Every finding on record at Kent County VNA - Hospice

Based on record review and staff interview it has been determined that the agency failed to immediately take action to prevent further potential violations while an alleged violation is being conducted in accordance with established procedures for 2 of 2 allegations of abuse reviewed, Patient ID #s 20 and 21. --- Findings are as follows: Review of an agency policy titled, ";Abuse and/or Neglect- 60 years and older" revealed in part: ";...The purpose of this Abuse and/or Neglect of Elder- 60 years and older policy is to describe the VNA of Care New England protocol and/or law for all professional and non-professional employees in reporting suspicion or actual abuse and/or neglect of an elder 60 years of age or older... ...All health care professionals and paraprofessionals are responsible for adhering to the elder abuse/ neglect reporting procedure... ...Allegation of abuse by a licensed home care agency or nursing facility should be reported to the Department of Health Facilities and Regulation and the Alliance of Better Long-Term Care... ...The report must contain... The name, address, telephone number, occupation, and employers address and the phone number of the person reporting... The name and address of the patient [pt] or resident who is believed to be the victim of the abuse, mistreatment, or neglect... The details, observations, and beliefs concerning the incident(s)... Any statement regarding the incident made by the patient or resident and to whom they were made... The date, time, and place of the incident... The name of any individual(s) believed to have knowledge of the incident... The name of any individual(s) believed to have been responsible for the incident... Duty To Report...medical profession or health officer or any person within the scope of their employment at a Home Nursing Care or Home Care Provider or in their professional capacity who has knowledge of or reasonable cause to believe that a patient or resident receiving or being assessed for services has been abused, mistreated or neglected shall make within 24 [hours] or by the end of the next business day a telephone or fax report to the licensing agency for those incidents involving home nursing, home care and in health care facilities... Allegations of Abuse/neglect by Licensed Agency/Facility... For allegations of abuse by a home care or other licensed facility the Rhode Island Department of Health (DOH) must be reported within 24 hours of discovery..." 1) Record review of the Hospice Plan of Care for Patient ID #20 revealed a start of care date of 10/16/2024. It further revealed in part, ";Patient Strengths/ Long Term Goals: Safe Personal Care with Dignity Throughout the Certification Period..." Record review of a social worker visit note dated 12/13/2024, revealed documentation that the patient expressed that the facility had ";mistreated" him/her. The patient had further stated ";I do not want to get anyone in trouble" and ";I just want to forget it." The documentation further reveals that the patient had said to his/her family member, ";She lifted the sheet, that [s/he] thinks [s/he] has a girlfriend." Record review of a care coordination note dated 12/14/2024, revealed in part, ";...a wellness check on the patient and caregiver...the caregiver reported that the patient is doing well after revealing [his/her] experiences, using client language sexual assault and way to friendly'...Additionally, [nursing home name redacted]...contacted the...Police on Friday night, regarding the allegation of sexual abuse..." Review of the record in the presence of the Director of Organizational Excellence and the Director of Hospice on 2/28/2025 failed to reveal evidence that the Agency had reported the allegation of abuse to the Department of Health. It further failed to reveal evidence that the agency had conducted a thorough investigation of the abuse allegation. During a surveyor interview on 3/3/2025 at approximately 12:00 PM with the Director of Organizational Excellence and the Director of Hospice, they acknowledged that they had failed to report the above incident of suspected abuse to the Department of Health. They further were unable to provide evidence that a thorough investigation was conducted by the agency regarding the alleged abuse of Patient ID #20. 2) Record review of the Hospice Plan of Care for Patient ID #21 revealed a start of care date of 6/27/2024. It further revealed in part, ";Long Term Goals...Patient will be maintained in a safe environment..." Record review of a patient care coordination note dated 8/19/2024, revealed that the patients family member called the agency to report that the patient left the family member a voicemail stating that s/he was abused by the staff that put him/her to bed. It further revealed that the family member was very upset. Record review of a nursing visit note dated 8/19/2024 revealed documentation that the visit was made due to the allegation of abuse. It revealed that the patient reported that a bigger woman was rough with him/her when putting him/her to bed 2 nights ago. It further revealed that the patient had a healing skin tear, but the patient was unsure how s/he obtained it. Review of the record in the presence of the Director of Organizational Excellence and the Director of Hospice failed to reveal evidence that the Agency had reported the allegation of abuse to the Department of Health. During a surveyor interview on 3/3/2025 at approximately 12:00 PM with the Director of Organizational Excellence and the Director of Hospice, they acknowledged that they had failed to report the above incident of suspected abuse to the Department of Health.

Based on surveyor observation, record review, staff and patient interview it has been determined that the agency failed to develop an individualized written plan of care that reflects patient and family goals and interventions identified in the initial, comprehensive and updated comprehensive assessments relative to ensuring that medications are administered according to the patients plan of care for 2 of 4 patients visits, Patient ID #s 3 and 4. --- Findings are as follows: Review of the agency policy titled, ";Medication Reconciliation" revealed in part, ";...To develop, reconcile, and maintain an accurate patient medication list... This policy applies to all...clinicians and patients with an active medication list in Home Health and Hospice services... Medication reconciliation- process of comparing the medications a patient is taking, including prescribed and over the counter medications, with newly ordered medications... The qualified clinician is responsible for conducting medication reconciliation by comparing the discharge medication list from the referral source with medications preset in the home and entering the medications into the...electronic record... Once medication reconciliation is confirmed then clinicians shall evaluate for any new, discontinued, or changed meds at all future visits... Clinicians will update both the electronic Medication Profile and the patients medication list as needed when conducting the medication reconciliation process. Medications in the electronic profile and the patients medication list in the home must match..." 1) Record review of the agency provided medication list for Patient ID #3, who resides in a Skilled Nursing facility (SNF) revealed the following orders: - order dated 3/14/2024 for Enulose 10 gram(gm)/15 milliliters (ml) (medication prescribed to treat constipation), take 90 ml two times daily. Review of the patients current orders provided by the SNF revealed the following: -order dated 10/23/2024 for Enulose 10 gm/15 ml, take 90 ml once daily During a surveyor interview on 2/26/2025 at approximately 2:30 PM with Registered Nurse, Staff A, she indicated that she was unaware of the discrepancy. 2) Record review of the agency provided medication list for Patient ID #4 revealed the following orders: -order dated 1/16/2024 for Advair Diskus (inhaler- prescribed to treat asthma) 250 micrograms (mcg)- 50 mcg, inhale 1 puff 2 times daily -order dated 10/3/2024 for clonazepam (medication prescribed to treat anxiety) 0.5 milligram (mg) take one tablet every 6 hours and one tablet 3 times a day as needed. -order dated 3/25/2024 for Haldol (medication prescribed to treat severe agitation/ hallucinations) 1 mg every 6 hours as needed. - order dated 10/2/2024 for Senna Plus 8.6 mg- 50 mg (medication prescribed to treat constipation) one tablet daily. - order dated 1/16/2024 for Spiriva Respimat 2.5 mcg (medication prescribed to treat Asthma) once daily. During a surveyor interview on 2/25/2025 at 3:00 PM of the patient, in the presence of the Chaplin, s/he revealed the following: - s/he has not taken the Advair Diskus for over two years -s/he takes the clonazepam 0.5 mg every four hours as needed. -the Haldol was prescribed to him/her approximately two years ago while s/he was hospitalized. The patient stated that s/he has never taken this medication. -s/he takes two tablets daily of the Senna Plus. S/he stated that taking one tablet a day didnt work for him/her. -s/he hasnt taken the Spiriva Respimat for 2 years. During a surveyor interview on 2/26/2025 at approximately 2:30 PM with Registered Nurse, Staff B, she acknowledged that the medication list should have been updated. She could not provide evidence that she had updated the medication list. During a surveyor interview on 2/26/2025 at 3:10 PM with the Director of Hospice, she revealed that she would expect the nurse to reconcile the patients medications during the home visits.

Based on record review and staff interview, it has been determined that the agency failed to ensure that care and services are provided in accordance with the plan of care for 1 of 1 patient reviewed relative to weekly measurements and assessments of pressure wounds, Patient ID #5. --- Findings are as follows: Review of the agency policy, titled ";Process: Use of the Wound Addendum" states in part, ";...The clinician will document all wound characteristics by completing each section of the Wound Addendum at each visit. Open wounds will be measured weekly on the first of the week..." Review of the plan of care, for recertification period 1/14/2025 through 3/14/2025, revealed a start of care date of 9/22/2023. Further review revealed s/he has a stage 3 pressure ulcer (a wound with full thickness skin loss, involving damage or death to the tissue under the skin that may extend down to, but not through underlying tissues and muscles) to his/her coccyx (a small triangular bone at the base of the spinal column) that originated on admission. In addition, s/he has a stage 2 pressure ulcer (a wound with partial-thickness skin loss, typically breaking through the top layer of the skin and part of the layer below) to the left thigh with an onset date of 8/7/2024. Additional review of the plan of care revealed interventions for the skilled nurse to assess the wounds weekly if the agency is performing wound care. Review of the weekly wound reports from 2/2/2025 through 2/22/2025 revealed the following: - 2/2/2025 through 2/8/2025: weekly skilled nurse visit was cancelled without a documented reason; therefore, no wound report, measurements nor wound assessments were completed. - 2/9/2025 through 2/15/2025: failed to reveal evidence of measurements to either the coccyx or thigh wounds. - 2/16/2025 through 2/22/2025: failed to reveal evidence of measurements or assessments to the coccyx or thigh wounds During a surveyor interview on 2/27/2025 at approximately 11:00 AM with the Wound Specialist, she acknowledged that the wound measurements and/or assessments were not completed for the above-mentioned weeks and indicated her expectation would be that the nurse would have either completed this documentation or documented the reason as to why it was not done. Furthermore, her expectation would be that a reason would be documented as to why the nurse visit was cancelled for the week of 2/2/2025 through 2/8/2025 and that the missed visit would have been rescheduled. During a surveyor interview 2/27/2025 at approximately 3:30 PM with the Director of Hospice, she was unable to provide evidence that the patients plan of care and the agency policy were followed.

Based on surveyor observation, record review, and staff interview, it has been determined that the hospice failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases for 1 of 1 patient reviewed, relative to the proper positioning of a Foley catheter and the maintenance of enhanced barrier precautions, Patient ID #3. --- Findings are as follows: 1. Review of the agency policy, titled ";Indwelling urinary catheter (Foley) care and management" states in part, ";...Ensure that the drainage bag is maintained below the level of the bladder to prevent backflow of urine into the bladder, which increases the risk of CAUTI [catheter-associated urinary tract infection]..." Surveyor observation of Certified Nursing Assistant (CNA), Staff C, providing ADL (activities of daily living) care to the patient while in bed on 2/26/2025 at 8:48 AM, revealed that while emptying the patients Foley catheter Staff C held the drainage bag above the level of the bladder and the urine in the tubing was observed back flowing into the tube leading to his/her bladder. During a surveyor interview with Staff C on 2/26/2025 at 10:00 AM, she acknowledged positioning the drainage bag above the patients bladder while emptying his/her Foley catheter. During a surveyor interview with the Director of Hospice on 2/26/2025 at 3:00 PM, she indicated that her expectation would be that the policy would be followed regarding maintaining the patients drainage bag below the level of his/her bladder. 2. Review of the agency policy, titled ";Infection Surveillance Policy" states in part, ";...Process measures may include, but are not limited to...Adherence to published standards, recommendations from stated accredited bodies...proper management of invasive medical devices..." According to the 3/20/2024 Centers for Disease Control (CDC) infection control guidance regarding enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that indicates targeted gown and glove use during high contact resident care activities) are implemented during high-contact care activities for residents of skilled nursing facilities with indwelling medical devices. Surveyor observation of Patient ID #3's room on 2/26/2025 at approximately 8:48 AM revealed a sign stating that the patient was on EBP. Surveyor observation of CNA, Staff C, on 2/26/2025 at 8:48 AM revealed she entered the patients room and washed her hands in the bathroom. Next, she proceeded to go to the hallway, donned gloves and a gown and then walked down the hallway to gather linen. Upon returning to the patients room, Staff C provided ADL care and emptied the patient's Foley catheter while wearing the same PPE. Further surveyor observation revealed after completing care and while still wearing the same PPE, Staff C exited the patient's room with a bag of soiled linen to place in a bin in the hallway. She then returned to the patient's room to discard her PPE. During a surveyor interview with Staff C on 2/26/2025 at 10:00 AM, she acknowledged wearing PPE in the hallway, touching multiple items, and then providing catheter care to the patient. She further acknowledged wearing the dirty PPE in the hallway to place the patient's linen into a bin. During a surveyor interview with the Director of Hospice on 2/26/2025 at 3:00 PM, she indicated that her expectation would be that the CNA would not wear PPE in the hallway of the skilled nursing facility. Additionally, she indicated that the dirty PPE and soiled linens should be disposed of prior to exiting the patients room.

Based on record review and staff interview, it has been determined that the hospice failed to ensure that bereavement services are available to families and other individuals in the bereavement plan of care up to 1 year following the death of the patient for 2 of 3 patient's reviewed, relative to bereavement services, Patient ID #s 17 and 18. --- Findings are as follows: Record review of an agency policy titled, ";Bereavement Program" dated 4/10/2024, revealed in part, ";...The purpose of this Bereavement Program Policy...is to describe the provisions of timely and professional help for patients/families to cope with grief and loss issues at time of hospice admission, during the illness, after the death, and through the bereavement period... At the time of death, needs are further assessed, a plan of care is established... The Bereavement Coordinator, Social Worker, Spiritual Care Coordinator or specially trained volunteer will make a bereavement contact (a telephone call) seven days for bereaved with high bereavement risk, fourteen days for bereaved with a moderate bereavement risk, thirty days for bereaved with a low bereavement risk... The Hospice RN and/or other team members place a condolence call within 24/48 hours after death... A personalized Bereavement plan of care is written for individuals depending on the needs of the bereaved party... Ongoing bereavement services are offered (unless declined by bereaved) for a minimum of 13 months after the patients death and include... Description of bereavement services offered... Follow-up phone calls and visits as needed or outlined in bereavement plan of care... Support groups (in person/virtual)... Individual counseling or referral for counseling if needed... Mailings detailing bereavement groups, seminars, memorial service (in person/virtual)... Volunteer support with telephone calls and home visits... Education and support materials... All bereavement contact is documented in the patient record..." 1) Record review for Patient ID #17 revealed his/her date of death was on 9/29/2024. Review of the patients record revealed that a family member was chosen to receive bereavement services. Record review in the presence of the Bereavement Coordinator on 2/27/2025 at approximately 2:30 PM, failed to reveal evidence that the family member had received any bereavement services after the patient passed away. He was unable to provide evidence of an opt out form indicating that the family declined bereavement services. Further he was unable to provide any documentation that the family member had declined bereavement services. During a surveyor interview on 2/27/2025 at the time of the above observation with the Bereavement Coordinator, he revealed that the bereavement plan for the family member was initiated on 9/29/2024 and was discharged on 10/1/2024. He acknowledged that there failed to be any documentation of calls, mailings or contacts for the patients family member. Further, he was unable to provide evidence that the patients family member declined bereavement services. 2) Record review for Patient ID #18 revealed his/her date of death was on 10/13/2024. Review of the patient's record revealed that a family member was chosen to receive bereavement services. Record review in the presence of the Bereavement Coordinator on 2/27/2025 at approximately 2:30 PM, revealed that discharge from bereavement services was documented on 11/12/2024. He was unable to provide evidence of an opt out form indicating that the family declined bereavement services. Further he was unable to provide any documentation that the family member had declined bereavement services. During a surveyor interview on 2/27/2025 at the time of the above observation with the Bereavement Coordinator, he acknowledged that there failed to be any documentation indicating that the patient's family member declined bereavement services, or that an opt out form was completed by the family member. During a surveyor interview on 2/27/2025 at approximately 3:30 PM with the Director of Hospice, she revealed that she would expect for an opt out form to be filled out, or a note to be written that the family declined bereavement services.

Based on record review and staff interview it has been determined that the agency's initial assessment failed to assess all the patient's immediate physical conditions for 3 of 3 patient's, Patient ID #'s 1, 2, & 5, relative to skin assessments. Findings are as follows: 1. Review of the clinical record for Patient ID #1, who has a start of care and initial assessment dated 5/24/2021 that reveals, the patient was admitted with a biliary drain. Review of the initial assessment fails to reveal a skin assessment. The record has a wound addendum note dated 5/24/2021 which states "Biliary drain". 2. Review of the clinical record for Patient ID #2, who has a start of care and an initial assessment dated 2/23/2019. The patient was noted upon admission to have a stage 2 pressure on right buttock and a stage 1 on the left hip fails to have these wounds assessed on the initial assessment. As the initial assessment lacked a skin assessment. 3. Review of the clinical record for Patient ID #5, who has a start of care and an initial assessment dated 12/28/2021. The initial visit note reveals that the patient has a "worsening pressure ulcer to the left buttock per the nurse's narrative note on 12/28/2021.Thisi wound was not assessed on the initial assessment, as the initial assessment lacked a skin assessment. During an interview with the Nurse Education Manager on 1/26/2022 at approximately 2:10 PM, she was unable to produce evidence that the staff had completed skin assessments during the initial assessments as required.

Based on record review and staff interview it has been determined that the agency failed to identify medication orders that could exceed the maximum daily dosage for 1 of 1 patient, Patient ID #9. Findings are as follows: Review of the agencies policy titled " Medication Reconciliation " dated 4/2/2021, states in part. "1. Purpose: A. To develop, reconcile, and maintain an accurate patient medication list. B. To maximize medication effectiveness and to reduce the potential for medication errors, side effects or adverse reactions. IV. Policy Statement: B. ... 1. if the medications are not reconciled with provider and patient at SOC [start of care] or evaluation visits, it is the responsibility of all qualified clinicians to attempt to reconcile until all medications are confirmed with provider and patient/caregiver are in agreement. 2. Once medication reconciliation is confirmed then clinicians shall evaluate for any new, discontinued, or changed meds at all future visits. 3. The clinician will document in the EMR [electronic medical record] that the medication reconciliation occurred at every visit." Patient ID #9 was admitted to hospice services on 9/2/2021 and had diagnosis to include but are not limited to end stage cardiac disease and atrial fibrillation. This patient resides in a skilled nursing facility. Review of the medication list for the patient, revealed the following orders on both the hospice orders and the Skilled Nursing Facility's current orders: - Acetaminophen tablet 325 milligrams (MG) give 2 tables by mouth every 6 hours as needed for pain/temp. - Acetaminophen 1000 mg three times a day for pain management. Per the manufacturer recommendations Tylenol has a maximum daily dosage of 3 grams (3,000 milligrams) due to the potential for liver damage. The surveyor interviewed the nurse, Staff A, on 1/25/2022 at approximately 10:00 AM, relative to the above orders. The nurse acknowledged, until brought to her attention by the surveyor, that she did not identify that the patient could receive more Acetaminophen than the recommended maximum daily dose.

Based on record review and staff interview it has been determined that the agency failed to follow the plan of care for 1 of 1 patient, Patient ID #6, relative to social work services. Findings are as follows: Review of the record for the patient, who has a start of care date of 6/23/2021, revealed a verbal order dated 9/7/2021, for social worker to visit once a month for two months, starting on 9/21/2021. Review of the record revealed that the social worker visited the patient on 10/4/2021. The record failed to reveal evidence that a visit was conducted in November 2021. During a surveyor interview on 1/26/2022 at approximately 9:15 AM with the Nurse Educator, she was unable to produce evidence that the social worker had visited the patient in November 2021.

Based on record review and staff interview it has been determined that the agency failed to review the plan of care with the patient's physicians for 3 of 3 patients, Patient ID #'s 4, 8 & 13, who sustained falls. Findings are as follows: Review of the facilities "Falls Process" provided to the surveyor by the Director of Quality, reveals that after a fall the documentation should include the name of doctor notified, time, any injuries, and a description of the fall. The visit note should also include an assessment of the patient, and medications. As well as immediate interventions and assessment of the need for increase in assistance or supervision. 1. Review of the record for Patient ID #4, reveals the patient sustained a fall on 11/20/2021 at 9:30 PM. The patient "stood up off the toilet- patient lost balance and hit forehead on door jam and scraped arms". The record fails reveal evidence that the physician was notified. During a surveyor interview with the Director of Quality, on 1/25/2022 at approximately 1:15 PM, she was unable to produce evidence that the agency's policy/procedure for falls was followed relative to notification of the physician and/or an assessment of the need for an increase in assistance or supervision. 2. Review of the record for Patient ID #8, reveals a falls report on 12/2/2021 at 5:00 PM, which states "spouse reports [s/he] was transferring patient in the wheelchair and patient bent forward and fell out of the wheelchair". The record fails to document that the physician was notified. Additionally, a review a nurses note dated 12/6/2021 the first nurse visit after the fall reveals, "instructed on safety measures to prevent injury or calls, clearing pathways, removing scatter rugs. Frequently used items within reach, side rails, supportive footwear/nonskid socks, proper lighting, 24-hour supervision, 1-1 to assist with ambulation". The record failed to reveal documentation of interventions and/or assessment of the need for increase in assistance or supervision relative to the patient's overall decline and safe transfers. The surveyor interviewed the nurse, Staff B, on 1/25/2022 at approximately 9:30 AM, she was unable to produce evidence that the plan of care had been updated after the fall, that an assessment of transfers was completed or that the physician was notified of the fall. 3. Review of the record for Patient ID #13, reveals the patient sustained a fall on 10/27/2021 at 8:00 AM, "tripped on rug going to commode, bruise to forehead". Review of the falls report fails to document that the physician was notified of the fall. During an interview with the Director of Quality on 1/25/2022 at approximately 1:15 PM, she acknowledged that the record lacked evidence that the fall procedure was followed.

Based on surveyor observation, record review and staff interview, it has been determined that the agency failed to maintain a system of communication and integration that ensures the hospice interdisciplinary group maintains responsibility for directing, coordinating, and supervising care for 1 of 2 sample patients residing in a Skilled Nursing Facility (SNF), Patient ID #9. Findings are as follows: Record review for the patient, who resides in a SNF, revealed an order dated 1/2/2022 for Lotrisone 1%-0.05% topical cream daily to neck /chest area for rash. Review of the physician's orders at the SNF revealed that the Lotrisone cream was discontinued on 1/9/2022. The SNF orders revealed an additional order dated 8/25/2021 for "antifungal powder" twice a day until area is well healed for rash. This order was present only on the physician orders for the SNF but was not on the hospice plan of care. The surveyor interviewed the nurse, Staff A, on 1/25/2022 at approximately 10:00 AM, who was unaware that the Lotrisone cream had been discontinued at the SNF, and that the patient had been receiving the antifungal power. During an interview on 1/25/2022 at approximately 3:00 PM with the Director of Quality she was unable to produce evidence that the interdisciplinary team communicated with the SNF to coordinate the above medication orders.

Based on record review and staff interview it has been determined that the agency failed to provide for sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness for 1 of 1 patient, Patient ID #1 relative to a biliary drain. Findings are as follows: Review of the record for the patient, reveals a start of care date of 5/24/2021. A certification of terminal illness on 5/24/2021, states; "metastatic ovarian cancer, with metastasis to liver, malignant ascites, biliary drain...". Review of the initial hospice plan of care certification from 5/24/2021- 8/21/2021, and all subsequent certifications through the current certification dated 1/19/2022- 3/19/2022 failed to include orders/information for the biliary drain. A wound addendum dated on 5/24/2021 states biliary drain first observed 7/4/2020. The record fails to reveal evidence of when the drain was inserted, drain output and who is overseeing care of the biliary drain. During a surveyor interview on 1/25/2022 at approximately 9:50 AM with the Director of Quality, she was unable to provide evidence of any coordination of care relative to the biliary drain. During a subsequent interview with the Director of Quality, on 1/25/2022 at approximately 2:15 PM, she acknowledged that the agency failed to obtain and share information relative to the biliary drain with the other healthcare providers furnishing services to the patient.

Based on record review and staff interview it was determined that the agency failed to provide a discharge summary to another Medicare/Medicaid certified provider with a summary of the patient's stay including treatments, symptoms, and pain management for 1 of 1 patient, Patient ID #14. Findings are as follows: Review of the clinical record for the patient, reveals, a nurses note stating that the patient was sent to the emergency room for an evaluation of increased confusion and combativeness. The patient was discharged from the agency on 1/14/2021. Review of the record fails to reveal evidence of a discharge summary. During a surveyor interview on 1/27/2022 at approximately 11:40 AM with the Nurse Educator, she was unable to produce evidence of a discharge summary.

Based on record review and staff interview it was determined that the agency failed to obtain and document an election to revoke the hospice care benefit as required for 1 of 1 patient, Patient ID #14. Findings are as follows: Review of the clinical record for the patient, reveals a start of care and election of hospice on 1/13/2021. Review of a nurses note dated 1/15/2021, reveals that the patient was sent to the emergency room for evaluation of increased confusion and combativeness. The note indicates that the hospice benefit will be revoked as of 1/14/2021. Review of the record lacks any beneficiary or representative written statement of revocation with a signature. During a surveyor interview on 1/27/2022 at approximately 11:40 AM with the Nurse Educator, she was unable to produce evidence of a revocation of benefits signed by the patient or representative as required.

Based on surveyor observation, record review and staff interview it has been determined that the agency failed to address health and safety issues for 1 of 2 patients, Patient ID # 8 relative to transfers. Findings are as follows: Review of the initial certification of terminal illness form dated 1/3/2021, states in part, "74-year-old with Alzheimer's dementia, functional and cognitive decline, cannot stand on own, and poor truncal support". Review of the current certification dated 12/29/2021-2/26/2022, indicates that the patient requires assistance with ambulation. The record also revealed that on 12/1/2021 the family called the hospice as the patient became unresponsive while on the toilet, and a question of seizure activity. On 12/2/2021 an additional call was received from the family, reporting that the patient fell during a transfer. During a surveyor home visit on 1/24/2022 at approximately 10:45 AM in the presence of the hospice aid, Staff C, the patient was observed sitting in a recliner chair. The surveyor observed that the patient's caregiver was trying to get the patient out of the recliner, into the wheelchair so that the health aid could bath him/her. The caregiver was assisted by the health aid, and on the third attempt they were able to get the patient out of the chair and into the wheelchair. The patient was then transported via wheelchair to the bathroom and again lifted from the chair and seated on the toilet. The patient was leaning to the left and the health aid had to grab onto the patient and hold him/her upright. The patient was unable to assist in any way, unable to place feet, unable to use arms and has loss of trunk control to hold self-upright. The surveyor spoke with Staff C, at the time of the observation and she said that she must wash the patient while holding him/her up with one hand so that the patient does not fall. She stated that s/he has been like this for a while now. The surveyor interviewed the Director of Quality on 1/25/2022 at approximately 9:00 AM, and she indicated that she was unaware that the patient's condition had declined. The surveyor interviewed Staff C, and Staff D hospice aids, on 1/25/2022, prior to the IDG (Interdisciplinary Group meeting) who both stated that the patient's condition had declined, and the caregivers can lift him/her out of the chair or bed, but that it is very difficult as the patient cannot assist in any way. They also stated that they cannot get him/her into the shower, and the patient's bed is too low to the ground to wash the patient, so they try to provide personal care by sitting the patient on the toilet per family request. The surveyor asked about providing personal care and they both acknowledged that it is very difficult as the patient leans over and cannot hold him/herself up. Both aids report that they have told the nurse about the decline and difficulty providing care. The surveyor interviewed the nurse, Staff B, on 1/25/2022 at approximately 9:30 AM, who acknowledged that she had not seen the aids providing personal care since the fall on 12/2/2021 nor had she observed anyone transferring the patient. She stated that the patient is seated in the recliner when she visits. She was unaware of the safety issues relative to transferring the patient for personal care. Additionally, she acknowledged that she does not see the patients back or buttocks when she assesses the patient's skin, as the patient is in the recliner during her visits. The surveyor attended the IDG meeting on 1/25/2022, after the staff's discussion of the patient, during which there was not any mention of the patients decline nor inability to safely transfer.