Every finding on record at Legacy Hospice, Inc.

The hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years. When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. If the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event. Conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. This exercise may include but is not limited to a second full-scale exercise that is community-based or a facility-based functional exercise; or a mock disaster drill; or a tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document review and interview. Review of the agency’s emergency preparedness plan, it was revealed that the agency did not ensure that the emergency preparedness plan was tested annually. Document 2: The emergency preparedness plan revealed tabletop exercises completed in 2021 and 2023, as well as activation of the plan in an actual emergency event in 2024. The emergency preparedness plan lacked documentation of an exercise to test the plan in 2022. In an interview on 08/08/2024, the Administrator reviewed the emergency plan and stated, "We do not have any documented drills or exercises for 2022”. In review of the emergency preparedness plan, it was revealed that the agency did not ensure that the emergency preparedness plan was tested annually.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review and interview. In 10 of 14 (71%) clinical records reviewed it was revealed that the agency did not ensure that all current medications were included in the patient's drug profile. Document 4: Agency Policy "Medication Profile" dated 02/01/2021 read in part "It is the policy of the hospice to review the patient's drug regimen upon election of hospice service, when there is any change made to existing drug uses, and with each comprehensive assessment. The admission comprehensive assessment drug regimen will include current list of prescription and over the counter medications, current list of supplements and/or herbal medications; current list of any alternative treatments that could possibly affect drug therapy.". Clinical Record 3: The election of the hospice benefit was 07/09/2024. The record revealed a physician's order dated 07/09/2024 that read in part "Oxygen 2-4 liters per nasal cannula as needed for shortness of breath.". The drug profile dated 07/09/2024 did not include oxygen. Clinical Record 4: The election of the hospice benefit was 05/08/2024. The record revealed a physician's order dated 05/08/2024 that read in part "Oxygen 2-4 liters per nasal cannula as needed for shortness of breath.". The drug profile dated 05/08/2024 did not include oxygen. Clinical Record 5: The election of the hospice benefit was 06/15/2024. The record revealed a physician's order dated 06/15/2023 that read in part "Oxygen 2-4 liters per nasal cannula as needed for shortness of breath.". The drug profile dated 06/15/2023 did not include oxygen. Clinical Record 7: The election of the hospice benefit was 07/12/2024. The record revealed a physician's order dated 07/12/2024 that read in part "Oxygen 2-4 liters per nasal cannula as needed for shortness of breath.". The drug profile dated 07/12/2024 did not include oxygen. Clinical Record 8: The election of the hospice benefit was 06/11/2024.The record revealed a physician's order dated 06/12/2024 that read in part "Oxygen 2-4 liters per nasal cannula as needed for shortness of breath.". The drug profile dated 06/12/2024 did not include oxygen. Clinical Record 9: The election of the hospice benefit was 06/20/2024. The record revealed a physician's order dated 06/20/2024 that read in part "Oxygen 2-4 liters per nasal cannula as needed for shortness of breath.". The drug profile dated 06/20/2024 did not include oxygen. Clinical Record 10: The election of the hospice benefit was 07/19/2024. The record revealed a physician's order dated 07/19/2024 that read in part "Oxygen 2-4 liters per nasal cannula as needed for shortness of breath.". The drug profile dated 07/19/2024 did not include oxygen. Clinical Record 11: The election of the hospice benefit was 01/16/2024. The record revealed a physician's order dated 01/16/2024 that read in part "Oxygen 2-4 liters per nasal cannula as needed for shortness of breath.". The drug profile dated 01/16/2024 did not include oxygen. Clinical Record 12: The election of the hospice benefit was 04/29/2024. The record revealed a physician's order dated 04/29/2024 that read in part "Oxygen 2-4 liters per nasal cannula as needed for shortness of breath.". The drug profile dated 04/29/2024 did not include oxygen. Clinical Record 14: The election of the hospice benefit was 07/05/2024. The record revealed a physician's order dated 07/05/2024 that read in part "Oxygen 2-4 liters per nasal cannula as needed for shortness of breath.". The drug profile dated 07/05/2024 did not include oxygen. In an interview on 08/07/2024, the Clinical Manager reviewed the records and stated, "Oxygen is not on these medication profiles but it should be".

It is required that each patient’s individualized written plan of care reflects patient and family goals; identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; includes all services necessary for the palliation and management of the terminal illness, including intervention to manage pain and symptoms; a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs; measurable outcomes anticipated from implementing and coordinating the plan of care; drugs and treatment necessary to meet the needs of the patient; medical supplies and appliances necessary to meet the needs of the patient; includes the Interdisciplinary Group’s documentation of the patient’s or representative’s level of understanding, involvement, and agreement with the POC. The documentation in the patient’s record is in accordance with the hospice’s policies and procedure. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed it was revealed that the agency did not ensure that interventions based on problems identified in the initial and updated comprehensive assessments were included in the patient's plan of care. Clinical Record 13: The record revealed an initial nursing assessment dated 12/08/2023 that read in part "Patient is diabetic.". The plan of care dated 12/08/2023-03/06/2024 did not include interventions and goals related to diabetes. In an interview on 08/07/2024, the Clinical Manager reviewed the record and stated, "There is not a care plan for diabetes for this patient."

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 8 of 13 (62%) clinical records with aide services provided reviewed it was revealed that the agency did not ensure that all patient care instructions were included in the aide care plan. Clinical Record 1: The record revealed a physician's order dated 06/13/2024 that read in part "Aide services 2x/week.". The aide care plan dated 06/13/2024 read in part "Bed bath 2x/week, tub bath 2x/week and shower 2x/week.". The aide care plan lacked specific instructions for which method of bathing to perform. Clinical Record 3: The record revealed a physician's order dated 07/09/2024 that read in part "Aide services 2x/week.". The aide care plan dated 07/09/2024 read in part "Bed bath 2x/week, tub bath 2x/week and shower 2x/week.". The aide care plan lacked specific instructions for which method of bathing to perform. Clinical Record 6: The record revealed a physician's order dated 06/24/2024 that included wound care with a wound dressing to a wound on the sacrum. The aide care plan dated 06/24/2024 lacked instructions related to the wound dressing on the sacrum. Clinical Record 7: The record revealed a physician's order dated 07/12/2024 that included wound care with a wound dressing for wounds to both legs. The aide care plan dated 07/12/2024 lacked instructions related to the wound dressings on the patient's legs. Clinical Record 10: The record revealed a physician's order dated 07/19/2024 that read in part "Aide services 2x/week. Anchor 16Fr foley catheter." The aide care plan dated 07/19/2024 lacked instructions for catheter care. The aide care plan dated 07/19/2024 read in part "Bed bath 2x/week, tub bath 2x/week and shower 2x/week.". The aide care plan lacked specific instructions for which method of bathing to perform. Clinical Record 12: The record revealed a nursing visit note dated 05/06/2024 that read in part "Patient has a 16Fr foley catheter.". The aide care plan dated 05/06/2024 lacked instructions for catheter care. The record also revealed a physician's order dated 05/06/2024 that read in part "Aide services 2x/week.". The aide care plan dated 05/06/2024 read in part "Bed bath 2x/week, tub bath 2x/week and shower 2x/week.". The aide care plan lacked specific instructions for which method of bathing to perform. Clinical Record 13: The record revealed a physician's order dated 12/08/2023 that read in part "Aide services 2x/week. Anchor 16Fr foley catheter.". The aide care plan dated 12/08/2023 lacked instructions for catheter care. The aide care plan dated 12/08/2023 read in part "Bed bath 2x/week, tub bath 2x/week and shower 2x/week.". The aide care plan lacked specific instructions for which method of bathing to perform. Clinical Record 14: The record revealed a physician's order dated 07/05/2024 that read in part "Aide services 2x/week.". The aide care plan dated 07/05/2024 read in part "Bed bath 2x/week, tub bath 2x/week and shower 2x/week.". The aide care plan lacked specific instructions for which method of bathing to perform. On 08/07/2024, the Clinical Manager reviewed the records and confirmed the above findings.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed it was revealed that the agency did not ensure that all physician's orders were included in the patient's clinical record. Clinical Record 12: The record revealed a nursing visit note dated 05/06/2024 that read in part "Patient has a 16Fr foley catheter.". The record lacked physician's orders for a foley catheter. In an interview on 08/08/2024, the Clinical Manager reviewed the record and stated, "There is not an order for the foley catheter in this patient's chart but there should have been”.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires but no less frequently than every 15 calendar days. A revised plan of care (POC) includes record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced through record review and interview, in which 3 of 5 (60%) plans of care reviewed for patient's on service greater than 2 weeks lacked documentation of the patient's progress toward outcomes and goals that were identified in the plan of care. Record #82147: A review of the plan of care revisions completed during the interdisciplinary team meetings (IDT) dated 10/8/21 and 10/22/21 lacked documentation of the patient's progress towards all stated goals on the POC. Record #61361: A review of the plan of care revisions completed during the interdisciplinary team meetings (IDT) dated 10/8/21 and 10/22/21 lacked documentation of the patient's progress towards all stated goals on the POC. Record #15186: A review of the plan of care revisions completed during the interdisciplinary team meetings (IDT) dated 10/8/21 and 10/22/21 lacked documentation of the patient's progress towards all stated goals on the POC. The Clinical Manager stated during an interview conducted on 11/3/21 at 9:07 am during a joint review of the clinical records that the patient's POC's lacked documentation of the patient's progress towards identified goals.