Every finding on record at Medi-Plex Hospice, LLC

Based on policy review, record review, and interview, the hospice provider failed to ensure a complete and accurate list of all the medications that the patient was currently using in two of four home visit observations (Records/Patients #1 and #4). This deficient practice has the potential to affect the hospice provider's ability to ensure safe and effective use of medications for all patients served by the provider. --- RECORD/PATIENT #4: During a home visit observation on 05/29/2024 beginning at 10:02 AM showed the following medication discrepancy with the current medication profile: - The providers medication profile showed an order for vitamin D3 50000 international units (IU) by mouth monthly. The patients caregiver stated he/she takes vitamin D3 50000 IU weekly and has been since 02/16/2024. Findings included: Review of the provider's policy titled, ";Medication Profile," revised 06/2019, showed in part: - The nurse will add all new/changed medication(s) to the medication profile; - Discontinued (D/C) medications will be documented and dated; and - The medication profile will be reviewed every home visit, updated as changes occur and reviewed by the interdisciplinary group (IDG). RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted on 02/03/2024 with senile degeneration of the brain. The patient resided in a long-term care facility (LTCF). Review of the hospice providers medication list and the LTCFs medication orders, showed the following discrepancies:- The hospice providers medication list, for benefit period 05/03/2024 to 07/31/2024, showed metoprolol succinate (a long acting medication used to treat high blood pressure) 50 milligram (mg) oral tablet extended release twice daily. The LTCFs medication orders, dated 05/28/2024, failed to contain this order and showed metoprolol tartrate (a short acting medication used to treat high blood pressure) 50 mg tablet twice daily; - The hospice providers medication list, for benefit period 05/03/2024 to 07/31/2024, showed Milk of Magnesia (used to treat constipation) 30 milliliters (ml) every four hours as needed. The LTCFs medication orders, dated 05/28/2024, showed Milk of Magnesia 30 ml every 24 hours as needed; - The hospice providers medication list, for benefit period 05/03/2024 to 07/31/2024, showed triamcinolone acetonide (used to treat rash) topical ointment 0.1 % three times daily. The LTCFs medication orders, dated 05/28/2024, showed triamcinolone acetonide topical ointment 0.1 % once daily; and - The LTCFs medication orders, dated 05/28/2024, showed permethrin (used to treat head lice and scabies) external cream 5% applied to entire body topically one time only for scabies for one day in the evening for 12 hours then shower in the morning with a start date of 5/30/2024. The hospice providers medication list did not have an order for permethrin. During an interview on 05/30/2024 at 5:30 PM, the hospice administrator stated that he/she was not aware of the need for the treatment of scabies and did not know about the medication order. The administrator stated that medication lists should be reconciled at every visit.

Based on policy review, record review, and interview, the provider failed to complete an initial bereavement risk assessment in one of five full records reviewed (Record/Patient #4.) This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the provider's policy, "Bereavement Services," revised 02/2022, showed an initial Bereavement Risk Assessment will be performed as a part of the Comprehensive Assessment and bereavement assessment and clinical notes are documented in the patient's permanent clinical records. RECORD/PATIENT #4: Review of the clinical record showed: -Patient was admitted to hospice services on 07/21/2023; and -Review of the clinical record failed to show an initial bereavement risk score. During an interview on 05/29/2024 at 1:30 PM, the registered nurse coordinator stated there was no bereavement assessment completed.

Based on policy review, record review, and interview, the hospice provider failed to ensure the patient's plan of care (POC) was individualized in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the provider's policy titled, "Initial Assessment/Comprehensive Assessment," dated 02/2021, showed in part, the initial assessment gathers essential information necessary to begin the plan of care and provide the immediate necessary care and services. RECORD/PATIENT #2: Review of the clinical record showed patient admitted to hospice services on 5/22/2024 with a terminal diagnosis of protein calorie malnutrition (state of inadequate food intake). The patient resided in a long-term care facility (LTCF). Review of the document titled, "Registered Nurse (RN) Initial/ Comprehensive Assessment," dated 05/22/2024, showed the patient wore a cardiac monitoring vest and was at an increased risk for falls. Review of the document titled, "Initial Plan of Care," dated 05/22/2024-08/19/2024, failed to show any interventions related to the patient's cardiac devices or risk for falls. During an interview on 05/30/2024 at 10:00 AM, the hospice administrator stated that he/she could not find where the items were care planned.

Based on policy review, record review, and interview, the hospice provider failed to ensure that the care and services were provided in accordance with the plan of care in, but not limited to, one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the provider's policy "Coordination of Patient Care" revised 06/2019, showed in part the provider ensured that care and services are provided in accordance with the plan of care and are based on all assessments of the patient and family needs. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted on 02/03/2024 with senile degeneration of the brain (mental deterioration or loss of intellectual ability). The patient resided in a long-term care facility (LTCF). Review of the patients plan of care, dated 02/03/2024 to 05/02/2024, showed the following: - Skilled Nurse one visit per week for 14 weeks; - Medical Social Worker three visits per month for four months; and - Spiritual Counselor three visits per month for four months. Review of the patients clinical record showed the following: - One medical social worker visit during the month of April; and - One spiritual counselor visit during the month of April. The clinical record failed to show any skilled nurse visits for the weeks of 04/21/2024 and 04/28/2024. Review of the patients plan of care, dated 05/03/2024 to 07/31/2024, showed the following: - Skilled Nurse one visit per week for 14 weeks; - Medical Social Worker one visit per month for three months; and - Spiritual Counselor one visit per month for three months. Review of the patients clinical record failed to show the following: - Any skilled nurse visits for the weeks of 05/05/2024 and 05/19/2024; - Any medical social worker visits for 05/03/2024 to 05/30/2024; and - Any spiritual counselor visits for 05/03/2024 to 05/30/2024. During an interview on 05/30/2024 at 9:50 AM, the administrator stated that the plan of care should not include three visits per month for the medical social worker and the spiritual counselor, because ";everyone" got one visit per month.

Based on policy review, contract review, and interview, the hospice provider failed to ensure professional management responsibility for services under arrangement when the long-term care facility (LTCF) for respite services and general inpatient care (GIP; short-term care for symptom management) contracts failed to include the following: - Required services to be authorized by the hospice; - Required services to be furnished in a safe and effective manner by qualified personnel; - Hospice must retain administrative management for oversight of services; and - Hospice must retain financial management responsibility for services. This deficient practice has the potential to affect all patients that receive respite care or GIP care that are on service with the provider. --- Review of the hospice provider's policy titled, "Written Agreements/Contracts with Providers," dated 02/2021, showed that when hospice has a written agreement with another agency, individual, or organization to furnish any services under arrangement, hospice will retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged services are supported by written agreements that require that all services be authorized by hospice, furnished in a safe and effective manner by qualified personnel, and delivered in accordance with the patient's plan of care. Review of the Skilled Nursing and Respite Facility Agreement, dated 09/11/2023, showed the contract failed to include that required services were to be furnished in a safe and effective manner by qualified personnel and that hospice must retain administrative management for oversight of services. Review of the Nursing Facility Services Agreement (Basic, Respite, and General Inpatient Care for Hospice Patients), dated 12/17/2014, showed the contract failed to include that hospice must retain financial management responsibility for services. Findings included: During the survey entrance on 05/29/2024 at 3:00 PM the long-term care respite contract and GIP contract was requested from the hospice administrator. Review of a Skilled Nursing Facility Agreement for respite services dated 10/10/2018, and a GIP contract showed no delineated information regarding the required services to be authorized by the hospice and for required services to be furnished in a safe and effective manner by qualified personnel and hospice administrative management for oversight of services. During an interview 05/30/2024 at 4:30 PM, the administrator stated that he/she did not know there were old contracts still and he/she has new contracts prepared but did not have them signed for those providers reviewed. The provider failed to ensure written contracts/agreements included all the required components to ensure professional management responsibility for services under arrangement.

Based on policy review, record review, and interview, the hospice provider failed to ensure that a discharge order was received for all patients in one of two discharge records reviewed (Record/Patient #7). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the provider's policy titled, "Discharge Summary," dated 06/2019, showed in part, the hospice discharge summary will include discharge orders, instructions, medication profile and allergies, if discharge is other than patients death. RECORD/PATIENT #7: Review of the discharge record showed the patient discharged from hospice services on 04/22/2024. Review of the record showed a physician's order for discharge dated 05/30/2024. During an interview on 05/30/2024 at 12:00 PM, the administrator stated that the order dated 05/30/2024 was the only discharge order they had for the patient.

Based on policy review, record review, and interview, the hospice provider failed to ensure all record entries were appropriately authenticated and dated in three of ten records reviewed (Records/Patients #1, #5, and #10). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: RECORD/PATIENT #1: Review of the patients initial plan of care electronically signed by the physician on 02/14/2024 and the recertification plan of care electronically signed by the physician on 05/26/2024 showed no known allergies. Review of the patients order summary report from the long term care facility (LTCF) dated 05/28/2024 showed the following allergies: codeine, hydrochlorothiazide, and Aleve. During an interview on 05/30/2024 at 9:50 AM, the administrator stated that it was an "oversight" to not include the patient's allergies on the hospice plan of care. RECORD/PATIENT #10: Review of the patients initial plan of care electronically signed by the registered nurse on 12/07/2023 showed bacitracin (used to treat bacterial skin infections) 500 units/gram topical ointment daily for wound care to peri wounds. Review of the patients initial plan of care electronically signed by the registered nurse on 12/07/2023 failed to address peri wounds. Review of the patients physician order electronically signed by the registered nurse on 12/07/2023 showed attending physician ordered bacitracin 500 units/gram topical ointment daily to peri wounds. During an interview on 05/30/2024 at 3:30 PM, the administrator stated that the patient had no peri wounds at the time of admission on 12/07/2023. He/She could not explain why there was an order for treatment if there were no wounds. Findings included: Review of the hospice provider's policy titled, "Timely Submission of Patient Documentation," dated 06/2019, showed itineraries, with all visit reports attached, must be submitted the next scheduled work day, not exceeding two business days. Review of the hospice provider's policy titled, "Patient Record Content," dated 06/2019, showed, in part, the following: -Hospice will initiate and maintain an individual and accurate patient record containing past and current findings for each patient receiving care in compliance with all federal/state laws and regulations; and -All entries must be legible, clear, complete, and appropriately authenticated. RECORD/PATIENT #5: Review of the psychosocial visits showed the following: -A visit, dated 04/18/2024, where the family expressed an interest in respite; -A visit, dated 04/26/2024, where the patient's son discussed that the family members are exhausted; and -A PRN (as needed) visit, dated 05/22/2024, that stated it was a routine followup visit to discuss client's caregiver services. During an interview on 05/30/2024 at 12:00 PM, the social worker (SW) provided a hand written visit addendum, dated 04/21/2024, that discussed further communication with the patient's family from 04/21/2024 to 05/22/2024. The social worker then stated that he/she wrote the note prior to the interview on 05/30/2024. During an interview on 05/30/2024 at 3:00 PM, the administrator stated that he/she would expect communication with patients and caregivers to be documented when completed.

Based on policy review, record review, and interview, the hospice provider failed to provide the discharge summary in, but not limited to, one of five discharged patients (Record/Patient #10). This deficient practice has the potential to affect all patients discharged by the provider. --- Findings included: Review of the provider's policy "Patient Record Content" revised 06/2019, showed in part, the following: - Each patient record will contain a discharge summary when patient is discharged from Hospice; and - Any summaries of the patient's care, treatment and services furnished to patient's physician. RECORD/PATIENT # 10: Review of the clinical record showed the patient was discharged on 02/27/2024 and a copy of the discharge summary was sent to the attending physician. During an interview on 05/30/2024 at 3:30 PM, the administrator failed to provide the discharge summary for Patient #10.

Based on policy review, record review, and interview, the hospice provider failed to ensure that the 24 hour nursing services that meet the needs of the patient in accordance with the plan of care (POC) be contained in the respite contract in one of one respite contract reviewed. This deficient practice has the potential to affect all patients that receive respite care. --- Findings included: Review of the provider's policy titled, "Written Agreements/Contracts with Providers," dated 02/2021, showed: -The written agreement with an outside agency or individual providing contracted services for Hospice includes: *Identification of the scope of services to be provided; and *A stipulation that services will be delivered in accordance with the patient's plan of care. Review of the Skilled Nursing and Respite Facility Agreement showed the contract failed to contain the verbiage that the facility must provide 24-hour nursing services that meet the needs of the patient in accordance with the POC. During an interview on 05/30/2024 at 4:30 PM, the administrator stated that he/she did not know that there were old contracts still in circulation and the provider had new contracts prepared.

Based on contract review and interview, the hospice provider failed to ensure that the respite contract included that the inpatient provider would establish patient care policies that were consistent with hospice and that the inpatient provider agreed to abide by the palliative care protocols and plan of care established by hospice in one of one respite contract reviewed. This deficient practice has the potential to affect all patients that receive short-term inpatient care. --- Findings included: Review of the Skilled Nursing and Respite Facility Agreement, dated 09/11/2023, showed the contract failed to contain the following elements: -The inpatient provider would establish patient care policies that were consistent with hospice; and -The inpatient provider agreed to abide by the palliative care protocols and plan of care established by hospice. During an interview on 05/30/2024 at 4:30 PM, the administrator stated that he/she did not know there were old contracts still in circulation and there were new contracts already prepared.

Based on contract review and interview, the hospice provider failed to ensure that the respite and general inpatient (GIP) contracts failed to contain elements regarding the clinical record in two of three contract reviewed. This deficient practice has the potential to affect all patients that receive respite or GIP services. --- Findings included: RESPITE CONTRACT: Review of the Skilled Nursing and Respite Facility Agreement, dated 09/11/2023, showed the contract failed to contain the following verbiage: -Inpatient clinical record includes all inpatient services furnished and events regarding care that occurred at the facility; and -Copy of the discharge summary and/or clinical record to be supplied to hospice at the time of discharge. GIP CONTRACT: Review of the Nursing Facility Services Agreement, dated 12/17/2014, showed the contract failed to contain the following verbiage: -Inpatient clinical record includes all inpatient services furnished and events regarding care that occurred at the facility; and -Copy of the discharge summary and/or clinical record to be supplied to hospice at the time of discharge. During an interview on 05/30/2024 at 4:30 PM, the administrator stated that he/she did not realize there were old contracts still in circulation and the provider had new contracts prepared.

Based on contract review and interview, the provider failed to specify the process in which the facility and provider are to communicate with each other and document to ensure the needs of the patient are met 24 hours per day/7 days per week. This deficient practice has the potential to affect care of any patient on hospice service that receives care in a long-term care facility (LTCF). --- Findings included: Review of the providers contract titled, "Skilled Nursing and Respite FACILITY AGREEMENT," dated 10/10/18 with a contracted LTCF failed to specify the process in which the facility and provider were to communicate with each other and document to ensure the needs of the patient were met 24 hours per day/7 days per week. The provider failed to ensure written contracts/agreements included all the required components to ensure professional management responsibility for services under arrangement. During an interview 05/30/2024 at 4:30 PM, the administrator stated that he/she did not know there were old contracts still and he/she had new contracts prepared but did not have them signed for the providers reviewed.

Based on contract review and interview, the written agreements between the provider and the skilled nursing facility (SNF) failed to specify the required provision of addressing when to immediately notify the hospice provider. This deficient practice has the potential to affect care of any patient on hospice service that receives care at a long-term care facility (LTCF). --- Findings included: Review of the respite contract dated 10/10/2018, showed the contract failed to include the provision that the hospice would be notified if: - Significant change in a patient's physical, mental, social or emotional status occurs; - Clinical complications appear that suggest a need to alter the plan of care; - A need to transfer from the facility - hospice makes arrangements for, and remains responsible for, any necessary continuous care or inpatient care related to the terminal illness and related conditions; and - A patient dies. The provider failed to ensure written contracts/agreements included all the required components to ensure professional management responsibility for services under arrangement. During an interview on 05/30/2024 at 4:30 PM, the administrator stated that he/she did not know there were old contracts still and he/she had new contracts prepared but did not have them signed for the providers reviewed.

Based on contract review and interview, the respite contract failed to specify the required provision addressing the extent of using facility staff to assist in the care of the patient. This deficient practice has the potential to affect care of any patient that is on hospice services and receives care at a long-term care facility (LTCF). --- Findings included: During the survey entrance on 05/29/2024 at 3:00 PM the respite contract was requested from the hospice administrator. The administrator provided a signed contract for respite dated 10/10/2018. Review of the respite contract, dated 10/10/2018, showed the contract failed to include the provision stating that the hospice may use facility nursing personnel for administration of prescribed therapies that a hospice family member would normally provide. The provider failed to ensure written contracts/agreements included all the required components to ensure professional management responsibility for services under arrangement. During an interview on 05/30/2024 at 4:30 PM, the administrator stated that he/she did not know there were old contracts still and he/she had new contracts prepared but did not have them signed for the providers reviewed.

Based on contract review and interview, the provider respite contract failed to specify the provision that hospice must report all alleged violations. This deficient practice has the potential to affect care of any patient on hospice service that receives care in a long-term care facility (LTCF). --- Findings included: During the survey entrance on 05/29/2024 at 3:00 PM the respite contract was requested from the hospice administrator. The administrator provided a signed contract for respite dated 10/10/2018. Review of the respite contract, dated 10/10/2018, showed the contract failed to include a provision stating that the hospice must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source and misappropriation of patient property by anyone unrelated to the hospice to the SNF (skilled nursing facility) administrator within 24 hours of the hospice becoming aware of the alleged violation. The provider failed to ensure written contracts/agreements included all the required components to ensure professional management responsibility for services under arrangement. During an interview on 05/30/2024 at 4:30 PM, the administrator stated that he/she did not know there were old contracts still and he/she had new contracts prepared but did not have them signed for the providers reviewed.

Based on contract review and interview, the provider respite contract failed to specify the provision that delineated the responsibilities of the hospice and the long-term care facility (LTCF) for bereavement for facility staff. This deficient practice has the potential to affect care of any patient on hospice service that receives care at a LTCF. --- Findings included: During the survey entrance on 05/29/2024 at 3:00 PM the respite contract was requested from the hospice administrator. The administrator provided a signed contract for respite dated 10/10/2018. Review of the respite contract, dated 10/10/2018, showed the contract failed to include and specify a provision to delineate the responsibilities of the hospice and the facility to provide bereavement services to facility staff. The provider failed to ensure written contracts/agreements included all the required components to ensure professional management responsibility for services under arrangement. During an interview 05/30/2024 at 4:30 PM, the administrator stated that he/she did not know there were old contracts still and he/she had new contracts prepared but did not have them signed for the providers reviewed.

Based on policy review, home visit observation, and interview, the hospice provider failed to provide the long-term care facility (LTCF) with a copy of the physician certification of terminal illness (CTI) in, but not limited to, one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients on hospice service that receive care at a LTCF. --- Findings included: Review of the provider's policy, "Patient Record Content", revised June 2019, showed in part that Hospice initiated and maintained an individual and accurate patient record containing past and current findings for each patient receiving care including certification and recertification of terminal illness statements . RECORD/PATIENT #1: Review of the clinical record showed a physician certification of terminal illness for hospice, dated 02/14/2024 and a physician second certification dated 05/17/2024. Observation on 05/28/2024 at 1:20 PM, showed the LTCF hospice binder failed to contain a copy of the CTI. During an interview on 05/30/2024 at 9:50 AM, the administrator stated that the CTI should have been in the hospice binder at the LTCF.

Based on review of the agency policy, the agency admission packet and interview, the agency failed to ensure the information provided to the patient and contained in their agency policy, included the requirement for the hospice to ensure that all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone furnishing services on behalf of the hospice agency are reported "immediately" by hospice employees and contracted staff to the hospice administrator. This deficient practice has the potential to affect the rights of all agency patients. Findings included: Review of the agency policy titled, "Patient Bill of Rights," revised June 2019, failed to include that the alleged violations are to be reported immediately by hospice employees and contracted staff to the administrator. The policy did not contain the word "immediately". Review of the agency admission packet failed to include information that the alleged violations are to be reported immediately by hospice employees and contracted staff to the hospice administrator. During an interview on 11/19/2021 at 10:15 AM, the director of clinical services stated that they could not find the requirement in the agency admission packet.

Based on review of the agency policy, review of the agency admission packet, and interview, the agency failed to include that the patient had the right to be free from mistreatment, neglect, mental, sexual, and physical abuse, including injuries of unknown origin, and misappropriation of patient property. This deficient practice has the potential to affect the rights of all agency patients. Findings included: Review of the agency policy titled, "Patient Bill of Rights, revised June 2019, failed to include that the patient had the right to be free from mistreatment, neglect, mental, sexual, and physical abuse, including injuries of unknown origin, and misappropriation of patient property. Review of the agency admission packet failed to include information that the patient has the right to be free from mistreatment, neglect, mental, sexual, and physical abuse, including injuries of unknown origin, and misappropriation of property. During an interview on 11/19/2021 at 10:15 AM, the director of clinical services stated that the agency could not find the requirement in the agency admission packet.

Based on policy review, record review, home visit observation, and interview, the agency failed to ensure a complete/accurate medication review and/or update of the patient's medications was completed in, but not limited to, one (Record/Patient #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Medication Reconciliation," revised June 2019, showed in part: - Hospice will reconcile patient's medications at time of admission and on an ongoing basis; - At time of initial assessment, the registered nurse (RN) will create and document a complete list of medications that patient is taking, including dose, route, and frequency; * Any discrepancies will be reconciled by a RN with the patient's physician; * Discrepancies include duplications, omissions, changes, contradictions and/or unclear information; and - Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. RECORD/PATIENT #4: During a home visit observation on 11/17/2021 beginning at 2:30 PM showed the following medication discrepancies with the current medication profile, plan of care (POC) and patient medication list on the electronic medical records (EMR) medication administration record (MAR) and treatment administration record (TAR) at the facility where the patient resided: - The agency POC showed an order for oxycodone (severe pain) extended release (ER) 5 milligrams (mg) one tablet by mouth every four hours as needed for pain. This was not included on the facility MAR; - The facility medication profile showed an order for Dulcolax suppository (to treat constipation) 10 mg, one suppository rectally every day as needed. This was not included on the agency medication profile; - The facility medication profile showed an order for Geri-Lanta (to treat indigestion) 30 milliliters (ml) by mouth every four hours as needed. This was not included on the agency medication profile; - The facility medication profile showed an order for milk of magnesia (to treat constipation) 30 ml by mouth every day as needed. This was not included on the agency medication profile; - The facility medication profile showed an order for tradjenta (anti-diabetic used to treat type 2 diabetes) 5 mg by mouth every day. This was not included on the agency medication profile; - The facility medication profile showed an order for Tylenol 325 mg take 650 mg by mouth every four hours as needed for pain or fever. This was not included on the agency medication profile; - The facility medication profile showed an order for fleet enema (constipation relief) 118 ml rectally every day as needed. This was not included on the agency medication profile; and - The facility medication profile showed an order for glucagon (hyperglycemic to treat severe low blood sugar) 1 mg intramuscular (IM) as needed for blood sugar less than 70 if patient lethargic and unresponsive. During an interview on 11/19/2021 at 01:30 PM, the director of clinical services stated that the medications and treatments should be reconciled and she would expect them to match.

Based on agency observation, home visit observations, policy review, review of the Centers for Medicare and Medicaid Services (CMS) COVID-19 focused Infection Control Survey Tool, and interview, the agency failed to screen two patients (Record/Patients #2 and #3) out of three home visits, the agency failed to notify a long-term facility that one patient (Record/Patient #5) had been exposed to COVID-19 prior to being admitted for respite care, and the agency failed to screen visitors as required in order to maintain and document an effective infection control program for COVID-19 that protects visitors and staff. This deficient practice has the potential to adversely affect the safety of all the agency's patients and the agency's visitors and staff. Findings included: Review of the agency policy titled, "COVID-19 Screening Employees and Guests," dated 04/01/2020, showed the following: -Policy: All employees will be monitored for signs and symptoms of COVID-19 prior to the start of work each day; -Purpose: To ensure the employee is COVID-19 free prior to working with others; -A staff nurse will conduct a temperature and pulse oxygen check upon entry into the building; and -Guest entering the building shall be required to wear a mask and have their temperature checked and recorded on the sign-in log. Review of the agency policy titled, "COVID-19 Patient Monitoring," dated 04/01/2020, showed the following: -Policy: All patient/caregivers will be monitored for signs and symptoms of COVID-19 prior to entering residence; -Purpose: To ensure the patient/caregiver is COVID-19 free prior to staff visit; -All staff shall actively monitor patient and caregivers prior to entering the residence at every visit for fever and respiratory symptoms (shortness of breath, new or change in cough, and sore throat) and document findings. Ask patient/caregiver to report if they feel feverish or have symptoms of respiratory infection. Staff to notify the health department about patients with severe respiratory infection; and -Health department and CDC (Centers for Disease Control and Prevention) criteria will be followed for testing of symptomatic patients. Review of the CMS publication titled, "Revised COVID-19 Focused Infection Control Survey Tool for Acute and Continuing Care-QSO-21-08-NLTC," dated 12/30/2020, showed the requirement for a screening process for those entering the facility (patients and visitors) to mitigate the risk of COVID-19 exposure (for example: exposure to COVID-19 screening questions and assessment of symptoms/illness). On 11/16/2021 at 3:20 PM, two surveyors approached the agency entrance door. Observation showed that all that entered the building needed to wear a mask. Observation failed to show any signage to visitors or staff to show visitation restrictions and screening procedures for COVID-19. After entering the agency, there failed to be any type of screening for visitors for COVID-19 signs and symptoms. Again on 11/17/2021, 11/18/2021, and 11/19/2021 upon the two surveyors entering the agency, the agency failed to do any type of screening for COVID-19. RECORD/PATIENT #2: Review of the clinical record, showed the patient was admitted to hospice on 12/17/2020 with a terminal diagnosis of malignant neoplasm of the prostate. The patient lived at home. During a home visit observation and interview on 11/18/2021 at 10:15 AM, the agency nurse did not screen the caregiver or ask the patient about having any signs or symptoms of COVID-19. The caregiver denied the nurse screening him/her prior to the visit. RECORD/PATIENT #3: Review of the clinical record, showed the patient was admitted to hospice on 06/25/2021 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a condition involving constriction of the airways and difficulty or discomfort in breathing). The patient lived at home. During a home visit observation on 11/18/2021 at 11:50 AM, the agency social worker failed to screen the patient or caregiver for signs and symptoms of COVID-19 prior to entering the residence. RECORD/PATIENT #5: Review of the clinical record, showed the patient was admitted to hospice on 04/27/2021 with a terminal diagnosis of malignant neoplasm of unspecified part of the bronchus or lung. The patient lived at home until 10/15/2021, when he/she was admitted to a long-term care facility for respite care and the patient passed away at the facility on 10/19/2021. Review of social worker note, dated 10/14/2021, showed the patient's daughter had not been feeling well and requested respite care. Review of case communication note, dated 10/15/2021, showed the patient was to be picked up by ambulance and transported to a long-term care facility. Registered Nurse (RN) A called the long-term care facility and gave report. Also the patient's medical records had been sent to the facility. The documentation failed to show the patient had been exposed to COVID-19. Review of the agency's complaint log, showed on 10/19/2021 when the patient had passed away, it was found out then that the patient had been exposed to COVID-19 and that was why he/she was on respite. RN A had not informed the long-term facility of this and knew about the patient's exposure on 10/15/2021, prior to the patient being admitted to the long-term care facility. RN A was suspended following the investigation of the complaint. During an interview on 11/19/2021 at 10:30 AM, the director of clinical services stated that RN A should have shared information with the long-term care facility about Record/Patient #5's exposure to COVID-19 prior to admission to the facility and that all visitors should be screened upon entering the agency and patients/caregivers should be screened prior to staff entering the patient's residence.

Based on the agency's quality assessment and improvement program (QAPI) review, review of the CMS (Centers for Medicare and Medicaid Services) COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, and interview, the agency failed to show that COVID-19 was an integral part of the hospice's quality assessment and improvement program. This deficient practice has the potential to adversely affect safety related to COVID-19 for all the agency's patients and families. Findings included: Review of the agency's QAPI notes, failed to show current data for COVID-19 infections and related performance improvement project(s). Review of the CMS waiver titled, "COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers-Home Health Agencies (HHAs) and Hospice," showed, in part, that CMS is modifying the requirements to narrow the scope of the QAPI program (during the public health emergency) to concentrate on infection control issues, while retaining the requirement that remaining activities should continue to focus on adverse events. During an interview on 11/19/2021 at 1:40 PM, the director of clinical services, stated that COVID-19 was not a part of the QAPI program.

Based on professional standards, policy review, record review, and interview the agency failed to ensure one of five full records reviewed (Record/Patient #5) had his/her wound measured weekly. This deficient practice has the potential to affect the quality of care for all patients with wounds on service with the agency. Findings included: Review of the National Pressure Ulcer Advisory Panel (NPUAP) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, revised 2014, showed pressure ulcer assessments should be done initially and then re-assessed at least weekly. Review of agency undated policy titled, "Wound Care," showed in part the following: -Policy: To provide wound care treatments/services based on evidence-based standards of care under the direction of a physician; -At each visit the patient's skin will be assessed. At each dressing change the wound will be assessed and documentation will include a description of the wound bed, drainage, signs and symptoms of infection, healing and peri wound skin condition. Include a full set of vital signs including temperature; and -At least every week, the wound assessment and documentation will include measurement of length, width, depth, and undermining and tunneling if present. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice on 04/27/2021 with a terminal diagnosis of malignant neoplasm of unspecified part of bronchus or lung. The patient lived at home. Review of the skilled nursing note, dated 10/01/2021, showed the patient had a newly developed pressure ulcer to his/her coccyx measuring 2.8 centimeter (cm) by 2.8 cm with a depth of 0. The wound bed was white with no signs or symptoms of infection noted. The agency failed to document any further measurements of the wound. The patient passed away on 10/19/2021 and only had the one measurement (10/01/2021) for the wound. During review of findings and interview on 11/19/2021 at 1:20 PM, the director of clinical services stated that he/she would have expected weekly measurements on the wound. Nothing further was provided as of the survey exit.

Based on record review and interview the agency failed to ensure the hospice aide reported changes in the patient's condition to the registered nurse (RN) in, but not limited, one (Records/Patients #4) of three records that received aide services. This deficient practice has the potential to affect all patients that receive aide services. Findings included: RECORD/PATIENT #4: Review of the hospice aide visit assignment dated 09/24/2021 showed the RN assigned oral hygiene every visit, peri care, and record last bowel movement. Review of the hospice aide visit notes showed: - On 10/06/2021 the patient had slimy bowel movement and he/she was crying an upset about tooth hurting; and - On 10/12/2021 the patient had loose bowel movement and he/she said his/her teeth hurt. There was no documentation that the aide notified the RN case manager or coordinator of the patient's abnormal bowel movements and teeth hurting. During an interview on 11/19/2021 at 01:30 PM, the director of clinical services stated that she would expect the aide to report to the RN that the patient's teeth were hurting.

Based on contract review and interview, the hospice provider failed to ensure professional management responsibility for services under arrangement when a long term care for respite services contract failed to include the following: - Required services to be authorized by the hospice; and - Required services to be furnished in a safe and effective manner by qualified personnel. The deficient practice has the potential to affect all patients on service with the hospice provider. Findings included: During the survey entrance on 11/16/2021 at 3:15 PM the long term care/respite contract was requested from the hospice administrator. Review of a Skilled Nursing Facility Agreement for respite services dated 08/17/2021, showed no delineated information regarding the required services to be authorized by the hospice and for required services to be furnished in a safe and effective manner by qualified personnel. During an interview on 11/23/2021 at 1:02 PM, the director of clinical services agreed the above information was missing from the contract and provided no further documentation. The agency failed to ensure written contracts/agreements included all the required components to ensure professional management responsibility for services under arrangement.

Based on policy review, record review, and interview, the agency failed to ensure physician orders were obtained in one (Record/Patient #5) of five full records reviewed. This deficient practice has the potential to affect the quality of care for all patients receiving services. Findings included: Review of the agency policy titled, "Physician Orders," revised June 2019, showed in part the following: -Policy: Nursing and other services that require a physician's order will be provided in accordance with a physician's order; -Purpose: To describe the requirements for physician orders; -Care and services provided will be provided according to physician orders. Orders are current and updated; -Drugs and treatments are administered by staff only as ordered by physician; and -Oral orders are: put in writing, signed and dated with the date of receipt by a Registered Nurse (RN) or therapist responsible for furnishing or supervising ordered services. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice on 04/27/2021 with a terminal diagnosis of malignant neoplasm of unspecified part of bronchus or lung. The patient lived at home. Review of skilled nurse's note, dated 09/20/2021, showed the patient had a cough and the nurse documented that the patient was to take Robitussin 100 milligram (mg)/5 milliliter (ml), 5 to 10 ml every six hours as needed for a cough. Review of the skilled nurse's note, dated 09/22/2021, showed the nurse instructed the patient's caregiver to use Vicks Vapor Rub on the patient's chest and called the patient's physician and received an order for Levaquin 500 mg daily for 5 days. Review of the skilled nurse's note, dated 10/01/2021, showed the patient had a new wound and the nurse documented that he/she cleansed the wound with normal saline, then applied triple antibiotic ointment and covered with opti-foam dressing and the dressing was to be changed daily and as needed. Review of the clinical record failed to show the following physician orders: -On 09/20/2021 Robitussin 100 mg/5 ml, give 5 to 10 ml every 6 hours as needed for cough; -On 09/22/2021 Vick's Vapor Rub and Levaquin 500 mg daily for 5 days; and -On 10/01/2021 Cleanse wound with normal saline, apply triple antibiotic ointment and cover with opti-foam dressing, change daily and as needed. During review of findings and interview with the director of clinical services on 11/19/2021 at 1:20 PM, he/she stated that there should be an order for any new medications or treatments. No further documentation was provided at exit.

Based on policy review, record review, and interview, the agency failed to ensure that all clinical record documentation was documented in a timely matter, in but not limited to, five of five full records (Records/Patients #1, #2, #3, #4, and #5) reviewed. This deficient practice has the potential to affect complete and accurate documentation of the patient's condition for all the agency's patients. Findings included: Review of the agency policy titled, "Timely Submission of Patient Documentation," revised June 2019, showed in part the following: -Policy: Hospice will ensure the timely and proper submission of patient documentation; -Purpose: To comply with state/federal laws and regulations related to timely submission of all patient documentation; and -Itineraries, with all visit reports attached, must be submitted the next scheduled work day, not exceeding two (2) business days. All patient visit reports from contract personnel must be submitted within three (3) business days from the date of the visit. RECORD/PATIENT #1: Review of the clinical record, showed the patient was admitted to hospice on 09/15/2020 with a terminal diagnosis of Alzheimer's. The patient lived at home. Review of the clinical record showed the following: -The skilled nurse (SN) visit was done on 10/21/2021 and charted by the SN on 10/25/2021, 4 days later; -The SN visit was done on 10/28/2021 and charted by the SN on 11/01/2021, 4 days later; -The SN visit was done on 11/04/2021 and charted by the SN on 11/08/2021, 4 days later; and -The SN visit was done on 11/11/2021 and charted by the SN on 11/15/2021, 4 days later. Review of the clinical record showed the following: - The social worker (SW) visit was done on 08/05/2021 and charted by the SW on 08/09/2021, 4 days later; - The SW visit was done on 09/09/2021 and charted by the SW on 09/15/2021, 6 days later; and - The SW visit was done on 10/21/2021 and charted by the SW on 10/29/2021, 8 days later. RECORD/PATIENT #2: Review of the clinical record, showed the patient was admitted to hospice on 12/17/2020 with a terminal diagnosis of malignant neoplasm of the prostate. The patient lived at home. Review of the clinical record showed the following: -The registered nurse (RN) visit was done on 10/25/2021 and charted by the RN on 10/31/2021, 6 days later; -The RN visit was done on 11/04/2021 and charted by the RN on 11/14/2021, 10 days later; -The RN visit was done on 11/08/2021 and charted by the RN on 11/16/2021, 8 days later; and -The RN visit was done on 11/11/2021 and charted by the RN on 11/17/2021. 6 days later. RECORD/PATIENT #3: Review of the clinical record, showed the patient was admitted to hospice on 06/25/2021 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a condition involving constriction of the airways and difficulty or discomfort in breathing). The patient lived at home. Review of the clinical record showed the RN visit was done on 11/10/2021 and charted by the RN on 11/17/2021, 7 days later. RECORD/PATIENT #4: terminal diagnosis of Alzheimer's. The patient lived at home until 10/05/2021 when he/she went to a long term care facility. Review of the clinical record showed the following: - The SN visit was done on 09/24/2021 and charted by the SN on 10/18/2021, 24 days later; - The SN visit was done on 09/26/2021 and charted by the SN on 10/04/2021, 8 days later; - The SN visit was done on 10/01/2021 and charted by the SN on 10/05/2021, 4 days later; - The SN visit was done on 10/14/2021 and charted by the SN on 10/19/2021, 5 days later; - The SN visit was done on 10/18/2021 and charted by the SN on 11/01/2021, 14 days later; - The SN visit was done on 10/22/2021 and charted by the SN on 10/25/2021, 3 days later; - The SN visit was done on 10/28/2021 and charted by the SN on 11/01/2021, 4 days later; and - The SN visit was done on 11/01/2021 and charted by the SN on 11/07/2021, 6 days later. Review of the clinical record showed the following: - The SW visit was done on 10/04/2021 and charted by the SW on 10/09/2021, 5 days later; and - The SW visit was done on 11/05/2021 and charted by the SW on 11/09/2021, 4 days later. Review of the clinical record showed the following: - The chaplain visit was done on 10/22/2021 and charted by the chaplain on 10/25/2021, 3 days later; and - The chaplain visit was done on 11/04/2021 and charted by the chaplain on 11/17/2021, 13 days later. Review of the clinical record showed the following: - The aide visit was done on 10/08/2021 and charted by the aide on 10/11/2021, 3 days later; - The aide visit was done on 10/12/2021 and charted by the aide on 10/18/2021, 6 days later; - The aide visit was done on 10/14/2021 and charted by the aide on 10/18/2021, 4 days later; - The aide visit was done on 10/28/2021 and charted by the aide on 11/01/2021, 4 days later; and - The aide visit was done on 11/11/2021 and charted by the aide on 11/15/2021, 4 days later. RECORD/PATIENT #5: Review of the clinical record, showed the patient was admitted to hospice on 04/27/2021 with a terminal diagnosis of malignant neoplasm of unspecified part of bronchus or lung. The patient lived at home until 10/15/2021 when he/she went on respite and passed away on 10/19/2021. Review of the clinical record showed the following: -The RN visit was done on 09/01/2021 and charted by the RN on 09/09/2021, 8 days later; -The RN visit was done on 09/09/2021 and charted by the RN on 09/15/2021, 6 days later; -The RN visit was done on 09/10/2021 and charted by the RN on 09/15/2021, 5 days later; -The RN visit was done on 09/27/2021 and charted by the RN on 10/11/2021, 14 days later; -The RN visit was done on 10/01/2021 and charted by the RN on 10/18/2021, 17 days later; -The RN visit was done on 10/04/2021 and charted by the RN on 10/19/2021, 15 days later; -The RN visit was done on 10/08/2021 and charted by the RN on 10/20/2021, 12 days later; and -The RN visit was done on 10/13/2021 and charted by the RN on 10/19/2021, 6 days later. During an interview on 11/19/2021 at 1:20 PM, the director of clinical services stated that he/she expected staff to document their visits within 2 days of the visit.

Based on review of an agency contract for respite services, and interview, the hospice agency failed to ensure the contract included the skilled nursing facility established patient care policies consistent with hospice and would agree to abide by palliative care protocols and the plan of care established by the hospice for its patients, in one of one respite contract reviewed. This deficient practice has the potential to affect respite services for all patients served by the agency. Findings include: Review of the agency's respite contract, dated August 17, 2021 with a skilled nursing facility failed to include the requirement that the skilled nursing facility established patient care policies consistent with hospice and would agree to abide by palliative care protocols and the plan of care established by the hospice for its patients. During an interview on 11/23/2021 at 1:02 PM, the director of clinical services agreed the above information was missing from the contract and provided no further documentation.

Based on review of an agency contract for respite services, and interview, the hospice agency failed to ensure the contract included the requirement for the hospice patient's clinical record to include that a copy of the discharge summary be provided to the hospice at the time of discharge and that a copy of the inpatient clinical record be available to the hospice at time of discharge, in one of one respite contract reviewed. This deficient practice has the potential to affect respite services for all patients served by the agency. Findings include: Review of the agency's respite contract, dated 08/17/2021 with a skilled nursing facility failed to include the requirement for the patient's clinical record to include that there be a copy of the discharge summary provided at discharge and a copy of the inpatient clinical record be available to the hospice at the time of discharge. During an interview on 11/23/2021 at 1:02 PM, the director of clinical services agreed the above information was missing from the contract and provided no further documentation.

Based on contract review and interview, the agency failed to include in the contract for respite care with the skilled nursing facility, the requirement for the facility to provide an identified individual within the inpatient facility who is responsible for the implementation of the provisions of the agreement in one of one respite contract reviewed. This deficient practice has the potential to affect the ease of communication and implementation of the contract for all hospice patients that use respite care. Findings included: Review of the agency's contract titled, "Skilled Nursing Facility Agreement," dated 08/17/2021 with a long term care facility failed to show any mention of an identified individual who is responsible for the implementation of the provisions of the agreement. During an interview on 11/23/2021 at 1:02 PM, the director of clinical services agreed the above information was missing from the contract and provided no additional information.

Based on contract review, and interview, the agency general inpatient (GIP) contract and respite contract with the skilled nursing facility, failed to include the requirement that specifies the hospice retains responsibility for ensuring training of personnel who will be providing the patient's care in the facility as well as description of the training and the names of those giving the training in two of two contracts reviewed. This deficient practice has the potential to affect respite services for all patients served by the agency. Findings include: Review of the agency's GIP contract, dated 02/10/2020 failed to include the requirement that the hospice will take responsibility for ensuring training of personnel who will be providing the patient's care in the inpatient facility including the description of the training and the names of those giving the training. Review of the agency's respite contract, dated 08/17/2021 with a skilled nursing facility failed to include the requirement that the hospice will take responsibility for ensuring training of personnel who will be providing the patient's care in the inpatient facility including the description of the training and the names of those giving the training. During interviews on 11/17/2021 at 3:25 PM and 11/23/2021 at 1:02 PM, the director of clinical services agreed the above information was missing from the contracts and provided no further documentation.

Based on contract review between the hospice agency and skilled nursing facility (SNF) for respite services, and interview, it was determined that the hospice failed to specify the requirements set forth at Section 418.108(b)(1)(ii) for inpatient care for respite services in a SNF meeting the standards for patient areas in one (Facility #1) of one facility contract reviewed. The deficient practice has the potential to affect all agency patients receiving respite services from the SNF and care of any patient that receives general inpatient care for symptom control. Findings include: Section 418.108(b)(1)(ii) states that inpatient care for respite purposes may be provided by a Medicare or Medicaid-certified nursing facility that also meets the standards specified in Section 418.110(e). Review of the SNF contract for respite services dated 08/17/2021 showed that it failed to include provisions that the SNF provided for visitors at any hour, including infants and small children. During an interview on 11/23/2021 at 1:02 PM, the above findings were reviewed with the director of clinical services and he/she agreed the above information was missing from the contract and provided no further documentation.

Based on contract review, and interview, the written agreements between the agency and the skilled nursing facility (SNF) and the general inpatient facility failed to specify the required provision addressing when to immediately notify the hospice agency. The deficient practice has the potential to affect care of any patient that receives general inpatient care for symptom control and/or respite care. Findings included: Review of the respite contract dated 08/17/2021, showed the contract failed to include the provision that the hospice will be notified if: - there is a need for transfer from facility and the hospice is to make arrangements for, and remains responsible for, any necessary continuous care or inpatient care necessary related to the terminal illness and related conditions; or - a patient dies. Review of the GIP contract dated 02/10/2020, showed the contract failed to include the provision that the hospice will be notified if: - there is a need for transfer from facility and the hospice is to make arrangements for, and remains responsible for, any necessary continuous care or inpatient care necessary related to the terminal illness and related conditions; or - a patient dies. During interviews on 11/17/2021 at 3:25 PM and 11/23/2021 at 1:02 PM, the director of clinical services agreed the above information was missing from the contracts and provided no further documentation.

Based on contract review, and interview, the agency general inpatient (GIP) contract and respite contracts failed to specify the provision that hospice must report alleged violations. The deficient practice has the potential to affect care of any patient that receives general inpatient care for symptom control and/or respite care. Findings included: Review of the signed GIP agreement dated 02/10/2020, showed the contract failed to include provision stating that the hospice must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the GIP facility administrator within 24 hours of the hospice becoming aware of the alleged violation. Review of the respite contract dated 08/17/2021, showed the contract failed to include a provision stating that the hospice must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the respite facility administrator within 24 hours of the hospice becoming aware of the alleged violation. During interviews on 11/17/2021 at 3:25 PM and 11/23/2021 at 1:02 PM, the director of clinical services agreed the above information was missing from the contracts and provided no further documentation.

Based on contract review and interview, the agency general inpatient (GIP) contract and respite contract failed to specify the provision that delineated the responsibilities of the hospice and the facility for bereavement for facility staff. The deficient practice has the potential to affect care of any patient that receives general inpatient care for symptom control and/or respite care. Findings included: Review of the signed GIP agreement dated 02/10/2020, showed the contract failed to include and specify a provision to delineate the responsibilities of the hospice and the facility to provide bereavement services to facility staff. Review of the signed respite agreement 08/17/2021, showed the contract failed to include and specify a provision to delineate the responsibilities of the hospice and the facility to provide bereavement services to facility staff. During interviews on 11/17/2021 at 3:25 PM and 11/23/2021 at 1:02 PM, the director of clinical services agreed the above information was missing from the contracts and provided no further documentation.