Every finding on record at Lutheran Home Care Agency, Inc

Based on record review and interview, the agency failed to ensure the emergency plan was tested annually; and failed to ensure participation in a full-scale or facility based functional exercise every 2 years, resulting in the potential for an unprepared agency response in the event of an actual emergency. Findings include: --- **Policy titled ";Emergency Preparedness Plan, Policies and Procedures" (revised 10/2024) stated under ";Drills and Exercises" on page 23 that, ";1. The Agency will: A. Review the emergency plan no less than annually (paper review); B. Conduct evaluation drills or exercises; and C. Update the plan based on results of those evaluations." The policy also stated, ";2. Agency staff members will participate in a minimum of one drill or exercise annually to determine the effectiveness and efficiency of the current policy and any forms developed for use in a disaster." The agencys Emergency Preparedness (EP) binder was reviewed on 2/27/25. During review of the binder, it was determined the drill for 2023 contained documentation regarding a table top drill for a heatwave. Upon further review of the documentation, it was determined the documentation contained general information on how to perform the drill and 3 exercise modules with follow-up discussion questions. However, the drill documentation lacked information regarding who participated in the drill as well as proof of any post-exercise discussion or detailed after action report. There was a short form labeled "Appendix C: AAR (after action report) Documentation" located in the binder, however, this form specifically stated it was not the final AAR document, and that facility-specific information would be entered on a different form. Upon review of the documentation for the drill in 2024, it was determined a table top drill for a winter storm/blizzard was performed. The documentation in the binder contained general information on how to perform the drill and 3 exercise modules with follow-up discussion questions. However, the drill documentation lacked information regarding what occurred during the drill as well as proof of any post-exercise discussion or detailed after action report. There was a short form labeled "Appendix C: AAR (after action report) Documentation" located in the binder, however, this form specifically stated it was not the final AAR document, and that facility-specific information would be entered on a different form. Additionally, it was determined the last full-scale or facility-based functional EP exercise was performed in 2022. During an interview with the Administrator (Adm #1) on 2/27/25 at 1:00 PM, Adm #1 confirmed the drills in 2023 and 2024 were both table top drills. Adm #1 confirmed, there was no full-scale or facility based functional exercise performed in 2024. Adm #1 was also asked for records of who attended, what occurred during the drills, discussion that took place following the scenarios, and an after-action report. Adm #1 stated she did not have that information for the above drills and acknowledged the findings.

Based on observation, record review and interview, the hospice failed to include pain interventions on the plan of care for 1 of 12 patients (P-7) receiving home health aide services from a total of 14 sampled patients, resulting in patient pain and discomfort during bathing. Findings include: --- P-7: The Start of Care (SOC) was dated 1/22/25. The Plan of Care (POC) for the certification period 1/22/25 through 4/21/25, identified diagnoses of cerebral atherosclerosis, dementia, hypertensive heart disease, and heart failure. During record review on 2/25/25, it was discovered that the plan of care (POC) documented the patient had a fractured femur at the hip with surgical intervention. The POC also documented pain control assessment at each visit. During a joint surveyor/home health aide (HHa) visit on 2/26/25, two surveyors observed the HHa performing a bed bath and dressing on P-7. The HHa asked the patient about her pain level prior to the bed bath and the patient stated she had a small amount of pain but not enough to need pain but declined pain medication. The patient did not appear to be in any pain, however, during the bath the patient moaned and verbally expressed pain including facial grimacing. The patient was in obvious distress. There was no evidence in the record that the patient had premedication orders for bathing and dressing or that the patient was premedicated prior to the bath with the patient having a fractured femur. There was surveyor observed ineffective pain management. After the bath HHa was questioned about premedication and the HHa said it is something she will discuss with the facility staff. During an interview on 2/28/25, at 10:20 a.m., the Clinical Manager (CM-1) acknowledged the above findings and said, "The patient had as needed pain medicine ordered, and they will communicate with the facility staff regarding premedicating for the patient's bath."

Based on record review and interview, it was determined the hospice failed to ensure the plan of care (POC) included patient specific measurable goals in 2 (P-6, P-8) of 14 records reviewed, which resulted in the potential for failure to meet the patient's needs, and unmet patient goals. Findings include: --- P-6: The Start of Care (SOC) was dated 4/13/24. The Plan of Care (POC) for the certification period 4/13/24 through 6/11/24, identified diagnoses of hypertension and angina. Upon review of the POC, it was noted that the goals on the POC were not objectively measurable. For example, one goal stated, "Energy conservation techniques utilized, increased activity and endurance; patient will have satisfaction with socialization." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-8: The Start of Care (SOC) was dated 2/8/25. The Plan of Care (POC) for the certification period 2/8/25 through 4/8/25, identified diagnoses of hemiplegia & hemiparesis, dysphagia, and heart disease. Upon review of the POC, it was noted that the goals on the POC were not objectively measurable. For example, one goal stated, "Aspiration prevented, increased safety in swallowing, patient/family aware of aspiration risk; patient displays effective coping with feelings of depression." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. During an interview on 2/28/25 at 10:20 a.m., the Clinical Manager (CM-1) acknowledged the above findings.

Based on record review and interview, it was determined the Hospice failed to ensure the plan of care (POC) included ordered interventions to meet patient needs in 1 (P-10) 4 records with oxygen ordered out of a total sample of 14 records reviewed, resulting in the increased potential for dyspnea (difficulty in breathing) and subsequent feelings of an unpeaceful death. Findings include: --- P-10: The SOC date to Hospice was 1/21/25 with diagnoses which included chronic systolic (congestive) heart failure, chronic kidney disease, and history of falls. On 2/26/25, record review noted under "Admission Orders" on 1/21/25 that O2 (oxygen) was to be administered at 2-4 LPM (liters-per-minute) via nasal cannula as needed for shortness of breath/dyspnea. However, review of P-10's POC noted the oxygen order above failed to be included under the problem of "Shortness of breath". No oxygen administration was found in any of the ordered interventions within the entire POC. The findings above were reviewed and acknowledged by the Clinical Manager (CM-1) and Administrator (Adm-1) during an interview on 2/28/25 at 9:18 AM. Both CM-1 and Adm-1 noted this did not meet agency expectations or its policy referenced below. Agency Policy: "Plan of Care" (revised 1/2023) under Section 0080 stated, "Nursing services ensures the nursing needs of the patient are met as identified in the patient's comprehensive assessment and updated assessments." Section 0440 stated, "As each patient is discussed, each team member provides appropriate input for updating the plan of care."

Based on record review and interview, the hospice failed to provide infection control education to 2 (Vol-1, Vol-2) of 2 pet therapy volunteers, resulting in a lack of infection control education for these two volunteers. Findings include: --- On 2/26/25, the personnel files for the following pet therapy volunteers were reviewed. Vol-1: Pet therapy volunteer started at hospice on 10/1/24. The personnel file failed to contain documentation of infection control education in 2024 or 2025. Vol-2: Pet therapy volunteer started at hospice on 10/1/24. The personnel file failed to contain documentation of infection control education in 2024 or 2025. The hospice policy titled, Volunteer Handbook (no date) states, volunteers will receive training appropriate to the task assigned. Training will include orientation and basic hospice training as a minimum. The policy failed to indicate volunteers would receive infection control education. The findings were reviewed with the Volunteer Coordinator (VC-1) during an interview on 2/26/25 at 3:30 p.m. VC-1 explained that since these volunteers are for pet therapy they were not trained the same as someone who sits with patients. VC-1 acknowledged there was no infection control education for Vol-1 or Vol-2.

Based on record review and interview, the Hospice failed to ensure the registered nurse prepared written care instructions specific to the needs of the patient in 2 (P-2, P-10) of 12 records reviewed in which aide services were provided, failed to include safety precautions for 1 (P-7) of 12 records with aide services provided, and failed to provide direct instructions which enabled the aide to make clinical decisions concerning patient care in 1 (P-10) of 12 records with aide services, out of a total sample of 14 records reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: --- P-2: This patient elected hospice care on 8/23/24 with diagnoses of cerebral atherosclerosis (a buildup of plaque in the arteries of the brain) and liver failure. The referral documentation indicates the patient was hospitalized from 8/12/24 to 8/19/24 due to right-sided abdominal pain. The patient underwent a percutaneous cholecystostomy (a surgical procedure to place a tube into the gallbladder to drain bile and relieve inflammation) on 8/14/24. During record review on 2/25/25, it was noted that the hospice registered nurse documented on the 8/23/24 start of care assessment that the patient has a bile drain to the right upper quadrant with minimal bilious output. The 8/23/24 aide care plan instructed the aide to provide a bed bath or shower once a week for 13 weeks. The aide care plan failed to alert the aide to the presence of the bile drain on the patient's right upper quadrant and failed to include any instructions for the aide regarding the care/cleaning of the bile drain during bathing. The findings were reviewed with the clinical manager (CM-1), during an interview on 2/28/25 at 8:30 a.m. CM-1 stated there should have been mention of the drain bag on the aide care plan. P-7: This patient elected hospice care on 1/22/25, with diagnoses of cerebral atherosclerosis, dementia, and hypertensive heart disease with heart failure. During record review on 2/26/25, it was noted that the aide care plan failed to include low bed position safety precautions for a fall risk patient. During a joint surveyor/home health aide visit on 2/26/25, two surveyors observed the home health aide performing a bed bath and dressing on P-7. The home health aide elevated the bed (The bed had no safety rails) prior to the bed bath and left the patient bed in the elevated position while the aide washed her hands in the bathroom, approximately 12 feet away, numerous times. During an interview on 2/28/25, at 10:20 a.m., the Clinical Manager (CM-1) acknowledged the above findings. P-10: The start of care date to Hospice was 1/21/25 with diagnoses which included chronic systolic (congestive) heart failure, chronic kidney disease, and history of falls. On 2/26/25, record review of the Hospice aide's plan of care (POC) effective 1/21/25, failed to incorporate an admitting order (1/21/25) that O2 (oxygen) was to be administered at 2-4 LPM (liters-per-minute) via nasal cannula as needed for shortness of breath/dyspnea. The aide POC under DME (durable medical equipment) failed to acknowledge that P-10 had oxygen ordered. In addition, the POC instructed that the aide "May apply moisture barrier to buttocks and groin as needed." This level of intervention by the aide contradicts CMS (Centers for Medicare and Medicaid Services) language which states an aide is authorized in "Recognizing and reporting changes in skin condition..." but not to treat skin conditions. The findings above were reviewed and acknowledged by the Clinical Manager (CM-1) and Administrator (Adm-1) during an interview on 2/28/25 at 9:22 AM.

Based on record review and interview, it was determined the Hospice failed to ensure that ordered interventions were appropriate and optimized to meet patient care goals in 2 (P-10, P-11) of 14 records reviewed, resulting in the increased potential for an unpeaceful transition towards death. Findings include: --- P-10: The start of care (SOC) date to Hospice was 1/21/25 with diagnoses which included chronic systolic (congestive) heart failure, chronic kidney disease, and history of falls. On 2/26/25, record review noted the plan of care (POC) under the problem "Shortness of breath" had a goal that "Patient will have managed shortness of breath as evidenced by an RDOS (Respiratory Distress Observation Scale) of less than 4." Additional review of the Hospice's RDOS scale noted the following: "An RDOS score greater than or equal to 3 (out of 16) signifies respiratory distress and need for palliation (increased comfort measures)." This finding was brought to the attention of the Clinical Manager (CM-1) and Administrator (Adm-1) during an interview on 2/28/25 at 9:42 AM. Both acknowledged that the goal of less than 4 was inappropriate since a level 3 signified respiratory distress, which is not a desirable goal for the patient/family. P-11: The SOC date to Hospice was 1/21/25 with diagnoses which included atherosclerosis (plaque buildup reducing blood flow) to arterial left and right lower extremities, hypertension, and chronic respiratory failure. On 2/26/25, record review noted the POC under the problem "Shortness of breath" had a goal that "Patient will have managed shortness of breath as evidenced by an RDOS of less than 4." Review of the Hospice's RDOS scale noted the following: "An RDOS score greater than or equal to 3 signifies respiratory distress and need for palliation." This finding was brought to the attention of the CM-1 and Adm-1 during an interview on 2/28/25 at 9:46 AM. Both noted again that the goal of less than 4 was inappropriate due to a level 3 signifying respiratory distress. The Hospice failed to interpret the RDOS scale correctly to meet the needs of the patient and failed to adhere to its policy referenced below. Agency Policy: "Plan of Care" (revised 1/2023) under Section 0400 stated, "The following areas are reviewed and approved by the patient/family: ... 6. Realistic and achievable goals and objectives; 8. Agreed-upon outcomes."

Based on record review and interview, the hospice failed to ensure 2 (Vol-1, Vol-2) of 2 pet therapy volunteers received orientation about the hospice philosophy, resulting in a lack of education regarding the hospice philosophy for these two volunteers. Findings include: --- On 2/26/25, the personnel files for the following pet therapy volunteers were reviewed. Vol-1: Pet therapy volunteer started at hospice on 10/1/24. The personnel file failed to contain documentation of orientation about the hospice philosophy. Vol-2: Pet therapy volunteer started at hospice on 10/1/24. The personnel file failed to contain documentation of orientation about the hospice philosophy. The hospice policy titled, Volunteer Handbook (no date) states, volunteers will receive training appropriate to the task assigned. Training will include orientation and basic hospice training as a minimum. The hospice failed to follow its own policy and ensure pet therapy volunteers received orientation about the hospice philosophy. The findings were reviewed with the Volunteer Coordinator (VC-1) during an interview on 2/26/25 at 3:30 p.m. VC-1 explained that since these volunteers are for pet therapy they were not trained the same as someone who sits with patients. VC-1 acknowledged that these two volunteers had not received orientation about the hospice philosophy.

Based on record review and interview, it was determined that the facility failed to develop and maintain an emergency preparedness communication plan that included contact information for all current staff, patient's physicians, any contract employees and volunteers, as appropriate, which had the potential to negatively affect the health and safety of the 17 patients currently serviced by this agency, resulting in the lack of effective communication in the event of an actual emergency. Findings include: On 3/8/22 at 12:02 p.m., during a review of the agency's Emergency Preparedness documents with the Executive Director (ED #1), it was noted that there was no contact information for all current and hospice staff, patient's physicians, contract employees or volunteers as appropriate, accessible and available for review. These findings were reviewed with and acknowledged by ED #1 at the time of discovery.

Based on record review and interview, the Agency failed to ensure all staff, including contracted staff, received initial training in the Agency's Emergency Preparedness program, including training every 2 years, resulting in staff being ill-prepared in the event of an actual disaster or emergency. This deficient practice could potentially affect all staff employed by this agency, including contracted staff, and all 17 patients currently serviced by this Agency. Findings include: On 3/8/22 at 12:02 p.m., the agency's Emergency Preparedness documents were reviewed with the Executive Director (ED #1). There was no documented evidence that all Agency staff, including contracted staff had received initial and ongoing training in the agency's Emergency Preparedness Plan, policies and procedures. During a review of the agency's personnel files, including contracted staff, it was noted that of 9 personnel files reviewed, only 1 staff had training in the agency's Emergency Preparedness plan/procedures. These findings were reviewed with and acknowledged by ED #1 at the time of discovery.

Based on record review and interview, it was determined the Agency failed to provide documentation for the required tabletop and community based full-scale exercises or any documentation of an actual event that would qualify as a test of the emergency plan, resulting in staff is not being properly prepared for an actual emergency. This deficiency had the potential to affect all 17 patients currently serviced by this agency, as well as all staff, in the event of an actual disaster. Findings include: On 3/8/22 at 12:02 p.m. the Agency's Emergency Preparedness documents were reviewed with the Executive Director (ED #1). When asked to provide documented evidence of full-scale community-based emergency preparedness exercises, and tabletop exercises, ED #1 reported that the agency used the topic of Covid-19 for their community based drill. During the review, it was noted that the agency failed to document their efforts/participation in the reported drill. It was further noted that there was documentation of attendees/participants. The Agency failed to conduct the needed exercises designed for the preparation of emergency situations within the Agency and surrounding community in accordance with this requirement.

Based on record review and interview, the Hospice failed to document the existence of patient's/caregiver's complaints, details of the investigation and the resolution for all complaints received, resulting in the inability of the patient/family member to exercise their rights and unresolved complaints. This deficient practice could negatively affect the 74 patients serviced over the past 12 months and the 17 patients currently serviced by this agency. Findings include: On 3/7/22 during the Entrance Conference, the Clinical Manager (CM #1) was asked for permission to review the agency's complaint log. On 3/8/22, the Executive Director (ED #1) presented 3 untitled documents with dates ranging from 7/24/21 to 2/24/22. During the review with ED #1, it was acknowledged that the untitled documents were in fact patient satisfaction surveys conducted by the agency. ED #1 reported, "I hadn't been documenting any of the complaints since 2019. I would just address the concern. I started back recording them (complaints) in February of this year (2022). ED #1 then presented a document titled "Patient Concerns/Complaints Report" dated 2/24/22 regarding coordination of care and services. The document logged a complaint that the agency had received on 2/24/22 regarding the patient in question not receiving showers as scheduled. ED #1 acknowledged that she had not documented any of the other complaints received. The agency failed to ensure that all complaints, investigations, and resolutions were documented. These findings were reviewed with and acknowledged by ED #1 at the time of discovery.

Based on record review and interview the Agency failed to provide documented evidence that the Comprehensive Assessment included a review of all the patient's medications in order to ascertain any untoward drug interactions for 10 (MR's #1, 2, 3, 4, 5, 6, 7, 9, 10, 11) of 11 records reviewed, and failed to ensure the Physician had been notified in accordance with the Agency's policy, from a total of 11 sampled records reviewed, resulting in the potential for harmful medication effects, exacerbated health status, poor patient outcomes and unmet care needs L530); failed to ensure the Initial Bereavement Assessment included the identification of the potential bereaved individuals, and the social, spiritual and cultural factors that may impact their ability to cope with the patient's death in 5 (MR's #2, 4, 5, 6 and 7) of 7 records reviewed that required a bereavement assessment, from a total sample of 11 sampled records reviewed, with 2 (BR #1 and BR #2), additional bereavement records reviewed, and failed to develop a bereavement plan of care that incorporated the bereavement assessment, resulting in the potential for ineffective grieving and lack of bereavement support for the family members, caregivers and others that may be affected upon the patient's death (L531). The cumulative effect of these systemic failures resulting in the Hospices inability to ensure the provision of quality Hospice end of life care for the Condition of Participation 42 CFR 418.54 Initial and Comprehensive Assess of the Patient.

Based on record review and interview the Agency failed to provide documented evidence that the Comprehensive Assessment included a review of all the patient's medications in order to ascertain any untoward drug interactions for 10 (MR's #1, 2, 3, 4, 5, 6, 7, 9, 10, 11) of 11 records reviewed, and failed to ensure the Physician had been notified in accordance with the Agency's policy, from a total of 11 sampled records reviewed, resulting in the potential for harmful medication effects, exacerbated health status, poor patient outcomes and unmet care needs. Findings include: Policy: Medication Review and Reconciliation, 11/2012 stated, "Medication review and reconciliation is conducted by a licensed nurse as part of the comprehensive assessment and with initiation of new medication. Enters the medication into Allscripts medication screen..., Runs a Drug/Drug interaction via Allscripts to assess for drug to drug interactions..., For interactions identified as moderate or major severity the managing Physician is notified..., For interactions identified as major severity the Pharmacist is notified and a copy of the Drug/Drug interactions report is faxed t [sic] the Pharmacist for review and recommendation." On 3/7/22, the Clinical Manager CM #1) was queried about the process for reviewing the patient's medications for any untoward reactions and responded, "On admission, the nurse enters the medications into the system and pushes the button to do the reconciliation. Any interactions are then documented." MR #1: The patient was admitted to Hospice on 2/10/22 with terminal diagnoses that included Right Upper Quadrant (RUQ) Mass and Dementia. During the record review on 3/7/22 at 12:10 p.m., it was noted that the "RN Initial Assessment" dated 2/10/22 documented, "Medications: NQF (National Quality Forum) #1617 There are no problems to display for this section." The "Summary/Comments" section documented, "...next day for medication reconciliation with facility..., Comfort Pack (medications to relieve common symptoms, without filling a prescription or waiting for medications to be delivered) ordered: no due to bein [sic] in facility. Morphine (Opioid Narcotic) and Xanax (Sedative) ordered and awaiting physician e [sic] script signature." The "Patient Medication Record" dated 2/10/22 completed by the Clinical Manager (CM #1) documented, "Physician Contacted regarding medication discrepancies: NA (Not Applicable) No Discrepancies, Physician notified of severe medication interactions? NA No Interactions." During an interview with CM #1 on 3/9/22 at 12:00 p.m., a request was made to review the results of the drug review. CM reported, "I don't see it. There is no evidence that we conducted the review." The Agency failed to ensure the Comprehensive Assessment included a thorough review of all the patient's medications, including the prescribed Comfort Pack, in order to ascertain any untoward drug interactions. MR #2: The patient was admitted to Hospice on 2/8/22 with terminal diagnoses that included Stroke and Vascular Dementia. During the record review on 3/9/22 at 1:15 p.m. The Initial Assessment dated 2/8/22 completed by CM #1 documented, "Next visit request: 2/9 for nursing to discuss medications..., Comfort Pack ordered: will be ordered at next visit (2/9/22)." There was no documented evidence that a review of the patient's medications had been conducted. The patient's 4 prescribed/listed medications, as listed on the medication record, were entered in Drugs.com (Online drug interaction checker) and revealed the following: 3 moderate drug to drug interactions and 3 moderate drug to food interactions. During a review of the Comfort Pack contents, it was noted that the pack contained 7 additional medications which were not included in the drug review process. Of the 7 medications, 1 was an Opioid narcotic (Morphine). The remaining medications, along with the 4 listed medications were entered in Drugs.com and revealed: 6 major drug to drug interactions, 22 moderate drug to drug interactions, 6 moderate drug to food interactions and 5 duplicate drugs. There was no evidence that a thorough review of the patient's medications, including the Comfort Pack medications, had been conducted. CM #1 acknowledged the findings during an interview on 3/9/22 at 12:05 p.m. MR #3: The patient was admitted to Hospice on 12/23/21 with a terminal diagnosis of Covid-19. The record review was conducted on 3/8/22 at 9:00 a.m. The Patient Medication Record documented no discrepancies and no interactions. The patient's 20 (13 listed and 7 Comfort Pack drugs) prescribed medications were entered in Drugs.com and revealed: 5 major drug to drug interactions, 40 moderate drug to drug interactions, 1 major drug to food interaction and 10 duplicate drugs. There was no documented evidence that a drug review, including all the patient's prescribed medications, had been conducted in order to ascertain any untoward reactions. These findings were reviewed with and acknowledged by CM #1 during an interview on 3/9/22 at 12:15 p.m. MR #4: The patient was admitted to Hospice on 7/22/21 with a terminal diagnosis of Pulmonary Fibrosis. The record review was conducted on 3/9/22 at 3:30 p.m. The Medication Record documented no discrepancies and no interactions. There was no report detailing the findings of the drug review. The patient's 10 listed/prescribed medications were entered in Drugs.com and revealed (2 major and 33 moderate drug to drug interactions, 6 drug to food interactions and 6 duplicate drugs. The 7 medications from the patient's comfort pack were added to the review and revealed: 17 drugs, 11 major drug to drug interactions, 67 moderate drug to drug, 8 drug to food interactions and 10 duplicate drugs. There was no documented evidence a comprehensive drug review had been conducted in order to ascertain any untoward reactions. These findings were reviewed with and acknowledged by CM #1 during an interview on 3/10/22 at 9:09 a.m. MR #5: The patient was admitted to Hospice on 2/22/22 with a terminal diagnosis of Parkinson's Disease. During the record review on 3/8/22 at 3:10 p.m., there was no evidence or results of the drug interaction report. The patient's 7 prescribed medications were entered in Drugs.com and revealed 4 major drug to drug interactions, 5 moderate drug to drug interactions, 2 major drug to food interactions and 1 duplicate drug. During an interview on 3/10/22 at 9:09 a.m., CM #1 was asked to review documented evidence of the drug review and reported, "I agree that it's not there. The Hospice Agency failed to ensure the Comprehensive Assessment included a review of all the patient's medications, failed to document the findings and failed to provide documented evidence that the Physician had been notified of the untoward findings. MR #6: The patient's hospice start of care (SOC) was 3/19/21 with a terminal diagnosis of Chronic Biliary Cirrhosis. During record review on 3/10/22, it was noted that the medication record documented no discrepancies and no interactions. The patient's 22 (15 listed and 7 Comfort Pack drugs) prescribed medications were entered in Drugs.com and revealed: 9 major drug to drug interactions, 49 moderate drug to drug interactions and 5 duplicate drugs. There was no evidence that a drug review was completed per the policy. MR #7: The patient's hospice start of care (SOC) was 4/22/21 with a terminal diagnosis of Congestive Heart Failure (CHF). During record review on 3/9/22, it was noted that the medication record documented no discrepancies and no interactions. The patient's 11 prescribed medications were entered in Drugs.com and revealed: 1 major drug to drug interaction, 9 moderate drug to drug interactions and 1 duplicate drugs. There was no evidence that a drug review was completed per the policy. MR #9: The patient's hospice start of care (SOC) was 10/7/21 with a terminal diagnosis of Lung Cancer. During record review on 3/9/22, it was noted that the medication record documented no discrepancies and no interactions. The patient's 18 (11 listed and 7 Comfort Pack drugs) prescribed medications were entered in Drugs.com and revealed: 8 major drug to drug interactions, 25 moderate drug to drug interactions and 10 duplicate drugs. There was no evidence that a drug review was completed per the policy. MR #10: The patient's hospice start of care (SOC) was 1/24/21 with a terminal diagnosis of Amyotrophic Lateral Sclerosis (ALS). During record review on 3/9/22, it was noted that the medication record documented no discrepancies and no interactions. The patient's 19 prescribed medications were entered in Drugs.com and revealed: 10 major drug to drug interactions, 35 moderate drug to drug interactions and 7 duplicate drugs. There was no evidence that a drug review was completed per the policy. MR #11: The patient's hospice start of care (SOC) was 10/20/21 with a terminal diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction. During record review on 3/7/22, it was noted that the medication record documented no discrepancies and no interactions. The patient's 12 (5 listed and 7 Comfort Pack drugs) prescribed medications were entered in Drugs.com and revealed: 3 major drug to drug interactions, 26 moderate drug to drug interactions and 6duplicate drugs. There was no evidence that a drug review was completed per the policy.

Based on record review and interview, it was determined that the Hospice failed to ensure the Initial Bereavement Assessment included the identification of the potential bereaved individuals, and the social, spiritual and cultural factors that may impact their ability to cope with the patient's death in 5 (MR's #2, 4, 5, 6 and 7) of 7 records reviewed that required a bereavement assessment, from a total sample of 11 sampled records reviewed, with 2 (BR #1 and BR #2), additional bereavement records reviewed, and failed to develop a bereavement plan of care that incorporated the bereavement assessment, resulting in the potential for ineffective grieving and lack of bereavement support for the family members, caregivers and others that may be affected upon the patient's death. Findings include: MR #2: The patient was admitted to Hospice on 2/8/22 with terminal diagnoses of Cerebral Vascular Attack (CVA/Stroke) and Vascular Dementia. On 3/9/22 at 1:15 p.m., during a review of social work note dated 2/9/22, it was documented that the patient and living spouse had 3 adult children and 7 grandsons. The Initial Bereavement Assessment dated 2/9/22 only acknowledged the patient's spouse as the "Bereaved Person" and documented a low risk of grief. The assessment made no mention of the additional parties that would be affected upon the patient's death. MR #4: The patient was admitted to Hospice on 7/22/21 with a terminal diagnosis of Pulmonary fibrosis. On 3/9/22 at 3:30 p.m., during the clinical record review, it was noted that the Bereavement assessment documented that the patient had 4 living children that live locally and 2 granddaughters. The Bereavement Assessment, dated 7/22/21 documented the patient's stepson as the only bereaved to be affected by the patient's death. There was no mention of other family members that would be affected by the patient's death. Additionally, no bereavement plan of care had been initiated. MR #5: The patient was admitted to Hospice on 2/22/22 with a terminal diagnosis of Parkinson's Disease. On 3/8/22 at 3:10 p.m., during the record review, the Initial Bereavement Assessment dated 2/22/22 documented the patient had a surviving spouse, 2 adult children and a good friend that would be affected by the patient's death. The section titled Bereaved Person only made mention of the patient's daughter. There was no acknowledgement of the additional family members who would be affected upon the patient's death. BR #1: The patient was admitted to hospice on 5/11/21 with terminal diagnosis of Colon Cancer. The Bereavement Assessment dated 5/12/21 documented that the patient had two living children ages 17 and 13. The section titled "Bereaved Person" only listed the patient's spouse. The patient subsequently passed away on 5/16/21. The initial bereavement assessment did not include all parties who would be affected by the patient's death. Additionally, at the time of this review, no bereavement plan of care had been initiated as per this requirement. BR #2: The patient was admitted to hospice on 1/20/21 with a terminal diagnosis of Acute Kidney Failure. The Social Work note dated 1/21/21 documented that the patient had 3 daughters. "Her daughter is staying with her at this time and sisters are taking turns." The section of the Bereavement Assessment titled "Bereaved Person" only listed one of the patient's daughters. The patient subsequently passed away on 2/10/21. The initial bereavement assessment did not include all parties who would be affected by the patient's death. Additionally, at the time of this review, no bereavement plan of care had been initiated as per this requirement. The above-mentioned records were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 3/10/22 at 9:09 a.m. These findings were also reviewed with the Bereavement Coordinator (BC #1) during several interviews throughout the survey. MR #6: The patient's hospice start of care (SOC) was 3/19/21 with a terminal diagnosis of Chronic Biliary Cirrhosis. During record review on 3/10/22, it was noted that there was no bereavement care plan developed after the patient's death on 5/27/21. Additionally, the initial bereavement assessment for the patient's son dated 3/19/21 noted, "Summary/Comments: Has minor children." The agency failed to develop a bereavement care plan and described a complete and accurate summary. MR #7: The patient's hospice start of care (SOC) was 4/22/21 with a terminal diagnosis of Congestive Heart Failure (CHF). During record review on 3/9/22, it was noted that there was no bereavement care plan developed after the patient's death on 4/26/21. Additionally, the initial bereavement assessment for the patient's daughter dated 4/22/21 was blank under the "Summary/Comments" section. The agency failed to develop a bereavement care plan and describe a complete and accurate summary. These findings were reviewed with and acknowledged by CM #1during an interview on 3/10/22 at 12:45 p.m.

Based on record review and interview, it was determined the Hospice failed to develop a patient specific plan of care that included interventions for pain and symptom management for 5 (MR's #1, 2, 3, 4, 5) of 5 records, from a total of 11 sampled records reviewed, resulting in the potential for unrelieved pain and unmet care needs. Findings include: MR's #1 - 5: During a review of the above-mentioned patient records, it was noted that the associated Plans of Care were void of any interventions to monitor/assess/treat pain. These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during interviews on 3/9/22 and 3/10/22 who reviewed the documents and reported, "You're right. I don't see anything that says to monitor pain." The Hospice Agency failed to develop a patient specific plan of care that included interventions for pain and symptom management.

Based on record review and interview, the Hospice failed to ensure care and services were provided at the frequency ordered in the plan of care in 2 (MR#'s 2, 5) of 2 records, from a total of 11 sampled records reviewed, resulting in the potential for lack of grooming and feelings of isolation. Findings include: **Agency Policy: Visit Frequency and Scheduling (Reviewed Date: 1/2021) states, "An individualized written plan of care is developed for each patient, which includes the frequency of services necessary to meet the specific patient and family needs." MR #2: The patient was admitted to Hospice on 2/8/22 with terminal diagnoses that included Stroke and Vascular Dementia. During the clinical record review on 3/9/22 at 1:15 p.m., it was noted that Hospice Aide services were ordered to be provided at a frequency of 2x/wk. x 13 wks. Upon review of the record, the Aide missed visits on 2/22/22 (Missed visit note documented HHA/Hospice Aide called off) and 2/25/22 (Missed visit note documented "family agreeable to missed visit due to staff shortage and illness. caregivers able to provide care today Nursing did PRN/as needed and offered care to patient after fall)." The Agency failed to ensure that care and services were provided as ordered. These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 3/9/22 at 12:05 p.m. MR #5: The patient was admitted to Hospice on 2/22/22 with a terminal diagnosis of Parkinson's Disease. During the record review it was noted that Volunteer services, specifically Music Therapy (MT), was to be provided at a frequency of 2x/Month. During the record review on 3/8/22 at 3:10 p.m., MT had not provided the services as ordered in the Plan of Care. The documented rationale for the missed visits were due to "staff vacation, scheduling and shortage." These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 3/9/22 at 12:30 p.m.

Based on record review and interview, the Hospice failed to ensure the plan of care included patient specific goals/outcomes for the Hospice patient, for 2 (MR's #3, 5) of 2 records reviewed, from a total sample of 11 sampled records reviewed, resulting in the potential for lack of progress towards needed goals and unmet care needs. Findings included: Policy: Plan of Care 0400, 1/2021 stated, "The plan of care is developed with participation from the patient and primary caregiver..., Each discipline provides appropriate input with focus on patient/family goals..., Realistic and achievable goals and objectives." MR #3: The patient was admitted to Hospice on 12/23/21 with a terminal diagnosis of Covid-19. During the record review on 3/8/22 at 9:00 a.m., it was noted that the POC reflected goals that were vague in nature such as, "Goal: patient will be in control of what they eat, Cg reports burden/role strain at acceptable level, breath sounds within baseline level..." The POC listed interventions in place of goals such as, "Goal: clean and cover affected area with foam dressing every 5 to 7 days..." The Agency failed to ensure goals were patient-specific and measurable. These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 3/9/22 at 12:15 p.m. MR #5: The patient was admitted to Hospice on 2/22/22 with a terminal diagnosis of Parkinson's Disease. During the record review on 3/8/22 at 3:10 p.m., it was noted that the POC goals were non patient-specific and immeasurable such as, "Goal: participate in decisions related to care.., Cg is receiving emotional support..., patient will be in control of what they eat...Pt (patient)/family satisfied with Pastoral Care." The Agency failed to ensure goals were patient-specific and measurable. These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 3/9/22 at 12:30 p.m.

Based on record review and interview, it was determined that the Hospice agency failed to ensure the Governing Body approved the frequency and detail of the data collection for the Quality Assurance Performance Improvement Program which had the potential to negatively affect all 74 patients admitted in the past 12 months and the 17 patients currently serviced by this agency. Findings include: During the review of the Governing Board meeting minutes for 2021, it was noted that there was no evidence the data collection plan for the Quality Assurance Performance Improvement Program (QAPI) program had been presented to and approved by the Governing Board. These findings were reviewed with and acknowledged by the Executive Director (ED #1) at the time of discovery.

Based on record review and interview, it was determined that the agency's governing body failed to ensure that an ongoing program for quality improvement was evaluated annually, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: On 3/9/22 at 2:15 pm., during a review of the agency's QAPI (Quality Assessment Performance Improvement) data, it was noted that the governing body failed to ensure that an ongoing program for quality improvement was evaluated annually. These findings were reviewed with and acknowledged by CM #1during an interview on 3/9/22 at 3:30 p.m.

Based on record review and interview, the Registered Nurse failed to ensure the written plan of care for the assigned Hospice Aide provided specific DME, supplies, guidance, and care instructions on the needs of the patient, for 3 (MR's #6, 7, and 10) of 9 records with Hospice Aide services ordered from a total of 11 records reviewed resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Policy: "Development and Utilization of the Aide Task List or Plan of Care", Date Reviewed: 1-2021, stated, "The Home Health Aide provides care as directed by the RN, Physical Therapist, Occupational Therapist or Speech Therapist on the Home Health Aide Care Plan. Procedure: RN/Therapist B. The RN, OT, ST or PT completes the Aide Care Plan with instructions specific to the patient's need, limitations, environment, signs and symptoms to report and precautions." MR #6: The patient's hospice start of care (SOC) was 3/19/21 with a terminal diagnosis of Chronic Biliary Cirrhosis. During record review on 3/10/22, it was noted that the Initial Comprehensive assessment and aide care plan was completed by the Registered Nurse (RN) on 3/17/21. The RN stated on 3/17/21, "Summary/Comments: ...Per physician orders for Pt (patient) Aspira drain that was placed yesterday, to drain 3x wk (week) or PRN (as needed) when pt feels pressure is painful or building. I assessed the dressing sites, one small incision on right side of abdomen and 4x4 gauze covering drainage site ..." The aide care plan failed to have interventions and safety precautions regarding the drain site and dressing. Additionally, the aide care plan documented, "Activities Permitted: Walker. Other: Pt is able to ambulate with her walker around the house." The aide care plan was never updated throughout the patient's services that concluded with their death on 5/27/21. The RN failed to ensure written patient care instructions for the Hospice Aide provided specific guidance and care instructions on the needs of the patient. MR #7: The patient's hospice start of care (SOC) was 4/22/21 with a terminal diagnosis of Congestive Heart Failure (CHF). During record review on 3/9/22, it was noted that the Initial Comprehensive assessment and aide care plan was completed by the RN on 4/22/21. The Initial Comprehensive noted DME (durable medical equipment) of a hospital bed and wheelchair. The aide care plan failed to have the hospital bed and wheelchair documented. The RN failed to ensure written patient care instructions for the Hospice Aide provided specific guidance and care instructions on the needs of the patient. MR #10: The patient's hospice start of care (SOC) was 1/24/21 with a terminal diagnosis of Amyotrophic Lateral Sclerosis (ALS). During record review on 3/9/22, it was noted that an updated aide care plan was completed by the RN on 1/10/22 and was blank under the DME and supplies section. The RN recertification dated 1/10/22 noted the following DME and supplies: Commode, hospital bed, overbed table, oxygen concentrator, and sit/stand Hoyer lift. The RN failed to ensure written patient care instructions for the Hospice Aide provided specific guidance and care instructions on the needs of the patient. These findings were reviewed with and acknowledged by CM #1during an interview on 3/10/22 at 12:55 p.m.

Based on record review and interview, it was determined the Hospice failed to ensure a Discharge Summary that detailed the course of care provided, including symptom and pain management for 1 (MR #3) 1 patient discharged to the community had been forwarded to the Physician, and failed to ensure a discharge summary had been completed for 1 (MR #4) of 1 patient who revoked the election of hospice care and forwarded to the Physician in accordance with the agency's policy, from a total of 11 sampled records reviewed, resulting in the potential for unidentified continuing health concerns and unmet care needs. Findings include: Policy: Discharge of The Hospice Patient, Reviewed 7/2020 stated, "Hospice may discharge a patient if: Hospice determines the patient is no longer terminally ill..., Completed discharge summary..., a patient or representative may revoke the election of hospice care at any time during an election period..., Documents the situation (s) leading decision to revocate..., Documents reason and date of revocation..." MR #3: The patient was admitted to Hospice on 12/23/21 with a terminal diagnosis of Covid-19. During the clinical record review on 3/8/22 at 9:00 a.m., it was noted that the Plan of Care (POC) ordered Skilled Nursing (SN), Aide services and Medical Social Work (MSW) services to be provided. The patient was discharged to the community on 2/11/22. At the time of this review, there was no documented evidence that a Discharge Summary authored by the above disciplines, had been forwarded to the patient's attending Physician as per this requirement. MR #4: The patient was admitted to Hospice on 7/22/21 with a terminal illness of Pulmonary Fibrosis. During the record review on 3/9/22 at 3:30 p.m., it was noted that the agency documented that the patient had revoked hospice services on 8/7/21. Further review revealed that no discharge summary, or summary of care had been completed documenting the reason for revocation and no summary had been sent to the patient's attending Physician as per this requirement. These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 3/10/22 at 12:00 p.m.

Based on record review and interview, it was determined that the Hospice failed to ensure a Discharge Summary was completed, detailed the course of care provided, including symptom and pain management, Physician's orders and the patient's health status at the time of discharge for 1 (MR #3) of 1 patient who was discharged to the community, from a total of 11 sampled records reviewed, resulting in the potential for unmet care needs and interruption in post-discharge continuity of care. Findings include: Policy: Discharge of The Hospice Patient, Reviewed 7/2020 stated, "Hospice may discharge a patient if: Hospice determines the patient is no longer terminally ill..., Completed discharge summary..." MR #3: The patient was admitted to Hospice on 12/23/21 with a terminal diagnosis of Covid-19. During the clinical record review on 3/8/22 at 9:00 a.m., it was noted that the Plan of Care (POC) ordered Skilled Nursing (SN), Aide services and Medical Social Work (MSW) services to be provided. The patient was discharged to the community on 2/11/22. At the time of this review, no discharge summary had been completed by the MSW and forwarded to the Physician in order to assist with Post Discharge Continuity of Care. A SN discharge note dated 2/11/22 was void of the patient's status at the time of discharge, course of care or any potential continuing needs. These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 3/9/22 at 12:00 p.m., who reported, "This (SN discharge note) would not tell you where she was (health status on admission) or where she is at the time of discharge." At the time of this record review, no Discharge Summaries had been completed by any of the ordered disciplines.

Based on record review and interview, it was determined the Hospice failed to identify the care and services that were needed and identify each provider's responsibility for performing the needed functions that had been agreed upon and included in the hospice plan of care in 2 (MR's #1 and 5) of 3 records of patients who resided in a Skilled Nursing Facility, from a total of 13 sampled records reviewed, resulting in the potential for needed care and services to be overlooked and unmet care needs. Findings include: MR #1: This patient was admitted to Hospice on 2/10/22 with a terminal diagnosis of Right Upper Quadrant Mass. During a review of the clinical record on 3/7/22 at 12:10 p.m., it was noted that the patient resided in a Skilled Nursing Facility (SNF) and was ordered to have Skilled Nursing (SN), Aide services, Spiritual Care (SC), Music Therapy (MT) and Medical Social Work (MSW) services to be provided. The patient's Hospice plan of care (POC) did not clearly specify who (Hospice or SNF) would provided the needed services. These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 3/9/22 at 12:00 p.m. MR #5: The patient was admitted to Hospice on 2/2/22 with a terminal diagnosis of Parkinson's Disease. During the record review on 3/8/22 at 3:10 p.m., it was noted that the patient resided in a SNF and was ordered to have SN, Aide services, SC, MT and MSW services to be provided. The patient's Hospice POC did not clearly specify who (Hospice or SNF) would provided the needed services. These findings were reviewed with and acknowledged by CM #1 during an interview on 3/10/22 at 9:09 a.m.

Based on record review and interview, it was determined the Hospice failed to ensure that staff at the Skilled Nursing Facility received orientation and training regarding the Hospice Philosophy and the needs of the Hospice patient, resulting in the potential for unmet care needs for all patients who resided at the Skilled Nursing Facility at the end of life. Findings include: An interview was conducted with the Executive Director (ED #1) on 3/9/22 at 8:20 a.m. During the interview, a request was made to review documented evidence that staff at the Skilled Nursing Facility (SNF) received orientation and training on the Hospice Philosophy, policies and procedures for symptom management and the principles of death and dying. ED #1 acknowledged, "No training on the Hospice Philosophy has been done." The Hospice failed to ensure orientation and training was provided to the staff of the SNF.

Based on record review and interview, the Hospice failed to obtain criminal background checks on personnel providing services directly to patients for 1 of 1 Clinical Manager and 1 of 1 Registered Nurse employed by the agency, whose personnel files were reviewed from a total of 9 personnel files reviewed, resulting in the risk of beneficiary mistreatment when receiving services in the home. Findings include: On 3/9/22 at 8:40 a.m., a review of the agency's personnel files revealed the following: 1). Clinical Manager (CM #1) date of hire 2/26/18. There was no evidence that the required criminal background check had been completed. 2). Registered Nurse (RN #1) date of hire 5/22/17. There was no evidence that a criminal background check had been completed. The above findings were reviewed with and acknowledged by the Clinical Manager during an interview on 3/9/22 at 9:55 a.m.