Every finding on record at Lutheran Senior Services

Based on the policy review, employee education record review, clinical record review, and interview, the hospice provider failed to ensure the hospice aide (Aide B) had successfully completed the basic skills test prior to the provision of patient care in one of one record reviewed (Record/Patient #12). This deficient practice has the potential to affect the provision of competent aide services for all of the provider's patients. Findings included: --- Review of the providers undated policy titled, ";Competency Program," showed in part, the providers competency program would:- Assess staff competency prior to assuming the duties for which they were hired, by a supervisor or peer that has also been assessed and meets the criteria for performing those skills;- Assure that each direct service staff member has demonstrated competency in any new task before being assigned to that task; and- Validation of skills competency is conducted annually thereafter. Review of the providers undated policy titled, ";Coordination of Services – Hospice Aide Training and Competency," showed that, in part, an individual may furnish aide services on behalf of the provider when that individual has successfully completed a competency evaluation program that includes, but is not limited to:- Completion of a bed and sponge bath; and- Washing of the hair while the patient is in bed. Review of the providers employee education files showed that the provider failed to provide a complete aide basic skills test for Aide-B. The basic skills test failed to include documentation that Aide-B successfully completed;- A bed and sponge bath; and- Washing of the hair while the patient is in bed. RECORD/PATIENT #12: Review of the hospice aide visit note, dated 05/30/2024, showed that Aide-B provided a complete bed bath and shampoo of the patients hair during his/her visit. During an interview on 06/04/2024 at 2:18 PM, the hospice administrator stated:- The bed and sponge bath, and washing of the hair while the patient was in bed had not been documented as successful on Aide-Bs basic skills test; and- It was the providers practice to perform aide competency testing that include all of the elements on the aide basic skills test.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure the registered nurse (RN) prepared complete written care instructions for the hospice aide in two of four applicable records (Records/Patients #1 and #4). This deficient practice has the potential to affect all patients who receive aide services from the provider. Findings included: --- RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 09/29/2023 with a terminal diagnosis of other symptoms and signs involving cognitive functions following cerebral infarction (stroke). The patient had comorbidities including, but not limited to, a history of edema (swelling) in the feet. The patient resided in a skilled nursing facility. Review of the plan of care dated 05/24/2024 showed, in part, the following:- ACE wraps to BLE (bilateral lower extremities) on in AM, off at HS (hour of sleep); and- Surgical shoe to left foot. The aide assignment sheet dated 05/28/2024 failed to contain: - Directions for the management of the ACE wraps to the BLE during the bathing process; and- The use of the surgical shoe to the left foot. During an interview on 06/05/2024 at 10.21 AM, the administrator stated that they would expect the aide assignment sheet to contain directions for the aide management of the ACE wraps during the bathing process and the use of the surgical shoe. Review of the Hospice providers policy titled, "Coordination of Services- ";Named Hospice" Aide," copyright date of 2016, showed in part, the following: - All aide services will be provided by qualified personnel in accordance with the states occupational certification regulations, where applicable, federal regulations and the organizations policies/job descriptions; - All aide services will be provided under the direction of a registered nurse with sufficient education and experience in the scope of services offered; - Written patient care instructions must be prepared by a registered nurse who is responsible for the supervision of a ";named Hospice" aide; - A named Hospice aide provides services that are ordered by the interdisciplinary group, included in the plan of care, permitted to be performed under state law, and consistent with the ";named Hospice" aide training. RECORD/PATIENT #1: Review of the clinical record showed that the patient was admitted to Hospice services on 02/06/2024 with an admitting terminal diagnosis of Huntington's disease (a progressive, genetic condition that affects the cells in your brain that regulate voluntary movement and memory). The patient resided in a long-term care facility. Review of the Hospice aide assignment, dated 02/06/2024, showed under the skin care section: apply barrier cream as directed was check marked with a frequency of every visit. It failed to include the location and the indication for application of the barrier cream. Observation on 06/04/ 2024, beginning at 8:10 AM, during the patients home visit, showed during the patients shower the dressing on the coccyx (tailbone) fell off. Hospice aide A, dried the patient off, applied barrier cream to the open abrased area to the coccyx, and stated he/she would tell the nurse it fell off. Per interview conducted during the patients home visit Hospice aide-A stated that he/she believed that applying barrier cream to the open wound on the coccyx was listed on the aide assignment sheet. During an interview on 06/05/2024 at 10:35 AM the administrator acknowledged the location and indication for barrier cream application was missing from the aide assignment sheet.

Based on policy review record review, observation, and interview the hospice provider failed to ensure the hospice aide followed the aide assignment/aide plan of care (POC) in 1 of 4 applicable records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients receiving aide services. --- Findings included: Review of the hospice providers policy titled, "Coordination of Services- ";Named Hospice" Aide", copyright date of 2016, showed in part, ";Named Hospice" aide provides services that are ordered by the interdisciplinary group and included in the plan of care. RECORD/PATIENT #1: Review of the clinical record showed that the patient was admitted to hospice on 02/06/2024 with a terminal diagnosis of Huntington's disease (a progressive, genetic condition that affects the cells in your brain that regulate voluntary movement and memory). The patient resided in a long-term care facility. Review of the hospice aide assignment (aide POC), dated 02/06/2024, showed under the skin care section: apply barrier cream as directed was check marked with a frequency of every visit. It failed to show that the aide was to provide wound care to the open coccyx (tailbone) wound. Observation on 06/04/2024, beginning at 8:10 AM, during the patients home visit, showed during the patients shower the dressing on the coccyx (tailbone) fell off. Hospice aide A, dried the patient off, applied barrier cream to the open abraded (also known as an abrasion, a superficial break in the skin's layers; caused by scraping, pressure, or impact) area to the coccyx, and stated he/she would tell the nurse it fell off. Per interview conducted during the patients home visit hospice aide-A stated that he/she believed that applying barrier cream to the open wound on the coccyx was listed on the aide assignment sheet. During an interview on 06/05/2024 at 10:35 AM the administrator stated that: - The licensed nurse should be doing the wound care, not the aide; and - If the wound was not open (no break in the skin) and the aide wanted to apply the protectant cream (barrier cream) then yes, they could.

Based on policy review, employee education file review, and interview, the hospice provider failed to complete an initial and annual skills competency for the chaplain and the social worker disciplines in two of four employee files reviewed (Chaplain-A and Social Worker-A). This deficient practice has the potential to affect the provision of competent services for all of the provider's patients. Findings included: --- Review of the providers undated policy titled, ";Competency Program," showed in part, the providers competency program would:- Assess staff competency prior to assuming the duties for which they were hired, by a supervisor or peer that has also been assessed and meets the criteria for performing those skills;- Assure that each direct service staff member has demonstrated competency in any new task before being assigned to that task; and- Validation of skills competency is conducted annually thereafter. Review of the providers employee education files showed that the provider failed to provide initial and annual competency evaluation(s) for Chaplain A and Social Worker A. During an interview on 06/04/2024 at 2:18 PM, the hospice administrator stated that they had not performed competency evaluations on chaplains or social workers in the past and would initiate the process in the future.

Based on agency policy, clinical record review, home visit observation, and interview, the agency failed to: - Ensure ongoing comprehensive assessment included a complete assessment of the patient's pain (L524); - Ensure each patient's medication profile was up to date and complete as part of the ongoing updates to the comprehensive assessment (L530); and - Ensure that the update of the comprehensive assessment included changes that have taken place since the initial assessment (L533). The cumulative effect of these systemic practices resulted in the agency's inability to ensure the patient's care needs were met.

Based on policy review, clinical record review, and interview, the hospice provider failed to ensure the comprehensive assessment identified the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process in five (Record(s)/Patient(s) #1, #2, #3, #4, and #5) of five full records reviewed. This deficient practice has the potential to affect all patients on service. Findings included: Review of the agency's undated policy titled, "Introduction," defines the comprehensive assessment as a thorough evaluation of the patient's physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions. Review of the agency's undated policy titled, "Pain Management," showed that: - The pain assessment conducted at the time of admission includes: * History of pain and its treatment (including non-pharmacological and pharmacological treatment); * Characteristics of pain, such as, intensity of pain, descriptor of pain, pattern of pain, location and radiation of pain, frequency/timing/duration of pain, impact of pain on quality of life; factors such as activities, care, or treatment that precipitate or exacerbate pain, strategies and factors that reduce pain, additional symptoms associated with pain; the patient/family's goal for pain management and their satisfaction with the current level of pain control; and - Ongoing pain assessment should include a thorough history of the pain and pain relief methods used to date. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services with diagnoses of multiple sclerosis (a chronic, progressive disease involving damage to nerve cells in the brain and spinal cord resulting in decreased mobility and ability to swallow), malnutrition, urine retention with use of urinary catheter to drain the bladder, a colostomy (the colon is diverted to an artificial opening in the abdominal wall to bypass a damaged part of the colon), and pressure ulcers on the right ankle, right heel, left heel, left ankle, left buttock, and sacrum. The patient resided in his/her own home. Review of the initial, registered nurse (RN) comprehensive assessment failed to contain documentation of the patient's: - Colostomy including stoma appearance, drainage, appliance used, and output; - Pain assessment including history of pain, pattern of pain, level of satisfaction with current medication regimen; and - Genitourinary assessment including color, consistency, character of urine, last urinary catheter change, the size of the urinary catheter including balloon volume. Review of nursing visits performed on 12/03/2021 and 12/08/2021 showed the documentation failed to contain assessment of the patient's: - Complete pain assessment including history of the pain and pain relief methods including, but not limited to, amount of pain medication used and satisfaction with pain management; - A genitourinary assessment, including but not limited to, the function of the urinary catheter; and - A gastrointestinal assessment, including but not limited to, the colostomy (stoma (opening), output, condition of the skin around the stoma). RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice service with diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and COVID-19. The patient resided in a skilled nursing facility. Review of the initial, registered nurse comprehensive assessment showed the patient had pain that occurred less than daily and was prescribed medication for pain control. The documentation failed to contain a complete pain assessment including history of the pain and pain relief methods including, but not limited to, amount of pain medication used and satisfaction with pain management. Review of documentation for nursing visits performed 12/08/2021 and 12/30/2021 failed to contain documentation of the amount and frequency of pain medication use, or the patient's level of satisfaction with the pain management regimen. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services with diagnoses of end stage heart failure. The patient resided in a skilled nursing facility. Review of the initial, registered nurse comprehensive assessment showed that: - The patient was prescribed acetaminophen and morphine as needed for pain control, and failed to contain a complete pain assessment including history of pain, pain relief method, the amount and frequency of pain medication use, or the patient's level of satisfaction with the pain management regimen; and - His/her pain was assessed using a verbal descriptor pain scale (a series of descriptive phrases that refer to different levels of pain severity or intensity. Patients select the phrase that best describes their current pain), but failed to contain documentation of the verbal descriptors provided by the patient. PATIENT/RECORD #4: Review of the clinical record showed the patient was admitted to hospice services on 07/08/2021 with diagnoses of end stage heart failure, rheumatoid arthritis, and osteoarthritis. The patient resided in an assisted living facility. Review of the nursing comprehensive assessment performed 09/27/2021 for recertification showed the patient had a current pain level of zero. The behavioral and advanced dementia pain scales were documented at zero, no pain. The assessment failed to contain a complete assessment including, but not limited to history of pain, pain relief methods, the amount and frequency of pain medication use, or the patient's level of satisfaction with the pain management regimen. Review of the updated plan of care/interdisciplinary group meeting note dated 10/05/2021 showed the patient was prescribed dilaudid (an opioid medication used to treat mild to moderate pain) to be given every one hour as needed. PATIENT/RECORD #5: Review of the clinical record showed the patient was admitted to hospice services on 12/01/2021 with diagnoses of difficulty swallowing following a stroke, right sided paralysis, and heart failure. The patient resided in a private residence. Review of the nursing comprehensive assessment performed 12/01/2021 showed that: - The patient, "denies pain during visit; and - The assessment failed to contain a complete assessment including, but not limited to history of pain, pain relief methods, the amount and frequency of pain medication used in the past, or the patient's level of satisfaction with the pain management regimen.

Based on policy review, record review, and interview, the agency failed to maintain a complete/accurate medication profile in one (Record/Patient #1) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the undated agency's policy titled, "Medication Regimen Review," showed that: - An accurate and current list of all prescription and over-the-counter medications taken by the patient will be maintained on the medication profile; - Nursing staff will assess on an ongoing basis the patient's response to the medication and the patient/caregiver's compliance with the medication regimen; - Changes in the medication regimen will be documented in the clinical record as well as communicated to the patient and/or caregiver; and - Review of medications will be on-going, but done a minimum of every 60 days. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services with diagnoses of multiple sclerosis (a chronic, progressive disease involving damage to nerve cells in the brain and spinal cord resulting in decreased mobility and ability to swallow), malnutrition, urine retention with use of urinary catheter to drain the bladder, a colostomy (the colon is diverted to an artificial opening in the abdominal wall to bypass a damaged part of the colon), and pressure ulcers on the right ankle, right heel, left heel, left ankle, left buttock, and sacrum. The patient resided in his/her own home. Review of the initial hospice plan of care dated 09/08/2021 showed the patient was to take Keflex (antibiotic to treat infections) capsules two times per day, effective 09/10/2021. Review of the hospice updated plan of care/interdisciplinary group meeting documentation for 12/07/2021, 12/21/2021, and 01/04/2022 showed that the patient was to take Keflex two times per day effective 09/10/2021. During an interview on 01/11/2022 at 09:38 AM, the patient stated that he/she had not taken the Keflex in a while, possibly, "weeks."

Based on agency protocol, clinical record review, and interview, the agency failed to ensure that the comprehensive assessment was updated when the skilled nurse (SN) failed to reassess the patient's condition in two (Records/Patients #1 and #3) of five records reviewed. This deficient practice has the potential to affect the quality of care for all patients receiving hospice care. Findings included: Review of the agency's protocol dated 04/03/2007 and titled, "Wound Irrigations," showed that the clinician would assess character and amount of wound drainage. Measure wound and document on visit report form at least weekly. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services with diagnoses of multiple sclerosis (a chronic, progressive disease involving damage to nerve cells in the brain and spinal cord resulting in decreased mobility and ability to swallow), malnutrition, urine retention with use of urinary catheter to drain the bladder, a colostomy (the colon is diverted to an artificial opening in the abdominal wall to bypass a damaged part of the colon), and pressure ulcers on the right ankle, right heel, left heel, left ankle, left buttock, and sacrum. The patient resided in his/her own home. Review of the nursing visit on 12/10/2021 failed to contain measurements of the wound on the coccyx. Review of nursing visits on 12/14/2021, 12/17/2021, 12/22/2021, 12/29/2021, 01/05/2022, 01/07/2022, and 01/10/2022 failed to contain measurements of wounds on the coccyx, sacrum, right medial pedal, left medial pedal, and left ankle. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services with diagnoses of end stage heart failure. The patient resided in a skilled nursing facility. Review of documentation for licensed practical nursing visit dated 12/30/2021 showed that: -The patient was starting to have breakdown (skin breakdown results from a lack of blood circulation. It can occur when soft tissue parts are pressed between two surfaces, most commonly bone and the surface on which the patient is resting); - The nurse ordered a LAL (low air loss mattress) (a mattress with tiny laser made air holes in its top surface which continually blow out air causing the patient to float) from the durable medical equipment provider; - Calmoseptine (a multipurpose moisture barrier that protects and helps heal skin irritations) was applied as needed (PRN); - Integumentary interventions were updated effective 12/30/2021 to include, "R and L buttock is starting to have breakdown. Encourage pt to shift weight while in recliner or lay down;" - Plan for next visit was to monitor pain, discomfort, intake, and appetite; and - The visit documentation failed to contain coordination of care with the interdisciplinary group. Review of nursing visits dated 01/03/2022, 01/05/2022, and 01/10/2022 failed to contain an assessment of the skin breakdown to right and left buttocks. During a home visit observation on 01/11/2022 at 11:45 AM, with hospice RN1, the patient's buttocks were observed and the skin integrity was intact and Calmoseptine was present on the skin. The patient was sitting in his/her recliner on a gel pad. The LAL mattress was on the bed. During an interview on 01/11/2022 at 12:15 PM with hospice RN1, he/she stated that he/she was not aware that the patient had breakdown on his/her buttocks.

Based on agency policy, clinical record review, home visit observation, and interview, the agency failed to: - Ensure an individualized plan of care was developed for each patient that included all services necessary for the palliation and management of the terminal illness and related conditions (L545); and - Ensure ongoing sharing of information between all disciplines providing care (L557). The cumulative effect of these systematic practices resulted in the agency's inability to ensure the patient's care needs were met.

Based on clinical record review and home visit observation, the agency failed to assure that the plan of care (POC) included all services necessary for palliation and management of the terminal illness and related conditions in one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to affect the symptom management of all the agency's patients. Findings included: RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services with diagnoses of end stage heart failure. The patient resided in a skilled nursing facility. Review of documentation for licensed practical nursing visit dated 12/30/2021 showed that: -The patient was starting to have breakdown (skin breakdown results from a lack of blood circulation. It can occur when soft tissue parts are pressed between two surfaces, most commonly bone and the surface on which the patient is resting); - The nurse ordered a LAL (low air loss mattress) (a mattress with tiny laser made air holes in its top surface which continually blow out air causing the patient to float) from the durable medical equipment provider; - Calmoseptine (a multipurpose moisture barrier that protects and helps heal skin irritations) was applied as needed (PRN); and - Integumentary interventions were updated effective 12/30/2021 to include, "R and L buttock is starting to have breakdown. Encourage pt to shift weight while in recliner or lay down;" Review of the facility records showed: -Calmoseptine to be applied to buttock during peri-care each shift to prevent skin breakdown with a start date of 12/27/2021 listed on the facility medication profile; and - Skin assessment one time weekly beginning 11/18/2021 was listed on the facility treatment administration record. Review of the updated POC/Interdisciplinary group (IDG) meeting notes dated 01/04/2022 showed that the document failed to contain orders for the LAL mattress placed 12/30/2021, the use of Calmoseptine PRN, and interventions to assess the right and left buttocks for further breakdown. During a home visit observation on 01/11/2022 at 11:45 AM, the patient's buttocks were observed and the skin integrity was intact and Calmoseptine was present on the skin. The LAL mattress was on the bed. PATIENT/RECORD #5: Review of the clinical record showed the patient was admitted to hospice services on 12/01/2021 with diagnoses of difficulty swallowing following a stroke, right sided paralysis, and heart failure. The patient resided in a private residence. Review of the comprehensive nursing assessment dated 12/01/2021 showed that the patient was to receive his/her nutrition through a tube inserted into his/her stomach four times per day and was not to take any food or fluids by mouth (NPO). Review of the hospice POC dated 12/01/2021 showed that the patient was to be NPO and received feedings through the tube in his/her stomach four times per day. Review of the nursing visit dated 12/09/2021 showed that the patient was eating a soft diet and not taking the feedings through the tube in his/her stomach. The clinical note for the visit showed the physician was notified. Review of the IDG meeting notes dated 12/21/2021 failed to contain orders for the patient to have a soft diet and stop feedings through the tube in his/her stomach. Review of nursing visits dated 12/22/2021 and 12/31/2021 showed that the patient had continued with the soft diet and was not taking the feedings through the tube in his/her stomach. Review of the IDG meeting notes dated 01/04/2022 failed to contain orders for the patient to have a soft diet or to stop feedings through the tube in his/her stomach.

Based on policy and record review, the agency failed to ensure coordination of care when the on-going sharing of information between all disciplines providing care failed to be provided in two (Records/Patients #1 and #3) of five full record reviews conducted. This deficient practice has the potential to adversely affect the coordination of care for all the agency's patients. Findings included: Review of the agency's undated policy titled, "Continuity and Coordination of Care," showed that: - The care is coordinated by the Interdisciplinary Team (IDT) members under the direction of the Clinical Coordinator, regardless of location of the patient. The registered nurse assigned to the patient is responsible for coordinating the services provided to that patient; and - The interdisciplinary care plan (IDPOC) is the major coordinating tool of patient care. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services with diagnoses of multiple sclerosis (a chronic, progressive disease involving damage to nerve cells in the brain and spinal cord resulting in decreased mobility and ability to swallow), malnutrition, urine retention with use of urinary catheter to drain the bladder, a colostomy (the colon is diverted to an artificial opening in the abdominal wall to bypass a damaged part of the colon), and pressure ulcers on the right ankle, right heel, left heel, left ankle, left buttock, and sacrum. The patient resided in his/her own home. Review of a clinical missed visit note dated 12/24/2021, for nursing visit scheduled 12/24/2021, showed that the patient and spouse refused the visit on that date. The note failed to contain documentation of physician notification of the change in the IDPOC. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services with diagnoses of end stage heart failure. The patient resided in a skilled nursing facility. Review of documentation for licensed practical nursing visit dated 12/30/2021 showed that: -The patient was starting to have breakdown (skin breakdown results from a lack of blood circulation. It can occur when soft tissue parts are pressed between two surfaces, most commonly bone and the surface on which the patient is resting); - The nurse ordered a LAL (low air loss mattress) (a mattress with tiny laser made air holes in its top surface which continually blow out air causing the patient to float) from the durable medical equipment provider; - Calmoseptine (a multipurpose moisture barrier that protects and helps heal skin irritations) was applied as needed (PRN); - Integumentary interventions were updated effective 12/30/2021 to include, "R and L buttock is starting to have breakdown. Encourage pt to shift weight while in recliner or lay down;" - Plan for next visit was to monitor pain, discomfort, intake, and appetite; and - The visit documentation failed to contain documentation of the coordination of care with the interdisciplinary group.

Based on home visit observation and interview, the agency failed to assure that clinicians followed accepted standards of practice to prevent the transmission of infections in one (Patient/Record #1) of three home visit observations. This deficient practice has the potential to affect the infection control practices for all of the agency's patients. Findings included: RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services with diagnoses of multiple sclerosis (a chronic, progressive disease involving damage to nerve cells in the brain and spinal cord resulting in decreased mobility and ability to swallow), malnutrition, urine retention with use of urinary catheter to drain the bladder, a colostomy (the colon is diverted to an artificial opening in the abdominal wall to bypass a damaged part of the colon), and pressure ulcers on the right ankle, right heel, left heel, left ankle, left buttock, and sacrum. The patient resided in his/her own home. During a home visit observation on 01/11/2022 at 8:35 AM, the clinician cleansed the patient's wound with a previously opened bottle of Dakin's solution (a bleach/water solution used to treat wounds). The Dakin's solution did not have the date or time it was opened written anywhere on the bottle or label. During an interview on 01/13/2022 at 10:00 AM, the administrator stated that opened, multi-use bottles should have the date and time they were opened documented on them.

Based on policy and record review, the agency failed to ensure the registered nurse (RN) adequately evaluated whether the hospice aide completed tasks/visits as assigned on the plan of care (POC) in one (Record/Patient #2) of five records reviewed that received aide services. This deficient practice has the potential to affect all patients receiving aide services. Findings included: Review of agency undated policy titled, "Coordination of Services - LSS Hospice Aide," showed that the registered nurse (RN) will make a supervisory visit to assess the quality of care and services provided by the LSS Hospice aide. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice service with diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and COVID-19. The patient resided in a skilled nursing facility. Review of clinical missed visit note dated 12/30/2021 for aide visit scheduled 12/30/2021 failed to contain documentation of physician notification that the visit was missed. Review of RN documentation of aide supervision showed inaccurately that the aide was following the POC, when the aide did not follow the prescribed visit schedule. The supervisory visit failed to address/update the aide assignment regarding the missed visit.

Based on policy review, home visit observation, and interview, the hospice failed to provide a skilled nursing facility (SNF) the required documents for coordination of care in one (Record/Patient #2) of two home visit observations for patients that reside in a SNF. The deficient practice has the potential to affect any hospice patient that reside in a SNF. Findings included: Review of the agency's undated policy titled, "Coordination of Care - Residents of a Nursing Facility," showed that the hospice assures the continuity of patient/family care in the community and inpatient services. When the hospice patient resides in a skilled nursing facility/nursing facility (SNF/NF) or intermediate care facility/assisted living facility (ICF/ALF), the hospice collaborates with the facility providing care to the patient and family to ensure coordination of services. The care is coordinated by the interdisciplinary team (IDT) members under the direction of the Director of hospice. The registered nurse (RN) assigned to the patient is responsible for coordinating the services provided to that patient. The hospice will provide the facility with: - The most recent plan of care (POC) specific to each patient; - The hospice election form and any advance directives specific to each patient; - The physician certification and recertification of the terminal illness; and - The hospice physician and attending physician (if any) orders specific to each patient. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice service with diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and COVID-19. The patient resided in a skilled nursing facility. Review of the hospice coordination of care documentation, during a nursing home observation visit on 01/11/2022 at 2:09 PM, showed that: - The copy of the patient's do not resuscitate (DNR) order was not readable; - The documentation failed to contain the physician certification of terminal illness (CTI), or the hospice physician orders; and - Contained three versions of the hospice coordinated task plan. During an interview on 01/11/2022 at 2:32 PM, the facility charge nurse stated that he/she: - Was unable to read the patient's DNR order; - Could not find copies of the physician CTI; - Was unable to find the hospice physician orders; and - Was unable to identify the most current version of the hospice coordinated task plan.