Every finding on record at Legacy Hospice, LLC

Upon patient record review, 5 of 19 (Patient #6, 8, 9, 11, 13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy Patient 6: The medication list indicates Miralax, but does not reflect the orders for reconstitution. (corrected onsite) Patient 8: The medication list indicates nitrostat 0.4mg 1 tab SL as directed, but does not reflect the orders for PRN use. (corrected onsite) Patient 9: The medication list indicates Nystatin topical cream 1 application bid PRN skin irritation, but does not provide a location for use of this topical medication. (corrected onsite) Patient 11: The medication list indicates Nystatin powder 1 application bid for rash, but does not provide a location for use of this topical medication. (corrected onsite) Patient 13: The medication list indicates atropine 1% ophthalmic gtts 2 gtts q 2 hours in the eyes PRN excess secretions. This medication list entry does not reflect the correct physician order of the sublingual route for administration of this medication. (corrected onsite)

Upon patient record review, 4 of 19 (Patient #3, 6, 7, 11) 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 patient has treatment orders for wound care that state cleanse area, pat dry, apply barrier cream topically bid & PRN. This is an incomplete treatment order as it does not indicate the location of the wound, who is to perform the wound care, and does not provide a specifier for the PRN indication. (corrected onsite) Patient 6: The patient has treatment orders for the catheter which are complete regarding size, frequency, and the like. However, the order indicates the catheter is to be changed monthly & PRN, which does not provide a specifier for the PRN indication. (corrected onsite) Patient 7: The patient has treatment orders for wound care that state only barrier cream tid & PRN. This is an incomplete treatment order as it does not indicate the location of the wound, who is to perform the wound care, and does not provide a specifier for the PRN indication. The patient has an additional wound care order that states cleanse wound, apply barrier cream & padded dressing. This is also an incomplete treatment order as it does not indicate the location of the wound, the frequency of the wound care, and who is to perform the wound care. (corrected onsite) Patient 11: The patient has treatment orders for the catheter which are complete regarding size, frequency, and the like. However, the order indicates the catheter is to be changed monthly & PRN, which does not provide a specifier for the PRN indication. (corrected onsite)

Upon patient record review, 1 of 19 (Patient #1) 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 1: The patient requires the use of a wheelchair for management of the terminal illness; however, this DME does not appear on the plan of care. (corrected onsite)

Based on review of the patient admission packet and interview, the agency failed to ensure that the patient rights booklet contained that the patient would receive verbal and written notice of rights in advance of providing care in a language that the patient understood. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the patient admission packet failed to show the verbiage that the patient would receive a verbal and written notice of rights in advance of providing care in a language that the patient understood. During an interview on 12/21/2022 at 10:50 AM, the administrator stated that he/she would expect the specific wording to be included in the patient rights booklet.

Based on policy review, record review, observation, and interview the agency failed to ensure that a review of the patient's prescribed medications and treatments was completed in three (Records/Patients #1, #2, and #3) of three home observations. This deficient practice has the potential to affect all patients served by the agency. --- RECORD/PATIENT #2: -Patient was admitted to hospice services on 11/18/2020; -Patient resided in a skilled nursing facility (SNF); -The hospice agency's medication profile lists the medications of Calmoseptine, Fiber 625 milligrams (mg), Levothyroxine 50 micrograms (mcg), Linzess 72 mcg every 3 days, Melatin 3 mg, oxygen 2 liters per minute (lpm) as needed, and pepcid 20 mg. The SNF's medication profile did not include these medications; and -The SNF's medication profile lists the medications of Famotodine 20 mg, Linzess 145 mcg every day, Metoprolol 25 mg, and Senna Plus. The agency's medication profile did not included these medications. Findings included: - Review of the agency's policy titled, "Medication Profile," dated 04/2020, showed in part: Patient's receiving medications administered by the organization will have a current, accurate medication profile in the clinical record; and The medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. RECORD/PATIENT #1: Review of the clinical record showed: - Patient was admitted to hospice services on 03/15/2022 and resided in a long term care facility (LTCF); - Diagnoses included: Alzheimer's Disease with late onset (a progressive disease of the brain that causes changes in mental function), abnormal weight loss, repeated falls, history of bacterial pneumonia (an infection of the lungs caused by bacteria), Cerebral Infarction (damage to tissues of the brain due to a loss of oxygen to the area), Aphasia (a brain disorder that affects communication) and Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar); - Review of the agency medication profile, dated 12/19/2022, failed to include the following: Magnesium Oxide tablet (a medication used to replace Magnesium) 400 milligrams (mg) one tablet three times per day; Potassium Chloride capsule extended (a medication used to replace Potassium) 10 milli-equivalents (mEq) two capsules three times per day; and Refresh Liquigel (a medication used to lubricate the eye) 1% two drops to each eye three times per day as needed. Observation on 12/20/2022 beginning at 9:00 AM, during the patient's LTCF home visit, showed the LTCF medication profile failed to include the following medications that were present on the agency medication profile: Omeprazole capsule extended release (a medication used to treat too much acid in the stomach) 20 mg one tablet every day; and Zofran tablet (a medication used for nausea and vomiting) 4 mg every six hours as needed. RECORD/PATIENT #3: Review of the clinical record showed: - Patient was admitted to hospice services on 08/24/2022 and resided at home; -Diagnoses included: Liver Cirrhosis (chronic liver damage that leads to scarring and liver failure), Hepatic Encephalopathy (the loss of brain function when a damaged liver does not remove toxins from the blood), and recurrent falls related to gait instability; Observation on 12/20/2022 beginning at 10:05 AM, showed that the patient reported using the following medications: Peroxide (a medication used as a mild antiseptic for cuts and scrapes of the skin) as needed for wounds on his/her arms; and Aspercreme gel (a medication used for mild pain relief) as needed to areas with pain. - Review of the agency medication profile, dated 12/19/2022, failed to include these medications.

Based on policy review, record review, and interview, the agency failed to ensure that the plan of care was being followed in collaboration with an attending physician in, but not limited to, one (Record/Patient #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's policy titled, "The Plan of Care," dated 04/2020, showed that the care provided to the patient must be in accordance with the plan of care, and the plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. RECORD/PATIENT #5: -The skilled nurse documentation dated 11/18/2022 showed that the patient had received four or more doses of PRN (pro re nata - as needed) pain medication; -The skilled nurse documentation dated 12/06/2022 showed that the patient had received four or more doses of PRN pain medication; -The skilled nurse documentation dated 12/19/2022 showed that the patient had received four or more doses of PRN pain medication; -The documentation states that if four or more doses of PRN pain medication are consistently required for pain relief within a 24 hour period, physician should be notified to determine need for medication adjustment; and -The documentation in the record failed to show any contact made with the doctor. During an interview on 12/21/2022 at 10:50 AM, the administrator stated that he/she would expect the nurses to contact the physician with continued high levels of pain.

Based on policy review, record review, observation, and interview the agency failed to ensure that an individualized plan of care was developed in, but not limited to, five (Records/Patients #1, #2, #3, #4, and #5) of five full records reviewed. This deficient practice has to potential to affect all patients served by the agency. --- Findings included: Review of the agency's policy titled, "The Plan of Care," dated 04/2020, showed that a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. RECORD/PATIENT #2: Review of the clinical record showed the following: -The patient was admitted to hospice services on 11/18/2022; -The patient had diagnoses of Alzheimer's disease, Atherosclerotic Heart Disease (A build up of cholesterol plaque in the walls of arteries causing obstruction of blood flow, major depressive disorder, anxiety disorder, type 2 Diabetes Mellitus, and Gastro-esophageal Reflux Disease; and -The patient's plan of care failed to show specific interventions regarding these diagnoses. RECORD/PATIENT #5: Review of the clinical record showed the following: -The patient was admitted to hospice services on 05/12/2022; -The patient had diagnoses of chronic obstructive pulmonary disorder (A group of lung diseases that block airflow and make it difficult to breathe), congestive heart failure, and malignant neoplasm of the right lung; and -The patient's plan of care failed to show specific interventions regarding these diagnoses. During an interview on 12/21/2022 at 10:50 AM, the administrator stated that he/she would expect that the plan of care contained individualized goals and interventions. RECORD/PATIENT #1: Review of the clinical record showed: - Patient was admitted to hospice services on 03/15/2022 and resided in a long term care facility (LTCF); - Diagnoses included: Alzheimer's Disease with late onset (a progressive disease of the brain that causes changes in mental function), abnormal weight loss, repeated falls, history of bacterial pneumonia (an infection of the lungs caused by bacteria), Cerebral Infarction (damage to tissues of the brain due to a loss of oxygen to the area), Aphasia (a brain disorder that affects communication) and Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar); - Review of Skilled Nurse (SN) notes dated 11/08/2022, 11/15/2022, 11/22/2022, and 12/01/2022 showed the following interventions related to falls: use good body mechanics; wear well-fitting nonskid shoes; use cane/walker; use handrails; and use good lighting and night-lights. - Review of SN notes dated 11/08/2022, 11/15/2022, 11/22/2022, and 12/01/2022 showed patient is maximum assistance to transfer out of bed and patient does not walk. - Observation on 12/20/2022 beginning at 9:00 AM, during the patient's LTCF home visit, showed that the patient had a low bed, had a scoop mattress, and had a fall mat beside his/her bed to prevent injuries from falls. - Review of the SN notes dated 11/08/2022, 11/15/2022, 11/22/2022, and 12/01/2022 failed to show any interventions related to Type 2 Diabetes Mellitus and review of current medication profile, dated 12/19/2022, showed patient received Metformin (a medication used to stabilize blood sugar) 850 milligrams (mg) one tablet two times per day since 11/28/2021. RECORD/PATIENT #3: Review of the clinical record showed: - Patient was admitted to hospice services on 08/24/2022 and resided at home; -Diagnoses included: Liver Cirrhosis (chronic liver damage that leads to scarring and liver failure), Hepatic Encephalopathy (the loss of brain function when a damaged liver does not remove toxins from the blood), and recurrent falls related to gait instability; - Review of SN notes dated 11/15/2022, 12/08/2022, 12/13/2022, and 12/20/2022 showed the following interventions related to falls: Reviewed use of assistive devices -Review of SN notes dated 11/15/2022, 12/13/2022, and 12/20/2022 showed the patient ambulates independently with no assistive devices. RECORD/PATIENT #4: Review of the clinical record showed: - Patient was admitted to hospice services on 08/30/2022 and resided at home; - Diagnoses include: Alcoholic Cirrhosis of the liver with Ascites (chronic liver damage that leads to scarring and liver failure with fluid build-up), Chronic Obstructive Pulmonary Disease (a chronic lung disease that blocks airflow in the lungs and makes it hard to breathe), and history of Venous Thrombosis and Embolism (a blood clot or travelling blood clot in the body); - Review of SN notes dated 11/28/2022, 11/30/2022, 12/05/2022, and 12/19/2022 showed the following interventions for safety related to increased bleeding: use soft toothbrush; use electric razor only; care with eating utensils; signs and symptoms of bleeding or hemorrhage; measures to control bleeding; change any dressing as often as necessary before saturation occurs; elevate head of bed and/or turn to side for nasal/oral bleeding; and reviewed medications/herbals that could affect bleeding. - Review of current medication profile, dated 12/19/2022, showed no medications that would cause excessive bleeding and no herbal medications.

Based on nationally-recognized standards, policy review, observation, and interview the agency failed to ensure that accepted standards of practice to prevent transmission of infections and communicable diseases were followed in three (Records/Patients #1, #2, and #3) of three home visit observations conducted. This deficient practice has the potential to affect all patients served by the agency. --- RECORD/PATIENT #2: Observation on 12/20/2022 beginning at 9:00 AM, during the patient's long-term care facility (LTCF) visit, showed the following: -Employee D performed hand hygiene prior to entering the patients room; -Employee D laid his/her computer tablet on the counter in the patient's room- no barrier present; -Employee D donned gloves to examine patient's skin; -Employee D examined patient's heels, bottom, and then patient's under eye conjunctiva without changing gloves between sites; -Employee D completed visit, picked up computer tablet, left room, and performed hand hygiene; -Employee D interacted with several staff members wile holding computer tablet prior to sitting tablet down in common area while filling out facility binder; and -Employee D exited the LTCF without cleaning computer tablet. During an interview on 12/20/2022 at 1:55 PM the administrator stated that he/she would expect the computer tablet to be disinfected prior to the employee leaving the patient's room. Findings included: Review of the Centers for Disease Control (CDC) policy titled, "Hand Hygiene Guidance," dated 01/30/2022, showed healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: - Immediately before touching a patient; - Before performing an aseptic task; - Before moving from work on a soiled body site to a clean body site on the same patient; - After touching a patient or the patient's immediate environment; - After contact with blood, body fluids, or contaminated surfaces; and - Immediately after glove use. Review of the agency's policy titled, "Hand Hygiene," dated 04/2020, showed in part: - Personnel providing care in the home setting will regularly wash their hands, per the most recently published CDC regulations and guidelines for hand hygiene in healthcare settings; - When hand are not visibly soiled, they should be washed using alcohol-based hand rub for routinely decontaminating hands. An alternative to use of an alcohol-based hand rub is to wash hands with an antimicrobial soap and water; and - Hand decontamination using an alcohol-based hand rub should be performed: Before having direct contact with patients; Before donning sterile gloves when performing sterile procedures; before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices; After contact with a patient's intact skin (when taking a pulse, blood pressure or lifting a patient); After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, if hands are not visibly contaminated; When moving from a contaminated body site to a clean body site during patient care; After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; and After removing gloves. Review of the agency's policy titled, "Bag Technique Procedure," dated 05/06/2022, showed in part: Purpose: - To prevent contamination of bag and equipment, avoid cross contamination, and establish a clean work area; and - Protect patients, family members, and healthcare workers from the spread of infection. Considerations: - Bag and equipment should always be placed on a water repellant disposable barrier such as a plastic sheet, wax paper, or chux pads; - Patient care equipment must be sanitized with alcohol swabs, disinfectant spray, Sani cloths, or Clorox mixture 1:10 after patient care; - Patients and/or care givers should be asked to use hand sanitizer before and after, or they may don gloves prior to, signing or touching the device; and - Devices should be sanitized after each use or patient/caregiver contact by wiping off with an alcohol swab containing at least 70% alcohol. RECORD/PATIENT #1: Observation on 12/20/2022 beginning at 9:00 AM, during the patient's long-term care facility (LTCF) visit, showed the following: - Employee B washed his/her hands prior to entering patient room; - Employee of LTCF reported to Employee B that resident was running a fever and had been swabbed for the flu and staff were awaiting results; - Employee B laid his/her computer tablet, stylus, and phone on the overbed table of the patient- no barrier present; - Employee B completed visit, picked up computer tablet, stylus, and phone, left room and washed hands; - Employee B carried computer tablet and phone to nurse's office and placed on table- no barrier present; - Employee B interacted with several staff members while holding computer tablet and phone and going to a common area to make a phone call to patient family member and used stylus to complete documentation; and - Employee B exited the LTCF without cleaning computer tablet, phone, or stylus. During an interview on 12/20/2022 at 9:55 AM, Employee B stated that he/she disinfects the computer tablet before entering a facility or home for the visit and when he/she gets back to the car. During an interview on 12/20/2022 at 1:55 PM the administrator stated that he/she would expect the computer tablet to be disinfected prior to the employee leaving the room. RECORD/PATIENT #3: Observation on 12/20/2022 beginning at 10:05 AM, during the patient's home visit, showed the following: - Employee C failed to perform hand hygiene prior to entering patient's home; - Employee C laid his/her computer tablet on a chest at the foot of a bed- no barrier present; - Employee C completed the visit, picked up computer tablet, and exited the home; and - Employee C failed to perform hand hygiene after leaving the home and failed to disinfect the computer tablet prior to leaving the driveway of the home. During an interview on 12/20/2022 at 1:55 PM, the administrator stated that he/she would expect the employee to perform hand hygiene per policy and to disinfect the computer tablet prior to leaving the home.

Based on record review and interview the agency failed to provide a copy of the discharge summary and the patient's clinical record to the receiving provider in one (Record/Patient #9) of six records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: RECORD/PATIENT #9: Review of the clinical record showed: - Patient was admitted to hospice services on 10/24/2022; - Diagnoses included Esophageal Cancer with Metastasis to the abdominal wall (a cancer that starts in the esophagus and spreads to the abdominal wall), Hypertension (elevated blood pressure), Rheumatoid Arthritis (a chronic inflammatory disorder that affects the joints), tobacco abuse, and placement of a percutaneous gastric tube (PEG tube) related to dysphagia (difficulty swallowing); - Patient was receiving nursing, chaplain, and social worker visits; - Patient was receiving pharmacy services and PEG tube nutrition and supplies; and - Patient caregiver signed change of designated hospice provider request on 11/10/2022. The agency failed to provide a discharge summary and a copy of the patient's clinical record to the receiving provider as of 12/21/2022. During an interview on 12/21/2022 at 10:50 AM, the patient care coordinator stated that he/she did not provide the necessary paperwork to the receiving provider because the agency was not notified of the transfer until it was completed.

Based on contract review and interview, the agency failed to ensure that inpatient contract (#1) of two contracts reviewed included that the hospice patient's inpatient clinical record includes a record of all inpatient services furnished, and events regarding care that occurred at the facility, and that a copy of the discharge summary and a copy of the inpatient clinical record is available to the hospice at the time of discharge. This deficient practice has the potential to affect all patient's served by the agency. --- Findings included: Contract #1: Review of contract #1 titled, "Hospital/Hospice Professional Service Agreement," dated 02/06/2006, showed on 12/20/2022, that the contract failed to include: -Inpatient clinical record includes all inpatient services furnished and events regarding care that occurred at the facility; and -Copy of the discharge summary and/or clinical record will be supplied to the hospice at the time of discharge. During an interview on 12/21/2022 beginning at 10:50 AM, the administrator stated that he/she would expect the wording of a contract to follow regulations.

Based on contract review and interview the agency failed to ensure that inpatient contract (#1) of two contracts reviewed included that a home-like atmosphere would be provided to patients of the agency. This deficient practice has the potential to affect all patients served by the agency. --- Review of contract #1 titled, "Hospital/Hospice Professional Service Agreement," dated 02/06/2006, showed on 12/20/2022, that the contract failed to include that a home-like atmosphere would be provided to patient's of the agency. During an interview on 12/21/2022 at 10:50 AM, the administrator stated that he/she would expect the wording of the contract to follow regulations.

Based on policy review, observation, and interview, the agency failed to ensure that staff were following policy and procedures related to Covid-19 contingency plans for unvaccinated staff. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the undated policy titled, "Covid-19 Vaccination Exemptions Policy" showed, in part, that the agency will take additional precautions to mitigate the spread of Covid-19 for unvaccinated staff, whose medical or religious exemption have been approved by the vaccine exemption committee. Some of these precautions include, but are not limited to, requiring applicable employees to undergo Covid-19 testing on a weekly basis and wearing PPE (personal protective equipment) at all times. Review of the document titled, "Medical/Religious Exemption", with the approval date of 11/29/2021, for Employee A showed that Employee A was approved for a religious exemption and the specific accommodation details listed were weekly testing and PPE per policy. Observation on 12/19/2022 at 10:00 AM, during entrance into the agency, showed that Employee A failed to wear PPE per policy. During an interview on 12/20/2022 at 12:30 PM, Employee A stated that they do weekly testing and wear PPE at all times in the patient care setting whether that be home or facility. Employee A stated that he/she sees how their policy says "at all times" and that they are not following what their policy states and they will work on updating their policy. Review of the document titled, "Medical/Religious Exemption Request Results," with the approval date of 11/17/2021, showed Employee C was approved for a Religious Exemption and the specific accommodation details listed were weekly testing and PPE per policy. RECORD/PATIENT #3: During observation on 12/20/2022 at approximately 10:35 AM, during a home visit, Employee C was observed exiting the house of the patient, getting into his/her car, exiting his/her car without a mask on, and re-entering the patient's home. During an interview on 12/20/2022 at 1:55 PM, the patient care coordinator stated that she would expect Employee C to wear a mask into the home of the patient.