Every finding on record at Midtown Hospice, Inc.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: Prescription and over-the-counter (OTC) drugs. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy; The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records and interview. 1 of 11 (9%) records reviewed revealed the hospice did not ensure that medication profiles were updated and drug regime reviews ocurred when new medications were ordered for patients. Clinical Record 3 identified thepatient elected hospice on 9/30/2022. The Plan of Care for the period 9/30/2022 - 12/28/2022- A skilled nurse (SN) visit note dated 10/4/2022, documented a Stage 3 wound on right buttock. Wound care documented by the SN was “clean with wound cleanser, apply calcium alginate and dry dressing”. There was a physician order dated 10/4/2022 to increase SN visits to three (3) times a week for wound care, clean wound with wound cleanser, apply calcium alginate and dry dressing. There was no documented evidence the Calcium Alginate was added to the medication profile. During joint record review with the Director of Nurses (DON) on 11/17/2022, the DON stated, “calcium alginate was not added to the medication profile”.

Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by a review of clinical records and interviews. 3 of 11 (27%) patient records reviewed revealed that services provided were inconsistent with the individualized plan of care as established by the IDG. Clinical Record 1 identified the patient elected hospice on 10/20/2022. The Plan of Care for 10/20/2022 - 1/17/2023- the skilled nurse (SN) was ordered two (2) times a week times 1 and then one (1) time a week. During the week of 10/20/2022, 2 visits were completed. During a joint record review on 11/16/2022, the Director of Nurses, stated, "the patient was only seen one time a week the first week by the nurse”. Clinical Record 8 identified the patient elected hospice on 7/7/2022. On the initial comprehensive assessment dated 7/7/2022, the SN documented the patient had a left (L) BKA with 24 staples in place. The Plan of Care dated 7/7/2022 – 10/4/2022 wound care was “clean wound with wound cleanser, apply xeroform over staples, wrap with kerlix and ace wrap. SN frequency daily”. A physician order dated 7/10/2022 stated to “Change SN to three times a week". During a joint record review with the Director of Nurses on 11/18/2022, the clinical record contained a physician order dated 8/1/2022 changing the wound care to “cleanse with wound cleanser, apply calcium alginate, cover with dressing”. . The SN documented on 8/15/22,8/17/22,8/19/22, 8/22/22,8/24/22, and 8/26/22, 9/12/22, and 9/14/22 wound cleaned with NS, pat dry Xeroform applied, dressing, secured with Kerlix and Ace Wrap”. The Director of Nurses stated "there is not an order changing the wound care back to the Xeroform. That was not the wound care.” During the continued joint record review with the Director of Nurse, there was documented evidence in the clinical record of a Physician Order dated 9/15/2022 changing the wound care to “clean with normal saline, apply collagen sheet to wound bed, wrap with kerlix, secure with ace bandage”. On 9/19/2022, the SN documented on the skill nurse visit note, “ wound clean with NS, pat dry, Xeroform applied, dressing secured with Kerlix and Ace Wrap. The DON stated, “ she documented the wrong wound care again”. Clinical Record 5 identified the patient elected hospice on 5/12/2021. The Plan of Care for the benefit period 9/4/2022 – 11/2/2022- The patient received respite care from 9/21/2022-9/26/2022. In the clinical record was a physician order dated 10/3/2022 for the SN to perform wound care on SN visits to “open wound, quarter size, 24.26 cm, above (R) elbow, some drainage, no slough, Clean with NS, pat dry, apply xeroform and cover with dressing”. SN frequency was two times a week. The SN documented “wound care provided Cleansed with NS, pat dry, calcium alginate and dsg” on 10/6/2022,10/10/22,10/13/2022 and 10/17/2022”. SN documented on 10/20/2022 “wound healed”.

It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records and interview. 1 of 11 (9%)records reviewed revelaed the agency failed to ensure the written plan of care identified planned interventions based on problems identified in the updated comprehensive assessment.. Clinical Record 3 identified the patient elected hospice care on 9/30/22. The Plan of Care for the period 9/30/2022 - 12/28/22 - A skilled nurse (SN) visit dated 10/12/22 documented “Wound Two Location-Left Heel, Onset date -10/4/22, Size-Quarter Size, Drainage- some drainage, Odor-no odor, Etiology-Pressure, Stage 3, Undermining No, Inflammation No. Left heel dressing changed with NS, pat dry, covered with calcium alginate, secured with Kerlix”. During a joint record review with the Director of Nurses on 11/18/2022 identified the SN documented wound care was provided on 10/12/22,10/14/22,10/17/22,10/19/22, 10/21/22, 10/24/22, 10/26/22 and 10/28/22. There was no documented evidence in the clinical record of a Physician order for wound care to be provided to the left heel wound. The DON stated, “I can’t find an order for this wound care and the onset date must be wrong. The patient only had the one wound on 10/4/2022 which was on the Right buttock”.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: Hand hygiene. This standard was not met as evidenced by document reviews and observations. 1 of 3 (33%) home observation visits revealed the agency did not ensure the clinical staff followed infection control procedures in accodance with agency policies related to hand washing. Home Visit 2 identified the patient elected hospice care on 7/7/2022. Patient lives in a private group home with five (5) other individuals. On 11/17/2022 during a home visit with the Hospice aide, site visitor observed the hospice aide using the open bar soap that was lying on the lavatory, drying her hands a paper towel, then donning a pair of gloves. She then moved the clean items to the patient's bedside table, removed the gloves, walked into the kitchen, opened the kitchen cabinet, removed a trash bag and returned to the patient's bedroom with the trash bag and donned another pair of gloves without using soap and water or hand sanitizing gel before donning a clean pair of gloves. A Review of the Agency's Hospice Policy and Procedure Hand hygiene JCC 041321 Hospice-CHAP (3 pages), Procedure for Hand-Hygiene Guideline, #B. on page 1 of 3 states" If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations or wash hands with and antimicrobial soap and water." On page 2 of 3, # H "Decontaminate hands after removing gloves, and in between glove changes".

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; included in the plan of care. Permitted to be performed under state law and regulation. Consistent with the hospice aide training. This standard was not met as evidenced by a review of clinical records and interview. 1 of 8 (12%) applicable records of hospice iades revealed the hospice did not ensure the hospice aide provided services that were consistent with the plan of care visit frequency. Clinical Record 1 identified the patient elected hospice care on 10/20/2022. The Plan of Care for the period of 10/20/2022 - 1/17/2023 - the hospice aide visit frequencyordered on 10/20/2022 was three (3) times a week. During the week of 10/20/2022, two hospice aide visits were completed. There was no documentation explaing the missed visit. During a joint record review on 11/16/2022, the Director of Nurses, stated, "the patient was only seen two times a week the first week."

It is required that drugs and biologicals are labeled and stored in accordance with state law and regulation, as well as accepted standards of practice. At a minimum, labels include: The patient’s full name; Generic, trade, or brand name of the medication, as well as amount dispensed; Directions for use, including route, rate, frequency, and method of administration. Prescriber’s name; and Cautionary instructions. This standard was not met as evidenced by document reviews, interviews and observations. 1 of 3 (33%) home visit observations revealead that the agency did not ensure the patient's medications from the Hospice Pharmacy were labeled in accordance with acceptable standards of practice.. Home Visit 2 on 11/17/2022 was a joint visit with the skilled nurse. A reveiw of the patient's medications complared to the medication profile identified a bottle of MiraLax did not havea label containing the patient's name, generic or brand name of medication, directions for use, including route, frequency or dose, prescriber's name or any cautionary instructions. There was no evidence that a label was loose in the patient's medication box. The skilled nurse stated, "This came from our pharmacy and should have a label. I will contact the pharmacy regarding why there is not a label." Upon return to the office, the skilled nurse contacted the pharmacy, and the pharmacy faxed a label of what should have been on the bottle. The faxed label was shown to the site visitor by the skilled nurse.