Every finding on record at Marlette Regional Hospital United Hospice Service

Upon patient record review 3 of 21 (Patient #6, 11, 12) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 06: The patient was admitted on 10/29/24, the initial comprehensive Psychosocial assessment was completed on 11/12/24. Patient 11: The patient was admitted on 2/12/25, the initial comprehensive Psychosocial assessment was completed on 2/21/25. Patient 12: The patient was admitted on 12/7/24, the initial comprehensive psychosocial assessment was completed on 12/16/24.

Upon patient record review 4 of 21 (Patient #1, 7, 10, 15) did not have evidence in the patient record that the comprehensive assessment identifies 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. Patient 01: The patient was admitted on 4/1/25, a comprehensive spiritual care assessment has not been completed to date. Patient 07: The patient was admitted on 7/10/24, the patient declines spiritual care, but the record does not include a comprehensive spiritual care assessment to date. Patient 10: The patient was admitted on 4/22/25, the patient declines spiritual care, the record does not include a comprehensive spiritual care assessment performed by SW or RN. Patient 15: The patient was admitted on 5/12/25, the patient declines spiritual care, the record does not include a comprehensive spiritual care assessment performed by SW or RN.

Upon patient record review, 1 of 21 (Patient #6) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 06: The patient was admitted on 10/29/24, the record does not include assessment of imminence of death, there is no PPS score documented, there is no narrative note entered in the admission assessment to describe the patients health decline and approaching death.

Upon patient record review, 2 of 21 (Patient #7, 9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 07: The medication profile includes polyethylene glycol 17G packet, one packet by mouth daily. It does not include a diluent. Patient 09: The medication profile includes polyethylene glycol 17G packet, one packet by mouth daily. It does not include a diluent.

Upon patient record review, 9 of 21 (Patient #1, 7, 11, 12, 14, 15, 19, 20, 21) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 01: The patient was admitted on 4/1/25, the record does not include an initial bereavement risk assessment. Patient 07: The patient was admitted on 7/10/24, the record does not include a bereavement risk assessment to date. Patient 11: The patient was admitted on 2/12/25, the record does not include a bereavement risk assessment to date. Patient 12: The patient was admitted on 12/7/24, the initial bereavement risk assessment was completed on 4/29/25. Patient 14: The patient was admitted on 9/27/24, the initial bereavement risk assessment was completed on 4/25/25. Patient 15: The patient was admitted on 5/12/25, the record does not include an initial bereavement risk assessment to date. Patient 19: The patient was admitted on 5/1/24, the record does not include an initial bereavement risk assessment. Patient 20: The patient was admitted on 9/4/24, the record does not include an initial bereavement risk assessment. Patient 21: The patient was admitted on 12/11/14, the record does not include an initial bereavement risk assessment.

Upon patient record review, 3 of 21 (Patient #1, 3, 15) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 01: Upon admit, the patient record includes documentation of 2+ edema to the right upper extremity and left lower extremity along with 3+ pitting edema to bilateral feet. The plan of care does not include interventions and goals for the management of the edema. Patient 03: The patient was admitted to the IPU on 4/30/25, with a primary diagnosis of colorectal cancer. She has a gastrostomy tube, nephrostomy tube, colostomy, a bowel obstruction with pain related symptoms and edema, the plan of care does not include any nursing related problems with interventions and goals. Patient 15: The patient was admitted on 5/12/24 with a diagnosis of pancreatic cancer, she has a secondary non-related diagnosis of diabetes mellitus type II and takes insulin Aspart Flex Pen 3 times daily per sliding scale, she also takes insulin Tresiba 7 units every morning, the patient record does not include a problem statement with interventions and goals for the management of the diabetes.

Upon patient record review, 1 of 21 (Patient #3) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 03: The patient was admitted on 4/30/25, plan of care does not include frequency orders for skilled nursing or hospice aide visits.

Upon patient record review, 2 of 21 (Patient #7, 9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 07: The medication orders upon admit for polyethylene glycol 17G packet, one packet by mouth daily, do not include a diluent. Patient 09: The patient record indicates that a foley catheter was placed "per family request" on 5/16/25, the patient record does not include an order for the foley catheter. Medication orders on 5/3/25 for polyethylene glycol 17G packet, one packet by mouth daily, do not include a diluent.

Upon patient record review, 1 of 21 (Patient #8) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 08: The patient record upon admit indicates that the patient uses a walker to assist with ambulation, this is not included in the plan of care.

Upon patient record review, 2 of 21 (Patient #1, 7) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 01: The patient record includes documentation that the patient was experiencing loose bowels and orders were requested from the skilled nursing facility for Imodium. An order was entered on 4-3-25 for the Imodium A-D, the plan of care does not include a problem statement with interventions and goals for the management of the diarrhea. On 5/8/25 the patient record indicates that her Lasix was increased due to increased BLE edema, the plan of care does not include a problem statement with interventions and goals for the management of the edema. Patient 07: The patient utilizes aspirin 81mg by mouth daily for anticoagulation, the plan of care does not include bleeding precautions.

Upon client record review, 2 of 21 (Patient #7, 19) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 07: The patient record includes visits made by the SW on 5/16/25, the plan of care does not include frequency orders for SW services Patient 19: The plan of care includes frequency orders for SW visits 1 x per month, there is no evidence in the record that a SW visit was made in June 2024.

Upon patient record review, 1 of 21 (Patient #21) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 21: The patient record does not include a plan of care for bereavement services being provided for the bereaved.

Upon patient record review, 2 of 21 (Patient #3, 7) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable. Patient 03: The plan of care for hospice aid task assignments does not include a frequency for performing tasks of linen changes, oral care, showering, nail care, hair care, shampooing, skin care. Patient 07: The patient takes aspirin 81mg daily for anticoagulation therapy, the hospice task assignment does not include bleeding precautions.

Upon patient client record review, 1 of 21 (Patient #8) did not have evidence that each patient record contains Advance Directives. Patient 08: The patient consent to admit and Election of Hospice benefit are signed by the power of attorney, the record does not include a copy of the document for power of attorney.

Upon observation, there was no evidence cooking equipment is properly aligned with the fire suppression system. Cooking equipment in the commercial kitchen are noted to be wheeled appliances that are frequently moved for cleaning purposes. Changes or modifications to the hazard after installation of the fire-extinguishing systems shall result in reevaluation of the system design by a properly trained, qualified, and certified person(s). NFPA 96 Chapter 10.2.7.4, where it states “Changes or modifications to the hazard after installation of the fire-extinguishing systems shall result in reevaluation of the system design by a properly trained, qualified, and certified person(s).” Nozzle Alignment and Coverage: Ensure nozzles are correctly aligned to cover the cooking equipment and appliances they are designed to protect. Large commercial kitchens are known to have appliances on wheels that are mobile to make cleaning and operational activities easier. It is important to place these appliances back in the same spot they were previously placed. Do not rearrange the equipment, as you would be exposing your building to the risk of serious fire damage. The fire suppression system is specifically designed to extinguish a fire on each of the different cooking surfaces. If equipment is not aligned properly under the hood suppression system nozzles, then the system may not protect these surfaces. Nozzles pointed at floors, walls or non-cooking surfaces are not providing the necessary protection. It is observed that the facility kitchen has multiple cooking appliances that are on wheels and upon verbal discussion, the staff admit to moving the appliances for cleaning. Multiple ansul nozzles are not in alignment with protected area.

Upon observation, there was no evidence the hospice inpatient facility provides a sanitary environment. Sanitation: Ice machines must be cleaned and sanitized regularly to prevent bacterial and mold growth. This typically involves cleaning food-contact surfaces and removing any limescale or mineral buildup. Coffee machines should be cleaned and sanitized routinely to prevent the build up of contaminants. Upon observation it is identified that the facility utilizes a portable ice maker in the family kitchen, the ice machine is noted to have contaminants in the water supply, along with particles, limescale, and residue in the water holding tank. The facility does not have a cleaning policy or schedule for the ice maker. Upon observation it is identified that the Bunn coffee maker in the family kitchen has a significant amount of mold and contamination built up around the coffee filtering system. The facility does not have a cleaning policy or schedule for the coffee maker.

Based on record review and interview, the Agency failed to ensure an Emergency Preparedness Plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, that included strategies for the Covid-19 global pandemic, resulting in the potential for lack of preparedness and poor patient and staff outcomes, in the event of an actual emergency. Findings include: On 6/7/22 2:28 p.m., the Agency's Emergency Preparedness documents were reviewed with the Administrator present. The Risk Assessment dated 1/20/22 failed to incorporate the Covid-19 global pandemic. These findings were reviewed with and confirmed by Adm #1 at the time of discovery.

Based on record review and interview, the Agency failed to ensure all staff, including staff from the Agency's Hospice Residence, received initial and ongoing training in the Agency's Emergency Preparedness policies and procedures, 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, and all 11 patients currently serviced by this Agency. Findings include: On 6/7/22 at 2:28 p.m., the Agency's Emergency Preparedness documents were reviewed with the Administrator (Adm #1). During the review, it was noted that there was no documented evidence that the Hospice Residence staff had received initial and ongoing training in the agency's Emergency Preparedness Plan, policies and procedures. These findings were reviewed with and acknowledged by Adm #1 at the time of discovery.

Based on record review and interview, the Agency failed to provide documental evidence of staff's participation, including staff of the Hospice Residence, for the required Community/Facility based full-scale exercises from an all hazards approach, and failed to provide documentation of staff's participation in an actual event that would qualify as a test of the emergency plan, resulting in staff being unprepared in the event of an actual emergency. This deficient practice could negatively affect staff and all patients serviced by this Agency. Findings include: During a review of the agency's Emergency Preparedness documents on 6/7/22 at 2:38 p.m. with the Administrator (Adm #1), it was noted that there was no documented evidence of staff's actions or participation, including staff from the Hospice Residence, in the full-scale Community/Facility based drill that would satisfy this requirement. During the review/interview, Adm #1 reported, "We (Adm #1 and the Quality Assurance Nurse) attended a training with Region 3 on the topic of Covid-19 so we used that as our drill." Upon review of a provided document titled "Covid-19 Pandemic Response", there was no documentation of what actions were taken by the Hospice Agency and no evidence of staff's participation. The above findings were reviewed with and confirmed by the Adm #1 and the Quality Assurance Nurse at the time of discovery.

Based on observation and interview, the facility failed to ensure doors in a required means of egress are not equipped with a latch or lock that requires the use of a tool, key, or coded card from the egress side unless meeting the special locking arrangements for clinical needs in accordance with 19.2.2.2.5.1 and 19.2.2.2.6, special needs locking arrangements in accordance with 19.2.2.2.5.2, delayed egress locking in accordance with 19.2.2.2.4, access-controlled egress doors in accordance with 19.2.2.2.4, or elevator lobby exit access in accordance with 19.2.2.2.4. This deficient practice could affect 10 occupants in the event of an emergency evacuation. Findings Include: 1. On June 15, 2022 at approximately 11:50 AM observation revealed the south emergency exit door labeled door 29 is locked to egress and requires the use of a coded card to unlock the door to exit in an emergency situation. This could allow occupants to be trapped in an emergency situation. 2. On June 15, 2022 at approximately 12:15 PM observation revealed the facility main entry doors are equipped with 15 second delayed emergency egress hardware, however the door is not labeled with a sign stating "PUSH UNTIL ALARM SOUNDS DOOR WILL OPEN IN 15 SECONDS. This may lead to occupants not knowing how to use the door in an emergency situation. These findings were confirmed through interview with the Maintenance Director at the time of observation.

Based on observation and interview, the facility failed to ensure hospice facilities are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, as required by 19.3.5.1 through 19.3.5.5, 19.4.2, 19.3.5.10, 9.7 and 9.7.1.1(1). This deficient practice could affect all occupants in the event of a fire. Findings Include: 1. On June 15, 2022 at approximately 12:00 PM observation revealed the network closet off the main corridor is not protected with an automatic sprinkler system as required. This could potentially allow a fire to grow large and spread into the adjacent areas. 2. On June 15, 2022 at approximately 12:45 PM observation revealed the facility wet fire suppression system is not equipped with a restricted orifice at the end of the sprinkler line to simulate the flow of a single sprinkler head discharge to verify alarm within 90 seconds. This could potentially lead to delays in alarm activation during a fire. These findings were confirmed through interview with the Maintenance Director at the time of observation.

Based on record review and interview, the hospice failed to ensure the initial comprehensive assessment included a review of all medications to determine significant drug to drug interactions and duplicative drug therapies in 13 (MR#'s 1, 2, 3, 4, 5, 6, 7 ,8, 9, 10, 11, 12, 13) of 13 records reviewed, resulting in the potential for harmful medication effects for all 11 patients currently serviced by this Agency. Findings include: Agency Policy: "Hospice Initial and Comprehensive Assessment" PolicyStat ID: 11397888 (Revised 11/16/2012) stated, "Drug therapy - A review of the patient's prescription and over-the-counter drugs... This includes, but is not limited to, identification of the following: Effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy..." MR#'s 1-13: During clinical record review on 6/7/22 through 6/9/22, no evidence was found that a comprehensive review of medications was performed to ascertain significant drug to drug interactions and duplicative therapies in 13 of 13 records reviewed. For example, on 6/8/2022, MR #10's listed medications were entered into Drugs.com (online pharmaceutical encyclopedia for healthcare professionals) and the following report was generated: 6 major (highest level), 35 moderate and 5 duplicative drug therapies were found. A request was then made to the Agency's administrative staff to produce documentation of a comprehensive drug review for MR #10. At the survey's conclusion on 6/9/22 at 12:55 PM, no documentation was submitted by the Agency to indicate a comprehensive review of medications had been performed on any of the records reviewed during the survey. In addition, no evidence was found that the physician was made aware of any of the significant findings noted above with the potential for poor patient outcomes. The findings were reviewed with and confirmed by the Administrator (Adm.#1) during an interview on 6/9/22 at 10:50 AM. Adm.#1 stated, "Our EMR (electronic medical record) does a review of the medication by itself, but it doesn't look like it runs a profile with all the medications put together."

Based on document review and interview, the hospice failed to ensure the initial Bereavement Risk Assessment was comprehensive and included patient family members identified during the Initial Social Work Assessment and also noted during clinical record review to determine factors that may impact the family's ability to cope with the patient's impending death for 6 (MR#'s 8, 9, 10, 11, 1, 2) of 13 records reviewed from a total sample of 13 records. This deficient practice has the potential to negatively affect the loss/grief issues for all 162 patients/family members serviced within the past 12 months. Findings include: Agency Policy: "Hospice Bereavement Program" (Revised 7/6/21) PolicyStat ID: 10054565 stated, "A bereavement assessment will be completed with those individuals identified during the Initial Social Work Assessment and/or by the IDG (inter-disciplinary group) meeting." MR #8: The patient was admitted to hospice on 10/8/21 with terminal diagnosis of chronic obstructive pulmonary disease (COPD). On 6/7/22 at 2:45 PM., review of the MSW's (Master of Social Work) initial assessment (dated 10/11/21) documented under "Family contacts" the following individuals: Spouse, daughters times 4, sister, and "lives with her husband, a step-daughter and a step-granddaughter." However, the initial Bereavement Risk Assessment (BRA) performed by MSW services (10/11/21) only acknowledged the patient's spouse and failed to mention and incorporate the other listed family members noted above. In addition, 6 of 8 questions listed within the BRA were documented as "Unable to determine (UTD)" with no further clarification found during clinical record review. Examples include: "Current support system: UTD; Guilt: UTD; Ineffective coping: UTD; Current risk level: UTD..." The hospice failed to ensure the initial BRA comprehensively assessed the needs the patient's family. MR #9: The patient was admitted to hospice on 10/19/21 with terminal diagnoses of colon and bone cancer. On 6/8/22 at 8:45 AM., review of the MSW's initial assessment (dated 10/22/21) documented under "Family contacts" her four sons. However, the initial BRA performed by MSW services (10/22/21) only acknowledged one of the four listed sons. In addition, the BRA was void of any information to ascertain grieving/coping strategies such as "Acceptance of the illness-UTD; Anticipated financial status of the bereaved-UTD; Current support system-UTD; Guilt-UTD; Ineffective coping-UTD; Recent of difficult past losses-UTD; Current risk level-UTD." No further information or clarification concerning the BRA was found in the clinical record during review. MR #10: The patient was admitted to hospice on 9/9/21 with terminal diagnoses of ovarian and liver cancer. On 6/8/22 at 11:00 AM., review of the MSW's initial assessment (dated 9/10/21) documented under "Family contacts" her husband, two sons and a daughter. However, the initial BRA performed by MSW services (9/10/21) only acknowledged the husband. The BRA documented under the question "Is there another person" (outside of the husband) to which the MSW documented "No". The Bereavement Risk Assessment failed to assess all parties identified within "Initial Social Work Assessment" as stipulated by the Agency's policy referenced above. MR #11: The patient had a hospice start of care date to hospice on 4/1/22 with terminal diagnosis of congestive heart failure. On 6/8/22 at 2:40 PM., review of the MSW's initial assessment (dated 4/1/22) documented under "Family contacts" a niece and nephew (patient and deceased husband had no children). However, the initial BRA performed by MSW services (4/1/22) only acknowledged the niece despite documenting within the initial assessment that the patient "has nieces and nephews that are supportive and assist in her care." The BRA documented under the question "Is there another person" (outside of the listed niece) to which the MSW documented "No". These findings were reviewed with and acknowledged by the Administrator (Adm.#1), during an interview on 6/9/22 at 11:05 AM. Adm.#1 stated, "We'll (Agency) go over and review to make sure future assessments include all family members listed." MR #1: The patient was admitted to Hospice on 1/31/22. The benefit period reviewed was 5/1/22 through 6/9/22 with a terminal diagnosis of Congestive Heart Failure. On 6/6/22 at 2:00 p.m., a scheduled home visit was conducted with the Social Worker (MSW #1). During the visit, the patient and MSW #1 discussed significant family members that came by daily or frequently to assist with meals, repairs, or simply provided companionship. Those family members included the patient's son, daughter and son-in-law. On 6/8/22 at 10:00 a.m., during a review of the patient's Initial Bereavement Assessment dated 2/4/22, it was noted that the patient's son was the only person identified as a bereavement risk. The Initial Bereavement Assessment made no mention of the patient's daughter or son-in-law as persons who would be affected by the patient's death. MR #2: The patient was admitted to Hospice on 4/20/22. The period reviewed was 4/20/22 through 6/9/22 with a terminal diagnosis of Heart Failure. On 6/7/22 at 10:00 a.m., a scheduled home visit was conducted with the Registered Nurse (RN #1) at the Skilled Nursing Facility where the patient resided. During the onsite visit, the patient's chart was reviewed and revealed the patient had 1 son and 3 daughters. All of whom were listed as caregivers and had equal power of attorney. On 6/8/22 at 10:39 a.m., during a review of the patient's Initial Bereavement Assessment dated 4/27/22, it was noted that the patient's son was the only person included in the "Pre-Death Bereavement Assessment" and subsequently identified as a bereavement risk. The patient's 3 daughter's were not included in the Pre-Death Bereavement Assessment as persons who would also be affected by the patient's death. On 6/6/22 at 3:55 p.m. during the Bereavement Coordinator interview protocol MSW #1 was queried regarding who would be captured in the Initial Assessment and responded, "The person who is present at the time of the assessment is the only one included in the Initial Bereavement Assessment." The Hospice Agency failed to ensure that all parties that would be affected by the patient's death were included in the Pre-Death Bereavement Assessment.

Based on document review and interview, it was determined the Hospice failed to develop a patient specific plan of care that included specific interventions for pain and symptom management for 12 (MR's #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13) of 13 records, from a total of 13 sampled records reviewed, resulting in the potential for unrelieved pain and symptom management, and unmet care needs. Findings include: MR's #1 - 6: During a review of the above-mentioned patient records, it was noted that the associated Plans of Care were void of any patient specific interventions to monitor/assess/treat pain or symptoms associated with end of life. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during interviews on 6/8/22 at 3:30 p.m. who reviewed the documents and reported, "You're right. I don't see any specific pain interventions." The Hospice Agency failed to develop a patient specific plan of care that included interventions for pain and symptom management. MR's #7, 8, 9, 10, 11, 13: On 6/6/22 through 6/9/22, review of the preceding medical records noted the patient Plans of Care (POC) failed to incorporate pertinent palliative care measures concerning pain interventions and goals of the patient, while other records that included interventions and goals were found to be vague, generic, and not individualized. Findings include: Agency Policy: "Rights of the Hospice Patient" PolicyStat ID: 9907134 (Revised7/12/2016) stated, "The patient has the right to the following: Receive effective pain management and symptom control from the hospice for conditions related to the terminal illness." Agency Policy: "Hospice Interdisciplinary Group Care Planning and Coordination of Care" (Revised 3/2/17) PolicyStat ID: 11398063 stated, "The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: 1. Interventions to manage pain and symptoms... 3. Measurable outcomes anticipated from implementing and coordinating the plan of care." MR#7: (2 of 2 interventions documented): "Pain-Assess/monitor pain every shift and prn (as needed) status change, Discipline SN (Skilled Nursing); Obtain MD/NP medication and titration orders for comfort, Discipline SN, CNA (Certified Nursing Assistant)." Goals: (1 of 1 indirect): "Patient's symptoms will be brought to an acceptable level. - Who: Patient; Outcome: Ongoing." MR#8: No pain interventions noted. Goals: "Will report that the pain is reduced to the level personally desired, from complete relief to minimal discomfort - Who: Patient; Outcome: Ongoing." MR#9: (1 of 1 indirect pain intervention): Evaluate the effectiveness of routine and prn medications provided for symptom management and/or disease process, Discipline SN. Goals: "Will report that the pain is reduced to the level personally desired, from complete relief to minimal discomfort - Who: Patient; Outcome: Ongoing." MR#10: (1 of 1 indirect pain intervention): Assess/monitor the causative factors of symptoms requiring management, Discipline SN. No pain goals noted. MR#11: (1 of 1 indirect pain intervention): Assess/monitor the causative factors of symptoms requiring management, Discipline SN. No pain goals noted. MR #13: The patient was admitted on 4/8/22 with terminal diagnoses of adult failure to thrive, recurrent aspiration pneumonia, dysphagia, and malnutrition. On 6/8/22, review of the patient's "Plan of Care/Comprehensive Assessment - Initial" noted the following skilled nursing narrative: "Patient has had 3 hospitalizations in the last four months related to pneumonia, aspiration due to lack of stomach and tpn (nutritional support via catheter) being used. Her pain is well controlled while in hospital with iv dialudid and ativan but has been discharged without adequate pain control, she is distraught and uncomfortable with pain, and feels "this is not living", She no longer wants to seek aggressive or curative treatment." (sic) Further review of the patient's "Primary Plan of Care" noted of the listed 12 interventions for hospice care, none specifically addressed individualized strategies to manage the patient's uncontrolled pain. Of the 8 goals listed, only one mentioned pain which documented: "Will report that the pain is reduced to the level personally desired, from complete relief to minimal discomfort - Who: Patient; Outcome: Ongoing. None of the 8 listed goals were written in measurable terms to track and trend quantitatively progress made or not made concerning selected goals. An IDG (inter-disciplinary group) meeting which occurred on 4/21/22 at 8:30 AM was reviewed. It noted the patient suffers from anxiety with a significant history of depression and severe physical abuse from ex-husband. She (Patient) reported to the Social Worker in an IDG note she has received "CMH (Community Mental Health) services for over 30 years." The IDG documentation of 4/21/22 further notes the patient's medical guardian is "contacted for any medical decisions when (patient) is not of sound mind." The patient was discharged from the Hospice agency on 4/21/22 at 5 PM. The Discharge Summary dated 4/21/22 at 5 PM documented the following under the Summary of Care: "Efforts made to control (Patient's) pain and nausea, with medication changes and non pharmacological suggestions. Nursing notified through on call service that patient presented to er and Guardian was called for consent to treat. Guardian acknowledged that nursing had advised the patient that this was not part of benefit and would require revocation." (sic) Additional clinical record review noted no further entries or follow-up with the patient. These findings were reviewed with and acknowledged by the Administrator (Adm.#1), during an interview on 6/9/22 at 11:45 AM. Adm.#1 stated, "At the very least we should have had documentation of any follow-up that was performed, and I don't see any." The Agency failed to ensure the patient's POC was written in measurable terms as referenced in the policy above and failed to be individualized to help meet the patient's specific palliative care needs concerning uncontrolled pain.

Based on record review and interview, the Hospice failed to ensure the Plans of Care included the frequency/duration of visits necessary to meet the individualized needs of the patient and family in 12 (MR's #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13) of 13 records, from a total of 13 sampled records reviewed, resulting in the potential for the patient's not receiving care and services as ordered and unmet care needs. Findings include: Policy: "Hospice Interdisciplinary Group Care Planing and Coordination of Care" 3/17/22, 11398063 stated, "The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs." MR #1 - 6: During the onsite survey on 6/6/22 through 6/9/22, the above records were reviewed. Upon review, it was noted that none of the identified Plans of Care included a detailed statement of the scope, frequency and duration of services to be provided. The Hospice failed to follow its policy and ensure the Plans of Care included specific services and frequency/duration of services to meet the patient's and family/caregiver needs. The findings identified in the aforementioned records were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 6/8/22 at 3:14 p.m.. MR's #7, 8, 9, 10, 11, 13: It was noted during medical record review on 6/7/22 through 6/9/22, the Plans of Care (POC) for the preceding medical records failed to incorporate the following: duration of services, visit frequencies, and disciplines assigned to the case. During the survey, it was discovered the Agency utilizes a combination of "Primary Plan of Care" and "Plan of Care/Comprehensive Assessment - Initial" for its POC electronic medical record documentation. Information concerning duration of services, visit frequencies, and assigned disciplines were found outside the patient's POC without physician authentication. These findings were reviewed with the Administrator on 6/9/22 at 11:20 AM., and it was acknowledged the Plans of Care did not incorporate.

Based on record review and interview, it was determined that the Hospice agency failed to ensure the plan of care included patient specific measurable goals in 6 (MR's #7, 8, 9, 10, 11, 13) of 13 records reviewed out of a total sample of 13 records, resulting in the potential for unmet patient goals. Findings include: Agency Policy: "Hospice Interdisciplinary Group Care Planning and Coordination of Care" (Revised 3/2/17) PolicyStat ID: 11398063 stated, "The hospice must develop an individualized plan of care for each patient. The plan of care must include all services necessary for the palliation and management of the terminal illness and... Measurable outcomes anticipated form implementing and coordinating the plan of care." MR#'s 7-11, and 13: During the 6/6/22 through 6/9/22 review of the preceding records, it was noted that the Plans of Care (POC) were generic, not individualized and were not quantitative. All 6 patient record care plans indicated they were not stated in measurable terms that would enable the staff to accurately perform an objective evaluation of the patient's progress toward their goals. For example, the POC's included goals such as, "Patient will be safe; Patient will assist with ADLs (activities of daily living) as appropriate and able; Will continue or resume activities as tolerated." On 6/9/22 at 10:55 AM., the findings were reviewed with the Administrator, and it was acknowledged the Plans of Care did not include measurable goals.

Based on record review and interview, it was determined the Hospice failed to make bereavement services available to the bereaved family members/caregivers and others who would be affected by the patent's death, up to 1 year following the death of the patient in 1 (BRV #2) of 2 bereavement records reviewed, and failed to complete a bereavement plan of care that listed the bereaved family members/caregivers, and the frequency of service delivery in 1 (BRV #2) 2 bereavement records, resulting in the potential for ineffective coping/grieving and unmet bereavement needs. Findings include: "Hospice Bereavement Program" PolicyStat ID: 10054565, 7/6/2021 stated, "The hospice provides bereavement services to the family, caregivers and/or significant others of deceased hospice patients for thirteen months following the patient's death..., The bereavement services provided are based on the assessed needs and/or requests of the deceased's survivors and are in accordance with a bereavement plan of care formulated after the patient's death." On 6/6/22 at 3:55 p.m., an interview was conducted with the Bereavement coordinator (MSW #1) who reported, "Bereavement services are available to family/other individuals for 13 months after the patient's death." When asked what parties are captured in the Initial Bereavement Assessment, MSW #1 reported, "spouse, children, family, friends, hired caregivers. The majority would include spouses or children." At the conclusion of the interview, MSW #1 was asked to provide 2 Bereavement records for review that included the Bereavement Plan of Care. On 6/7/22, during a subsequent interview and review of the bereavement records, MSW #1 was asked what parties are included in the Initial Bereavement Assessment and responded, "Usually the person who is there/present at the time." No Bereavement POC had been provided as requested, or by the survey's end. The Agency failed to develop a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery, and failed to make bereavement services available to all who may have been affected by the patient's death.

Based on record review and interview, the Hospice failed to provide spiritual counseling to meet the needs of the patient and family; and failed to make all reasonable efforts to provide a clergy/pastoral visit for 2 (MR #3, 5) 3 records in which Spiritual Care Services were to be provided, from a total of 13 sampled records reviewed, resulting in spiritual care needs not being met prior to the patient's death and feelings of hopelessness. Findings include: Policy: "Hospice Counseling Services" 11398180, dated 3/17/22 stated, "Spiritual counseling: The hospice will provide spiritual counseling to meet these needs in accordance with the patient's and family's acceptance of this service, and in a manner consistent with patient and family beliefs and desires..., Make all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or other individuals who can support the patient's spiritual needs to the best of its ability." MR #3: This patient was admitted to Hospice on 6/5/22 with a terminal diagnosis of CVA (Stroke). During the clinical record review on 6/8/22 at 11:23 a.m., it was noted that the plan of care (POC) indicated the patient was to receive Spiritual Care services at a frequency of 2x/wk. No Spiritual Care services had been initiated/provided by the end of the survey. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 6/8/22 at 3:14 p.m. MR #5: The patient was admitted to Hospice on 2/9/22 with a terminal diagnosis of Covid-19. The POC ordered Spiritual Care services to be provided at a frequency of 2x/wk. During the clinical record review on 6/8/22 at 1:55 p.m., it was noted that the patient was discharged to the community on 4/9/22. Further review revealed the patient did not receive any Spiritual Care (SC) services the first week of care. The patient was scheduled to receive a total of 18 SC visits. Upon review, the patient was only provided 9 SC visits. Additionally, there was no documented evidence of patient refusal of services. On 6/9/22 at 10:25 a.m., an interview was conducted with the Volunteer/Spiritual Care Coordinator (VSCC #1). When queried about the SC missed visits, VSCC #1 reported, "The pastor became ill and couldn't visit the patient." When asked if there were any other clergy available to meet the needs of the patient, VSCC #1 reported, "Yes. I didn't think to ask him (Clergy) to cover. I just didn't think of that." The Agency failed to ensure the patient's Spiritual Care needs were adequately met.

Based on record review and interview, skilled nursing (SN) failed to ensure the written plan of care for the assigned Hospice Aide provided specific guidance/care instructions and all pertinent safety precautions concerning the needs of the patient for 2 (MR#'s 7 and 10) of 12 records with Hospice Aide services ordered from a total of 13 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes for all 11 patients serviced by this Agency. Findings include: MR #7: The patient's start of care (SOC) was 6/4/22 with a terminal primary diagnosis of congestive heart failure (CHF). On 6/7/22, review of the Hospice Aide plan of care (POC) found the following instructions to be performed by the aide: "Bed bath, 2x (twice) per week & prn (as needed); Clean Nails HAND, with bath & prn; Clean Nails FOOT, with bath & prn." The frequencies of the Hospice Aide POC interventions referenced above were written in terms that enabled the Hospice Aide to potentially provide care without specific instructions concerning the timeframes for all services provided by the Hospice Aide. This finding was reviewed and discussed with the Administrator (Adm.#1) during an interview on 6/7/22 at 11:45 AM. Adm.#1 stated, "We know the aide care plan cannot have prn instructions written on them, I'll send out an email reminding the nurses of this." MR #10: The patient's SOC was 9/9/2021, with a terminal primary diagnosis of ovarian cancer with dementia. The patient was transferred from home to the Agency's Hospice Residence facility on 9/20/21 with Hospice Aide services to be provided effective from the SOC date though admission. On 6/8/22, review of the initial physician admitting orders (dated 9/9/21) noted under "Safety Precautions" that aspiration (swallowing) precautions were to be implemented. Further review of the clinical record found no evidence that an Aide POC was written when the patient was living at home from 9/9/21 through 9/20/21. In addition, when the patient was transferred to the Hospice Residence on 9/20/21, a new Aide POC was generated by skilled nursing (effective 9/20/21). This Aide POC failed to incorporate the aspiration precautions noted on the physician orders.

Based on record review and interview, the Agency failed to ensure the information in the clinical record was accurate and complete in 3 of 13 records reviewed (MR#'s 8, 9, 10) out of a total sample of 13 records reviewed, resulting in pertinent information to be missing within the clinical record and the potential for patient needs not being met. Findings included: Agency Policy: "Hospice Interdisciplinary Group Care Planning and Coordination of Care" (Revised 3/2/17) PolicyStat ID: 11398063 stated, "The hospice IDG (in collaboration with the individual's attending physician, if any) must review, revise and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days." Agency Policy: "Hospice Clinical Record" (Revised2/4/2013) PolicyStat ID: 11077481 stated, "A clinical record containing past and current findings will be maintained for each hospice patient. The patient record will contain sufficient information to identify the patient, describe patient problems and needs, justify care, accurately document care provided and results in detail..." MR #8: The patient was admitted to hospice on 10/8/21 with terminal diagnoses of chronic obstructive pulmonary disease (COPD). On 6/7/22, the Agency's IDG (Inter-Disciplinary Group) meeting documentation concerning the patient's hospice care was reviewed. The clinical record noted IDG meetings on 3/24/22 with the next IDG meeting occurring on 4/21/22. The Administrator (Adm.#1) was queried about this finding (IDG meetings are to be held within 15 days per policy above) during an interview on 6/9/22 at 10:25 AM. Adm.#1 after reviewing the clinical record, acknowledged the finding and stated, "I'll have my staff look into it because I know it was done on or around April 7th." MR #9: The patient was admitted to hospice on 10/19/21 with terminal diagnoses of colon and bone cancer. On 6/8/22, the Agency's IDG meeting documentation concerning patient care was reviewed. The clinical record noted IDG meetings on 2/3/22 with the next IDG meeting occurring on 3/3/22. The Adm.#1 was queried about this finding during an interview on 6/9/22 at 10:40 AM. Adm.#1 after reviewing the clinical record acknowledged the finding and stated, "Looks like the same issue, we have our IDG meetings every Thursday, it's just not showing up in our records for some reason." MR #10: The patient's start of care (SOC) was 9/9/2021, with a terminal primary diagnosis of ovarian cancer with dementia. The patient was transferred from home to the Agency's Hospice Residence facility on 9/20/21 with hospice aide services to be provided effective from the SOC date though admission. On 6/8/22, review of the clinical record noted aide services were to provide weekly visits when the patient resided at home, which was changed to twice a day (morning and night shift) upon Hospice Residence admission on 9/20/21. However, no hospice aide plan of care (POC) was evidenced in the clinical record during review. Administrative staff was then queried to produce evidence of an aide POC. At time of survey exit on 6/9/22 at 12:55 PM., no submission of a hospice aide POC was noted. During an interview with the Administrator (Adm.#1) on 6/9/22 at 11:35 AM, the above findings were reviewed and acknowledged. Adm.#1 stated, "We worked with Hummingbird (Agency's electronic medical records company) to try and find it but weren't able to." The Agency failed to ensure the clinical records noted above were maintained to reflect accurately the clinical treatments, interventions, and plans of care implemented.

Based on record review and interview, the hospice failed to ensure the Plan of Care (POC) was appropriately authenticated by the physician for 13 (MR#'s 1-13) of 13 records reviewed, resulting in the POC scheduled visit frequency to be implemented without documented physician approval for all 11 patients currently serviced by this Agency. Findings include: Agency Policy: "Hospice Interdisciplinary Group Care Planning and Coordination of Care" (Revised 3/2/17) PolicyStat ID: 11398063 stated, "The hospice IDG (in collaboration with the individual's attending physician, if any) must review, revise and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days." MR#'s 1-13: During clinical record review on 6/7/22 through 6/9/22, all patient POC's (13 of 13) were found to be void of any proposed visit frequencies. The Agency's EMR (electronic medical record) utilized proposed "Visit Frequencies" in a separate section apart from the patient's POC. No physician authentication concerning scheduled patient visits (all disciplines) was found until the first IDG (inter-disciplinary group) meeting was scheduled per policy referenced above. The above findings were reviewed with and confirmed by the Administrator (Adm. #1) during an interview on 6/9/22 at 10:50 AM. Adm. #1 stated, "We'll work with Hummingbird (Agency's EMR) to get this addressed."

Based on observation and interview, it was determined that the Agency failed to ensure expired drugs were removed from patient use, which resulted in potential for harm to all 5 patients currently admitted to the Hospice Residence should outdated medications be given. Findings include: On 6/7/22 at 9:20 AM, during the tour of the hospice residence medication room with the Agency Administrator and the Director of Support Services, the following expired medications were observed on the shelf ready for patient use: 2 of 4 boxes of Humulin N (insulin) U-100 with an expiration date of 5-2022. During an interview 0925 AM., the pharmacy technician was queried concerning the finding and responded, "It looks like those boxes expired this last month and were missed." The Administrator confirmed the finding during the time of observation.

Based on obervation and interview the facility failed to ensure the hospice residence physical plant was safe from fire. The cumulative effect of the non-compliant equipment have the potential lead to delays in supressing fire and/or impedeing patient, staff, and visitor egress from the facility. (see L-728).

Based on observation and interview, the hopsice failed to ensure that Life Saftey Code (LSC) standards had not been met when inspected by the Bureau of Community & Health Systems, Environmental Health and Safety Section found non-compliance with fire doors and sprinkler systems present within the facility. The non-compliant equipment have the potential lead to delays in supressing fire and/or impedeing patient, staff, and visitor egress from the facility in case of fire. See attached LSC report.

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 #2, 6) of 2 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 #2: The patient was admitted to Hospice on 4/20/22 with a terminal diagnosis of Heart Failure. During a review of the clinical record on 6/8/22 at 10:39 a.m., it was noted that the patient resided in a Skilled Nursing Facility (SNF) and was ordered to have Skilled Nursing (SN), Aide services, and Medical Social Work (MSW) services provided. On 6/7/22 at 10:00 a.m., a visit was conducted at the SNF with the Skilled Nurse (RN #1). During the onsite visit, the patient's Hospice plan of care (POC) was reviewed. The POC did not clearly specify who (Hospice or SNF staff) would be responsible for the provision of the ordered/needed services. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 6/8/22 at 3:12 p.m. MR #6: The patient was admitted to Hospice on 1/4/22 with a terminal diagnosis of Pneumonitis due to inhalation of food/vomit. During a review of the clinical record on 6/8/22 at 10:39 a.m., it was noted that the patient resided in a SNF and was ordered to have SN and MSW services provided. Upon review, the POC did not clearly specify who (Hospice or SNF staff) would be responsible for the provision of the ordered/needed services. These findings were reviewed with and acknowledged by Adm #1 during an interview on 6/8/22 at 3:30 p.m.

Based on record review and interview, it was determined that the Hospice failed to ensure the Hospice plan of care reflected the collaborative participation of the Hospice, Skilled Nursing Facility and the patient/family in 2 (MR's #2, 6) of 2 records of patients who resided in a Skilled Nursing Facility, resulting in the potential for ineffective coordination and provision of care and unmet care needs. Findings include: MR #2: Nursing home resident, admitted 4/20/22. The period of review was 4/20/22 through 6/9/22. On 6/8/22 at 10:39 a.m., during the review of the patient's Hospice Plan of Care (POC), it was noted that participation by the nursing home staff and patient/family was not reflected in the problems, interventions and documentation of outcomes. MR #6: Nursing home resident, (Discharged), admitted 1/4/22. On 6/8/22 at 6:00 p.m., during the review of the patient's Hospice POC, it was noted that participation by the nursing home staff and patient/family was not reflected in the problems, interventions and documentation of outcomes. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 6/8/22 at 3:30 p.m.

Based on observation, interview and record review, it was determined that the Hospice failed to ensure the Hospice Election of Benefits form, patient Advance Directives and the Physician's Certification of Terminal Illness was provided to the Skilled Nursing Facility for 1 (MR #2) of 1 patient who resided in the Skilled Nursing Facility and observed during an onsite visit, from a total of 13 records review, resulting in the potential for lack of coordinated care during the end of life. Findings include: MR #2: This patient was admitted to Hospice on 4/20/22 with a terminal diagnosis of Heart Failure. During a review of the clinical record on 6/8/22 at 10:39 a.m., it was noted that the patient resided in a Skilled Nursing Facility (SNF) and was ordered to have Skilled Nursing (SN), Aide services, and Medical Social Work (MSW) services provided. On 6/7/22 at 10:00 a.m., a visit was conducted at the SNF with the Hospice Skilled Nurse (RN #1). During the onsite visit, the patient's chart was reviewed. None of the aforementioned documents were observed in the patient's physical chart. A nurse seated at the nurse's station was asked if there were any other documents for this patient with their EMR (electronic medical record) system to which she replied "yes". The nurse printed the SNF generated face sheet and a copy of the Hospice plan of care (POC). RN #1, who was present during the request, stated, "We keep all those papers at the Hospice." There was no evidence the Hospice provided the SNF with a copy of the above-mentioned documents as required. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 6/8/22 at 3:12 p.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 Administrator (Adm #1) on 6/7/22 at 12:40 p.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. Adm #1 provided a stack of documents with various titles that included: Safety precautions, Pain in Geriatric patient, End of Life education and stated, "These are the in-services we make available to our staff. We basically let them pick whichever topic they want." When ask if training had been provided to the staff at the SNF, Adm #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.