Every finding on record at Medical Services of America, Inc.

Based on policy and procedure, clinical record review and staff/patient interview the agency failed to include all current medications on the plan of care for 3 of 4 home visits conducted [ #3,4,and 7]. Findings included: --- 3. Patient # 7 had a Start of Care date of 12/29/23 with a terminal diagnosis of Senile Dementia. Review of the Plan of Care [POC] for the certification period 3/28/24-6/25/24 included orders for SN [skilled nursing] 2 times a week for 12 weeks. On 6/11/24, at approximately 8:30 am, a joint visit was conducted with RN # 16. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Furosemide [fluid medication] 20 mg, take 1 tablet on Tuesday, Thursday, Saturday and Sunday. Review of the medication administration record at the assisted living facility [ALF] revealed the patient was taking Furosemide 20 mg – 2 tablets [40 mg] on Monday, Wednesday and Friday and 20 mg on Tuesday, Thursday, Saturday and Sunday with a start date of 4/26/24. The medication profile listed Meloxicam [anti-inflammatory] 7.5 mg, take 1 tablet daily as needed for pain and Meloxicam 7.5 mg, take 1 tablet daily [medication listed twice on the profile-both entries had a start date of 12.29/23]. The medication administration record from the ALF revealed the patient had Meloxicam 7.5 mg daily, there was no PRN order noted. During an interview with RN # 1 on 6/12/24 at approximately 10 am, RN # 1 confirmed the medication profile was not correct. Review of a policy ";Medication Management", revised 09/2023 was received from agency staff on 06/11/24 at 3:45 p.m. The policy stated," ...the patients medications are reviewed and assessed during every comprehensive visit...". 1.Patient #3 was admitted on 03/29/24 with diagnoses of senile degeneration of the brain (loss of intellectual ability), and hypothyroidism (low thyroid). The Plan of Care for 03/29/24- 06/26/24 included orders for skilled nursing 1 time a week for 14 weeks, medical social work 1 time a month for 3 months, and chaplain 1 time a month for 3 months. A home visit was conducted on 6/11/24 at 8:30 a.m. with the skilled nurse. A review of the facility MAR (medication administration record) was conducted and revealed the following medication was not included on the patient plan of care: Melatonin 10 mg (milligrams) take 1 capsule by mouth at bedtime for sleep Interview with the agency skilled nurse on 6/11/24 at 8:42 a.m. confirmed the medication should have been included on the medication administration record. 2. Patient #4 was admitted on 10/20/2020 with diagnoses of copd, pulmonary hypertension, dependence on supplemental oxygen, and type 2 diabetes. The Plan of Care for 06/01/24-07/30/24 included orders for skilled nursing 1 time a week for 9 weeks. A home visit was conducted on 6/11/24 at 9:00 a.m. with the registered nurse. A review of the medications was conducted and revealed the following medication was not included on the plan of care: Vitamin B12 1 capsule daily by mouth as a supplement Interview with the patient on 6/11/24 at 9:27 a.m. confirmed the patient has been taking this supplement for over a year.

Based on policy and procedure, clinical record review and staff interview the agency failed to have visit frequency projections every 15 days for the chaplain IDG (interdisciplinary group) for 7 of 19 records reviewed [#3,14, 15,1, 11, 12, and 16]. Findings included: --- 4. Patient # 1 had a Start of Care date of 9/5/23 with terminal diagnoses of unspecified severe protein calorie malnutrition and unspecified dementia. Review of the Plan of Care [POC] for the certification period 5/2/24-6/30/24 included orders for chaplain services 1 time a month for 2 months. Review of the IDG [interdisciplinary group] minutes dated 5/7/24, 5/21/24 and 6/4/24 revealed no visit projections for the next 15 days from the chaplain. During an interview with Chaplain # 8 on 6/12/24 at 9:45 am, the chaplain confirmed he failed to project the visit frequency during the meetings. 5. Patient # 11 had a Start of Care date of 12/23/23 with terminal diagnoses of unspecified serve protein calorie malnutrition and encephalopathy [a group of conditions that cause brain dysfunction]. Review of the Plan of Care [POC] for the certification period 3/2/24-5/30/24 included orders for chaplain visits 1 time a month for 3 months. Review of the IDG [interdisciplinary group] minutes dated 3/12/24 and 3/26/24 [patient expired 3/27/24] revealed no visit projections for the next 15 days from the chaplain. During an interview with Chaplain # 8 on 6/12/24 at 9:45 am, the chaplain confirmed he failed to project the visit frequency during the meetings. 6. Patient # 12 had a Start of Care date of 1/16/24 with a terminal diagnosis of COPD [chronic obstructive pulmonary disease-lung condition making it difficult to breath]. Review of the Plan of Care [POC] for the certification period 1/14/24-4/14/24 included orders for chaplain visits 1 time a month for 3 months. Review of the IDG [interdisciplinary group] minutes dated 1/30/24-3/14/24 revealed no visit projections for the next 15 days from the chaplain for 5 of 5 IDG meetings. During an interview with Chaplain # 8 on 6/12/24 at 9:45 am, the chaplain confirmed he failed to project the visit frequency during the meetings. 7. Patient # 16 had a Start of Care date of 12/23/23 with a terminal diagnosis of Alzheimers Disease. Review of the Plan of Care [POC] for the certification period 3/22/24-9/19/24 included orders for Chaplain 1 time a month for 3 months. Review of the IDG [interdisciplinary group] meetings dated from 3/28/24-6/6/24 revealed no visit projections for the next 15 days from the chaplain for 6 of 6 IDG meetings. During an interview with Chaplain # 8 on 6/12/24 at 9:45 am, the chaplain confirmed he failed to project the visit frequency during the meetings. Review of a policy ";Plan of Care", revised 10/2023 was received from agency staff on 06/11/24 at 3:45 p.m. The policy stated," ...revises and documents the individualized plan as frequently as the patients condition requires, but no less frequently than every 15 calendar days..." 1.Patient #3 was admitted on 03/29/24 with diagnoses of senile degeneration of the brain (loss of intellectual ability), and hypothyroidism (low thyroid). The Plan of Care for 03/29/24- 06/26/24 included orders for skilled nursing 1 time a week for 14 weeks, medical social work 1 time a month for 3 months, and chaplain 1 time a month for 3 months. The IDG on 5/9/24 and 06/6/24 did not include a projected individualized plan for the next 2 weeks for the chaplain for 2 of 2 meetings. 2. Patient #14 was admitted on 05/24/24 with diagnosis of unspecified protein malnutrition, type 2 diabetes, chronic kidney disease and anxiety disorder. The Plan of Care for 05/24/24-07/22/24 included orders for skilled nursing 1 time a week for 1 weeks, and 2 times a week for 8 weeks, and chaplain 1 time a month for 3 months. The IDG on 6/6/24 did not include a projected individualized plan for the next 2 weeks for the chaplain for 1 of 1 meetings. 3. Patient #15 was admitted on 04/18/24 with a diagnosis of senile degeneration of the brain, dementia, anxiety, depression, and parkinson disease. The Plan of Care for 04/18/24-07/16/24 included orders for skilled nursing 1 visit every week for 13 weeks, and chaplain 1 visit every month for 3 months. The IDG on 05/09/24 5/23/24, and 06/06/24 did not include a projected individualized plan for the next 2 weeks for the chaplain for 3 of 3 meetings. Interview with Employee #8 on 6/12/24 at 9:15 a.m. revealed, ";I have my frequencies for monthly and have prns built in, I dont usually project my visits any differently".

Based on agency policy, direct observation and staff interviews, the Registered Nurse failed to follow agency policy related to infection control practices for 2 of 4 homes visits [#6 and 7]. The findings included: --- The policy, Bag Technique HC.56 [10/23] , was provided by the agency director on 6/11/24 at 11:35 am. The policy stated, "...After performing hand hygiene, all the clean supplies and equipment needed for the visit are removed from the bag. The bag is then closed..." 1. Patient # 6 had a Start of Care date of 8/19/22 with a terminal diagnosis of Alzheimers Disease. Review of the Plan of Care [POC] for the certification period 6/9/24-8/7/24 included orders for SN [skilled nursing] 2 times a week for 8 weeks, 1 time a week for 1 week. On 6/11/24, at approximately 9:30 am a joint visit was made with RN # 17. During the visit the RN was noted to place her nursing bag on a barrier on the bedside table. After placing the nursing bag on the barrier, and performing hand hygiene, the RN unzipped the nursing bag to remove the vital sign equipment. The RN failed to rezip the nursing bag after removing the vital sign equipment and the nursing bag remained open the entirety of the visit. During an interview with RN # 1 on 6/11/24 at approximately 3 pm, RN # 1 confirmed the nursing bag should have been rezipped after the RN removed the vital sign equipment. RN # 1 confirmed RN #17 failed to follow agency policy related to infection control practices. 2. Patient # 7 had a Start of Care date of 12/29/23 with a terminal diagnosis of Senile Dementia. Review of the Plan of Care [POC] for the certification period 3/28/24-6/25/24 included orders for SN [skilled nursing] 2 times a week for 12 weeks. On 6/11/24, at approximately 8:30 am, a joint visit was conducted with RN # 16. During the visit the RN was noted to place her nursing bag on a barrier on the bedside table. The nurse removed vital sign equipment and gloves for the visit. After removing the vital sign equipment and the gloves, the RN failed to rezip the middle and outer sections of the nursing bag. The bag remained unzipped [both compartments] throughout the entire of the visit. During an interview with RN # 1 on 6/11/24 at approximately 3 pm, RN # 1 confirmed the nursing bag should have been rezipped after removing the items. RN # 1 confirmed RN # 16 failed to follow agency policy related to infection control practices.

Based on agency policy, clinical record review, and staff interviews, the skilled nurse failed to assess/measure skin tears in accordance with agency policy for 1 of 2 patients with a wound [#5]. The findings included: --- The policy, Wound Care [11/23], was provided by agency staff on 6/11/24 at approximately 11:46 am. The policy stated, "...The skilled nurse will assess the wound and document the wound status at every visit. The wound measurements will be documented at least weekly... Patient # 5 had a Start of Care date of 12/5/22 with a terminal diagnosis of Alzheimers Disease. Review of the Plan of Care [POC] for the certification period 3/29/24-5/27/24 included orders for SN [skilled nursing] 1 time a week for 8 weeks. Further review of the POC revealed a nursing intervention related to a skin tear on the left calf/ankle area. The intervention was to clean the wound and apply Silvadene and cover with a foam dressing. The skin tear was identified on 3/14/24. Review of the clinical record revealed the SN completed wound care to the left calf/ankle area on 3/20/24, 4/4/24, 4/9/24, 4/18/24, 4/23/24, 5/2/24 and resolved the intervention on 5/7/24. There were no wound assessment/measurements documented in 6 of 6 SN visits. The RN was not available for interview. An interview was conducted with RN # 1 on 6/12/24 at approximately 11 am, during the interview the RN confirmed the wound should have been assessed each visit and measured weekly. On 3/28/24 a skin tear was identified to the right ankle/calf with an order to clean the wound with wound cleanse and apply Silvadene to wound and cover with foam dressing. Change 2 times per week and as needed. Review of the clinical record revealed the wound care was completed on 4/4/24, 4/9/24, 4/18/24, 4/23/24, 5/2/24 and 5/16/24. There were no wound measurements or wound assessments documented related to the skin tear for 6 of 6 visits. During an interview with RN # 1 on 6/12/24 at approximately 11:15 am, the RN confirmed the wound should be been measured weekly and assessed with each visit.

Based on policy and procedure, clinical record review and staff interview the agency failed to follow the aide care plan for 2 of 19 records reviewed with an aide [#13 and #16]. Findings included --- Patient # 16 had a Start of Care date of 12/23/23 with a terminal diagnosis of Alzheimers Disease. Review of the Plan of Care [POC] for the certification period 3/22/24-9/19/24 included orders for hospice aide 1 time a week for 1 week, 2 times a week for 12 weeks, 1 time a week for 1 week. Review of the aide care plan dated 3/22/23 and completed by RN # 13 included instructions [related to personal care] for the aide to do a complete bed bath each visit if the patient was unable to tolerate a complete shower. The aide POC also included the following verbiage ";..._____ [name of assisted living staff [not RN] may direct care". Review of the aide documentation revealed the patient received 21 aide visits from 3/22/24-6/10/24. Out of those 21 visits the patient received 7 bed baths directed by the facility staff, not in accordance with the POC. During an interview with RN # 1 on 6/12/24 at approximately 10:15 am, the RN stated, ";The facility staff usually directs the aide when the aide feels like the patient isnt up to a complete shower. The facility staff isnt always and RN. The facility staff in this situation is not a RN." Review of a policy ";Personal Care Instructions", revised 02/2024 was received from agency staff on 06/11/24 at 3:45 p.m. The policy stated," ...the hospice aide is only allowed to document on care within the care plan..." 1.Patient #13 was admitted on 5/24/24 with diagnoses of copd (chronic obstructive pulmonary disease), hypertension, depression and anxiety. The Plan of Care for 5/24/24- 8/21/24 included orders for skilled nursing 1 time a week for 1 week, and 2 times a week for 13 weeks, hospice aide 2 times a week for 13 weeks. The hospice aide plan of care included orders for a complete shower every visit. Review of the aide visit completed on 5/28/24 revealed the aide had given the patient a partial bed bath. Review of the aide visit on 6/10/24 revealed the aide had given the patient a complete bath. Interview with Employee #9 on 6/12/24 at 8:38 a.m. revealed, ";No, it is not on my care plan that I can do a partial bath, I told the RN but Im not sure if she updated the care plan". Interview with Employee #4 on 6/12/24 at 9:11 a.m. revealed, ";they both did tell me that he was refusing, and I was supposed to update the care plan".

Based on clinical record review and staff interview, the agency failed to include the psychosocial and emotional needs in the comprehensive assessment for 3 of 4 patients that had declined medical social work services (#1, 6, and 7). Finding include: 1. Patient #1 was admitted on 10/15/21 with diagnoses of pulmonary hypertension, hypertensive heart disease with heart failure, and hypoxemia. The Initial Assessment was conducted on 10/15/21 by RN #5. The Plan of Care for 10/15/21-1/12/22 revealed the patient declined medical social worker. There was no evidence the initial assessment included the psychosocial and emotional needs of the patient. There was no evidence the initial assessment included the psychosocial and emotional needs of the patient. An interview with the clinical manager on 12/1/21 at 2:30 p.m. confirmed there was no evidence the psychosocial and emotional needs assessment was conducted. 2. Patient #6 was admitted on 8/30/21 with diagnosis of Alzheimer's disease and repeated falls. The Initial Assessment was conducted on 8/30/21 by RN #7. The Plan of Care for 8/30/21-11/27/21 declined medical social worker. There was no evidence the initial assessment included the psychosocial and emotional needs of the patient. An interview with the clinical manager on 12/1/21 at 2:30 p.m. confirmed there was no evidence the psychosocial and emotional needs assessment was conducted. 3. Patient #7 was admitted on 11/10/21 with a diagnosis of chronic obstructive pulmonary disease (COPD-lung disease). The Initial Assessment was conducted on 11/10/21 by RN #5. The Plan of Care for 11/10/21-2/7/21 revealed the patient declined medical social worker. There was no evidence the initial assessment included the psychosocial and emotional needs of the patient. An interview with the agency director on 12/2/21 at 3:45 p.m. confirmed there was no evidence the psychosocial and emotional needs assessment was conducted. An interview with the agency administrator on 12/1/21 at 2:30 p.m. revealed the RN should document the psychosocial and emotional needs in the absence of medical social work services

Based on clinical record review, and staff interviews, the agency failed to ensure oxygen orders were included on the plan of care for 4 of 5 patients that used oxygen (1, 4, 6, and 10). Findings include: 1. Patient #1 was admitted on 10/15/21 with diagnoses of pulmonary hypertension, hypertensive heart disease with heart failure, and hypoxemia. The Initial Assessment was conducted on 10/15/21 by RN #5. The Initial Assessment revealed the patient had an oxygen concentrator and portable oxygen in the home. The note stated, "He has wheezing in upper lobes. Skilled nurse applied oxygen as patient did not have it in place at time of visit. He appear [sic] short of breath with minimal exertion." The Plan of Care for 10/15/21-1/12/21 stated "Patient is oxygen dependent ...Administer supplemental oxygen as ordered." There were no orders for amount, rate, or frequency for the oxygen. An interview with the clinical manager on 12/1/21 at 2:30 p.m. confirmed the plan of care did not include specific orders for oxygen. 2. Patient #4 was admitted on 10/13/21 with diagnoses of amyotrophic lateral sclerosis (ALS) and chronic respiratory failure. The Initial Assessment was conducted on 10/13/21 by RN #6. The Initial Assessment revealed the patient had an oxygen concentrator and portable oxygen in the home; "O2 at Ventilator setting." The note stated, " ...[patient] is unable to breath [sic] on his own and is using prn trilogy with constant ventilation via [tracheostomy]." The Plan of Care for 10/13/21-1/10/21 stated, "Administer supplemental oxygen as ordered." An interview with the Director of Professional Service on 12/2/21 at 4:05 p.m. confirmed the plan of care did not include specific orders for oxygen. 3. Patient #6 was admitted on 8/30/21 with diagnosis of Alzheimer's disease and repeated falls. The Initial Assessment was conducted on 8/30/21 by RN #7. The Initial Assessment revealed the patient was on oxygen 2.5 liters per minute. "She wears oxygen and relies heavily on nebulizer treatments." The Plan of Care for 8/30/21-11/27/21 stated, "Administer supplemental oxygen as ordered." An interview with the clinical manager on 12/1/21 at 12:40 p.m. confirmed the plan of care did not include specific orders for oxygen. 4. Patient #10 was admitted on 10/27/21 with diagnoses of sepsis, Alzheimer's disease, and chronic obstructive pulmonary disease (COPD-lung disease). The Initial Assessment was conducted on10/27/21 by RN #6. The Initial Assessment revealed the patient oxygen at 2 liters per minute via nasal cannula and there was an oxygen concentrator and portable oxygen in the home. The Plan of Care for 10/27/21-1/24/21 did not include oxygen orders. An interview with the clinical manager on 12/2/21 at 3:20 p.m. confirmed the plan of care did not include specific orders for oxygen.

Based on clinical record review and staff interview, the agency failed to update the hospice aide care plan with a change in mobility status for 1 of 1 patients that received hospice aide services and had a change in mobility status (#6). Findings include: Patient #6 was admitted on 8/30/21 with diagnoses of chronic obstructive pulmonary disease (COPD-respiratory disease), dementia, and repeated falls. The Plan of Care for 8/30/21-11/27/21 included orders for a hospice aid 2 times per week for 12 weeks. The Aide Care Plan was completed on 8/30/21 stated activities permitted included "up as tolerated" with walker. The LPN conducted a visit on 9/13/21 and found "Patient has immobilized brace to [right] knee from sprain injury." RN #7 visited on 9/16/21. The note stated, "She is wheelchair bound for 10 days per provider order, a rollator walker was ordered to assist patient with balance after 10 days." The hospice aide visited the patient on 9/17/21. The aide care plan was not updated to include the knee immobilizer or the patient was wheelchair bound. The visit note revealed the aide assisted in transfer and ambulation. The aide was unavailable for interview. An interview with RN #7 on 12/2/21at 4:00 p.m. that "wheelchair bound" means non-weight bearing. An interview with the clinical manager on 12/2/21 at 4:00 p.m. confirmed the aide care plan did not include the knee immobilizer or the wheelchair bound status.

Based on review of skilled nursing facility (SNF) contracts and staff interview, the agency failed include in the agreement the 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 related to the hospice, to the SNF within 24 hours of the hospice becoming aware of the alleged violation for 2 of 3 skilled nursing facility contracts reviewed (Contract #2 and 3). Findings include: Interview with the agency director on 11/30/21 at approximately 2:00 p.m. confirmed the written agreements for Contract #2 and 3 omitted the 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 related to the hospice, to the SNF within 24 hours of the hospice becoming aware of the alleged violation.

Based on review of skilled nursing facility contracts and staff interview, the agency failed to include in the agreement the responsibilities for bereavement services to be provided to the skilled nursing facility staff for 2 of 3 skilled nursing facility contracts reviewed (Contract #2 and 3). Findings include: An interview was conducted with the agency director on 11/30/21 at approximately 2:00 p.m. The agency director stated the contract did not contain the bereavement responsibilities.