Every finding on record at Life's Journey of Avon LLC

Based on record review and interview, the agency failed to document, investigate, and document resolutions for 1 of 1 known patient complaints. (Patient: #5) Findings Include: --- 1. A review of an agency policy effective date 09/13/2024, titled “Complaint/Grievance Process” indicated but was not limited to, “   …  Any difference of opinion, dispute, or controversary between a patient or family/caregiver or patient representative and Life’s Journey of Avon concerning any aspect of services or the application of policies or procedures will be considered a grievance   …   The organization staff member receiving the complaint will discuss, verbally and in writing the grievance with a supervisor within (5) days of the alleged grievance. The supervisor will investigate the grievance within five (5) days after receipt   …    Executive Director/Administrator will respond to the patient within ten (10) days of notification   …   Complaints and any action taken will be documented on a complaint form   …   ” 2. A review of an agency policy effective date 09/13/2024, titled “Patient Bill of Rights” indicated but was not limited to, “   …  The Patient Bill of Rights statement defines the right of the patient to: E. Receive an investigation by the organization of complaints made by the patient or the patient‘s family    …   the existence of the complaint and the resolution of the complaint must be documented   …   ” 3. A review of agency documents titled “Patient Grievance Tracking Log” dated 1/21/2024 through 06/16/2025. The grievance tracking logs failed to evidence Patient #5’s family complaint. 4. A review of the clinical record for Patient #5, subject of the complainant, election date 06/11/2025, terminal diagnosis of Senile Degeneration of the Brain, evidenced Patient #5 had been admitted for respite stay on 06/11/2025. Patient #5’s discharge date 06/16/2025, to home with Entity 2’s hospice company for continued care. During an interview on 07/07/2025 at 2:15 PM, when queried regarding any complaints they had regarding care, LPN 1 indicated Person 5, the family member of Patient #5, found Patient #5 soiled at mealtime and was upset. 5. During an interview on 07/08/2025 at 6:55 AM, RN 1 confirmed Person 5, the family member of Patient #5, had made them aware they found their mother soiled and cleaned them up. RN 1 further indicated Patient #5’s bed broke, they had to change out the beds, and had moved Patient #5 across the hall. RN 1 communicated Person 5 kept telling Patient #5, “It will be okay [Patient #5]," repetitively, and Patient #5 had not shown any signs of being anxious. RN 1 indicated they had made Admin 7, the unit manager, aware.  6. During an interview on 07/08/2025 at 10:31 AM, when asked regarding the grievance regarding Patient #5, the Executive Director/Administrator confirmed the family had visited the patient, and they had soiled themselves. The Administrator further communicated, they had explained the patient had received a suppository, and the family member understood.  The administrator stated, “I guess if it can’t be satisfied, it goes in as a complaint. I guess there is a fine line where you just solve it or document it.”

Based on observation, record review, and interview, the facility failed to inform contracted agency hospice providers, families, and patients, regarding the air conditioning not working at the inpatient facility and failed to follow up the HVAC process of repairs for 1 of 1 inpatient facilities. Findings include: --- 1. A review of an agency policy effective date 01/2025, titled “Physical Environment” indicated but was not limited to “ To ensure the physical environment of the Inpatient Unit (IPU) promotes patient comfort, privacy, safety, infection control, and compliance   …   All patient rooms shall be maintained in a home-like condition with appropriate lighting, temperature control   …   Maintenance issues must be reported immediately and addressed in a timely manner   …   ” 2. A review of an agency document titled “HVAC Timeline” indicated the following:  On 05/01/2025, RN 1 contacted management regarding a complaint the air conditioning was not working. Upon investigation the nurse’s station had been hot.  On 05/19/2025, repairs had been made to the air conditioning unit and on 05/23/2025 the system had been working properly. On 06/14/2025, it had been reported the air conditioning had not been functioning properly. On 06/20/2025, fans had been placed at the nurse’s station, data room, and patient’s rooms. On 06/23/2025 portable air conditioner units had been placed in the building. On 06/25/2025 additional fans, industrial fans added to the facility’s north end. 3. During the entrance conference on 07/07/2025 at 8:30 AM, the Administrator confirmed they had air conditioning issues, fans were provided, and portable air conditioner units were placed in the hallways and patient rooms. The Administrator indicated Admin 7, the inpatient unit manager, had made all contracted agencies, families, and patients aware prior to their admission regarding the air conditioner concerns.4. During an interview on 07/07/2025 at 2:00 PM, CNA 1 communicated they had some complaints from families that weren’t there now regarding the air conditioning system not working. CNA 1 further indicated they check the patient every 2 hours for changing and repositioning. CNA 1 indicated meals come out on trays and they feed the patients that were unable to feed themselves.5. During an interview on 07/07/2025 at 3:19 PM, Person 3, the Administrator for Entity 2, Patient #5’s hospice agency, indicated they had not been informed regarding the air conditioning not working at Life’s Journey of Avon LLC, prior to sending Patient #5’s referral for respite care. Person 3 further communicated they were unaware until after the family had complained upon Patient #5’s return home.6. During an interview on 07/08/2025 at 1:33 PM, Person 7, a supervisor for Entity 6, a hospice agency, confirmed the hospice agency had not been made aware of air conditioning issues with their contracted incenter agency, Life’s Journey of Avon LLC.

Upon patient record review, 1 of 22 (Patient #13) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities.

Upon patient record review, 1 of 22 (Patient #13) did not have evidence that the patient chooses a health care provider, including an attending physician.

Upon patient record review, 1 of 22 (Patient #13) did not have evidence of the appropriate documentation for release of confidential information.

Upon patient record review, 1 of 22 (Patient #13) did not have evidence that the patient received information about the services covered under the hospice benefit.

Upon patient record review, 1 of 22 (Patient #13) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services.

Upon patient record review, 9 of 22 (Patient #2, 3, 4, 5, 6, 10, 13, 20, 21) 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 • Drug therapy currently associated with laboratory monitoring Patient 2, 4, 20 Mirlax did not include instructions for how to mix/diluent. Patient 3 nursing visit on 4/19/24 documented oxygen in use, along with nursing visit on 8/30/24. No evidence of oxygen on the medication profile. Patient 4 Tylenol 1000mg BID prn pain and Tylenol/Hydrocodone 325/5mg 2 every 4h prn moderate pain, no evidence of a max dosage allowance which could exceed 4000mg. Nursing documentation on 7/26/24 documented to increase hydrocodone to 10mg, no evidence of an increase to the dose on the medication profile. Patient 5 nursing visit 9/24/24 documents Ibuprofen for headaches and arthritic pain, no evidence of Ibuprofen on the medication profile. Patient 6 nursing visits 9/3/24 and 9/4/24 document oxygen in use, no evidence of oxygen on the medication profile. Patient 10 nursing visits 9/13/24 and 9/24/24 document oxygen in use, no evidence of oxygen on the medication profile. Patient 13 no evidence of medications on the medication profile from admit on 7/1/24 until 7/31/24, no medication profile for Miralax, Albuterol, Lorazepam, Guaifenesin, Levothyroxine, Senna, Ventolin, KCL, Ondansetron, Paroxetine until 7/31/24. Patient 20 nursing visit on 8/21/24 documented oxygen 2LPM in use, no evidence of oxygen on the medication profile. Patient 21 care plan include a NPO order, Morphine, Lorazepam, and Diphedryl are on the medication profile as orally. Nursing visit on 7/17/24 documents oxygen initiated at 2LPM, no evidence of oxygen on the medication profile.

Upon patient record review, 3 of 22 (Patient #9, 12, 19) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care.

Upon patient record review, 1 of 22 (Patient #4) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 4 Nursing comprehensive assessments completed on 7/26/24, 8/20/24 and then again on 9/6/24.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 7 of 22 (Patient #3, 4, 9, 11, 20, 21, 22) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 3 initial nursing visit documents oxygen in use, no care plan to address respiratory and oxygen safety. Patient 4 on Aspirin, antibiotics, and Lorazepam, no evidence of care plans to address bleeding precautions, respiratory infections, or anxiety. Patient 9 on Aspirin, no evidence of bleeding precautions. Patient 11 spiritual care is seeing the patient, no evidence of a care plan to address spiritual concerns. Patient 20 nursing visit 8/21/24 documented edema bilateral feet, lasix and KCL to manage edema, no evidence of a care plan to address edema. Patient 21 initial nursing visit documents oxygen in use, no evidence of a care plan for respiratory or oxygen. Patient 22 has a foley, admitted for CVA, and has hemiplegia, no evidence of a care plan to address these identified problems.

Upon patient record review, 2 of 22 (Patient #9, 20) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 9 7/23/24 SW ordered as 1 prn, no routine frequency. Patient 20 order on 8/28/24 for volunteer 1w3 this order discontinued on 8/28/24 and new order entered 8/28/24 as may have volunteer, no evidence of a frequency.

Upon patient record review, 9 of 22 (Patient #2, 3, 4, 5, 6, 10, 13, 20, 21) 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 2, 4, 20 Miralax did not include instructions for how to mix/diluent. Patient 3 nursing visit on 4/19/24 documented oxygen in use, along with nursing visit on 8/30/24. No evidence of an order for oxygen. Patient 4 Tylenol 1000mg BID prn pain and Tylenol/Hydrocodone 325/5mg 2 every 4h prn moderate pain, no evidence of a max dosage allowance which could exceed 4000mg. Nursing documentation on 7/26/24 documented to increase hydrocodone to 10mg, no order to increase the dose. Patient 5 nursing visit 9/24/24 documents Ibuprofen for headaches and arthritic pain, no evidence of an order for Ibuprofen. Patient 6 nursing visits 9/3/24 and 9/4/24 document oxygen in use, no evidence of an order for oxygen. Patient 10 nursing visits 9/13/24 and 9/24/24 document oxygen in use, no evidence of an order for oxygen. Patient 13 no evidence of orders for medication from admit on 7/1/24 until 7/31/24, no orders for Miralax, Albuterol, Lorazepam, Guaifenesin, Levothyroxine, Senna, Ventolin, KCL, Ondansetron, Paroxetine. Patient 20 nursing visit on 8/21/24 documented oxygen 2LPM in use, no evidence of an order for oxygen. Patient 21 care plan include a NPO order, Morphine, Lorazepam, and Diphedryl are ordered orally. Order that states may administer 240ml H2O bolus for headaches, can be administered in 60ml bolus 4x/day, does not include a frequency or route. Nursing visit on 7/17/24 documents oxygen initiated at 2LPM, no evidence of an order for oxygen. Initial care plan ordered 12fr foley with 5ml balloon. Nursing visit on 9/22/24 @2100 documents 14fr foley in place. Nursing visit on 9/22/24 @0730 and 9/21/24 @ 0100 document patient is voiding without a foley. No evidence of an order to remove foley and no evidence of an order for a 14fr foley.

Upon patient record review, 1 of 22 (Patient #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 equipment and supply needs. Patient 11 initial nursing visit documents the use of a walker, no evidence of an order for the walker.

Upon patient record review, 3 of 22 (Patient #3, 4, 9) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 3 lasix and KCL ordered for edema, immodium ordered for diarrhea, and oxygen in use. No evidence of a care plan for these identified problems. Patient 4 social work has an active care plan and has not had orders to see the patient. Patient 9 social work has an active care plan and social work is not visiting the patient. Spiritual care is seeing the patient and does not have a care plan to include any problems or goals for spiritual care.

Upon patient record review, 11 of 22 (Patient #5, 8, 9, 10, 11, 12, 13, 14, 20, 21, 22) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5 order to report oxygen saturation below 90 to MD. Nursing visits on 9/6/24, 9/10/24, 9/13/24, 9/17/24, 9/20/24 and 9/24/24 document oxygen saturation below 90% and there is no evidence the MD was notified. Patient 8 volunteer ordered to visit weekly, no evidence of visits documented after 8/31/24. Patient had a respite stay at the IPU 8/28/24-9/2/24, nursing ordered 2x week, yet provided 24h/d during the respite stay. Patient 9 volunteer ordered weekly, no evidence of visits documented after 8/7/24. Chaplain ordered to evaluate and then effective 10/1/24 3m1m. Chaplain visits completed on 8/10/24, 8/15/24, 8/26/24, 9/5/24, 9/19/24 without an order. Patient 10 social work order 9/13/24 to complete an evaluation, no evidence the evaluation visit was completed. Patient 11 nursing frequency ordered 2x week. Respite/routine stay at the IPU 9/11/24-9/22/24 and nursing care provided 24h/d. Patient 12 volunteer ordered 1x week, no evidence of volunteer visits. Patient 13 social work ordered effective 8/1/24 2m2m. Social work visit completed on 7/31/24, no evidence of an order for this visit. Nursing visits completed from 7/1/24-7/31/24 without an order for these visits. Nursing frequency ordered 8/4/24 as 2x week, respite stay at the IPU 8/30/24-9/4/24 and nursing care provided 24h/d. Patient 14 social work and chaplain ordered to complete an evaluation of the patient, no frequency orders after the evaluation. Social work visit completed on 9/20/24 and Chaplain visit completed on 9/18/24, no evidence of an order for these visits. Patient 20 admitted routine level of care in the IPU, nursing frequency is ordered as 2 visits per week, nursing care is being provided 24h/d. Social work and Chaplain frequency ordered as evaluation. Social visits completed on 8/28/24 and 9/9/24 without an order. Chaplain visit completed on 9/9/24 and no order for this visit. Patient 21 Chaplain frequency ordered effective 7/17/24 as 1m3m, Chaplain visits completed on 7/19/24 and 7/31/24. Nursing frequency ordered as 2x week, patient is routine level of care in the IPU and receiving 24h/d nursing care. Patient 22 Nursing frequency ordered as 2x week, patient is routine level of care in the IPU and receiving 24h/d nursing care. Nursing visit 9/22/24 documented unable to flush foley and it was removed, no order to remove foley.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 12 of 22 (Patient #1, 2, 3, 7, 8 ,9 ,10, 11, 13, 20, 21, 22) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 1 aide care plan did not include aspiration or fall precautions as identified on the care plan. Patient 2 aide care plan did not include seizure precautions and the patient is on seizure medication. Patient requires complete care, bathing the patient is on the aide care plan however dressing the patient is not on the aide care plan. Nursing note on 9/9/24 documents patient requires 2 person transfers, the aide care plan include one person transfer assist. Patient 3 aide care plan does not include oxygen precautions. Aide care plan states bath and does not specify the type of bath. Patient requires complete care, bathing the patient is on the aide care plan however dressing the patient is not on the aide care plan. Patient 7 aide care plan does not include aspiration precautions. Patient 8 aide care plan does not include aspiration precautions. Patient 9 aide care plan did not include aspiration or bleeding precautions. Patient 10 aide care plan did not include aspiration precautions. Patient 11 aide care plan did not include aspiration precautions. Aide care plan include ambulate with cane, walker, and crutches. Patient 13 aide care plan did not include aspiration precautions. Patient 20 aide care plan includes bathing but does not specify the type of bath to be provided. Patient 21 aide care plan does not include aspiration precautions. Aide care plan includes assist with meal prep set up and prn feeding, also includes report to RN if no BM, however no frequency identified. Patient 22 aide care plan does not include aspiration precautions.

Upon patient record review 10 of 22 (Patient #1, 2, 3, 8, 11, 13, 14, 20, 21, 22) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 1 aide visit on 9/4/24 documented not applicable for the following tasks that were to be completed every visit linen, make bed, foot care, nail and shave. Aide visit 9/9/24 and 9/16/24 documented not needed for nail care that was to be performed every visit. Aide visit 9/12/24 documented not needed for nail care and shave that were to be performed every visit. Patient 2 during the aide visit with the surveyor the aide performed shaving, oral/brushing teeth, and dressing the patient that were not on the aide care plan. Patient 3 aide visits on 8/29/24, 9/6/24, 9/10/24, 9/13/24, 9/17/24, and 9/20/24 documented nail care not applicable, the aide care plan included nail care every visit. Patient 8 aide visit frequency on 8/13/24 is 1w8, patient is respite at the IPU 8/28/24-9/2/24 and the frequency does not include the 24h/7d week aide care. Patient 11 aide visit frequency on 8/26/24 is 2x week, patient is respite/routine at the IPU 9/11/24-9/22/24 and the frequency does not include the 24h/7d week aide care. Patient 13 aide visit frequency on 8/4/24 is 2x week, patient is respite at the IPU 8/30/24-9/4/24 and the frequency does not include the 24h/7d week aide care. Patient 14 aide visit frequency on 8/26/24 is 2w13, patient is respite at the IPU 9/17/24-9/22/24 and the frequency does not include the 24h/7d week aide care. Patient 20 aide visit frequency on 8/25/24 is 2w11 patient admitted to IPU with 24h/7d week aide care provided. Patient 21 aide visit frequency on 9/1/24 is 2w6, patient is admitted to IPU with 24h/7d week aide care provided. Patient 22 aide visit frequency on 9/14/24 is 2w13, patient is admitted to IPU with 24h/7d week aide care provided.

Upon patient record review 7 of 22 (Patient #1, 3, 7, 11, 12, 14, 21) did not have evidence documentation in the patient record that a Registered Nurse made 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 and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 1 no evidence of aide supervision after 9/4/24. Patient 3 no evidence of aide supervision after 8/30/24. Patient 7 no evidence of aide supervision from 8/15/24-9/5/24. Patient 11 admitted on 8/26/24, no evidence of aide supervision since admission and aide visits began the week of 8/26/24. Patient 12 no evidence of aide supervision after 8/23/24. Patient 14 no evidence of aide supervision after 9/5/24. Patient 21 aide visits started on 9/4/24, no evidence of aide supervision documented.

Upon patient record review, 7 of 22 (Patient #1, 2, 4, 9, 20, 21, 22) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient 1, 2, 4, 9, 20, 21, 22 no evidence of a verbal certification within 2 days of admission documented in the EMR.

Upon patient record review, 2 of 22 (Patient #10, 13) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 10 election of benefit did not include the effective date, it was blank. Patient 13 no evidence of consents or election of benefit for the 7/1/24 (current) admission.

Upon patient record review, 1 of 22 (Patient #9) did not have evidence that each patient record contains responses to medications, symptom management, treatments, and services. Patient 9 nursing visits on 9/5/24, 9/9/24, 9/11/24, 9/15/24, 9/19/24 document wound care provided per orders, no documentation of how the patient tolerated the wound care.

Upon patient record review, 1 of 22 (Patient #3) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 3 no evidence of a certification of terminal illness from the attending physician CJ.

Upon patient record review, 1 of 22 (Patient #9) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 9 nursing visits on 9/5/24, 9/9/24, 9/11/24, 9/15/24, 9/19/24 document wound care provided per orders, no detail of the wound care provided.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. Patient 13 No evidence that this was provided.

Upon patient record review, 1 of 22 (Patient #13) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed.

Upon patient record review, 1 of 22 (Patient #7) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 7 Chaplain ordered for evaluation, then effective 9/20/24 1w4w. Chaplain visits completed on 8/19/24 and 9/3/24; no evidence of an order. Social work ordered for evaluation, 7/24/24 the visit was missed, no documentation to explain why the visit was not completed.

Upon personnel record review, 1 of 14 (Personnel #14) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions.

Upon personnel record review, 1 of 14 (Personnel #13) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions.

Upon personnel record review, 1 of 14 (Personnel #12) did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state's Physical Therapy Practice Act and the hospice's policies and procedures and/or job descriptions.

Upon personnel record review, 3 of 14 (Personnel #12, 13, 14) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records.

Upon observation, there is no evidence the smoke compartmentation and control of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. New Construction: Penetrations shall be properly firestopped. It was observed that openings in the ceiling of the data room, the riser/boiler room and in the kitchen surrounding the commercial dishwasher were not properly sealed to prevent the passage of fire and smoke. Corrected on site. In addition, hazardous areas shall be separated from other parts of the building by having a minimum 1 hr fire resistance with communicating openings protected by approved self closing fire doors, or such areas shall be equipped with automatic fire extinguishing systems. Fire-rated doors must be able to self-close and corridor doors (fire-rated or non-rated) shall not be held open by any device other than those that release when the door is pushed or pulled. Upon observation it was noted that doors to the laundry room door was being held open using a towel wrapped around a handle and secured to the wall, it was further noted that the door did not have self closing latch. It was noted that a supply room with multiple chemical products does not self-close and latch and it was observed that two separate kitchen doors leading into the corridor were obstructed by tape to prevent the door from latching securely. All doors and latching mechanisms corrected on site. In addition, upon observation, there was no evidence cooking equipment meets the NFPA 96 standards for ventilation control and fire protection. The kitchen exhaust hood penetrates the ceiling and is not properly sealed.

Upon observation, there was no evidence the hospice inpatient facility provides a sanitary environment. The ice maker in the kitchen and the ice maker in the north wing in the dietary area both had mold in the ice compartment.

Based on record review and interview the agency failed to ensure nursing staff documented medication/treatment administration and responses to medications timely or accurately, in 1 of 5 closed clinical records reviewed. (Licensed Practical Nurse (LPN) 1) Findings include: --- 1.Review of an agency policy dated 03-16-2023, titled 'ADMINISTRATION OF MEDICATIONS POLICY 4-052' failed to evidence a requirement for documentation of medications administered or responses to medications and treatments. 2.Review of the clinical record for Patient #1 with a Benefit Election date of 7-09-2024, and diagnoses which included but were not limited to: COPD (lung disease that limits airflow and causes breathing problems) and Non-small Cell Lung Carcinoma (type of lung cancer), contained a Respite stay nursing note, titled 'Shift Running Document' dated 07-15-2024, 15:10 (3:10 PM) to 15:20 (3:20 PM), which stated, "... Patient did request a prn (as needed) nebulizer treatment earlier ..." and the entry failed to evidence when the medication had been given and whether the medication had produced it's intended effect. Further review of the record evidenced a MAR (Medication Administration Record) Report which indicated a nebulizer treatment (a procedure that involves using a small machine to turn liquid medicine into a mist that a person can inhale into their lungs) had been administered, "... Albuterol 2.5mg/3ml (0.083%) inhalation solution ... Inhale 3 milliliter(s) by nebulizer 3 times a day as needed ... 7/15/24 16:32 [4:32 PM] ... [LPN 1] ... patient requested a nebulizer treatment, no signs of SOB [shortness of breath] or distress noted ... Reassessment time 17:00 [5:00 PM] ... Reassessment Clinician ... [LPN 1] ... no further complaints at this time ..." The nurse failed to document the administration of medication in timely manner. 3.On 08-28-2024 at 1:50 PM, queried as to when Patient #1's nebulizer treatment had been given on 07-15-2024, as the nursing note only indicated 'requested a treatment earlier', Licensed Practical Nurse (LPN) 1 indicated they recalled the patient had been given the treatment just after morning medications (the record indicated between 8:45 and 9:00 AM), and remembered this specifically, because the tubing had not yet been set up and LPN 1 remembered having to do this first. When queried as to the discrepancy between what had been documented in the Shift Running Document versus the MAR Report, LPN 1 indicated they must have put time in wrong but reiterated knew it happened after 9:00 AM. Indicated 'should have documented right after I gave it'. 4.On 08-28-2024 at 2:55 PM, the Administrator indicated she would have asked for addendum to correct the discrepancy. 5.On 08-28-2024 at 3:48 PM, after researching further, the Administrator indicated there was not a policy which addressed timely/accurate documentation of medication administration

Based on record review and interview the agency failed to include the patient or patient caregiver in changes and interventions to the plan of care in 1 of 5 records reviewed. (Patient #2) Findings include: --- 1. A review of a policy received from the Administrator titled "Patient Rights and Responsibilities" indicated but was not limited to " The patient has the right to be fully informed of the care/services provided . . . as well as any modifications to the plan of care." 2. A review of Patient #2s clinical record evidenced an election of benefit of 11-30-2023 and a benefit period of 01/17/2024 to 04/15/2024 indicating a primary diagnosis of Neoplasm of Uncertain Behavior (a growth of cells without a known cause or potential to spread) with secondary diagnoses including but not limited to unspecified dementia, unspecified severity without psychotic behavioral disturbances, mood disturbances, and anxiety. A plan of care dated 01/17/2024 contained orders for skilled nursing 2 times a week for 12 weeks The Hospices plan of care for patient #2 included skilled nursing 2 times a week for 12 weeks, a home health aide (HHA) 2 times a week for 12 weeks and an entry indicating HHA services would be discontinued on 03/29/2024 signed by the Administrator on 03/29/2024. A document titled ";Skilled Nursing Visit Note" dated 04/02/2024 at 10:45 AM signed by Licensed Practical Nurse #1, evidenced a narrative note stating "; . . . [caregiver] wanting to know if patient will continue on hospice services. Office to follow-up next week . . . . " A document titled ";Interdisciplinary Referral Communication" dated 04/02/2024 at 1:30 PM, signed by the Family Care Coordinator noted Patient #2 was "; . . . no longer appropriate for hospice care and instead would be discharged from our care as a result of the inability to ensure the proper health and safety of those workers charged with caring for [gender of Patient #2]. Hospice staff is currently working with this patient and [caregiver] . . . ." A document titled ";Interdisciplinary Group Meeting dated 04/09/2024 at 9:30 AM contained an entry including "; . . . [Caregiver] under the impression [gender of Patient #2] was being discharged completely, which was not accurate. Will continue with POC." A document titled ";Interdisciplinary Referral Communication" dated 4/09/2024 at 1:41 PM signed by the Family Care Coordinator, stated, ";Patient allegedly struck our CNA [certified nursing assistant] on multiple occasions during the previous CNA visit. This represents the second time this has happened . . . we did not verify that we had already made attempts to modify the undesirable behavior . . . as such the patient is staying on our services . . . . "; During an interview on 04/15/2024, with Patient #2s Caregiver, they reported Patient #2 was in respite care in February (patient is cared for in a facility for up to 5 days while the caregiver is given a rest from care). During this respite stay the Caregiver reported they received a report Patient #2 was combative and had hit an Aide and the Caregiver was not clear as to what had happened. They also reported being aware of combativeness occurring in the home recently with the Aide. The caregiver explained they were informed Patient #2 was going to be discharged from Hospice effective 04/02/2024 and the hospice never reached out to address the issue, never assisted with solutions or ";ways to deal with it," and had no discussion of alternative assistance. They stated, "; I feel they are not discussing what is going on . . . . " The Caregiver reported they were informed of the issue and informed of a discharge from hospice 6 days before the effective discharge date. When queried if the agency had reached out to them, they reported a Social Worker called and when they returned the call, there was no answer. A nurse called to schedule a visit last week (Referring to the week of April 7th, 2024)They further explained no one discussed alternative assistance or a change in the plan of care. They reported talking to the Family Care Coordinator on or around 04/05/2024 and asked him to have his "boss" call them. During an interview on 04/16/2024 at 7:45 AM, the Administrator reported ";We failed with communication with the [family member] who is the primary caregiver for Patient #2." She reported they needed to review this and have already taken steps with the Interdisciplinary Group (Registered Nurse, Medical Director, and Social Worker) to resolve this. The agency failed to include and update the Patient Caregiver to changes in the Plan of Care, interventions for behaviors, and provide information on services to be provided.

Based on observation, record review, and interview, the agency failed to ensure staff followed standard precaution practices, including hand hygiene, gloving, and bag technique according to the agency policy in 2 of 2 home visits with Certified Nursing Assistant (CNA). (Employees: CNA 1 and 2) Findings Include: --- 1. An agency policy dated 12-13-2023 and titled ";Hand Hygiene Policy and Compliance Program" Policy No. 7-004, indicated but was not limited to, "; ... To prevent transfer of germs and transmission of infections to patients and caregivers ... Procedure: 1. Indications for hand hygiene are: before and after direct patient care, before and after each procedure ... when hands are soiled, after any contact with contaminated materials, before re-entering nursing bag or patients clean supplies ..." 2. During a home visit at Patient #3s residence, Entity 3, an Assisted Living Facilitys Memory Care Unit, on 04-16-2024 at 9:47 AM, observed CNA 1 assist the patient with a shower and provide hair care. CNA 1 failed to perform hand hygiene upon entering Patient #3s residence and touching the patient. CNA 1 selected the patients clothing, donned gloves to transfer the patient to their wheelchair, and assisted the patient with their shower. CNA 1 failed to perform hand hygiene before donning gloves to assist the patient with their shower. CNA 1 was observed using the same gloves to wash, dry, apply lotion, and wipe the patients buttocks after the patient urinated. CNA 1 failed to perform hand hygiene after cleaning the patients bottom. The patient had a bowel movement during the transfer from the shower chair to their wheelchair, CNA 1 wiped the patients buttocks and doffed their gloves. CNA 1 failed to perform hand hygiene after doffing their gloves. CNA 1 combed the patients hair and donned new gloves. CNA 1 failed to perform hand hygiene before donning new gloves. CNA 1 was observed picking up all the washcloths used on the patient for their shower, bowel movement, and elimination. CNA 1 failed to perform hand hygiene after doffing the used gloves. During an interview with CNA 1 on 04-16-2024 at 10:50 AM, they indicated hand hygiene should be performed when entering the patients room, before and after changing gloves, and before doing different tasks. CNA1 indicated they should remove their gloves after cleaning up after a patients bowel movement and perform hand hygiene. They indicated they received in-person and web-based training for infection control. 3. During a home visit at Patient #4s residence on 04-16-2024 at 1:23 PM, observed CNA 2 perform a bed bath for Patient #4 and provide nail care. CNA 2 failed to perform hand hygiene upon entering the patients residence. CNA 2 removed the gloves they used to give the patient a bed bath and failed to perform hand hygiene before touching the patient. CNA 2 donned new gloves and put barrier cream under the patients breasts. CNA 2 failed to perform hand hygiene prior to donning new gloves. CNA 2 removed their new gloves after applying barrier cream under the patients breasts and failed to perform hand hygiene after doffing gloves. CNA 2 proceeded to assist the patient with oral care without performing hand hygiene and wearing gloves. It was evidenced the patient had saliva accumulated on their chin and CNA 2 was observed wiping the saliva off with a paper towel. After assisting the patient with oral care, CNA 2 failed to perform hand hygiene prior to reaching into their clean bag to collect clean nail clippers. After CNA 2 retrieved the nail clippers from their clean bag, they failed to perform hand hygiene prior to donning gloves to provide nail care. CNA 2 removed their gloves after nail care and failed to perform hand hygiene prior to touching their clean tablet. Exited Patient #4s residence, CNA 2 failed to perform hand hygiene. During an interview with CNA 2 on 04-16-2024 at 2:30 PM, they indicated they should have performed hand hygiene when they entered and exited the patients residence, performed different tasks, and before and after gloving. They indicated they were supposed to change gloves when going from the patients main body to the perineum area, when they finished a task, when a patient was clean and they applied lotion. CNA 2 confirmed they should always wear gloves when providing patient care. They indicated they were trained on infection control and when to perform hand hygiene through their web-based training modules. 4. Employee records evidenced CNA 1 and 2 received training in infection control during initial and annual training.

Based on observation, record review, and interview, the agency failed to ensure that all staff were compliant with standard precaution practices including bag technique according to the agency policy in 1 of 2 home visits. (Patient: #4) (Employee: Registered Nurse (RN), RN 1) Findings Include: --- 1. On 09-01-2023 at 2:39 PM, a dated 02-11-2022, Lifes Journey Hospice policy titled, ";Bag Technique" was provided by the executive Director, Admin 1. The policy indicated but was not limited to, ";As part of the infection/exposure control plan. Lifes Journey of Avon personnel will consistently implement principles to maximize efficient use of the patients care supply bag ... The bag will be placed on a clean surface ... If paper towels/newspapers have been used as protective barrier for bag placement in the patients home, they will be discarded ... " 2. During a home visit at Patient #4s residence on 09-01-2023 at 9:40 AM, observed RN 1, complete their assessment. The RN entered the residence and placed their supply bag on the kitchen floor. RN 1 failed to place their bag on a clean barrier. 3. During a home visit at Patient #5s residence, Entity 5, an Assisted Living Facilitys Memory Care Unit, on 09-01-2023 at 11:41, observed the Licensed Practical Nurse (LPN), LPN 2 complete their assessment. LPN 2, placed their supply bag on a clean barrier. When queried regarding the policy regarding bag technique, LPN 1 confirmed the staff are to place their bags on a clean barrier.

Upon patient record review, 2 of 12 applicable (Patient #5 and #6) did not have evidence in the patient record that hospice aide assignments and duties are: • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #5: Aide care plan included nail care weekly and nail care each visit. Patient #6: Aide care plan included transfer patient from bed to chair as tolerated mainly bedbound.

Upon patient record review 3 of 12 applicable (Patient #4, #8, and #9) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #4: Aide care plan included nail care weekly. Aide visits on 9/13/21, 9/15/21, 9/29/21, and 10/1/21 documented nail care completed. Patient #8:Aide care plan included shampoo and shave weekly. Aide visits on 9/2/21, 9/7/21, 9/13/21, 9/16/21, 9/20/21, and 9/23/21 documented shampoo and shave completed. Aide visits on 9/27/21 and 9/30/21 documented shampoo completed. Patient #9: Aide care plan included report bowel movement to RNCM each visit, change linen on first visit of the week, and incontinent supplies on the second visit of the week. Aide visits on 9/7/21 and 9/15/21 contained no evidence that report bowel movement was completed. Aide visits on 9/7/21, 9/10/21, 9/15/21, 9/17/21, 9/21/21, 9/24/21, 9/28/21, and 10/1/21 documented linen change and incontinent supplies completed.

Upon observation, there was no evidence the automatic sprinkler system or the storage of medical gases in a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The agency records indicted an annual sprinkler inspection on May 28, 2021. There is no evidence of quarterly testing/inspection of the sprinkler system. In the equipment room on the south hall one sprinkler head was missing the escutcheon plate and one sprinkler head escutcheon plate was partially hanging from the ceiling, corrected on site. Oxygen storage room contained several oxygen cylinders that were not properly secured or labeled full or empty. Corrected on site.

Upon observation, there was no evidence the inpatient facility has adequate supply of hot water at all times and include plumbing fixtures with control valves that automatically regulate the temperature of hot water used by patients. Patient room water temperatures documented on 8/26/21 for room 201 as 124F, room 203 as 122F, room 204 as 120F, room 206 as 125F, and room 208 as 125F. Patient room water temperatures documented on 9/2/21 for room 207 as 121F and room 209 as 120F. CMS recommended water temperatures at the plumbing fixtures should be maintained at or below 110F. Water heater temperature adjusted while on site.

Upon patient record review, 2 of 5 applicable (Patient #6 and #8) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #6: Order on 3/26/21, 5/20/21, 8/23/21 and 8/23/21 for chaplain frequency of 1x/month. Chaplain visit made on 3/29/21 and no evidence of any further visits by chaplain. IDG documented declined chaplain services. Patient #8: Order on 4/30/21, 5/10/21, 5/20/21, 7/28/21, 8/23/21, and 8/27/21 for chaplain visit frequency of 1x/month. No evidence of chaplain visits. IDG documented declined chaplain services.