Every finding on record at Kern Hospice Care, Inc.

It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. The hospice also makes all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or others who can support the patient’s spiritual needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 16 (6%) clinical records reviewed, the agency did not ensure documentation that reasonable efforts were made to facilitate visits by local clergy. Clinical Record 12: The patient elected the hospice benefit on 09/04/2024. The plan of care dated 09/04/2024 to 12/02/2024 included an order for Spiritual Counselor frequency of visits one (1) time per month. The Spiritual Counselor documented on the spiritual counseling visit dated 11/21/2024, the patient was requesting a priest to come and give communion, if possible. The clinical record contained no documented evidence that the priest was contacted about a possible visit to the patient. During an interview on 12/12/2024, the Administrator and the Director of Patient Services stated they did not know if the Spiritual Counselor had made any follow-up.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: Assess the quality of care and services provided by the hospice aide; Ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 14 (7%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse completed supervisory visits for the Hospice Aide no less frequently than every 14 days. Agency policy No. 2-041.1 Internal Control Systems/Accountabilities, required in part, "Aide supervisory visits are performed and documented every 14 days." Clinical Record 12: The patient elected the hospice benefit on 09/04/2024. The plan of care dated 09/04/2024 to 12/02/2024 included an order for the hospice aide to provide services twice per week. The clinical record included documentation that the patient received aide services as ordered. Clinical record review revealed the Registered Nurse completed an aide supervisory visit on 11/10/2024 and the next aide supervisory visit was dated 11/25/2024, a total of 15 days and one day outstanding. During an interview on 12/12/2024, the Director of Patient Care Services stated that they try so very hard to stay on top of it, they will continue with additional education to clinical staff.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: A copy of the hospice discharge summary; and the patient's record, if requested. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 1 (100%) clinical record reviewed with live discharge, the agency did not ensure the discharge summary was completed and forwarded to the patient’s attending physician. Agency policy Discharge from Hospice Program, required in part, "A copy of the discharge summary will be sent to the attending physician. If requested, the patient's clinical record will be provided." Clinical Record 18: The patient elected hospice benefit on 12/23/2023 and signed the revocation of hospice services on 07/30/2024. Clinical record review revealed no documented evidence that a discharge summary was developed and sent to the patient’s attending physician. During an interview on 12/12/2024, the Director of Patient Care Services stated they are planning on educating the clinical and administrative staff on the discharge process.

Observed in Record Review. In 1 of 6 patient records reviewed, The organization failed to maintain complete and accurate records, as the surveyor noted the pt record was inaccurate or contains errors (i.e. conflicts with other documentation). For example: on review of RRNHV#3 the plan of care noted that hospice aide services were declined in early April, yet the RN continued to document aide supervisory visits every 14 days each RN visit since. This observation was reviewed with the DPCS.

Observed in Record Review. In 6 of 6 patient records reviewed, the organization failed to ensure the plan of care reflect patient and family goals that were specific, measurable, and time-bound. On review of RRNHV#1 goals were noted to not be SMART such as Minimize complications due to impaired mobility and Pt/pcg will verbalize understanding of medication/treatment orders and side effects All of the goals had an achieve by date of the end of the certification period. In RRNHV#2 examples were Pt needs will be met daily as communicated. -Will minimize episodes of confusion and forgetfulness. -Pt/pcg will verbalize understanding of medication/treatment orders and side effects. In RRNHV#3 example was Pt needs will be met on a day to day basis as communicated. Goals that lacked being specific, measurable, and time-bound were noted throughout all records reviewed. These observations were reviewed with the DPCS.

Observed in Record Review. In 5 of 6 patient records reviewed, The organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRNHV#2 there was documentation of a fall and difficulty swallowing with changes in diet, yet the changes were not reflected in the plan of care. In RRNHV#2, RRNHV#3, RRNHV#4, and RRNHV#5 the psychosocial and spiritual services were ordered yet there were no psychosocial or spiritual care plans established. In RRNHV#6 there was documentation of changes in mobility, fall risk, and diminishing motor skill yet the issues were not reflected in the care plans. Further the chaplain documented visits but no spiritual care plan. These observations were reviewed with the DPCS.

Observed in Leadership Session. No evidence that the governing body and leadership had established processes to support patient care treatment and services through sustained compliance as evidenced by lack of sustained compliance and repeat findings with 418.56.

Observed in Record Review. In 3 of 3 patient records reviewed, The organization failed to maintain complete and accurate records, as the surveyor noted the pt records were inaccurate or contains errors. RR#1, #2 and #3 contained different numbers of PRN visits for the SN visits and PRN visits without reasons the visits should be performed. The POC Summary was different from the Frequency of Visits on the IDG summary in the records reviewed. In addition during RR#1, the RN initial assessment listed comorbidities of COPD, pneumonia and HTN that were not listed on the POC. RR#2, RN initial assessment listed GERD, constipation, asthma, seizures and pressure ulcers that were not listed on the POC. RR#3 RN initial assessment included diabetes, insulin dependent that was not listed on the POC. This was discussed with the DPCS and DPCS designee.

Observed in Record Review. In 3 of 3 patient records reviewed, Goals on the POCs lack measurable outcomes. RR#1 goals: ADL needs are met to an optimal level. Maintain optimal value of blood pressure. Prevent discomfort related to edema in bilateral lower extremities. Facilitate bowel elimination and comfort. Minimize risk of fall. Patient will tolerate performing activities of daily living (ADLs). The patient will free from complications related to weakness. Pt needs will be met on a day-to-day basis as communicated. Pt will remain free of injury. Pt will have adequate food and fluids as tolerated or desired. Pt will have adequate food and fluids to maintain comfort as exhibited by expressed verbal and non-verbal communication. Patient, family and PCG will verbalize comfort in taking care of their loved ones needs. Patient, family and PCG will verbalize that there will be sufficient care at home setting till the end of life. Minimal episodes of shortness of breath. Promote comfort level. RR#2 goals: Pt will maintain optimum peripheral circulation. The patient/ pcg will verbalize understanding of the disease process and potential complications. Facilitate bowel elimination and comfort. Altered skin will heal for patient comfort. Altered skin will be free of infection. Minimize complications related to impaired mobility. Patient will tolerate performing activities of daily living (ADLs). Pt needs will be met on a day-to-day basis as communicated. Pt will remain free of injury related to seizures. Minimal episodes of shortness of breath. Promote comfort level. RR#3 Patient will maintain BP within individually acceptable range. Patient will demonstrate stable cardiac rhythm and rate within patient’s normal range. Patient will participate in activities that will prevent stress (stress management, balanced activities and rest plan). Blood sugar management for pt. comfort. Prevent hospitalization. Patient will not sustain a fall or injury due to fall to be assessed every SN visit. Prevent pain and discomfort due to injury. Pt/Family/PCG will verbalize understanding of increased risk of fall. Improve bowel function and relieving associated symptoms such as bloating and pain. Reduce discomfort with improved bowel elimination status. Patient demonstrates the use of adaptive devices to increase mobility Patient uses safety measures to minimize potential for injury. Medicate before procedures and activities. Patient/ pcg will identify the factors that aggravate decreased tolerance to activity. Patients will have behavioral problems identified and controlled. Pt will remain free of injury. Pt will have adequate food and fluids as tolerated or desired. Pt/Family/PCG will verbalize understanding that symptom is a part of the disease process and the limitations of treatments. The findings was discussed with the DPCS.

Observed in Record Review. In 1 of 3 patient records reviewed, During RR#3 it was noted an order on the POC for the SN to check the patient's blood glucose every visit. It was noted in 3 out of 4 visits reviewed lack of documentation that the blood sugar was checked by the SN. This was discussed with the DPCS and DPCS designee.

Observed in Record Review. In 3 of 3 patient records reviewed, During RR#1, 2 and #3 it was noted the frequency of visits for SN, and MSW lacked either the number of PRN visits ordered or the reason for the PRN visits to be completed. RR#1: MSW: Initial Assessment and once month as needed, RN: 1 per 2 Week + 1 PRN Visits, SC: 1 - Initial Assessment and once month as needed, SN: 1 per Week +3 PRN Visits. The frequencies were correct on the POC summary but incorrect on the IDG summary. RR#2: RN to perform LVN supervisory visits every 30 days and as needed for any change of patient’s condition. RN to perform reassessment every 14-15 days and as needed for any change of patient’s condition. SN visit once per week for clinical care and support and as needed for any change of patient’s condition. RR#3 MSW: 1 As needed and Recert - Initial Assessment and Recertification, RN: 1 per 2 Week + 1 PRN Visits, SC: 1 As needed and Recert - Initial Assessment and Recertification, SN: 1 per Week +3 PRN Visits on POC summary: RN to perform LVN supervisory visits every 30 days and as needed for any change of patient’s condition. RN to perform reassessment every 14 days and as needed for any change of patient’s condition. SN visit once a week for clinical care and support and as needed for any change of patient’s condition. The findings were discussed with the DPCS an DPCS designee.

Observed in Record Review. In 6 of 6 patient records reviewed, the Surveyor noted members of the Interdisciplinary Group had not completed their initial assessments within five days after the election of hospice. In review of all 6 active records reviewed, it was noted that all failed to complete the comprehensive assessment within 5 calendar days of the election of hospice. On RRNHV#1, RRNHV#2, and RRNHV#3 there was no documentation of an initial spiritual assessment. In RRNHV#3 and RRNHV#4 there was no documentation of a psychosocial assessment completed. In RRNHV#5 there comprehensive assessment was not completed withing 5 days as the MSW completed on day 10 and the SC completed on day 13. In RRNHV#6 the MSW completed the psychosocial assessment on day 25 and the spiritual counselor on day 18. These observations were reviewed with the Office Manager and DPCS.

Observed in Record Review. In 4 of 6 patient records reviewed, the organization failed to conduct and document a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. For example: on review of RRNHV#1, and RRNHV#2 there was no documentation of a spiritual assessment completed on the record. Documentation on the RN initial comprehensive assessment noted that a spiritual assessment was needed. In RRNHV#3 there was no documentation of a psychosocial or spiritual assessment completed. There was documentation noted of calls to schedule a visit but no documentation of any attempt beyond calls to complete the assessment, nor discussion with the IDG team of efforts to complete. In RRNHV#4 there was no documentation of a psychosocial assessment completed. These observations were reviewed with the Office Manager and DPCS.

Observed in Record Review. In 3 of 6 patient records reviewed, The HCO had not completed the initial Bereavement Assessment according to their policy No. 2-010.1, which states: Policy No. 2-010.1 A bereavement Risk assessment will be completed by the hospice social worker, registered nurse or spiritual counselor at the time of admission to hospice. In review of RRNHV#1, RRNHV#2, and RRNHV#3 there was no documentation of an initial bereavement risk assessment. These observations were reviewed with the Office Manager, and DPCS.

Observed in Record Review. In 2 of 6 patient records reviewed, The organization failed to ensure the comprehensive assessment was accomplished by the hospice interdisciplinary group no less frequently that every 15 days. For example: on review of RRNHV#2 the last documented comprehensive assessment was noted in mid October leaving a 28 day gap in update to the comprehensive assessment. An RN visit was documented early November yet was documented as a limited (short form) visit and did not document a comprehensive assessment. In RRNHV#4 there was documentation of RN visits completed yet each visit for October (total of 3) were blank with only a time in and time out without documentation of a comprehensive assessment as required. These observations were reviewed with the Office Manager, and DPCS.

Observed in Record Review. In 3 of 6 patient records reviewed, The organization failed to maintain complete and accurate records, as the surveyor noted the pt record was inaccurate or contains errors (i.e. conflicts with other documentation). For example: on review of RRNHV#2 the IDG documentation from the RN noted the patient skin intact and then goes on to say the patient with 2 wounds to the right arm. Further, there was a conflict in the frequency for the MSW and Chaplain as the IDG documentation noted 1 time a week, yet the physician order noted both the MSW and Chaplain at as needed only. In RRNHV#3 the physicians order for SN was noted to be 1 x week, yet the IDG documentation noted 2 x week. The documentation noted the SN was visiting 1 x week. In RRNHV#4 the Physicians order for SN said 2 x week, yet the IDG documentation noted 1 x week. These observations were reviewed with the DPCS.

Observed in Record Review. In 5 of 6 patient records reviewed, the organization failed to ensure the plan of care reflect patient and family goals that were specific, measurable, and time-bound. On review of RRNHV#2 goals were noted to not be SMART such as Patient will be aware and oriented if possible, and reality will be maintain at an optimal level. Patient will have improved thought processing or will be maintained at a baseline level, and Medicate before procedures and activities. The goals all had a target date for the end of the year. In RRNHV#3 examples were Patient will participate in activities that reduce BP/cardiac workload. Patient will maintain BP within individually acceptable range. Patient will demonstrate stable cardiac rhythm and rate within patient's normal range. In review or RRNHV#4 the only goal was noted for pain with no further goals were established. In RRNHV#5 non-specific without target dates examples were The patient/ pcg will identify the relationship of signs/symptoms to the disease process and correlate symptoms with causative factors. The patient/ pcg will verbalize understanding of therapeutic needs. In RRNHV#6 examples were Patient will have improved thought processing or will be maintained at a baseline level and patients will have behavioral problems identified and controlled. These observations were reviewed with the Office Manager and DPCS.

Observed in Record Review. In 5 of 6 patient records reviewed, The organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRNHV#2 there was documentation of a fall with wounds yet the changes were not reflected in the plan of care. In RRNHV#3 the documentation noted the patient was treated for a UTI yet there was no care plan to direct the care. In RRNHV#4 the only care plan open was for pain, yet the patient had a terminal diagnosis of COPD and multiple wound but no care plans to guide the care. Further, there were no physicians orders noted for oxygen even though the supply list noted oxygen in the home, nor were there wound care orders but the patient had documentation of multiple wounds and treatments provided. In RRNHV#5 there was documentation of an infection to the patient's toes treated with antibiotics but the issue was not reflected on the care plan. In RRNHV#6 the chaplain documented visits but no spiritual care plan. These observations were reviewed with the Office Manager and DPCS.

Observed in Record Review. In 3 of 6 patient records reviewed, the organization failed to ensure the patient care and services were provided in accordance with the plan of care. For example: on review on RRNHV#2 the aide was ordered a frequency of 2 times a week, but in week 3 only one visit was made, no visits were documented in week 4, and only one visit documented in week 5 of the current benefit period. Further, the SN was ordered 2 x week but no SN visits were documented for week 2, and only one SN visit was noted in weeks 1 and 4. In RRNHV#4 there were no documented SN visits the last week of September. In RRNHV#5 the SN was ordered 1xwk yet there were no SN visits documented in weeks 2, 4, 6, and 8 of the current benefit period. These observations were reviewed with the Office Manager and DPCS.

Observed in Record Review. In 2 of 5 patient records reviewed, where the patient had Hospice Aide (HA) care, the Surveyor noted HA supervision not completed every 14 days. In review of RRNHV#2 the documentation noted there to be a 28 day gap since last aide supervisory visit completed in the record. In review of RRNHV#4 there were RN visits noted in the record for every other week in October yet the entries noted a time in and time out only and did not document aide supervisory visits completed for the month of October and to date of survey. These observations was reviewed with the Office Manager and DPCS.

Observed in Tracer Activities. No evidence that the governing body and leadership had established processes to support patient care treatment and services through sustained compliance as evidenced by lack of sustained compliance with 418.54 and 418.56. Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by not ensuring compliance with CoP's 418.56 and 418.54.

Observed in Tracer Activities. The Surveyor noted the agency had not completed a Hazard Vulnerability Analysis nor had a policy that spoke to conducting one as evidenced by the HCO had been unable to present the HVA during the survey.

Observed in Record Review. In 1 of 11 patient records reviewed, the Surveyor noted members of the Interdisciplinary Group had not completed their initial assessments within five days after the election of hospice. In HH/RR #3, the Spiritual Care provider had not conducted a visit until 60 days post election of hospice benefit. This was validated with the Director of Patient Care Services.

Observed in Record Review. In 1 of 11 patient records reviewed, The HCO had not completed the initial Bereavement Assessment according to their policy No. 2-010.1, which states: Policy No. 2-010.1 A bereavement Risk assessment will be completed by the hospice social worker, registered nurse or spiritual counselor at the time of admission to hospice. RR #4, the patient had not had an initial bereavement assessment completed until 60 days post admission. This was validated with the Director of Patient Care Services.

Observed in Record Review. In 1 of 11 patient records reviewed, The Surveyor noted that an RN had not visited the hospice patient every 15 days per standard to conduct a comprehensive assessment. In HV /RR #3, the RN had not documented a patient visit in 29 days. This was validated with the Director of Patient Care Services.

Observed in Record Review. In 11 of 11 patient records reviewed, the Surveyor noted the patient goals had been broad, not measurable, and had not contained a time frame for achievement. Examples include: 'Pt will maintain optimum peripheral circulation', 'Prevent physical and emotional stress due to preventable sickness', 'Optimal bowel elimination and comfort', 'Pt/Family/PCG will verbalize having urinary elimination needs met at an acceptable level', Pt/Family/PCG will verbalize understanding of increased risk of fall, Family/PCG will verbalize understanding of safety intervention. These findings were validated with the Director of Patient Care Services and the Administrator.

Observed in Record Review. In 6 of 11 patient records reviewed, the medication orders had not specified the indications for use of 'as needed' medications. For example, in HV/RR #1 the patient had Morphine Sulfate 20mg/1mL q4hr prn moderate to severe pain, and Norco 5mg-325mg take 1 tablet by mouth every 6 hours as needed mild to moderate pain, without clear definitions of what mild, moderate or severe was to this patient. HV/RR #2, the patient had Tylenol Extra Strength 500mg 1 Tab every 4 hours as needed for pain and Tramadol Hydrochloride 50mg, 1 Tab every 4 hours as needed for severe pain. HV/RR #3, the patient had Morphine Sulfate 0.25 ml every 4 hours as needed mild pain and Acetaminophen 325mg 2 Tab every 6 hours as needed for mild pain. RR #4, the patient had both Docusate Sodium 100mg Capsule take 1 capsule by mouth once daily as needed and Fleet Enema as needed for constipation. The patient also had Tylenol 325mg, take 2 tablets by mouth every 6 hours as needed for pain and Morphine Sulfate 0.25 ml every 4 hours as needed mild pain. RR #5 had Morphine Sulfate 0.25 ml every 4 hours as needed mild pain, and Tylenol 325mg, 2 tablets every 8 hours as needed for mild to moderate pain. RR #8 had Hydrocodone Bitartrate/Acetaminophen 5mg-325mg 1 tablet by mouth every 6 hours as needed Pain and Morphine Sulfate 20 mg/ml, 0.5 ml every 4 hours as needed moderate pain. The same patient also had Levsin every 2 hours and Atrophine 1-2 drops sublingual every 2 hours, both to treat increased secretions. This was validated with the Director of Patient Care Services.

Observed in Record Review. In 1 of 7 patient records reviewed, RR #8, the HA POC had the HA visiting 2 times per week. There were 2 missed visits the last week of the plan of care. This was validated with the Director of Patient Care Services.

Observed in HR File Review. In 1 of 1 HR files reviewed, of a Hospice Aide (HA), the Surveyor noted the initial competency validating the HCO defined skills required of the HA had not been completed. In HR #5, the HA required elements of performance had not been documented as assessed, including: treating family, palliative care approach, interdisciplinary practices, philosophy of comfort, dignity, normal vs abnormal vital signs, cultural attitudes toward death, grieving fears of the dying patient, denial and defense mechanisms and anticipatory grief. This was validated with the Director of Patient Care Services.

Observed in Record Review. In 1 of 7 patient records reviewed, where the patient had Hospice Aide (HA) services, the HA plan of care (POC) had not been followed as ordered. For example, RR #4, the HA POC ordered the HA to check vital signs every visit; however, there had been 8 visits where no vital signs had been checked. This was validated with the Director of Patient Care Services.

Observed in Record Review. In 3 of 6 patient records reviewed, where the patient had Hospice Aide (HA) care, the Surveyor noted HA supervision not completed every 14 days. HV/RR #3, there had not been a HA Supervisory visit completed in a 28 day period. RR #4, the HA supervisory visit had not occurred for 42 days, and in RR #6, the HA Supervisory visit had not occurred for 28 days. This was validated with the Director of Patient Care Services.

Observed in Tracer Activities. No evidence that the governing body and leadership had established processes to support patient care treatment and services through sustained compliance as evidenced by not ensuring compliance with CoP's 418.76 Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by not ensuring compliance with CoP's 418.104 and 418.54.

Observed in Record Review. In 2 of 11 patient records reviewed, the Surveyor noted the pt record was inaccurate or contains errors (i.e. conflicts with other documentation). For example, in RR #5, the CHHA plan of care had Oxygen 4-5 lpm via nasal cannula, the medication profile had Oxygen 2 lpm, may titrate to 4 lpm for shortness of breath. Iin RR #8, the Interdisciplinary Group (IDG) meeting documented in the 'other' discussion area that CHHA: 2 per Week to assist patient with personal care and ADLs, and then 5 lines below this had been written CHHA: Declined at this time. Will continue to be offered. This had been documented in 3 IDG meetings for the patient. This was validated with the Director of Patient Care Services.

Observed in Record Review. In 1 of 11 patient records reviewed, the Surveyor noted documentation that had been entered in error had not been corrected in an acceptable format. For example, in HV/RR #1, the patient POLST had an incorrect patient name and date of birth. There had been a line through the incorrect information, and a new patient name and date of birth had been hand written above. There had been no message with 'error', with an initial and date. This was validated with the Director of Patient Care Services.

Observed in Record Review. In 2 of 3 patient records reviewed, where the patient passed while on service, the staff did not provide patient care within the scope of their license. The surveyor noted the LVN pronounced the patient's death in RR #7 and RR #8 as evidenced by the documentation from the death visit stated the clinician noted no signs of life, and the time of death was recorded, and the mortuary notified prior to notifying the physician. This was confirmed with Director of Patient Care Services and the Administrator. Of note, this issue with the LVN has already been addressed by the HCO.

Based on observation, interview, and record review, the agency failed to follow its policy and procedure to review all the medication profile and current medications during the licensed nurse home visit for one of 11 sampled patients (Patient 7). This failure had the potential for drug interactions, side effects and missing medications undetected for the end of life comfort medications. Findings: During a home visit observation on 3/3/22, at 10:50 AM, in Patient 7's home, with Licensed Vocational Nurse (LVN) 2, LVN 2 checked Patient 7's vital signs (temperature, pulse rate, respiratory rate and blood pressure). LVN 2 proceeded to perform Patient 7's wound dressing to her right elbow. After LVN 2 completed Patient 7's wound dressing, LVN 2 left Patient 7's home. LVN 2 was not observed checking Patient 7's medications. During an interview on 3/4/22, at 11 AM, with Director of Operation (DOO), DOO stated, "Part of the Home Visit by the LVN is to check the medications [of the patient] and the need for refill." During an interview on 3/4/22, at 4:20 PM, with Administrator, Administrator stated, she spoke to LVN 2 and LVN 2 reported she did the home visit for Patient 7 for the purpose of performing the wound dressing and not to check Patient 7's medications and medication profile. Administrator stated, LVN 2 did not checked Patient 7's current medications. During a review of the agency's policy and procedure (P&P) titled, "Medication Profile," dated 4/21, the P&P indicated, ". . .4. During subsequent hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understands the medication regimen. This includes, but will not be limited to: A. Using the medication profile to evaluate the use of the drugs in the home setting. B. Using the medication profile to teach drug purpose, dosages, routes, side effects, and contraindications C. Using the medication profile as a communication tool for other clinicians involved in care. . . "

Based on interview and record review, the agency failed to: 1. Follow the individualized plan of care for wound treatment as ordered by the physician for one of 11 sampled patients (Patient 7). This failure had the potential for a delayed wound healing. 2. Ensure the home visit order for skilled nursing from the Licensed Vocational Nurse (LVN) was followed for one of 11 sampled patients (Patient 7). This failure had the potential for unmet end of life comfort care needs. Findings: 1. During a review of Patient 7's "POC [Plan Of Care] Summary" (POCS), dated 1/27/22, the POCS" indicated, "Cleanse wound to right elbow with Normal Saline. Apply triple antibiotic ointment [used to treat skin infections]. . . " During a concurrent interview and record review on 3/7/22, at 2:10 PM, with Director of Patient Care Services (DPCS), Patient 7's "Skin Impairment Assessment (SIA)"," dated 1/28/22, 2/7/22, 2/9/22, 2/10/22, 2/14/22, 2/18/22, 2/21/22, 2/23/22, 2/24/22, and 2/28/22 were reviewed. The SIA indicated, "Narrative. . . Cleanse wound to right elbow with Normal Saline. . . Apply triple antibiotic ointment and Honey med [anti-bacterial and anti-inflammatory]. . . " DPCS was unable to find in the physician's order for an order for the 'honey med'. 2. During a review of Patient 7's "History of Frequency Of Visit" (HFOV), dated 1/3/22, the "HFOV" indicated, "Discipline. . . LVN [Licensed Vocational Services]. . . NO [number] Of Visit. . . 2. . . per week + 2 PRN [as needed] Visits. . . " During a concurrent interview and record review on 3/7/22, at 2:10 PM, with DPCS, Patient 7's "SIA," dated 1/30/22 to 2/5/22 was reviewed. DPCS was unable to find documentation for the "SIA" for the wound on the right elbow for the week of 1/30/22 to 2/5/22. DPCS stated, LVN was unable to do the home visits for the week and the wound treatment on the right elbow was not done. During an interview on 3/7/22, at 1:55 PM, with Family Member (FM) 1, FM 1 stated, I never refused their [hospice agency] care and home visits [for the week of 1/30/22 to 2/5/22]. There's no reason for me to refuse." During a review of the agency's policy and procedure (P&P), titled "ORDERS FOR MEDICATION AND TREATMENT," undated, the P&P indicated, Medications and treatments shall be administered as prescribed and shall be recorded in the patient's health record, as administered." During a review of the agency's P&P, titled "STANDARDS OF CARE AND PRACTICE," dated 4/17, the P&P indicated, "Ongoing assessments will determine if the standards of care continue to be appropriate for patient and family/caregiver needs. . . 6. Use of standards of care and practice will be evident in the documentation of visits and assessments. . . "

Based on observation, interview, and record review, the agency failed to develop a plan of care for one of 11 sampled patients (Patient 1) when Patient 1 had inappropriate behaviors and was not addressed. This failure resulted in allegations of sexual abuse by an unknown female individual and had the potential to affect other staff and patients getting violated by Patient 1. Findings: During an observation on 3/3/22, at 1:50 PM, in Patient 1's home, Patient 1 was in bed, confused and unable to be interviewed. During an interview on 3/4/22, at 10:13 AM with the Adult Protective Services Employee (APSE), she stated she went to visit Patient 1's home to visit another patient. APSE stated, the other patient was accusing Patient 1 of sexually touching her. APSE stated, the Director of Patient Care Services (DPCS) told her Patient 1 had a history of being a sexually offender. APSE stated, "[Agency's name] was aware this patient [1] is a sexual offender but they did not put him [Patient 1] in safe place away from female patients." During an interview on 3/7/22, at 10:31 AM, with Certified Hospice Aide (CHA) 1, she stated, "[Patient 1] was trying to touch me inappropriately during showers. He was touching my private parts. I felt uncomfortable. Went again and again, did the same thing everytime I go give him a shower." CHA 1 stated, she did not report and document because she thought it will pass. During a concurrent interview and record review on 3/8/22, at 10 AM with DPCS, DPCS stated, the agency was aware Patient 1 had a history of being a sexual offender. DPCS stated, she was not aware Patient 1 had inappropriate behaviors. DPCS reviewed Patient 1's Plan of Care and verified Patient 1's behaviors were not addressed. During a review of the agency's policy and procedure (P&P) titled, "The Plan of Care", dated 4/2017, the P&P indicated, ". . .10. Any change in the patient's condition must result in a change in the plan of care, prior to implementation of new service. . .12. The written plan of care will contain, but will not be limited to, the following: . . .F. Safety measure to protect against abuse, injury, infection, or communicable disease, as appropriate."

Based on interview and record review, the agency failed to communicate and share information to other disciplines for one of 11 sampled patients (Patient 1) when Certified Hospice Aide (CHA) 1 observed an inappropriate behavior of Patient 1 but did not document and communicate with the agency. This failure had the potential to result in Patient 1 continually violating staff and other patients. Findings: During an interview on 3/7/22, at 10:31 AM, with CHA 1, she stated, "[Patient 1] was trying to touch me inappropriately during showers. He was touching my private parts. I felt uncomfortable. Went again and again, did the same thing everytime I go give him a shower." CHA 1 stated, she did not report Patient 1's inappropriate behavior because she thought it will pass. During a review of Patient 1's "Visit Notes" (VN), dated 3/2/22, it was noted there was no documentation of Patient 1's inappropriate behaviors. During an interview on 3/7/22, at 11 AM, with Director of Patient Care Services (DPCS), DPCS stated, "She [CHA 1] did not report to us, or we have addressed the issue." DPCS stated, she was aware Patient 1 had a history of being a sexual offender. During a review of the CHA's Job Description, dated 4/2017, the CHA's Job Description indicated, "Essential Job Functions/Responsibilities: . . .8. Reporting on patient's condition and significant changes to the Case Manager. Also aware of the caregiver or other individuals living with the patient and interpersonal issues."

Based on observation, interview, and record review, the agency failed to follow infection control practices when staff did not performed hand hygiene after removing the old wound dressing from the right elbow wound and changed it to a new dressing for one of 11 sampled patients (Patient 7). This failures had the potential for the development of infection on the wound site and delayed wound healing for Patient 7 who is an end of life patient. Findings: During a home visit observation on 3/3/22, at 11:20 AM, in Patient 7's home, with Licensed Vocational Nurse (LVN) 2, LVN 2 was performing treatment to Patient 7's right elbow wound. LVN 2 removed the old dressing from Patient 7's right elbow wound and disposed of the old dressing in a plastic bag. LVN 2 did not performed hand hygiene after she removed the old dressing from Patient 7's wound. LVN 2 proceeded to apply the triple antibiotic to Patient 7's wound by patting the triple antibiotic ointment using her gloves to the wound bed of Patient 7's right elbow. LVN 2 proceeded to apply the new dressing to Patient 7's wound to her right elbow. During an interview on 3/7/22, at 2:25 PM, with Director of Patient Care Services (DPCS), DPCS stated, LVN 2 should have used a Q-tip to apply the ointment to Patient 7's right elbow wound bed to prevent wound contamination. DPCS acknowledged, hand hygiene should be performed after removing an old soiled dressing and changed to a new dressing. During a review of the agency's policy and procedure (P&P) titled, "Aseptic Technique [using practices and procedures to prevent contamination from pathogens - organism that causes disease] In The Home," undated, the P&P indicated, "Purpose. . .To prevent the introduction of microorganisms onto a designated field. . .Variations in technique may be used in performing procedures in the home as long as use of aseptic principals governs actions during the procedures. . . 1.Wash hands per agency policy. . . " During a review of the agency's P&P titled, "HAND WASHING," undated, the P&P indicated "Purpose To prevent the spread of infection by contaminated hands. . .The Center for Disease Control (CDC) recommends routinely washing hands in the following situations. . . Before and after handling dressings or touching open wounds. "

Based on interview and record review, the agency failed to routinely provide core services when: 1. Home visit notes were not completed for one of 11 sampled patients (Patient 1). This failure had the potential to have incomplete information in determining Patient 1's Plan Of Care (POC). 2. Home visits were not provided for one of 11 sampled patients (Patient 3) when the Master of Social Work (MSW) did not visit Patient 3 as indicated in the Plan of Care (POC). This failure resulted in Patient 3 not receiving social services, affecting his psychosocial needs during end of life. Findings: During a review of Patient 1's Visit Notes (VN), dated 2/3/22, 2/12/22, 2/15/22, 2/18/22, 2/21/22, and 2/26/22, it was noted there was no evidence visit notes were completed during the home visits During an interview on 3/4/22, at 1:51 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, "I was not able to complete my visit notes because I was juggling with work, I also work in the office as a case manager." LVN 1 stated, she was not aware she needed to complete her visit notes timely. During an interview on 3/4/22, at 3 PM, with Director of Patient Care Services (DPCS), DPCS stated, staff should complete their visit notes weekly. During a review of the agency's policy and procedure (P&P) titled, "Documentation and Submission of Records", undated, the P&P indicated, "All clinical notes must be completed and submitted to the agency on the following Monday after the home visit. Clinical notes will be put in the clinical chart weekly." 2. During a review of Patient 3's "POC Summary", dated 10/5/21. the POC Summary indicated, "Order date: 10/5/21 - Social Worker: once a month and as needed to identify psychosocial needs/support to patient and family." Patient 3's Monthly Calendar Visits, dated 10/2021, indicated, there were no MSW visits on 11/2021, 12/2021, 1/2022, and 2/2022. During an interview on 3/4/22, at 3:23 PM with MSW 1, MSW 1 stated, "This patient [3] was not referred to me." During an interview on 3/4/22, at 3:47 PM with MSW 2, MSW 2 stated, "I don't know this patient [3], the agency did not refer him to me." During an interview on 3/4/22, at 4 PM, with Director of Patient Care Services (DPCS), DPCS stated, she did the initial screening for Patient 3. DPCS stated, this patient should be referred to MSW for social services. DPCS stated, she assumed this patient did not need MSW. During a review of the agency's MSW Job Description, dated 4/2017, the MSW Job Description indicated, "Essential Job Functions/Responsibilities: . . .2. Carries out social evaluations and plans intervention based on evaluation findings."

Based on interview and record review, the agency failed to: 1. Ensure psychosocial assessments were completed by the Medical Social Worker (MSW) for four of 11 sampled patients (Patient 8, Patient 9, Patient 10, and Patient 11) when these patients were referred to Master of Social Work (MSW). 2. Ensure social services were provided for five of 11 sampled patients (Patient 2, Patient 3, Patient 4, Patient 5, Patient 6) when these patients were referred to MSW to provide social services. These failures had the potential for unidentified and unmet psychosocial (thoughts, behavior, and social support) needs for the patient and family during end of life. Findings: 1. During a review of Patient 8's "Comprehensive Nursing Assessment" (CNA), dated 10/4/21, the "CNA" indicated, "Referral. . . Refer for. . . Social Work. . . " During a concurrent interview and record review, on 3/4/22, at 10:20 AM, with Director of Operation (DOO), Patient 8's MSW documentation was reviewed. DOO stated, MSW services was offered to Patient 8 and Patient 8 refused MSW services. She was unable to provide MSW documentation for Patient 8's refusal of MSW services. During a concurrent interview and record review, on 3/4/22, at 3:30 PM, with Director of Operation (DOO), Patient 8's MSW documentation was reviewed. DOO stated, MSW services was offered to Patient 8 and Patient 8 and family stated, MSW services "not needed at this time" dated 6/16/21. DOO stated the MSW services should be offered during the IDG (Interdisciplinary Group) meeting every two weeks. No additional information was provided. During a concurrent interview and record review, on 3/7/22, at 11:30 AM, with Director of Patient Care Services (DPCS), Patient 8's psychosocial assessment by the MSW was requested. DPCS was unable to provide a psychosocial assessment was completed for Patient 8 by the MSW. DPCS stated, the psychosocial assessment should have been completed for Patient 8 by the MSW. During a review of Patient 9's "CNA," dated 7/5/21, the "CNA" indicated, "Referral. . . Refer for. . . Social Work. . . " During a concurrent interview and record review, on 3/7/22, at 2:20 PM, with DPCS, Patient 9's psychosocial assessment by the MSW was requested. DPCS was unable to provide a psychosocial assessment was completed for Patient 9 by the MSW. DPCS acknowledged the psychosocial assessment should have been completed for Patient 9 by the MSW. During a review of Patient 10's "CNA." dated 12/5/21, the "CNA" indicated, "Referral. . . Refer for. . . Social Work. . . " During a concurrent interview and record review, on 3/7/22, at 11:30 AM, with DPCS, Patient 10's psychosocial assessment was requested. DPCS was unable to provide a psychosocial assessment was completed for Patient 10 by the MSW. DPCS stated, the psychosocial assessment for Patient 10 should have been completed by the MSW. During a review of Patient 11's "CNA," dated 6/2/21, the "CNA" indicated, "Referral. . . Refer for. . . Social Work. . ." During a concurrent interview and record review, on 3/7/22, at 11:30 AM, with DPCS, Patient 11's psychosocial assessment for Patient 11 was requested. DPCS was unable to provide the psychosocial assessment for Patient 11. DPCS stated, the MSW should have completed the psychosocial assessment for Patient 11. During an interview on 3/4/22, at 3:30 PM, with DOO, DOO stated, the Social Worker services is offered to the patients/family every IDG [Interdisciplinary Group) meeting every two weeks." During an interview on 3/7/22, at 1:55 PM, with Family Member (FM) 1, FM 1 stated, I have talked to a Social Worker in the beginning of the Hospice services, the very first week. I talked to [DPCS] asking her twice for a Social Worker. No response. She never called me back [regarding the request for a Social Worker]. I don't know if they have a Social Worker." 2. During a review of Patient 2's "Comprehensive Nursing Assessment (CNA)", dated 2/22/22, the CNA indicated, "Refer to: Social Work." During a review of Patient 2's "Initial Psychosocial Assessment (IPA)", dated 2/22/22, the IPA indicated, no documented MSW initial assessment. Patient 2's Monthly Calendar Visits, dated 2/2022, indicated, there were no MSW visits. During a review of Patient 3's "Comprehensive Nursing Assessment (CNA)", dated 11/16/21, the CNA indicated, "Refer to: Social Work." During a review of Patient 3's "IPA", dated 11/16/21, the IPA indicated, no documented MSW initial assessment. Patient 3's Monthly Calendar Visits, dated 2/2022, indicated, there were no MSW visits. During a review of Patient 4's "CNA", dated 2/4/22, the CNA indicated, "Refer to: Social Work." During a review of Patient 4's "IPA", dated 2/4/22, the IPA indicated, no documented MSW initial assessment. Patient 4's Monthly Calendar Visits, dated 2/2022, indicated, there were no MSW visits. During a review of Patient 5's "CNA", dated 11/12/21, the CNA indicated, "Refer to: Social Work." During a review of Patient 5's "IPA", dated 11/12/21, the IPA indicated, no documented MSW initial assessment. Patient 5's Monthly Calendar Visits, dated 2/2022, indicated, there were no MSW visits. During a review of Patient 6's "CNA", dated 10/5/21, the CNA indicated, "Psychosocial Screening: None indicated. Refer to: Social Work." During a review of Patient 6's "IPA", dated 10/5/21, the IPA indicated, no documented MSW initial assessment. Patient 6's POC (Plan of Care) Summary, dated 10/5/21 was reviewed. The POC Summary indicated, "Order date: 10/5/21 - Social Worker: once a month and as needed to identify psychosocial needs/support to patient and family." Patient 6's Monthly Calendar Visits, dated 10/2021, indicated, there were no MSW visits. During an interview on 3/4/22, at 3:23 PM with MSW 1, MSW 1 stated, "These patients [Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6] were not referred to me." During an interview on 3/4/22, at 3:47 PM with MSW 2, MSW 2 stated, "I don't know these patients [Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6] the agency did not refer them to me. I will visit them if they were referred." During an interview on 3/4/22, at 4 PM, with Director of Patient Care Services (DPCS), DPCS stated, she did the initial screening for Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6]. DPCS stated, these patients should be should be referred to MSW for psychosocial assessment. DPCS stated, she assumed the patients did not need MSW. During a review of the agency policy and procedure (P&P) titled, "Psychosocial Assessment", dated 4/2017, the P&P indicated, "An in-depth psychosocial assessment will be completed by a qualified hospice social worker or hospice registered nurse. The assessment includes, but is not limited to: 1. Coping and adjusting to the patient's terminal illness. 2. Making final arrangements. 3. Reaction to the terminal and subsequent bereavement needs. 4. Social and financial needs. Procedure: 1. A social work contact will be made by a home visit or by telephone based on the patient's and family's needs and acceptance of these services. . .4. The assessment will be completed and placed in the patient's clinical record. 5. After assessment is performed, ongoing contact will be maintained by phone and/or home visits by the hospice social worker. 6. If the patient and/or family refuses psychosocial visits, patient and family/caregiver needs will continue to be assessed on an ongoing basis."

Based on interview and record review, the agency failed to provide appropriate staff training for one licensed staff (Licensed Vocational Nurse - LVN 2) on wound assessment for one of 11 sampled patients (Patient 7). This failure had the potential for Patient 7 to receive inappropriate wound treatment and delayed wound healing. Findings: During an interview on 3/7/22, at 1:55 PM, with Family Member (FM) 1, FM 1 stated, "Her [Patient 1] wound [on the right elbow] has a black area. I don't think it was healing. Two weeks ago this Thursday [3/10/22], the Orthopedic [a specialist who treats bones and joint disease] doctor had a concern about the wound. It's not healing the way he wanted it to. Her [Patient 7] wound had been under the care with Hospice for two months. They're not treating it correctly." During a concurrent interview and record review on 3/7/22, at 2:10 PM, with Director of Patient Care Services (DPCS), Patient 7's "Skin Impairment Assessment (SIA)", dated 1/26/22 to 3/3/22 were reviewed. The SIA indicated, "Location. . . Elbow-right. . . Description. . . wound. . . Stage. . . II [the ulcer is superficial or a blister] Size. . . 0.5 [length] 0.5 [width]. . . Color. . . B [Black]. . . " The wound assessments were all the same with no changes in size, color and wound staging as indicated above on the following dates: 1/26/22, 1/28/22, 2/7/22, 2/9/22, 2/10/22, 2/14/22, 2/18/22, 2/21/22, 2/23/22, 2/24/22, 2/28/22, and 3/3/22. DPCS confirmed the findings and stated, the black colored wound should not be assessed as stage II (skin breaks open, which is tender and painful). During a concurrent interview and record review, on 3/7/22, at 2:30 PM, with Director of Patient Care Services (DPCS), LVN 2's "Skilled Nursing Checklist (SNC)" dated 11/16/21 was reviewed. DPCS was unable to find in the SNC LVN 2's skills and competency regarding Wound Assessment training. DPCS stated, LVN 2 needed to have the Wound Assessment training and competency. During a review of the agency's policy and procedure (P&P), titled, "Wound Assessment," undated, the P&P indicated "Policy: To observe, evaluate, and assess the wound for appropriateness and effectiveness of treatment and care rendered. . . If the patient has pressure sore(s), the RN will determine the stages of pressure by using HCFA [Health Care Financing Administration] staging guidelines as follows: Stage 1: Non blanchable erythema of intact skin. . . Stage II: Partial thickness of skin loss. . . The ulcer is superficial and present clinically as an abrasion, blister or shallow crater. . . Stage III: Full thickness of skin loss, involving damaged or necrosis of subcutaneous tissue. . . Stage IV: Full thickness of skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures. . . The wound will be reassessed and measured at least once a week or as often as needed. . . "

Based on interview and record review, the agency failed to ensure wound assessment was completed consistently and accurately for one of 11 sampled patients (Patient 7). This failure had the potential for inappropriate and ineffective intervention for wound management. Findings: During a review of Patient 7's "Visit Notes" (VN), dated 2/23/22, the "VN" indicated, ". . . Narrative. . . Wound is healing slowly. Wound measurements are [length 1.5 (cm - centimeter)] x 1 cm [width] at elbow, red no active bleeding noted. . . " During a review of Patient 7's "LVN [Licensed Vocational Nurse] Visit Note" (LVNVN), dated 3/3/22, the "LVNVN" indicated, "Integumentary - Skin. . . Wounds. . . Stage 1[skin reddened and does not blanch (lose color briefly when you press your finger on it and then remove your finger)." During an interview on 3/3/22, at 11:20 AM, with LVN 2, in Patient 7's home, LVN 2 stated, Patient 7 had an open area on her right elbow from the cast to her right upper arm before. She had a fall and broke her right upper arm. LVN 2 stated, Patient 7's wound bed has some yellowish colored tissue. During an interview on 3/7/22, at 1:33 PM, with LVN 2, LVN 2 stated, during her last home visit (on 3/3/22), Patient 7's wound (on the right elbow) was slowly healing. LVN 2 stated, "The wound was pink in color around the wound with yellow eschar [dry, dead tissue within a wound] falling off. No signs and symptoms of infection, no drainage, no redness, no foul smell. It's improving," LVN 2 also stated, there was no black colored tissue in the wound bed. During a concurrent interview and record review on 3/7/22, at 2:10 PM, with Director of Patient Care Services (DPCS), Patient 7's "Skin Impairment Assessment (SIA)", dated 1/26/22 to 3/3/22 were reviewed. The SIA indicated, "Location. . . Elbow-right. . . Description. . . wound. . . Stage. . . II [the ulcer is superficial or a blister] Size. . . 0.5 [length] 0.5 [width]. . . Color. . . B [Black]. . . " The wound assessments were all the same with no changes in size, color and wound staging on 1/26/22, 1/28/22, 2/7/22, 2/9/22, 2/10/22, 2/14/22, 2/18/22, 2/21/22, 2/23/22, 2/24/22, 2/28/22, and 3/3/22. DPCS verified the findings. DPCS confirmed the findings and stated, the black colored wound should not be assessed as stage II. DPCS also stated, the SIA on 2/23/22 and the VN for the right elbow wound narrative notes on 2/23/22 did not match. During an interview and record review on 3/7/22, at 2:10 PM, DPCS was unable to provide a SIA for the right elbow for the week of 1/30/22 to 2/5/22. DPCS stated, the SIA should be done at least once a week. Requested from DPCS, Patient 7's wound photographs of the right elbow. DPCS was unable to provide a wound photograph was consistently done after each wound treatments and wound assessments. During an interview on 3/7/22, at 1:55 PM, with Family Member (FM) 1, FM 1 stated, "Her [Patient 1] wound [on the right elbow] has a black area. I don't think it was healing. Two weeks ago this Thursday [3/10/22], the Orthopedic [a specialist who treats bones and joint disease] doctor had a concern about the wound. It's not healing the way he wanted it to. Her [Patient 7] wound had been under the care with Hospice for two months. They're not treating it correctly." During a review of the agency's policy and procedure (P&P), titled, "Wound Assessment,", undated, the P&P indicated "Policy: To observe, evaluate, and assess the wound for appropriateness and effectiveness of treatment and care rendered. . . If the patient has pressure sore(s), the RN will determine the stages of pressure by using HCFA [Health Care Financing Administration] staging guidelines as follows: Stage 1: Non blanchable erythema of intact skin. . . Stage II: Partial thickness of skin loss. . . The ulcer is superficial and present clinically as an abrasion, blister or shallow crater. . . Stage III: Full thickness of skin loss, involving damaged or necrosis of subcutaneous tissue. . . Stage IV: Full thickness of skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures. . . The wound will be reassessed and measured at least once a week or as often as needed. . . The SN [Skilled Nurse] is responsible to obtain the new order(s) from the attending physician, if he/she feels that the treatment is ineffective. . . "The photograph of the wound may be obtained after the patient has signed the consent, on admission to establish the baseline and periodically after treatments are rendered to see if the progression of the treatment or ineffective treatment. "