Every finding on record at Monarch Hospice Care, Inc

Based on interview and record review the hospice agency failed to review and revise the emergency preparedness plan annually and provide emergency preparedness training to the staff. This failure had the potential to place the patients at risk in the event of an emergency or disaster. Findings: A review of the hospice policy and procedure titled "Emergency Management Plan" , indicated the policy had not been revised since 11/15/2019, with corresponding signatures by the governing body. Further review of the Disaster Drill training indicated no documented evidence it was provided to the staff as required. During an interview with the Administrator on 5/9/22, at 11 a.m., stated she was aware that the policy should be reviewed annually but could not provide the signatures of the governing body's participation. Administrator stated she could not provide evidence of a disaster drill and emergency preparedness training for all the staffs.

Based on observation, interview, and record review, the SN (skilled nurse) failed to notify the physician regarding the low blood pressure reading for one out of 11 patients (1). This deficient practice placed the patient at risk for having hypotensive reactions (blurred/fading vision, dizziness/lightheadedness, fainting) that could lead to complications. Findings: A review of Patient 1's face sheet indicated admission to hospice services on 4/10/22, with primary diagnosis of chronic obstructive pulmonary disorder (a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 1's "Plan of Care (POC)" dated 5/6/22, indicated the SN visit was twice a week and as needed, to evaluate and assess for any uncontrolled pain, shortness of breath and any sudden change of condition. On 5/5/22, at 11:30 a.m., a home visit was conducted at Patient 1's residence with the DPCS (director of patient care services). Patient 1 was observed sitting in his wheelchair at his bedroom, alert and oriented, well groomed and able to move both upper and lower extremities. DPCS was observed taking the patient's B/P (blood pressure) reading. During the interview, the DPCS stated the patient's blood pressure reading was 89/53 and she stated that this was a very low B/P reading for this patient. On 5/6/22, at 1 p.m., during an interview with the DPCS, when asked if she notified the physician regarding the patient's low blood pressure reading, she stated that she forgot to notify the physician. She also stated that the low B/P reading was considered a change of condition and she should have notified the physician right away. A further review of Patient 1's clinical record indicated that there was no documented evidence the physician was notified regarding Patient 1's low blood pressure reading. A review of Agency's policy "Change of Condition (undated)," indicated the clinician is responsible for any specific treatment would notify the attending physician of significant changes in the patient's condition.

Based on interview, and record review, the hospice agency failed to ensure there is an ongoing communication between the hospice nurse and the skilled nursing facility (SNF) nurse for one of 11 patients (Patient 7) provided wound care management. This deficient practice has the potential to result in the non-continuity of patient care that could delay the healing process of the wound and further delay the provision of an appropriate treatment to the wound. Findings: A review of Patient 7's face sheet indicated admission to hospice on 4/8/22, with primary diagnosis of malignant neoplasm of prostate (cancer that forms in tissues of a gland in the male reproductive system) A review of Patient 7's "Plan of Care (POC)" dated 5/4/22, indicated the Skilled Nurse (SN) visit was twice a week +3 PRN visits, the Medical Social Worker (MSW) visit was one time then as needed, the hospice aide (HA) service was twice a week for self care needs. A review of Patient 7's "current treatment/medication/DME List" dated 4/20/22, indicated to cleanse wound with normal saline, pat dry, apply skin prep to periwound, apply medihoney and calcium alginate to wound and cover with dry dressing and bordered foam dressing, change daily or as needed for excessive soiling. During an interview on 5/9/22, at 1:05 p.m., with the ADM, when asked about if her nursing staff should be doing wound care for hospice patients she stated "Yes, but sometimes the SNF wound care nurse does it first before our staff gets there". When asked if there should be communication between Hospice staff and SNF staff regarding the coordination of care ADM stated "Absolutely yes, but this did not happen and will be addressed during our next inservice".

Based on observation, interview, and record review, the hospice agency failed to implement COVID-19 (an acute respiratory illness) procedures and policy. This failure had the potential to spread infection. Findings: During an interview with the Administrator on 5/9/22, at 11 a.m., stated she did not know if all staffs were fitted for N95 masks and did not have evidence all staffs were fit tested for N95 masks. A review of the agency's policy and procedure "Infection Control Plan" indicated the organization will address surveillance, prevention, identification, control and reporting of infections, utilizing current scientific methods and epidemiologic principles.

Based on record review, observation, and interview, the hospice agency failed to ensure the Condition of Participation for Medical Director was met as follows: The hospice agency's Medical Director failed to coordinate with the patient's attending physicians to review the patient clinical information to determine certification for eligibility for admission to the hospice program among three of 11 sampled patients (Patients 1, 2, and 8). This deficient practice resulted in the provision of hospice services with anticipation of life expectancy of six months of less to Patients 1, 2, and 8, who were not clinically eligible to receive hospice service (refer to ( L 667). The cumulative effect of these systemic practice resulted in the failure to deliver statutorily mandated compliance with federal regulations for Medical Director services to ensure the highest quality of patient care are provided to the patients certified to receive hospice services.

Based on observation, interview, and record review, the hospice agency's medical director failed to coordinate with the patient's attending physicians to review the patient's clinical information to determine certification for eligibility for admission to the hospice program among three of 11 sampled patients (Patients 1, 2, and 8). This deficient practice resulted in the provision of hospice services with anticipation of life expectancy of six months of less to Patients 1, 2, and 8, who were not clinically eligible to receive hospice services. Findings: a. A review of Patient 1's face sheet indicated admission to hospice on 4/10/22, with primary diagnosis of chronic obstructive pulmonary disorder (a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 1's "Plan of Care (POC)" dated 5/6/22, indicated the Skilled Nurse (SN) visit was twice a week and as needed, the Medical Social Worker (MSW) visit was one time then as needed, the hospice aide (HA) service was twice a week for self care needs. A review of Patient 1's Physician's Certificate of Terminal Illness (CTI), dated 4/10/22, Benefit period #1 indicated the patient was alert, oriented with dyspnea (labored breathing) with speech, oxygen satuation (amount of oxygen circulating in the blood and oxygen saturation normal range is between 95% and 100%) of 88 percent (%) and oxygen at 2 liters per minute. The Medical Director signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less, if the terminal illness runs its normal course. On 5/5/22, at 11:30 a.m., a home visit was conducted at Patient 1's residence. Patient 1 was observed sitting on his wheelchair at his bedroom. Patient 1 was observed alert, oriented, well groomed, able to move both upper and lower extremities, and was not receiving oxygen. On 5/5/22, at 11:40 a.m., during an interview, Patient 1 stated he uses oxygen when he has breathing difficulty. Patient 1 stated he does not need hospice care and he was not dying. Patient 1 also stated that his attending physician did not refer him to the hospice services, had a slight stroke and all she needed was physical therapy (PT) service. Patient 1 further stated that the hospice administrator told her in order to get PT service, he needed to sign-up for their hospice services and his daughter referred him to their hospice agency. b. A review of Patient 2's face sheet indicated the patient was admitted to the hospice agency on 11/16/21, with primary diagnosis of artherosclerosis heart disease of native coronary artery (a disease of the arteries characterized by deposition of plaques of fatty material on their inner wall). A review of Patient 2's "Plan of Care (POC)" dated 5/4/22, indicated the Skilled Nurse visit was twice a week and as needed, the Medical Social Worker (MSW) visit was one time then as needed, the hospice aide service was twice a week for self care needs. A review of Patient 2's Physician's Certificate of Terminal Illness (CTI), dated 11/16/21, Benefit period #1 indicated the patient was on hospice because of declining in physical strength and mental functioning. The patient was dependent on a walker and wheelchair for walking. Patient 1 had weakness, fatigue, and had shortness of breath with mnimal exertion and even at rest. The Medical Director signed the attending physician referral section that indicated Patient 1 had a life expectancy of six months or less, if the terminal illness runs its normal course. On 5/5/22, at 12:30 p.m., a home visit was conducted at Patient 2's residence. Patient 2 was observed sitting on her bed, being alert and oriented, well groomed and able to move both upper and lower extremities. On 5/5/22, at 12:45 p.m., during an interview with Patient 2, she stated she does not need hospice care and she was not dying. She also stated that her attending physician did not refer her to hospice services. She further stated she had a stroke and all she needed was physical therapy (PT) service, and now she got better and recovered from the stroke. Patient 2 stated that walks without using a walker or wheelchair. Patient 2 also stated that she goes out every week to shop to the department store. During an interview with the Medical Director on 5/9/22, at 12 p.m., he stated that he was not the attending physician and he does not know who the attending physicians are for Patient 1 and 2. He also stated that since these patients were admitted to their hospice service, they are now the patient's attending physician, that he signed the referral attending physician section because no one would signed it. He further stated that he did a face to face encounter with Patient 1 and 2 during their admissions and from his head to toe assesments, review of patients' medical records provided by the hospital and assessment report given by the registered nurse upon her initial visit to the patients, he determined the patients were eligible for hospice services. On 5/9/22, at 1 p.m., during an interview with the Administrator (ADM) when asked how their hospice agency admits their patients, she stated that all patients being admitted to their hospice service should be referred by their attending physician with a referral order for hospice service. ADM also confirmed that both attending physicians for Patients 1 and 2 did not refer the patients to the hospice agency. A review of the facility's policy and procedures titled, "Admission Criteria and Process," dated April 2019 indicated the patient must have a life-limiting illness with a life expectancy of six months or less as determined by the attending physician and hospice medical director, utilizing standard clinical prognosis criteria in the organization's intermediary local coverage determination. The admission criteria indicated the agency would admit a patient only on recommendation of the medical director in consultation with, or input from, the patient's attending physician, if any. The information can be obtained from the hospice nurse or others sharing the attending physician's knowledge of the patient. The patient's physician must order and approved the provision of hospice care. The admission critieria also included the patient must desire hospice services and be aware of the diagnosis and prognosis, and the patient and family/caregiver desire hospice care and agree to participate in the plan of care. c. A review of Patient 8's face sheet indicated admission to hospice on 1/15/22, with primary diagnosis of atherosclerotic heart disease of native coronary artery (inflammation and a buildup of plaque in the artery supplying blood to the heart) A review of Patient 8's "Plan of Care (POC)" dated 5/4/22, indicated the Skilled Nurse (SN) visit was twice a week and as needed visits, the Medical Social Worker (MSW) visit was one time then as needed, the hospice aide (HA) service was twice a week for self care needs. A review of Patient 8's Certificate of Terminal Illness (CTI), dated 1/16/2022, Benefit period #2 indicated the Medical Director signed the attending physician referral section to indicate Patient 8 had a life expectancy of six months or less, if the terminal illness runs its normal course. During an interview with the Medical Director on 5/9/22, at 12 p.m., he stated that he was not the attending physician and he does not know who the attending physicians are for Patient 1, 2, and 8. He also stated that since these patients were admitted to their hospice service, he is now the patient's attending physician, that he signed the referral attending physician section because no one will signed it.. He further stated that he did a face to face encounter with these patients during their admissions and from his head to toe assesments, review of patient's medical records provided by the hospital and assessment report given by the registered nurse upon her initial visit to the patient, he determines the patient is eligible for hospice services. On 5/9/22, at 1 p.m., during an interview with the Administrator when asked how their hospice agency admits their patients, she stated that all patients being admitted to their hospice service should be referred by their attending physician with a referral order for hospice service. She also confirmed that the attending physicians for Patients 1, 2, and 8 did not refer the patients to the hospice agency. A review of the facility's policy and procedures titled, "Admission Criteria and Process," dated April 2019 indicated the patient must have a life-limiting illness with a life expectancy of six months or less as determined by the attending physician and hospice medical director, utilizing standard clinical prognosis criteria in the organization's intermediary local coverage determination. The admission criteria indicated the agency would admit a patient only on recommendation of the medical director in consultation with, or input from, the patient's attending physician, if any. The information can be obtained from the hospice nurse or others sharing the attending physician's knowledge of the patient. The patient's physician must order and approved the provision of hospice care. The admission critieria also included the patient must desire hospice services and be aware of the diagnosis and prognosis and the patient and family/caregiver desire hospice care and agree to participate in the plan of care.

Based on observation, interview, and record review, the hospice agency failed to ensure medical supplies stored were not expired. This deficient practice has the potential for these expired medications/supplies will be used to an already compromised patients. Findings: During an observation and interview on 5/4/2022, at 11:13 a.m., with the Office Manager (OM 1), the following were noted : a. 12 bottles of Hydrox 3% hydrogen peroxide (a mild solution used to prevent infection) expired on 7/2020 b. two spray bottles of Swan 3% hydrogen peroxide) expired on 6/2020 c. six bottles of Jevity 1.2 (therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding) expired on 4/1/2021. During a concurrent interview with OM 1 stated supplies were checked once a week and the expiration dates of the supplies used most frequently were checked. Both OM 1 and ADM 1 stated the nurses were responsible for checking the expiration dates. During an interview with the ADM 1 on 5/4/2022 at 11:46 am, ADM 1 stated we are all responsible for checking the expiration date on the medical supplies. ADM 1 stated we usually check every couple of weeks. ADM 1 stated it was important to throw away expired supplies because it could be accidentally picked up by a nurse and used on a patient. A review of the facility's policy and procedure, Supply Maintenance, (undated), indicated supplies will be checked for expiration date prior to use. If outdated, the supplies will be immediately removed from stock and discarded.