Every finding on record at Majestic Hospice and Palliative Care, LLC

Based on clinical record reviews, home visit observations, and staff interviews it was determined the agency failed to ensure patient's medication profile was updated to reflect current medications at the time of the comprehensive assessment for two of three patients (P#) (P#2 and #3) observed during home visits. The findings include: 1. Review of the plan of care for patient#2 who resides in an Assisted Living Facility (ALF) with a recertification period of 1/23/22 to 3/23/22, revealed a hospice admission on 3/29/21, with diagnosis of Dementia with behavioral disturbance. During a home ALF visit observation on 3/15/22, at approximately 11:30 a.m., the surveyor compared P#2's current hospice agency medication profile dated 3/15/22, with the ALF medication profile dated 3/15/22. The medications listed on the ALF medication profile dated 3/15/22, as follows: Docusate NA (stool softener) 100 mg capsule; one capsule by mouth once daily, the Hospice agency medication profile did not include the above-mentioned medication. The medication listed on the hospice agency medication profile as follows; Tessalon Pearls (used to stop cough) 100 mg capsule, once capsule twice daily. The ALF medication profile did not include Tessalon pearls 100 mg. The Hospice agency failed to ensure the medication profiles accurately reflected P#2's current medication regimen. 2. Review of the plan of care for patients #3 with certification period of 2/1/22 to 5/1/22, revealed a hospice admission date on 2/1/22, with vascular dementia without behavioral disturbance. During a home visit observation on 3/15/22, at approximately 9:45 a.m., the surveyor compared the medications in P#3 home to the hospice agency's medication profile. The hospice agency medication profile listed the following medications: Atenolol 25 mg (blood pressure), one tab via peg tube once daily (inhaler). calcium carbonate and vitamin D 600 mg 20 mcg (800 unit) via peg tube twice daily. ciclesonide CFC (used for asthma) free 160 mcg/inhaler aerosol twice daily. Flomax 0.4 mg (enlarged prostate)one capsule via peg tube daily. During an interview with patient #3's caregiver on 3/15/22, at approximately 9:50 a.m., the caregiver verbalized the patient is not taking the above-mentioned medications. The agency medication profile listed Tylenol 500 mg (pain medication) every 6 hours as needed via peg tube, daily. The caregiver verbalized the patient is taking Tylenol 325 mg one tablet on as needed basis for pain. Additionally, the caregiver stated the patient takes the following medications that were not on the agency medication profile: Amlodipine ( blood pressure) 10 mg once daily via peg tube and Folic acid (vitamin) 800 mg once daily via peg tube. The agency failed to ensure the medication profile accurately reflected P#3's current medication regimen. During record review interview on 3/15/22, at 4:45 p.m., the Administrator stated, medications are reviewed with the patient/caregiver at each visit and provided no evidence the medication profile had been updated to reflect the patient's current medication regimen.

Based on clinical record reviews, and staff interviews, it was determined the interdisciplinary group (IDG) failed to ensure comprehensive assessments/plan of care were updated to include evaluation and documentation of the patient's response to wound care, pressure ulcer treatment and progress toward desired outcomes for one of two patients P# (P#3) reviewed for altered skin conditions. The findings include: Review of the plan of care for patient #3 revealed an admission date on 2/1/22, with an admitting diagnosis of pressure ulcer on the buttock and hips. Review of the skilled visit (SN) note dated 2/2/22, the SN documents patient has stage 4 decubitus and bilateral hips with tissue injury. Review of the SN visit note dated 2/9/22, SN documents patient has stage 4 sacral wound , bilateral deep tissue injury, unstageable wounds to both heels with eschar tissue present and trauma/scab area to left upper flank/scapula area. Review of the SN note dated 2/16/22, the SN documents patient has a wound to right shoulder. Review of SN note dated 2/17/22, the SN documents patient has multiple stage 2 wounds on right shoulder blade area. Review of the SN visit note dated 3/2/22, SN documents patient has a new wound to right ankle. The clinical record review included IDG meeting notes dated 2/15/22 and 3/1/22. The IDG meeting notes for each date lacked documentation of the location, size, and specific orders for multiple wounds. The IDG notes lacked documentation of progress or lack of progress toward the desired outcomes/goals and the patient's response to wound care treatment. During a record review meeting on 3/15/22, at 4:45 p.m., the Administrator stated, the SN notes are reviewed during IDG meetings, but IDG notes lacked documentation of updated status/assessment, intervention, and progress of patient's multiple wounds and its complications.

Based on clinical record review and staff interview, it was determined the Interdisciplinary team (IDT) failed to ensure the plan of care reflected the specific problems identified in the assessments, goals, interventions, and services necessary to meet the assessed needs of one of three patients (P#) (P#3) who were current hospice beneficiaries. The findings include: Review of the plan of care for patient #3 revealed an admission date of 2/1/22, with an admitting diagnosis of pressure ulcer of buttock and hip. Review of the skilled nurse (SN) visit note dated 2/2/22, the SN documents patient has stage 4 sacral decubitus and bilateral hips with tissue injury. Review of the SN visit note dated 2/9/22, documents patient has stage 4 sacral wound, bilateral deep tissue injury, unstageable wounds to both heels with eschar tissue present, and trauma/scab area to left upper flank/scapula area. Review of the SN note dated 2/16/22, the SN documents patient has a wound to right shoulder. Review of SN note dated 2/17/22 , the SN documents patient has multiple stage 2 wounds on right shoulder blade area. Review of the SN visit note dated 3/2/22 , SN documents patient has a new wound to right ankle. During home visit on 3/15/22, at approximately 10: 00 a.m., the surveyor observed RN AA and RN BB provide multiple wound care to the patient as follows: 1. RN AA and RN BB cleansed the sacral area with saline and packed with Dakin's moist gauze and covered with ABD pads and secured with tape. 2. RN AA and RN BB cleansed bilateral heels with saline and applied Triad cream and covered with mepilex border. 3. RN AA and RN BB cleansed bilateral hips wound with saline , applied Triad cream, and covered with 4x4 gauze and mepilex border dressing. 4. RN AA and RN BB cleansed right ankle with saline and applied Triad cream and covered with mepilex border. 5. RN AA and RN BB changed the dressing at peg tube insertion site and flushed the tube with water. The comprehensive plan of care with certification period dated 2/1/22 to 5/1/22, lacked specific orders for Peg tube care, and wound care orders for bilateral hip, bilateral shoulder, bilateral heel, and the right ankle wound. On 3/16/22, upon request the Administrator provided the surveyor with wound care order dated 2/2/22, as follows: Cleanse sacral wound with wound cleanser, lightly pat dry, apply Dakin's solution (half or full solution) wet to dry dressing to wound bed, apply tape to keep ABD in place. Wound dressings to be changed three times a week. The plan of care and wound care orders lacks documentation of specific wound orders, status of the wound, progress towards the specific treatment, goals, and outcomes specific to P#3's multiple wounds. During an office interview on 3/16/22, at 12:00 p.m., the Administrator confirmed the surveyor was provided with current plan of care and wound care orders upon request.

Based on home visit observations, staff interviews and review of the agency's policy titled "Universal Precautions", it was determined the agency failed to ensure the staff followed accepted standards of practice to prevent the transmission of infectious and communicable diseases for one of three patients (P#3) sampled home visits. The findings include: During a home visit with patient#3 on 3/15/22, at 9:45 a.m., the surveyor observed Registered Nurse (RN BB) perform an bed bath and wound care to P#3 . During the entire bathing and wound care procedure, the RN did not change gloves, use sanitizer or wash hands between wound care and bed bath. RN BB used the same gloves to bathe P#3 and performed wound care to multiple wounds. The nurse failed to follow the agency policy for infection control measures to minimize the transmission of infectious and communicable diseases. During an interview on 3/16/21, at 12:00 p.m., the Administrator acknowledged the nurse did not follow acceptable standards for infection control to prevent transmission of infectious and communicable diseases.

Based on clinical record review and staff interview , it was determined that the hospice failed to ensure that a written form titled "Revocation or Transfer", and the discharge summary was completed at the time of patient's discharge for two of two discharged patients (P) (P#4 and P#5) who were previous hospice beneficiaries. The findings include: 1. The clinical record for patient#4 reflected an admitted to hospice on 8/9/21. Review of unattended discharge note dated 2/2/22, reflected P#4 was discharged from hospice services because the patient was transferred to another hospice per family request. The clinical record lacked the "Revocation or Transfer" form that would include the P#4 or caregiver's signature and date. The clinical record also lacked discharge summary that included a summary of the patient's stay including treatment; symptoms and pain management; the patient's current plan of care; the patient's latest physician orders; and any other documentation that would assist in post-discharge continuity of care. 2. Review of the clinical record for patient#5 revealed a admission date of 1/11/22 and revoked the hospice benefit on 2/2/22, to seek aggressive treatment. The clinical record lacked the "Revocation or Transfer" form that would include the patient's signature and date. The clinical record also lacked documentation of discharge summary to include a summary of the P#4 stay including treatment; symptoms and pain management; the patient's current plan of care; the patient's latest physician orders; and any other documentation that would assist in post-discharge continuity of care. During an interview on 3/16/22, at approximately 12:00 p.m. the Administrator was unable to provide documentation of the transfer /revocation form and the discharge summary for P#4 and P#5.

Based on clinical record review and staff interview , it was determined that the hospice failed to ensure a discharge summary was completed at the time of patient's discharge for two of two sampled discharge patients (P) (P#4 and P#5) who were previous hospice beneficiaries. The findings include: 1. The clinical record for patient #4 reflected an admission date of 8/9/21. Review of unattended discharge note dated 2/2/22, P#4 was discharged from hospice services because the patient was transferred to another hospice per family request. The clinical record lacked discharge summary of P#4's stay including treatment; symptoms and pain management; the patient's current plan of care; the patient's latest physician orders; and any other documentation that would assist in post-discharge continuity of care. 2. Review of the clinical record for patient #5 revealed an admission date of 1/11/22, and revoked the hospice benefit on 2/2/22, to seek aggressive treatment. The clinical record lacked documentation of discharge summary of P#5's stay including treatment; symptoms and pain management; the patient's current plan of care; the patient's latest physician orders; and any other documentation that would assist in post-discharge continuity of care. During an interview on 3/16/22, at approximately 12:00 p.m. the Administrator did not provide and addition information required to be noted on the discharge summary for P#4 and P#5.