Every finding on record at Legacy Hospice, LLC

Upon patient record review, 4 of 19 (Patient #3, 6, 12, 13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 3:The comprehensive nursing assessment, subsequent patient visits, and supply list indicates that the patient utilizes an indwelling catheter; however, the plan of care does not include orders and instructions for ongoing care and maintenance of the catheter. Additionally, the plan of care includes wound care orders for the SN/CG to cleanse wound with wound cleanser, pat dry with gauze, leave open to air; wound to be cleaned PRN. This order fails to indicate the location of the wound and does not contain a specifier for the PRN indication. (corrected onsite) Patient 6:The plan of care includes catheter orders for SN to insert indwelling Foley catheter. This order fails to indicate the size of the catheter or balloon, frequency of changing, need for irrigation or other maintenance/patency, etc. (corrected onsite) Patient 12: The plan of care includes wound care orders to cleanse wound with wound cleanser, pat dry with gauze, apply medihoney and calcium alginate, cover with foam dressing; wound care daily and PRN soilage. This order fails to indicate the location of the wound and does not indicate who will be performing the wound care. (corrected onsite) Patient 13: The plan of care includes wound care orders to cleanse wound with wound cleanser, pat dry with gauze, apply medihoney, cover with foam dressing; wound care daily and PRN soilage. This order fails to indicate the location of the wound and does not indicate who will be performing the wound care. (corrected onsite)

Upon patient record review, 2 of 19 (Patient #3, 13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 3, 13: The patient had nebulized medications ordered for use during the ongoing provision of hospice services; however, a nebulizer was not added to the plan of care. (corrected onsite)

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. There was evidence of the governing body appointing two Administrators with the agency having one CCN number assigned to the agency. Personnel #6 and #7 had personnel records with job descriptions as Administrators.

Upon observation, there was no evidence that the lines of authority, professional and administrative control must be clearly delineated in the provider's organizational structure and in practice, and must be traced to the location issued the certification number. There was evidence of two appointed Administrators with the agency having one CCN number assigned to the agency. Personnel #6 and #7 had personnel records with job descriptions as Administrators.

Upon patient record review, 1 of 19 (Patient #16) did not have evidence that the discharge summary includes all required information. Patient 16: There was no evidence of a discharge summary.

Upon patient record review, 2 of 19 (Patient #2, 6) did not have evidence that the hospice assumes responsibility for professional management of the resident's hospice services in accordance with the hospice plan of care. The hospice is responsible for providing all hospice services including: • Ongoing assessment, care planning, monitoring, coordination and provision of care by the Hospice IDG • Assessment, coordination and provision of any needed general inpatient or continuous care • Consultation about the patient's care with facility staff • Coordination by the hospice RN for the implementation of the plan of care for the patient • Provision of hospice aide services, if these services are determined necessary by the IDG to supplement the nurse aide services provided by the facility • Provision, in a timely manner, of all supplies, medications, and DME needed for the palliation and management of the terminal illness and related conditions • Financial management responsibility for all medical supplies, appliances, medications and biologicals related to the terminal illness and related conditions • Determination of the appropriate level of care to be given to the patient (routine homecare, inpatient, or continuous care) • Arranging any necessary transfers from the facility, in consultation with the facility personnel Patient 2: The patient was admitted for hospice services on 06.01.2024 with a terminal diagnosis of protein calorie malnutrition. Weekly MAC measurements were ordered and obtained by the hospice nurse. On 06.06.2024, labs were ordered, including albumin. In July 2024, the patient's diet was changed to pleasure feedings and weekly MAC measurements were discontinued. There was no evidence in the hospice charting relating to the ordered labs. It was determined by the hospice nursing director that the SNF had collected and reviewed the lab results, and they were present in the SNF chart. The hospice failed to monitor and coordinate care with the SNF relating to this patient. It is unclear if all relevant information was reviewed by the hospice IDG prior to making changes to the care plan and related interventions, such as changes to the patient's diet. Patient 6: On 11.02.2024, the patient was noted to have a UTI. This infection did not respond to antibiotics and on 11.13.2024 alternate antibiotics and a KUB Xray were ordered. There was no evidence in the hospice charting relating to the ordered Xray. It was determined by the hospice nursing director that the SNF had performed and reviewed the X-ray, and it was present in the SNF chart. The hospice failed to monitor and coordinate care with the SNF relating to this patient. It is unclear if all relevant information was reviewed by the hospice prior to making changes to the care plan and related interventions, such as changes to the patient's medication.

Based on clinical record review and staff interview the Agency failed to have a process to review oxygen for actual or potential drug interactions in 10 (#1, #2, #3, #5, #6, #7, #8, #9, #10, and #11) out of 10 (#1, #2, #3, #5, #6, #7, #8, #9, #10, and #11) clinical records reviewed for patients currently utilizing oxygen. This failure to conduct a complete medication review could potentially result in the patient's attending Physician ability to make informed decisions regarding the patient's individualized medication regimen. Findings follow: --- 1. Review of clinical record #1 with a start of care (SOC) of 09/20/22 and a diagnosis of Alzheimer's Disease revealed a form titled ";Order Number: 98933" with orders for ";O2-OXYGEN 2-5 Liter" with ";Instructions: OXYGEN FOR ANTICIPATORY USE FOR RESPIRATORY DISTRESS AT 2-5 LPM (LITERS PER MINUTE) VIA NASAL CANNULA PRN (AS NEEDED)". There was no documentation in the clinical record to indicate oxygen had been reviewed for actual or potential drug interactions. 2. Review of clinical record #2 with a SOC of 12/29/22 and a diagnosis of Malignant Neoplasm of Frontal Lobe revealed a form titled ";HOSPICE CERTIFICATION AND PLAN OF CARE" with orders for ";OXYGEN 2 liter" with ";Instructions: APPLY 2 LPM OF OXYGEN VIA NASAL CANNULA AS NEEDED FOR SHORTNESS OF BREATH". There was no documentation in the clinical record to indicate oxygen had been reviewed for actual or potential drug interactions. 3. Review of clinical record #3 with a SOC of 12/30/22 and a diagnosis of Acute and Chronic Respiratory Failure revealed a form titled ";HOSPICE CERTIFICATION AND PLAN OF CARE" with orders for ";OXYGEN 2-5 liter" with ";Instructions: O2 AT 2-5 PER NASAL CANNULA FOR SOB (SHORTNESS OF BREATH)". There was no documentation in the clinical record to indicate oxygen had been reviewed for actual or potential drug interactions. 4. Review of clinical record #5 with a SOC of 12/21/22 and a diagnosis of Colon Cancer revealed a form titled ";HOSPICE CERTIFICATION AND PLAN OF CARE" with orders for ";O2-OXYGEN 4 Liter" with ";Instructions: OXYGEN CONTINUOUSLY AT 4 LPM (liters per minute) VIA NASAL CANNULA FOR RESPIRATORY DISTRESS". There was no documentation in the clinical record to indicate oxygen had been reviewed for actual or potential drug interactions. 5. Review of clinical record #6 with a SOC of 12/27/22 and a diagnosis of Alzheimer's Disease revealed a form titled ";HOSPICE CERTIFICATION AND PLAN OF CARE" with orders for ";O2-OXYGEN 2 Liter" with ";Instructions: PLACE 2 LITERS BY NASAL CANNULA AS NEEDED FOR SHORTNESS OF BREATH". There was no documentation in the clinical record to indicate oxygen had been reviewed for actual or potential drug interactions. 6. Review of clinical record #7 with a SOC of 12/21/22 and a diagnosis of Atherosclerotic Heart Disease revealed a form titled ";HOSPICE CERTIFICATION AND PLAN OF CARE" with orders for ";OXYGEN 2 Liter" with ";Instructions: APPLY 2 LPM VIA NASAL CANNULA AS NEEDED FOR SHORTNESS OF BREATH". There was no documentation in the clinical record to indicate oxygen had been reviewed for actual or potential drug interactions. 7. Review of clinical record #8 with a SOC of 12/20/22 and a diagnosis of Intrahepatic Bile Duct Carcinoma revealed a form titled ";HOSPICE CERTIFICATION AND PLAN OF CARE" with orders for ";OXYGEN 2-5 Liter" with ";Instructions: APPLY O2 VIA NASAL CANNULA 2-5L AS NEEDED FOR ANXIETY OR SOB". There was no documentation in the clinical record to indicate oxygen had been reviewed for actual or potential drug interactions. 8. Review of clinical record #9 with a SOC of 11/28/22 and a diagnosis of Malignant Neoplasm of Rectum revealed a form titled ";HOSPICE CERTIFICATION AND PLAN OF CARE" with orders for ";O2-OXYGEN 2.5 Liter" with ";Instructions: OXYGEN VIA NC (nasal cannula) FOR SHORTNESS OF BREATH". There was no documentation in the clinical record to indicate oxygen had been reviewed for actual or potential drug interactions. 9. Review of clinical record #10 with a SOC of 11/04/22 and a diagnosis of Atherosclerotic Heart Disease revealed a form titled ";HOSPICE CERTIFICATION AND PLAN OF CARE" with orders for ";O2-OXYGEN 2 Liter" with ";Instructions: GIVE 2LPM VIA NASAL CANNULA CONTINUOUSLY FOR ANTICIPATORY USE". There was no documentation in the clinical record to indicate oxygen had been reviewed for actual or potential drug interactions. 10. Review of clinical record #11 with a SOC of 11/02/22 and a diagnosis of Chronic Obstructive Pulmonary Disease revealed a form titled ";HOSPICE CERTIFICATION AND PLAN OF CARE" with orders for ";OXYGEN 2-4 Liter" with ";Instructions: WEAR OXYGEN 2-4L PER NASAL CANNULA". There was no documentation in the clinical record to indicate oxygen had been reviewed for actual or potential drug interactions. 11. An interview on 01/27/23 at 1:35 PM with Agency Personnel #1 and #2 confirmed the agency did not have a process in place to check oxygen for actual or potential drug interactions.

Based on clinical record review and staff interview it was determined the Agency failed to develop an individualized Plan of Care (POC) which included patient specific scope and frequency of visits to be made by the Skilled Nurse (SN) in 11 (#1 - #11) of 13 (#1 - #13) clinical records reviewed. This lack of individualized POC specific scope and frequency of visits could potentially result in a failure to meet the patient and/or families specific spiritual needs for all patients on current census. Findings follow: --- 1. Review of clinical record #1 with a start of care (SOC) of 09/20/22 and a diagnosis of Alzheimer's Disease revealed a form titled "IDG (Interdisciplinary Group) Summary Report" dated 12/21/22, 01/04/23, and 01/18/23 showed no evidence of a frequency of visits for the skilled nurse (SN). 2. Review of clinical record #2 with a SOC of 12/29/22 and a diagnosis of Malignant Neoplasm of Frontal Lobe revealed a form titled "IDG Summary Report" dated 01/03/23, and 01/11/23 showed no evidence of a frequency of visits for the SN. 3. Review of clinical record #3 with a SOC of 12/30/22 and a diagnosis of Acute and Chronic Respiratory Failure revealed a form titled "IDG Summary Report" dated 01/04/23, and 01/18/23 showed no evidence of a frequency of visits for the SN. 4. Review of clinical record #4 with a SOC of 12/24/22 and a diagnosis of Neurocognitive Disorder with Lewey Bodies revealed a form titled "IDG Summary Report" dated 01/03/23, and 01/11/23 showed no evidence of a frequency of visits for the SN. 5. Review of clinical record #5 with a SOC of 12/21/22 and a diagnosis of Colon Cancer revealed a form titled "IDG Summary Report" dated 01/04/23 showed no evidence of a frequency of visits for the SN. 6. Review of clinical record #6 with a SOC of 12/27/22 and a diagnosis of Alzheimer's Disease revealed a form titled "IDG Summary Report" dated 01/03/23, and 01/11/23 showed no evidence of a frequency of visits for the SN. 7. Review of clinical record #7 with a SOC of 12/21/22 and a diagnosis of Atherosclerotic Heart Disease revealed a form titled "IDG Summary Report" dated 01/03/23 showed no evidence of a frequency of visits for the SN. 8. Review of clinical record #8 with a SOC of 12/20/22 and a diagnosis of Intrahepatic Bile Duct Carcinoma revealed a form titled "IDG Summary Report" dated 01/04/23 showed no evidence of a frequency of visits for the SN. 9. Review of clinical record #9 with a SOC of 11/28/22 and a diagnosis of Malignant Neoplasm of Rectum revealed a form titled "IDG Summary Report" dated 12/07/22, 12/21/22, 01/04/23 and 01/18/23 showed no evidence of a frequency of visits for the SN. 10. Review of clinical record #10 with a SOC of 11/04/22 and a diagnosis of Atherosclerotic Heart Disease revealed a form titled "IDG Summary Report" dated 11/09/22, 11/23/22, 12/07/22, 12/21/22, 01/04/23 and 01/18/23 showed no evidence of a frequency of visits for the SN. 11. Review of clinical record #11 with a SOC of 11/02/22 and a diagnosis of Chronic Obstructive Pulmonary Disease revealed a form titled "IDG Summary Report" dated 11/09/23 showed no evidence of a frequency of visits for the SN. 12. An interview on 01/27/23 at 1:35 PM with Agency Personnel #1 and #2 confirmed the SN frequency was not included on the IDG updates.

Based on clinical record review and staff interview, it was determined the Agency staff failed to follow the Attending Physician orders contained in the Plan of Care (POC) for 1 (#4) of 13 (#1 - #13) clinical records reviewed. This failed practice had the potential to affect the quality of care received by all patients currently on census, in that, there was a risk of adverse outcomes, potential to affect the attainment of the patients' individual goals and a risk of hospitalizations due to disease exacerbation. Findings follow: --- 1.Review of clinical record #4 with a SOC of 12/24/22 and a diagnosis of Neurocognitive Disorder with Lewey Bodies revealed a form titled ";HOSPICE CERTIFICATION AND PLAN OF CARE" with a certification period of 12/24/22 to 03/23/23 which contained the following ";Frequency/Duration of Visits": A. SN (skilled nurse) 1WK1 (1 times a week for 1 week), 6WK1 (6 times a week for 1 week),2WK12 (2 times a week for 12 weeks), 2PRN (2 visits as needed) SYMPTOM MANAGEMENT/DECLINE." Documentation showed 1 SN visit missed the week of 12/25/22-12/31/22. There was no evidence the Attending Physician was notified of the SN missed visit. B. HHA (Home Health Aide) EFFECTIVE 12/25/2022 3WK12 (3 times a week for 12 weeks) 2WK1 (2 times a week for 1 week)". Documentation showed 1 HHA visit missed the week of 12/25/22-12/31/22. There was no evidence the Attending Physician was notified of the HHA missed visit. 2.An interview on 01/27/23 at 1:35 PM with Agency Personnel #1 and #2 confirmed the SN and HHA visits not completed as ordered and no documentation the Attending Physician was notified of the missed visits as required.

Based on clinical record review and staff interview, it was determined the Registered Nurse (RN) failed to supervise and assess the quality of care and services through supervisory aide visits (SAV) every 14 days in 1 (#7) of 7 (#1, #2, #4, #7, #8, #11 and #13) current patients records reviewed with Hospice Aide (HA) services. This lack of supervision by the RN had the potential to place all patients receiving HA services at risk for adverse outcomes due to possible delays in the discovery of noncompliance with the Plan of Care by the HA or possible changes in the needs of the patient and family. Findings follow: --- 1. 1. Review of clinical record #7, with a start of care (SOC) of 12/21/22 and a diagnosis of Atherosclerotic Heart Disease revealed orders for HA services three to five times per week. HA services began on 12/22/22. The RN documented on a form titled, "Visit Note Report", SAV conducted on 12/30/22 and 01/16/23 (3 days late). 2. 2. An interview on 01/27/23 at 1:35 PM with Agency Personnel #1 and #2 confirmed SAVs not conducted every 14 days as required.