bathing, Shampoo, Skin care, Oral care, Nail care, Dressing, Empty urinal, Change linens. There was no documentation the RN was notified when ordered tasks were not performed on 1/25/22, 1/27/22, 2/1/22, 2/3/22, 2/9/22, 2/10/22, 2/15/22, 2/17/22, 2/22/22, 3/1/22, 3/8/22, 3/15/22, 3/29/22, 4/5/22 and 4/12/22. In an interview conducted 4/21/22 at 1:47 PM, EI # 2 confirmed the HA failed to perform tasks ordered and documented on the Aide Care Plan Report and notify the RN when tasks ordered were not completed. 3. MR # 2 was admitted to hospice on 2/9/22 with diagnoses including Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure. Review of the Hospice Certification and Plan of Care dated 2/9/22 revealed orders for HA 1 x a week for 1 week, 3 x a week for 12 weeks, then 1 x a week for 1 week. Review of the Aide Care Plan Report dated 2/9/22 revealed instructions including a shampoo every visit and oral care every visit. Review of the Visit Note Report (VNR) dated 2/16/22 revealed the HA documented the shampoo was not completed with a note stating "not required this visit". Review of the VNR dated 2/21/22 revealed the HA documented the shampoo was not completed, "not required this visit". Review of the VNR dated 2/23/22 revealed the HA documented the shampoo and oral care were not completed, with a note stating "not required this visit". Review of the VNR dated 2/28/22 revealed the HA documented the shampoo was not completed, with a note stating "not required this visit". Review of the VNR dated 3/2/22 revealed the HA documented the shampoo was not completed, with a note stating "not required this visit". Review of the VNR dated 3/4/22 revealed the HA documented the shampoo and oral care were not completed, with a note stating "not required this visit". Review of the VNR dated 3/9/22 revealed the HA documented the shampoo was not completed, with a note stating "not required this visit". Review of the VNR dated 3/11/22 revealed the HA documented the shampoo and oral care were not completed, with a note stating "not required this visit". Review of the VNR dated 3/14/22 revealed the HA documented the shampoo was not completed, with a note stating "not required this visit". Review of the VNR dated 3/18/22 revealed the HA documented the shampoo was not completed, with a note stating "not required this visit". Review of the VNR dated 3/21/22 revealed the HA documented the shampoo was not completed, with a note stating "not required this visit". Review of the VNR dated 3/28/22 revealed the HA documented the shampoo was not completed, with a note stating "not required this visit". Review of the VNR dated 3/30/22 revealed the HA documented the shampoo was not completed, with a note stating "not required this visit". Review of the VNR dated 4/1/22 revealed the HA documented the shampoo was not completed, with a note stating "not required this visit". Review of the VNR dated 4/4/22 revealed the HA documented the shampoo was not completed, with a note stating "not required this visit". Review of the VNR dated 4/6/22 revealed the HA documented the shampoo was not completed, with a note stating "not required this visit". Review of the VNR dated 4/8/22 revealed the HA documented the shampoo was not completed, with a note stating "not required this visit". Review of the VNR dated 4/11/22 revealed the HA documented the shampoo and oral care were not completed, with a note stating "not required this visit". Review of the VNR dated 4/15/22 revealed the HA documented the shampoo was not completed, with a note stating "not required this visit". There was no documentation on any of the HA VNR the RN was notified the assigned tasks were not completed. In an interview conducted on 4/21/22 at 12:20 PM, EI # 2 confirmed the HHA failed to complete all assigned tasks and failed to notify the RN the assigned tasks had not been completed.

Based on review of medical records (MR), agency policy and procedure and interviews with the staff it was determined the agency failed to ensure the hospice aide notified the Registered Nurse (RN) in changes in the patient's condition and changes needed to the Aide Plan of Care. This affected 3 of 8 MR's reviewed with aide service and did affect MR # 6, MR # 8, Home Visit (HV) # 1 and had the potential to negatively affect all patients served by the agency with hospice aide service. Findings include: Agency Policy: Hospice Aide Assignments and Duties Policy Number: PC.H20 Effective Date: 10.1.2017 Policy: Hospice Aides are assigned to specific patients by a hospice RN and follow written patient care instructions in providing care to assigned patients. Procedures: 4. Hospice aides must report changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities. 1. MR # 6 was admitted to the agency on 3/30/22 with an admitting diagnosis of Senile Degeneration of Brain, Not Elsewhere Classified. Review of the Hospice Certification and Plan of Care dated 3/30/22 revealed the hospice aide frequency of visits to be conducted were 3wk1 (3 times a week for 1 week), 5wk12 (5 times a week for 12 weeks), and 1wk1 (1 time a week for 1 week. Review of the Hospice Certification and Plan of Care dated 3/30/22 revealed the skilled nurse (SN) frequency of visits to be conducted were 2wk13 (2 times a week for 13 week), 1wk1 (1 time a week for 1 week). Further review of the Hospice Certification and Plan of Care dated 3/30/22 revealed the SN was to change the Foley catheter every month or as needed. Review of the Aide Care Plan Report dated 3/30/22 revealed the following tasks to be performed: Routine Catheter Care every visit. Review of the SN visit note dated 3/30/22 revealed the patient had a Foley catheter in place. Review of the SN visit note dated 3/31/22 revealed in the narrative section of the nurse note the SN removed the Foley catheter. Review of the Aide visit notes dated 4/1/22, 4/4/22, 4/5/22, 4/6/22, 4/7/22, 4/8/22, 4/11/22, 4/12/22, 4/13/22, 4/14/22, 4/15/22, 4/18/22 and 4/19/22 revealed the aide task to perform catheter care every visit remained on each note. The aide documented not required this visit does not have one. Review of the Aide visit notes revealed there no documentation by the aide reported to the RN of not performing catheter care. Review of the Aide Plan of Care dated 3/30/22 revealed no documentation the SN updated the Aide Plan of Care to meet the patient's needs and removed the catheter care every visit. An interview was conducted on 4/21/22 at 12:45 PM with Employee Identifier (EI) # 2, Director of Quality and Education, who confirmed the SN should have updated the Aide Plan of Care when the Foley catheter was removed. 2. MR # 8 was admitted to the agency on 2/12/21 with recertification dates of 4/13/21 to 6/11/21 and admitting diagnoses of Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure unspecified with Hypoxia. Review of the Hospice Certification and Plan of Care dated 2/12/21 revealed the hospice aide frequency of visits to be conducted were 3wk6 (3 times a week for 6 weeks) to begin 5/2/21. Review of the Aide Care Plan Report dated 4/14/21 revealed the aide was assigned the following task: Bathing (tub bath/shower) Review of the Aide Visit Note Reports dated 5/12/21 and 5/17/21 revealed the patient refused a bath or shower. Review of the narrative section of the aide notes revealed no documentation per the hospice aide an RN (Registered Nurse) was notified of the patient refused a bath. An interview was conducted on 4/21/22 at 1:35 PM with EI # 2 who confirmed the aide should have notified an RN of the patient refusing to be bathed and should have documented the notification to the RN on the aide note. 3. HV # 1 was admitted to the agency on 11/01/2019 and recertified for hospice care from 2/18/22 to 4/18/22 with diagnoses including Corticobasil Degeneration and Dementia. Review of the Visit Note Report (VNR) dated 3/3/22 revealed the Hospice aide documented the patient had a seizure the night before. There was no documentation the RN was notified of the seizure. Review of the VNR dated 3/28/22 revealed the Hospice aide documented HV # 1 "has some discoloration on coxius (coccyx) bone, dark color". There was no documentation the Hospice Aide notified the RN of the changes in skin condition. Review of the VNR dated 4/11/22 revealed the Hospice aide documented a red skin irritation in the crease of the left side. There was no documentation the RN was notified of the change in skin condition. In an interview conducted on 4/21/22 at 12:07 PM, EI # 2 confirmed the Hospice aide failed to notify the RN of changes in the patient condition.

Based on review of the hospice volunteer service policy and procedure, hospice volunteer files, and interviews with staff, it was determined the hospice failed to ensure: 1. Eight (8) of 8 direct and indirect care community volunteers received orientation to hospice including the hospice philosophy and specific volunteer duties prior to assignments. This had the potential to negatively affect all patients served by the hospice. Findings include: Hospice Policy PC.V20 Effective 10.1.17 Title-Volunteer-Services POLICY...ensure it is functioning as intended and meeting the needs of the hospice program and its patients. PROCEDURES: 1. Volunteers are...used in prescribed roles including... a. providing emotional and practical support to patients and families. e. Assisting with office duties. 5. Volunteers are required to complete an orientation and training program prior to assignment... 6. A personnel file is maintained for each volunteer... On 4/19/22 at 10:15 AM the surveyor requested the volunteer program documentation including volunteer training and personnel files. Employee Identifier (EI) # 8, the Volunteer Coordinator, reported the hospice currently had 8 volunteers recruited from the community and volunteer activities included the Baking Brigade (cookie decorating/delivery), completion of monthly birthday cards mailed to patients, "Kare cards (cards of encouragement)" and weekly phone calls to patients/families. On 4/19/22 at 1:00 PM, review of the 8 community volunteer personnel files of indirect and direct care volunteers revealed no volunteer training and no orientation/training for specific volunteer job duties and responsibilities documented. On 4/20/22 at 8:30 AM the surveyor requested all volunteer training/personnel file documentation from EI # 2 , Director of Quality and Education. On 4/20/22 at 1:03 PM, EI # 2 reported the hospice had identified the volunteer file documentation including training was not complete. In an interview conducted on 4/21/22 at 9:00 AM, EI # 8, verified there was no documentation the 8 community volunteers had completed volunteer training for assigned duties per the hospice policy/procedure.

Based on review of agency policy and procedure, medical record (MR) review and interview with staff it was determined the agency failed to ensure physician orders for oxygen were written and complete to included the flow rate, route of administration and frequency. This did affect 3 of 7 patients with oxygen including Home Visit (HV) # 2, MR # 6, MR # 1 and had the potential to negatively affect all patients requiring oxygen. Findings include: Policy: Physician Orders Policy number: PC.P30 Effective 10.1.17 Policy: Physician orders are obtained as needed and received from the physician within the time frames required by laws and regulations. Procedures: 2. ...receiving the order documents its receipt and a verbal order confirmation .... 3. Some of the reason's orders are obtained from physicians include, but not limited to: a. New medication, change in medication... 1. HV # 2 was admitted to the agency on 3/18/22 with diagnoses including Dementia with Lewy Bodies and Alzheimer's Disease Early Onset. Review of the physician order dated 4/07/22 revealed "O2 (oxygen) concentrator and portable tank." The order failed to include the oxygen flow rate, route of administration and frequency. An interview conducted 4/21/22 at 1:40 PM with Employee Identifier (EI) # 1, Branch Director, confirmed the physician order was incomplete and did not include flow rate, route of oxygen administration and frequency. 2. MR # 6 was admitted to the agency on 3/30/22 with an admitting diagnosis of Senile Degeneration of Brain, Not Elsewhere Classified. Review of the Hospice Certification and Plan of Care dated 3/30/22 revealed the skilled nurse (SN) frequency of visits to be conducted were 2wk13 (2 times a week for 13 week), 1wk1 (1 time a week for 1 week). Review of the skilled nurse visit (SNV) note dated 4/6/22 revealed under the respiratory section of the visit note the patient was on O2 at 2-4 L (liters) by NC (nasal cannula) PRN (as needed). Review of the physician orders in the MR revealed no documentation an order was written for the Oxygen at 2-4 L NC PRN. An interview was conducted on 4/21/22 at 12:45 PM with EI # 2, Director of Quality and Education, who confirmed an order should have been written for the Oxygen. 3. MR # 1 was admitted to the hospice on 3/22/22 with terminal diagnosis of Idiopathic Pulmonary Fibrosis. MR review revealed a physician order dated 3/29/22 for oxygen 2-4 liters continuous per NC. Review of the Hospice Interdisciplinary Group Comprehensive Assessment and Plan of Care Update Report dated 4/8/22 revealed oxygen was increased to 5 liters per nasal cannula with oxygen 5 liters in use during the 4/11/22 RN Subsequent Visit. Review of the 4/15/22 RN Subsequent Visit narrative documentation revealed oxygen was in use 7 liter/minute via NC. There was no physician's order to increase the oxygen to 7 liters/minute. During an interview conducted on 4/21/22 at 12:25 PM, EI # 2 confirmed there was no physician order for oxygen 7 liters/minute per NC.

Based on Medical Record (MR) review, agency policy and procedure and interviews, it was determined the agency failed to ensure: 1. Education was provided for the use of narcotics in the home 2. A count of the narcotics was completed on each Registered Nurse (RN) visit. This deficient practice affected 2 of 11 records reviewed including MR # 2, MR # 3, and had the potential to negatively affect all patients served by this agency. Findings include: Hospice Policy Number: PC.M70 Effective 10.1.17 Title: Medications-Use and Disposal of Controlled Substances ...Definitions: Controlled substances-drugs or other material that, because of their potential for abuse, are closely regulated by the Federal government... POLICY...instructs patient/caregivers in the safe use and disposal of controlled substances... PROCEDURES: 1. At the time when controlled substances are ordered, the hospice nurse... a. provides a copy of...written policies and procedures on the management and disposal of controlled drugs to the patient and...family. b. discusses the...policies and procedures for managing the safe use and disposal of controlled drugs... c. documents...that written...procedures for managing controlled drugs were provided and discussed. d. discuss and document required narcotic count during each scheduled RN (Registered Nurse) visit. The name of the medication and number remaining will be documented... 1. MR # 2 was admitted to hospice on 2/9/22 with diagnoses including Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure. Review of the Hospice Certification and Plan of Care (POC) dated 2/9/22 revealed an order for Morphine Concentrate 100 milligrams (mg)/5 milliliters (ml). Take 0.5 to 1 ml as directed/prn (as needed) for respiratory distress and severe pain. Further review of the POC revealed orders for SN frequency of 2 x a week for 13 weeks. Review of the SN Visit Note Reports (VNR) from 2/9/22 through 4/14/22 revealed no documentation of patient/caregiver teaching of the use of the Morphine Concentrate for pain. Review of the VNR dated 3/22/22 revealed the RN documented MR # 2 complained of aching and burning right eye pain with current pain score of 3. Further review of the 3/22/22 VNR revealed the RN documented "no" to the question "are narcotics ordered". Review of the VNR dated 4/7/22 revealed the RN documented MR # 2 complained of throbbing pain to the right eye at a pain level of 4. Further review of the 4/7/22 VNR revealed the RN documented "no" to the question "are narcotics ordered". Review of the SN VNRs dated 2/9/22, 2/10/22, 2/14/22, 2/16/22, 2/22/22, 2/24/22, 3/1/22, 3/3/22, 3/8/22, 3/10/22, 3/15/22, 3/22/22, 3/24/22, 3/29/22, 3/31/22, 4/5/22, 4/7/22, and 4/12/22 revealed no documentation of the narcotic count of the Morphine. In an interview conducted on 4/21/22 at 12:20 PM, Employee Identifier (EI) # 2, Director of Quality and Education, confirmed the Morphine was in the home from date of admission and no patient or caregiver education on use had been provided and counts of the narcotic had not been conducted on each visit. 2. MR # 3 was admitted to the hospice on 1/22/22 with the terminal diagnosis of Metastatic Colorectal Cancer. Review of the RN Hospice Start of Care visit documentation MR # 3 lived in a camper trailer in the backyard of the CG (caregiver), which was an adult child. In addition the RN documented an opiod was initiated for pain control on 1/21/22 which was Oxycodone 5 mg every 8 hours PRN for pain. MR review revealed the following visit RN documentation regarding pain assessment and controlled drug management: On 1/25/22-Pain assessment- 0 (0-10 pain scale -0 no pain, 10 worst pain) and Are narcotics ordered? No. On 1/28/22-Pain assessment-0, Are narcotics ordered? Yes. Narcotic count unknown at present-(CG taking care of COVID positive sick family). On 2/1/22-Pain assessment- 0, Are narcotics ordered? No. On 2/4/22- Pain assessment-0, Are narcotics ordered? No On 2/8/22-Pain assessment-0, Are narcotics ordered? Yes, Narcotic count Unknown- CG keeps in his/her home. States patient has not taken any since being on hospice. On 2/12/22-Pain assessment-0, Are narcotics ordered? Yes, Narcotic count-patients CG keeps in his/her home and not home. On 2/15/22-Pain assessment-0, Are narcotics ordered? Yes, Narcotic count - CG keeps in his/her home and he/she is not available, patient states has not taken pain pill since being on service. On 2/17/22-Pain assessment-0, Are narcotics ordered? Yes, Narcotic count-CG not home. On 2/22/22-Pain assessment-0, Are narcotics ordered? Yes, Narcotic count -in CG home, Patient has not taken since being on service. On 3/2/22-Pain assessment-0, Are narcotics ordered? Yes, Narcotic count-Kept at caregivers home, unable to access at this time, CG reports patient has not taken any since being on service. On 3/8/22-Pain assessment-0, Are narcotics ordered? Yes, Narcotic count-in CG home. On 3/15/22-Pain assessment-0, Are narcotics ordered? Yes, Narcotic count-NA (Not applicable). On 3/21/22 -Pain assessment-0, Are narcotics ordered? Yes, Narcotic count-UATO (unable to access) the CG has them. On 3/29/22-Pain assessment-0, Are narcotics ordered? No. On 4/5/22 Pain assessment-0, Is patient receiving opiod medication? Yes. Narcotic Count-locked in CG home, CG not home. To Skill Nurse knowledge patient has only taken 1 pain pill since being on service. On 4/12/22-Pain assessment-0, Are narcotics ordered? No. There were no documented attempts to perform a narcotic count on each RN visit documented above. There was no documentation the RN monitored use of the federally controlled substance Oxycodone, and documented the remaining number of Oxycodone tablets in the home each visit as per the hospice policy and procedure. In an interview on 4/21/22 at 1:00 PM, EI # 2 stated no Oxycodone refills were authorized and confirmed staff had not completed and documented narcotic counts each visit per hospice policy and procedure.