Every finding on record at Kelton Hospice, Inc.

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 medication review process includes the identification of the following, the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. 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 clinical record review and interview. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure a medication reconciliation was completed and medications updated to the medication profile during the comprehensive assessment. HOME VISIT 1/CLINICAL RECORD 6: The patient's date of election was 02/13/2024 with diagnosis of Chronic obstructive pulmonary disease, Secondary DX: pneumonia, acute and chronic respiratory failure with hypoxia, history COVID-19, hypertension, atrial fibrillation. The patient resided in a skilled nursing facility (SNF). The medication profile printed on 04/01/2025 by the hospice agency included three medications that were duplicated. The Tylenol with Codeine #3 300-30 mg tablet, take one tablet three times a day as needed for pain; Acetaminophen-Codeine 300-30 mg tablet, take one tablet three times a day as needed for pain; Budesonide Inhalation Suspension 0.25 mg/2 ml, inhale one vial twice daily; Budesonide Inhalation Suspension 0.5 mg/2 ml, inhale 2 ml daily; Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg/3 ml, inhale one vial every two hours as needed for shortness of breath; Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg/3 ml, inhale 3 ml every 4 hours as needed for shortness of breath); Diltiazem HCl 60 mg tablet, take one tablet daily; Benzonatate 100 mg capsule, take one capsule three times a day as needed for cough/congestion; Metoprolol Tartrate 25mg tablet, take 0.5 tab twice daily; and Promethazine HCl 25 mg, take one tablet every 4 hours as needed for nausea/vomiting. During the home visit with the Registered Nurse (Personnel Record 3), a review of the medication at the facility revealed Multivitamin with Minerals, take one tablet daily, started on 01/13/2025; Claritin 10 mg tablet, take one tablet every 24 hours as needed for allergy, started on 12/27/2024; and Azithromycin 250 mg, take one tablet every Monday, Wednesday, and Saturday, started on 01/13/2025. The facility medications did not include Diltiazem, Benzonatate, Metoprolol Tartrate, and Phenergan. The facility medications only listed the medications duplicated on the hospice agency medication profile one time. There was no documented evidence that the registered nurse comprehensive assessment dated 03/25/2025 included a medication reconciliation and medication profile update. During a joint record review and interview on 04/02/2025, the Hospice Supervising Nurse/Registered Nurse confirmed that there was no documented evidence the medications were reconciled at the time of each comprehensive assessment and updated to the drug profile. HOME VISIT 3/CLINICAL RECORD 8: The patient's date of election was 04/27/2024. The patient resided at an assisted living facility . The medication profile printed on 04/01/2025 by the agency was reviewed during the home visit (Clinical Record 8) with the Chaplain (Personnel Record 7). The medications at the facility revealed Ibuprofen 200 mg capsule, take two capsules every six hours as needed for mild pain, started on 10/02/2024. The Ibuprofen was not included in the hospice agency’s medication profile. The last registered nurse comprehensive assessment was dated 03/26/2025. There was no documented evidence that the registered nurse comprehensive assessment dated 03/26/2025 included a medication reconciliation and medication profile update. During a joint record review and interview on 04/02/2025, the Director of Hospice confirmed that there was no documented evidence the medications were reconciled at the time of each comprehensive assessment and updated to the drug profile.

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, such as hand hygiene. This standard was not met as evidenced by document review, interview, and observation. In 2 of 3 (67%) home visit observations revealed the agency did not ensure the staff followed the agency hand hygiene policy. Agency Policy: Hand Hygiene IC.15, last reviewed 09/01/2024, stated in part, "Hand Hygiene with Soap and Water: Staff will identify and gather appropriate supplies. Staff will wet hands and wrists with water using temperature that is comfortable. Staff will apply the amount of product recommended by the manufacturer to hands and rub hands together vigorously for at least 15 seconds (with recommendation of 20 seconds, but either time is acceptable), covering all surfaces of the hands and fingers. Staff will rinse hands and wrists thoroughly with water. With hands held upright, staff will dry hands and wrists thoroughly with a clean paper towel. They will use a paper towel to turn off the faucet... Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Staff may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situations described below: after removing gloves." HOME VISIT 1: During the home visit (Clinical Record 6) on 05/22/2024 with the Registered Nurse (RN) (Personnel Record 3), the RN was observed donning gloves. The RN was observed removing the gloves three times during the visit without disinfecting the hands after each glove removal. HOME VISIT 2: During the home visit (Clinical Record 3) on 04/02/2025 with the Hospice Aide (Personnel Record 8), the aide was observed washing the hands with soap and water. The aide rinsed the hands and then turned off the water faucet with wet hands. The aide used paper towels to dry the hands. During a joint document review and interview on 04/02/2025, the Director of Hospice agreed the staff did not follow the hand hygiene policy.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview revealed the agency volunteer program lacked evidence of efforts to retain volunteers. During an interview on 04/02/2025, the Director of Hospice and Volunteer Coordinator confirmed that the retention efforts from January 2024 through March 2025 were not documented. Upon reviewing the volunteer program, the documentation lacked evidence of efforts to retain volunteers.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of the volunteer program revealed the documentation lacked evidence of the number of direct care staff hours, the volunteer percentage, and the cost savings the hospice would have incurred if paid employees occupied the positions from April 2024 through January 2025. The total patient care hours from April 2024 through January 2025 was 0.3% and for February and March 2025 revealed 26 volunteer hours, which equaled 3.4%. Total volunteer hours from April 2024-March 2025 were 3.7%. During a joint review of the volunteer program records and interview on 04/02/2025, the Volunteer Coordinator confirmed the documented volunteer hours, patient care hours, and current percentage. The Volunteer Coordinator stated that the previous Coordinator had not kept any documentation for volunteer efforts from April 2024 through January 2025. Upon reviewing the volunteer program, the documentation lacked evidence of the number of direct care staff hours, the volunteer percentage, and the cost savings the hospice would have incurred if paid employees occupied the positions from April 2024 through January 2025. The documentation for February and March 2025 revealed 26 volunteer hours, which equals 3.4% of the total patient care hours for the two months and 0.3% of the total patient care hours over the last twelve months.

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years. This standard was not met as evidenced by review of personal records, documentation reveiw, and interview. 1 of 12 (8%) of personnel records reviewed revealed the hospice did not ensure all personnel receive EP training at least every 2 years. Personnel Record #95045 was reviewed and identified the volunteer date of hire was 7/19/2018. The record did not include documentation of EP training, nor did hospice in-service documentation include this employee as a participant in EP training records with dates, participants, and content since hire date of 7/19/18, the iinitial orientation and EP training. During an interview on 5/26/2022, the Administrator confirmed the employee record does not included documentation of 2-year EP training in the personnel file or the in-service documentation log provided to employees.

It is required that the plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions This standard was not met as evidenced by review of clinical records and interview. 1 of 11 (9%) clinical record reviewed revealed the plan of care did not specify hospice care necessary as identified in the comprehensive assessment. Clinical Record #19495 was reviewed and identified patient elected hospice care on 8/29/21. The comprehensive assessment in the clinical record documented on 8/29/21 identified the patient has diabetes with hypertension and suffers from migraines. The plan of cares dated 8/29/21 and 4/22/2022 did not include hospice care necessary to meet these specific needs of the patient as identified in the comprehensive assessment. During an interview on 5/26/2022, the Administrator confirmed the plan of care did not include hospice care necessary to meet these specific needs (diabetes, hypertension, migraines) identified in the plan of care.

It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by review of clinical records and interview.1 of 11 (9%) patient records reviewed revealed that services provided were inconsistent with the individualized plan of care as established by the IDG. Clinical Record #70918 was reviewed and identified the patient elected hospice care on 1/5/21. The ordered social work visit frequency initiated on 7/1/21 was 2 times a month with 2 prn visits a month. The clinical record revealed 5 visits were completed in July 2021, 1 extra visit. There was no documentation explaining the extra visit. During an interview on 5/26/2022, the Administrator confirmed the visit frequencies did not occur as ordered in the patient’s plan of care, and that there was no documentation to support the reason the visit frequency did not follow orders present in the patient’s plans of care.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician revise the plan of care to include information from the patient’s updated comprehensive assessment. This standard was not met as evidenced by review of clinical records and interview. 1 of 11 (9%) clinical records reviewed revealed the plan of care was not revised to include information from the patient’s updated comprehensive assessment. Clinical Record # 68712 was reviewed and identified patient elected hospice care on 4/8/21. The plan of care dated 4/8/21 included an order for oxygen at a dose of 2 LPM via NC continuously. A comprehensive assessment completed on 9/24/21 documents oxygen was assessed and increased oxygen to 4L for SOB. The plan of care was not revised to include the updated information from the comprehensive assessment. During an interview on 5/26/2022, the Administrator confirmed the plan of care was not revised to include the updated information from the comprehensive assessment.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by review of personal records, documentation reveiw, and interview. 1 of 12 (8%) of personnel records reviewed revealed the hospice did not ensure assessments of skills and competencies of volunteers providing services and provide in-service training and education where required. Personnel Record #95045 was reviewed and identified the volunteer date of hire was 7/19/2018. The record did not include documentation of assessments of skills and competencies and in-service training and education in 2019. Hospice in-service documentation did not include this employee as a participant in training and education records with dates, participants, and content in 2019. During an interview on 5/26/2022, the Administrator confirmed the personnel record does not include 2019, 2020 and 2021 documentation of training and education or the in-service documentation log provided to employees.

It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). The Interdisciplinary Group ensures that the safe use and disposal of controlled drugs is understood, and documents in the patient record that the policies and procedures for managing and disposing of controlled medications is provided and discussed. This standard was not met as evidenced by review of the hospice admission packet, clinical records, and interview. 11 of 11 (100%) clinical records reviewed revealed the hospice did not ensure the provision of written policies and procedures for the management and disposal of controlled medications. Clinical Record #20092 was reviewed and identified patient elected hospice care on 5/17/21. The admission packet did not include written policies and procedures for the management and disposal of controlled medications. Clinical Record #98820 was reviewed and identified patient elected hospice care on 10/22/21. The admission packet did not include written policies and procedures for the management and disposal of controlled medications. Clinical Record #51663 was reviewed and identified patient elected hospice care on 7/21/21. The admission packet did not include written policies and procedures for the management and disposal of controlled medications. Clinical Record #44335 was reviewed and identified patient elected hospice care on 12/23/20. The admission packet did not include written policies and procedures for the management and disposal of controlled medications. Clinical Record #77052 was reviewed and identified patient elected hospice care on 3/10/21. The admission packet did not include written policies and procedures for the management and disposal of controlled medications. Clinical Record #19495 was reviewed and identified patient elected hospice care on 8/29/21. The admission packet did not include written policies and procedures for the management and disposal of controlled medications. Clinical Record #94942 was reviewed and identified patient elected hospice care on 1/18/22. The admission packet did not include written policies and procedures for the management and disposal of controlled medications. Clinical Record #62875 was reviewed and identified patient elected hospice care on 1/11/22. The admission packet did not include written policies and procedures for the management and disposal of controlled medications. Clinical Record #41562 was reviewed and identified patient elected hospice care on 2/9/22. The admission packet did not include written policies and procedures for the management and disposal of controlled medications. Clinical Record # 68712 was reviewed and identified patient elected hospice care on 4/8/2021. The admission packet did not include written policies and procedures for the management and disposal of controlled medications. Clinical Record #70918 was reviewed and identified patient elected hospice care on 1/5/21. .The admission packet did not include written policies and procedures for the management and disposal of controlled medications. Hospice policy PC.28, titled “Medication Disposal” states, in part, “On admission the agency will provide a copy of the agency’s written policies and procedures on the management of disposal of controlled drugs to the patient or patient representative and family.” During an interview on 5/26/2022, the Administrator confirmed that on admission the agency did not provide a copy of the agency’s written policies and procedures on the management of disposal of controlled drugs to the patient or patient representative and family.