Every finding on record at Kelley Health Hospice, Inc.

Based on medical record (MR) review, agency policy and procedure, and interviews, it was determined the Registered Nurse (RN) failed to provide patient specific written instructions for the hospice aide (HA) providing care.  This affected Home Visit (HV) # 1, one of four MRs reviewed with a HV, and had the potential to negatively affect all patients receiving aide services.Findings include:  Agency Policy:  Hospice Aide Assignments and DutiesPolicy Number:  PC.H20Revised Date:  NonePolicy:HAs are assigned to specific patients by a hospice RN and follow written patient care instructions in providing care to assigned patients.Procedure:1. The hospice RN responsible for supervising the hospice aide prepares written patient care instructions that are patient-specific and not generic. --- 1. HV # 1 was admitted to the agency on 12/11/23 with a diagnosis of Alzheimer's Disease, and recertified for care 8/2/25 to 9/30/25.Review of the Hospice Plan of Care (POC), effective 8/1/25, revealed HV # 1 was bedbound and had orders for the Hospice Aide to visit three times a week.Review of the HA visit task list written by the RN for 8/1/25 to 9/30/25 revealed instructions for the HA to provide a shower.Review of 13 HA visits from 8/4/25 to 9/8/25 revealed the HA documented a shower was provided each visit for the bedbound patient.An interview was conducted on 9/17/25 at 2:24 PM with Employee Identifier (EI) # 2, Branch Director, who confirmed the HA task list was not specific to the needs of HV # 1.

Based on review of medical records (MR), agency policy, and staff interviews, it was determined the agency failed to ensure the staff completed documentation within seven days of the patient visit.This deficient practice affected five of 19 MRs reviewed including MR # 5, MR # 9, MR # 10, MR # 15, MR #13, , and had the potential to negatively affect all patients admitted to the agency.This is a continuing deficiency from the survey of 12/15/22.Findings include:Agency Policy: Clinical RecordsPolicy Number: PC.C15Revision Date: NonePolicy:A clinical record is established and maintained for every patient receiving care and services from Southeast Hospice Network. The record is complete, promptly and accurately documented, readily accessible, and systematically organized to facilitate retrieval.All hard copy documentation should be filed in the hospice MR or electronically locked in the electronic medical record (EMR) within seven days of service... --- 4. MR # 15 was admitted to the agency on 7/9/25 with diagnoses of Multiple Sclerosis and Adult Failure to Thrive. A SN visit was conducted on 7/15/25 and completed by the SN on 7/28/25, thirteen days after the visit occurred. A SN visit was conducted on 7/18/25 and completed by the SN on 7/28/25, ten days after the visit occurred. A HA visit was conducted on 7/15/25 and completed by the HA on 8/5/25, twenty one days after the visit occurred. A HA visit was conducted on 7/17/25 and completed  by the HA on 8/5/25, nineteen days after the visit occurred. A HA visit was conducted on 7/22/25 and completed by the HA on 8/5/25, fourteen days after the visit occurred. An interview was conducted on 9/17/25 at 1:02 PM with EI # 6, Administrator, who confirmed the staff failed to follow the agency policy for completion of documentation in the EMR.5. MR # 13 was admitted to the agency on 8/14/25 with a diagnosis of Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure. A SN visit was conducted on 8/15/25 and completed by the SN on 8/24/25, nine days after the visit occurred. A SN visit was conducted on 8/25/25 and completed by the SN on 9/8/25, fourteen days after the visit occurred.A SN visit was conducted on 8/27/25 and completed by the SN on 9/8/25, twelve days after the visit occurred. An interview was conducted on 9/17/25 at 1:26 PM with EI # 6, who confirmed the staff failed to follow the agency policy for completion of documentation in the EMR.  1. MR # 5 was admitted to the agency on 8/21/25 with a diagnosis of Parkinsonism, Unspecified. A Hospice Aide (HA) visit was conducted on 8/26/25 and was completed by the HA on 9/7/25, twelve days after the visit occurred. An interview conducted on 9/16/25 at 5:15 PM with Employee Identifier (EI) # 1, Executive Director, confirmed staff failed to follow the agency policy for completion of documentation in the EMR.2.  MR # 9 was admitted to the agency on 8/18/25 with a diagnosis of Alzheimer's Disease, Unspecified. Skilled Nurse (SN) visits were conducted on 8/26/25 and 8/29/25. The visit notes were completed by the SN on 9/8/25, thirteen and ten days after the visits occurred. An interview conducted on 9/17/25 at 1:40 PM with EI # 1 confirmed the staff failed to follow the agency policy for completion of documentation in the EMR. 3. MR # 10 was admitted to the agency on 8/14/25 with a diagnosis of Cerebrovascular Disease, Unspecified. A SN visit occurred on 8/15/25 and the visit note was completed on 8/24/25, eight days after the visit. SN visits were also completed on 8/25/25 and 8/27/25. The visit notes were completed by the SN on 9/8/25, fourteen and twelve days after the visits occurred. An interview conducted on 9/17/25 at 1:35 PM with EI # 1 confirmed the staff failed to follow the policy for documentation completion in the EMR.

Based on Home Visit (HV) observations, agency procedure, and interview, it was determined the hospice agency failed to ensure the Skilled Nursing Facility (SNF) was provided the following:1. The most recent hospice plan of care (POC).2. Hospice election form and any advance directives. 3. Physician certification and recertification of the terminal illness.4. Names and contact information for hospice personnel involved in hospice care.5. Instructions on how to access the hospice's 24-hour on-call system.6. Hospice medication information specific to the patient.7. Hospice physician orders.This affected HV # 4, one of one HVs conducted in a SNF, and had the potential to affect all patients with the hospice agency residing in a SNF.Findings include:Agency Policy:  Hospice Care For Nursing Facility Residents-Coordination of ServicesPolicy Number:  PC.H40Revised Date:  NoneProcedures:1. The hospice designates a member of each interdisciplinary group (IDG) that is responsible for a patient who is a resident of a facility.  The designated IDG member is responsible for:a. Providing overall coordination of the hospice care of the resident with facility representatives;b. Communicating with facility representatives...for the terminal illness and related conditions and other conditions to ensure quality of care for the patient and family.....3. The following information is provided to the facility:a. the most recent hospice POC...b. hospice election form and any advance directives...c. physician certification and recertification of the terminal illness...d. names and contact information for hospice personnel involved in the hospice care...e. instructions on how to access the hospice's 24 hour-on-call system;f. hospice medication information specific to each patient; andg. hospice physician...orders specific to each patient --- 1. HV # 4 was admitted to the agency on 9/30/24 with a diagnosis of Alzheimer's Disease With Late Onset.A HV was conducted to the SNF where HV # 4 resided on 9/16/25 at 10:05 AM to observe care provided by Employee Identifier (EI) # 3, Chaplain. After the visit was completed, the surveyor went to the SNF nurse station to review the documentation provided by the hospice for HV # 4's coordination of care.  There was no documentation available.  The surveyor asked the SNF Registered Nurse (RN) on duty for any information available from the hospice for HV # 4.  The RN searched the unit, but was unable to find any documentation on-site from the hospice for HV # 4.The hospice failed to provide documentation required to the SNF for coordination of HV # 4's care.An interview was conducted on 9/17/25 at 2:04 PM with EI # 2, Branch Director, who confirmed there was no documentation provided to the SNF to coordinate the care provided.

Based on review of agency policy and procedure, observations, medical records (MR), and interviews with staff, it was determined the agency failed to assess and maintain an accurate medication list (ML). This deficient practice affected two of three home visits (HV) including HV # 1 and # 3 and one of ten MR reviewed including MR # 1 and had the potential to affect all patients served by the agency. Findings include: Policy: Hospice Medication Oversight Policy Number: None Revision Date : None Procedure: ...D. Changes in the medication regimen must be included in the plan of care (POC) and discussed /approved by the Interdisciplinary Team... --- 3. MR # 1 was admitted to the agency on 8/12/22 and was recertified for care 11/20/22 to 2/7/23 with diagnoses including Chronic Obstructive Pulmonary Disease, Unspecified and Chronic Systolic (Congestive) Heart Failure. Review of the Hospice Certification of Terminal Illness (CTI) dated 11/09/22 revealed SN documented "Pt (patient) is O2 dependent on 3L per NC (nasal cannula)." Further review of the ML recorded on the CTI dated 11/9/22 revealed Oxygen was not listed. Review of the Interdisciplinary Group (IDG) comprehensive assessments dated 11/17/22 and 12/1/22 revealed patient is O2 dependent on 3L per NC and oxygen was not listed as a current medication. In an interview conducted on 12/13/22 at 4:43 PM EI # 1, Administrator confirmed the staff failed to ensure the ML was assessed, maintained and accurate per the agency's policy. 2. HV # 3 was admitted to the agency on 2/02/20 and recertified for care 11/18/22 to 1/16/23 with a diagnosis of Alzheimer's Disease, Unspecified. Review of the Plan of Care (POC) dated 11/09/22 revealed skilled nurse (SN) visits were ordered one time a week. A HV was conducted on 12/14/22 at 10:00 AM to observe care provided by Employee Identifier (EI) # 3 Hospice Aide. A review of the patient's medications was conducted with the caregiver (CG) using the ML provided by the agency. The following medications were found on the list but not currently taken by the patient. a. Bactrim DS 800-160 milligram (mg) tablets take 0.5 tablet one time a day order date 5/06/21. CG stated the he/she was finished taking this "several, several months ago." b .Protonix 40 mg tablets take one time a day order date 4/21/21. CG stated he/she hasn't taken this in "two and a half years." An interview was conducted with EI # 5 Executive Director, on 12/15/22 at 3:10 PM, who confirmed the staff failed to maintain an accurate ML. 1. Home Visit (HV) # 1 was admitted to the agency on 10/15/21 with diagnoses including Cerebrovascular Disease, Unspecified and Vascular Dementia, Unspecified Severity, with Behavioral Disturbance. Review of the physicians order dated 9/28/22 revealed Oxygen (O2) to be administered at 4L (liters) as needed (prn). Review of the physicians order dated 11/9/22 revealed Milk of Magnesia 30ml by mouth (PO) daily prn constipation. Review of the Current Medication List printed on 12/13/22 revealed that neither the Oxygen nor the Milk of Magnesia were listed. This was confirmed with a facility nurse. In an interview on 12/15/22 at 3:40 PM with EI # 5, Executive Director, he/she confirmed that the staff failed to maintain an accurate ML.

Based on review of medical records (MR), agency policy and procedure, completed visit note documentation and interviews, it was determined, the agency failed to ensure the staff completed documentation within seven days of the patient visit. This deficient practice affected one of three home visits (HV) including HV # 1 and three of ten MR including MR # 2, MR # 4 , MR # 3, and had the potential to affect all patients admitted to the agency. Findings include: Agency Policy: Hospice Medical Record Policy Number: None Revision Date: None Policy: Hospice will maintain a comprehensive and accurate record of services provided in all care settings for each patient and family. Procedure: A. All hard copy documentation should be filed in the hospice MR or electronically locked in the EMR within seven days of service... --- 4. MR # 3 was admitted to the agency on 10/25/22 with diagnoses including Senile Degeneration of the Brain and Chronic Obstructive Pulmonary Disease. Review of the hospice aide visit notes (VN) revealed the following VN were not recorded and signed within seven days per policy. 10/26/2022 VN recorded and signed 11/04/22, which was nine days later. 11/07/2022 VN recorded and signed 11/17/2022, which was ten days later. 11/09/2022 VN recorded and signed 11/17/2022, which was eight days later. 11/21/2022 VN recorded and signed 12/11/2022, which was twenty days later 11/23/2022 VN recorded and signed 12/11/2022, which was eighteen days later. 11/28/2022 VN recorded and signed 12/11/2022, which was thirteen days later. 11/30/2022 VN recorded and signed 12/11/2022, which was eleven days later. 12/02/2022 VN recorded and signed 12/11/2022, which was nine days later. An interview conducted 12/15/22 at 2:41 PM with EI # 5, Executive Director, confirmed the VN documentation was not completed and electronically locked in the EMR within seven days per policy. 1. Home Visit (HV) # 1 was recertified for hospice 12/9/22 to 2/6/23 with diagnoses including Cerebrovascular Disease, Unspecified and Vascular Dementia, Unspecified Severity, with Behavioral Disturbance. Review of the Hospice Plan of Care dated 12/9/22 to 2/6/23 revealed the Medical Social Worker (MSW) was to visit once per month. Review of the Medical Social Worker Visit Note dated 11/3/22 revealed the MSW digitally signed the note on 11/28/22 which was 25 days after the visit. An interview conducted 12/15/22 at 2:41 PM with EI # 5, Executive Director, confirmed the Visit Note (VN) listed above was not electronically locked in the EMR within seven days per policy. 2. MR # 2 was admitted to the agency on 11/2/22 with diagnoses including Heart Failure, Unspecified and Cardiomyopathy, Unspecified. Review of the Hospice Plan of Care dated 11/2/22 to 1/30/23 revealed the Skilled Nurse (SN) was to visit once weekly, and the Chaplain and MSW were to visit once monthly. Review of the MSW VN dated 11/7/22 revealed the MSW digitally signed the note on 12/13/22 which was 36 days after the visit. Review of the Chaplain VN dated 11/14/22 revealed the chaplain digitally signed the note on 11/23/22 which was 9 days later. Review of the SN VN dated 12/2/22 revealed the SN digitally signed the note on 12/11/22 which was 9 days later. An interview conducted 12/15/22 at 2:41 PM with EI # 5, Executive Director, confirmed the VN listed above were not electronically locked in the EMR within seven days per policy. 3. MR # 4 was admitted to the agency on 7/15/22 and was recertified for hospice 10/13/22 to 1/10/23 with diagnoses including Alzheimers Disease, Unspecified and Hypertensive Heart Disease without Heart Failure. Review of the Hospice Plan of Care dated 10/13/22 to 1/10/23 revealed the SN was to visit once weekly, the Hospice Aide (HA) was to visit twice weekly, and the Chaplain was to visit once monthly. Review of the Chaplain VN dated 10/6/22 revealed the chaplain digitally signed the note on 10/26/22 which was 20 days after the visit. Review of the HA VN dated 10/13/22 revealed the HA digitally signed the note on 10/23/22 which was 10 days later. Review of the HA VN dated 10/18/22 revealed the HA digitally signed the note on 10/30/22 which was 12 days later. Review of the SN VN dated 10/20/22 revealed the SN digitally signed the note on 10/30/22 which was 10 days later. Review of the HA VN dated 10/25/22 revealed the HA digitally signed the note on 11/5/22 which was 11 days later. Review of the HA VN dated 10/27/22 revealed the HA digitally signed the note on 11/5/22 which was 9 days later. An interview conducted 12/15/22 at 2:41 PM with EI # 5, Executive Director, confirmed the VN listed above were not electronically locked in the EMR within seven days per policy.

Based on observation, policy and procedure, and interview of agency staff, it was determined the hospice agency failed to provide the Skilled Nursing Facility (SNF) the most current plan of care. This affected one of three Home Visits (HV) for a patient residing in a SNF and did affect HV # 1, and had the potential to affect all patients served by the agency that reside in a facility. Findings include: Agency Policy: Facility-Based Home Care Purpose: To ensure the coordination of services for each patient. Policy: ...Hospice will make every reasonable effort to ensure that the environment of the facility supports the needs of the hospice patient/family. Procedure: ...2. All services are delivered under the direction of the interdisciplinary team, coordinated by the Nurse Manager, and evaluated by the hospice. ...3. The Nurse Manager of designee is designated by the hospice to act as a liaison with the facility. ...4. The facility will identify one of its staff to be a liaison with the hospice. --- HV # 1 was admitted to hospice services on 10/15/21 with diagnoses including Cerebrovascular Disease, Unspecified and Vascular Dementia, Unspecified Severity, with Behavioral Disturbance. A HV was conducted on 12/13/22 at 12:05 PM to observe care provided by Employee Identifier (EI) # 4, Chaplain for this patient residing in a SNF. Review of the facility medical record documentation revealed no hospice plan of care or documentation to demonstrate coordination of care between the facility and the agency. An interview conducted on 12/15/22 at 3:40 PM with EI # 5, Executive Director, revealed no documentation was provided to the facility for coordination of care.