Every finding on record at Monroe County Health Care Authority

Based on review of Medical Records (MR), agency policies and procedures, Hospital A (Hospital providing General Inpatient) MR, and staff interviews it was determined the hospice failed to ensure all medications administered to the patient were on the agency medication profile. This deficient practice did affect MR # 11, one of two MR's reviewed with General Inpatient (GIP), and Home Visit (HV) # 1, one of three HV conducted. This deficient practice had the potential to affect all patients. Findings Include: Agency Policy: Coordination of Care During GIP or Respite Policy Number: HP 007 Reviewed Date: 3/24 Policy: A patient who is admitted to a facility for pain and symptom management...will have their plan of care (POC) coordinated by the Hospice throughout their stay... Procedure: ...2. Services provided in an inpatient setting must conform to the written POC, coordinated by Hospice. The services must be reasonable and necessary for: Palliation or management of the terminal illness Procedures necessary for pain control. Agency Policy: Medication Reconciliation Policy Number: MCHHP-041 Reviewed Date: 2/24 Policy: Hospice will reconcile patient's medication at time of admission and on an ongoing basis. Purpose: To define the medication reconciliation process. Procedure: 1. At time of the initial assessment, the RN will create and document a complete list of medications that patient is taking, including dose, route, and frequency... 2. 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... --- 2. HV # 1 was admitted to the agency on 7/5/24 with diagnoses including Vascular Dementia, Moderate, with Mood Disturbance, Major Depressive Disorder, and Adjustment Disorder with Depressed Mood. HV # 1 resides in a Nursing Home. A HV was conducted on 7/23/24 at 1:59 PM with EI # 4, Medical Social Worker, to observe care provided. During the home visit medications at the facility were compared to the agency medication profile and verified by facility nurse as current medications for HV # 1. The following medications were current and not documented on the medication profile: Lorazepam 0.5 mg at bedtime, started on 6/14/24. Lorazepam 0.5 mg daily as needed, started on 6/14/24. Zyrtec 10 mg daily for allergies, started on 6/29/24. Potassium Chloride Extended Release 20 milliequivalents daily, started on 6/29/24. Tylenol 325 mg 2 tablets, every 4 hours as needed for pain or fever, started on 5/8/24. Albuterol Hydrofluoroalkane 90 micrograms 2 puffs every 4 hours as needed for wheezing, cough or shortness of breath, started on 6/5/24. An interview was conducted on 7/23/24 at 3:41 PM with EI # 1 who confirmed the agency failed to ensure all medications administered to the patient were on the agency medication profile. 1. MR # 11 was admitted to the agency on 5/17/24 with a diagnosis of Chronic Kidney Disease, Stage 3 Unspecified. Review of the Skilled Nurse (SN) Admission Visit Note dated 5/17/24 revealed the patient was in GIP at Hospital A and was receiving Normal Saline Intravenously (IV). There was no documentation of the amount and duration of the Normal Saline. Review of Hospital A Physician order, provided by the agency, dated 5/17/24 revealed an order for Morphine 2 milligrams (mg) IV every four hours and Ativan 0.5 mg IV every four hours. Review of Hospital A Physician order dated 5/18/24 revealed an order for a one time dose of Benadryl 25 milligrams IV and Decadron 4 mg IV. Review of the agency Medication Profile dated from 5/17/24 to 5/26/24 reveled no documentation of the Morphine 2 mg every four hours, Ativan 0.5 mg every four hours, Normal Saline, Benadryl one time dose, and Decadron one time dose. An interview was conducted on 7/25/24 at 2:57 PM with Employee Identifier (EI) # 1, Director, who confirmed the agency failed to ensure all medications administered to the patient were on the agency medication profile.

Based on review of the Medical Record (MR), agency policy and procedure, and staff interviews it was determined the agency failed to include all interventions and goals on the patient's Plan of Care (POC) which were necessary for the palliation and management of the terminal illness and related conditions. This deficient practice did affect HV # 3, MR # 10, MR # 9, MR # 11, MR # 3, and HV # 2, six of 14 MR's reviewed, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: IDG (Interdisciplinary Group) Care Planning Process Policy Number: HP 063 Reviewed Date: 3/24 Policy: In order to assure that care provided is appropriately planned to meet each patient's specific needs and problems, (the) hospice will utilize data/information gathered during the comprehensive assessment, updates to the comprehensive assessment and reassessments, in the care planning process to provide care that is consistent with the patient and family needs... Procedure: ...2. The care of plan specifies the care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions. ...6. All care and services furnished to patients and their families follows an individualized written POC established by the IDG in collaboration with the attending physician... 8. An individualized written POC is developed for each patient. The POC reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The POC is written to include all services necessary for the palliation and management of the terminal illness and related conditions... --- 6. HV # 2 was admitted to the Hospice Agency on 6/28/24 with diagnoses including Parkinson's Disease with Dyskinesia, with Fluctuations, Non-Rheumatic Aortic (valve) Stenosis, and Pulmonary Hypertension, Unspecified. Review of the SN Visit Admission Note dated 6/28/24 and SN Note dated 7/3/24 revealed documentation of a right forearm skin tear and right buttock skin tear. Review of the Hospice POC dated 6/28/24 and IDG dated 7/8/24 revealed no documentation of interventions and goals for the wound to the right forearm and right buttock. An interview was conducted on 7/25/24 at 3:38 PM with EI # 1 who confirmed the agency failed to ensure the right forearm and right buttock wound interventions and goals were included in the POC. 5. MR # 3 was admitted to the agency on 9/14/23 with diagnoses including Vascular Dementia, Severe, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Tremor, and Type 2 Diabetes Mellitus. Review of SN Visit Note dated 10/24/23 revealed documentation the patient had an unstageable pressure ulcer to the coccyx and the SN received a verbal order to apply Resinol and cover with Mepilex. There was no documentation of the frequency the wound care was to be completed, how to clean the wound, and the physician the order was received from. Review of the Hospice POC dated 9/14/23 to 12/12/23 and IDG meeting dated 11/6/23 revealed no documentation of a coccyx wound intervention and goal. An interview was conducted on 7/25/24 at 4:19 PM with EI # 1 who confirmed the nurse failed to update the POC. 1. HV # 3 was admitted to the agency on 7/16/24 with diagnoses including Cerebral Infarction, Unspecified, Personal History of Urinary (Tract) Infections, and Presence of Other Vascular Implants and Grafts. Review of the SN (Skilled Nurse) Admission Visit Note dated 7/16/24 revealed the patient had a Med port (implanted port under skin used to deliver medications) to the right chest wall, an indwelling Foley catheter, and was receiving daily Fortaz 2 gram intramuscular (IM) injections for the next 5 days for a Urinary Tract Infection. Review of the Hospice POC dated 7/16/24 to 10/13/24 revealed no documentation of an intervention for the flush of the Med port, the change and irrigation of the Foley catheter, and the administration of the Fortaz IM injections. Further review of the Hospice POC dated 7/16/24 to 10/13/24 revealed no goal for the Med port. An interview was conducted on 7/25/24 at 3:25 PM with Employee Identifier (EI) # 1, Director, who confirmed the agency failed to include interventions for the Med port, Foley catheter, and Fortaz injections and a goal for the Med port on the patient's POC. 2. MR # 10 was admitted to the agency on 4/15/24 with diagnoses including Traumatic Subdural Hemorrhage with Loss of Consciousness Greater than 24 Hours without Return to Pre-existing Conscious Level with Patient Surviving, Subsequent Encounter, Personal History of Pneumonia (Recurrent), and Encounter for Attention to Gastrostomy. Review of the SN Admission Visit Note dated 4/15/24 revealed the patient had a Gastrostomy tube to the abdominal left upper quadrant and receiving Jevity 1.2 calorie bolus feedings every four hours followed by a flush with 8 oz (ounce) of water. Review of the Hospice POC dated 4/15/24 to 7/13/24 revealed no documentation of an intervention for the Gastrostomy tube change, flush of the Gastrostomy tube, and the amount and frequency of the Jevity feedings. Further review of the Hospice POC dated 4/15/24 to 7/13/24 revealed no documentation of an intervention and goal for the Medical Social Worker (MSW). Review of the MSW visit note dated 4/16/24 revealed the plan for the next visit was a face to face visit to follow up on coping strategies, to check on the caregiver to ensure the caregiver was coping normally, and to see if intervention by the MSW was needed to prevent caregiver burnout. There was no documentation of the MSW scope and frequency for future visits by the MSW on the patient POC. Review of the MSW visit note dated 7/10/24 revealed a second MSW visit was completed. Review of the SN Visit Note dated 7/10/24 revealed the nurse removed and replaced the 16 Fr (French) 6 ml (milliliter) Gastrostomy tube at the visit. An interview was conducted on 7/25/24 at 4:09 PM with EI # 1 who confirmed the agency failed to ensure interventions for the Gastrostomy tube change, flush of the Gastrostomy tube, the amount and frequency of the Jevity feedings, and an intervention and goal for the MSW were included in the patient's POC. 3. MR # 9 was admitted to the agency on 5/30/24 with a diagnosis of Unspecified Dementia, Severe, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. Review of the Hospice POC dated 5/30/24 to 8/27/24 revealed no documentation of an intervention and goal for a wound. Review of the Patient Care Order dated 6/24/24 revealed a physician order to clean the stage 2 pressure ulcer to the posterior buttocks with soap and water, pat dry, apply Chamosyn (Brand name) ointment, and cover with an Allevyn (Brand name) dressing every three days and as needed. Review of the IDG (Interdisciplinary Group) Meetings dated 7/1/24 and 7/15/24 revealed no documentation of an intervention and goal for the stage 2 pressure ulcer to the posterior buttocks. An interview was conducted on 7/25/24 at 4:37 PM with EI # 1 who confirmed the agency failed to ensure interventions and goals for the stage 2 pressure ulcer to the posterior buttock wound were included in the patient's POC. 4. MR # 11 was admitted to the agency on 5/17/24 with a diagnosis of Chronic Kidney Disease, Stage 3 Unspecified. Review of the SN Admission Visit Note dated 5/17/24 revealed the patient had a Diabetic Ulcer to the left lateral 5th toe, Foley catheter, 3 plus (Deep pitting, indentation remain for a short time) edema to the bilateral lower extremities and scrotum, itching, constipation with the last bowel movement date unknown, nausea and vomiting, poor appetite, was a falls risk, required Hospice Aide (HA) services, and was receiving Normal Saline intravenously. Review of the Hospice POC dated 5/17/24 to 8/14/24 and the IDG dated 5/20/24 revealed no documentation of any interventions and goals for the patient. An interview was conducted on 7/25/24 at 2:57 PM with EI # 1 who confirmed the agency failed to ensure interventions and goals for the patient were included in the patient's POC.

Based on review of Medical Records (MR), agency policies and procedures, and staff interviews it was determined the agency failed to ensure the scope and frequency of services necessary to meet the specific patient and family needs was included or followed in the Plan of Care (POC). This deficient practice did affect MR # 10, MR # 9, MR # 11, and Home Visit (HV) # 2, four of 14 MR's reviewed, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: IDG (Interdisciplinary Group) Care Planning Process Policy Number: HP 063 Reviewed Date: 3/24 Policy: In order to assure that care provided is appropriately planned to meet each patient's specific needs and problems, (the) hospice will utilize data/information gathered during the comprehensive assessment, updates to the comprehensive assessment and reassessments, in the care planning process to provide care that is consistent with the patient and family needs... Procedure: ...2. The care of plan specifies the care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions. ...8. An individualized written POC is developed for each patient. The POC reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The POC is written to include all services necessary for the palliation and management of the terminal illness and related conditions including: ...A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Agency Policy: Missed Visit Policy Policy Number: HP-141 Effective Date: 8/21 Policy: ...A missed visit is an alteration of the Plan of Care (POC) and modifies the frequency. A missed visit (is to) be reported and documented per policy. Procedure: A missed visit modifies the frequency of visits the physician ordered...The agency must notify the physician about the missed visit. Reason: The Conditions of Participation require staff to notify the physician about changes that suggest a need to modify the POC...The case communication note should include reason for the missed visit, collaboration with IDT (Interdisciplinary Team) and physician. --- 4. HV # 2 was admitted to the agency on 6/28/24 with diagnoses including Parkinson's Disease with Dyskinesia, with Fluctuations, Non-Rheumatic Aortic (valve) Stenosis, and Pulmonary Hypertension, Unspecified. Review of the Hospice POC dated 6/28/24 to 9/28/24 revealed a HA frequency of five times a week for twelve weeks. Review of the HA visit notes the week of 6/28/24 revealed two visits were completed and not three as ordered. There was no documentation the physician was notified of the missed visits. An interview was conducted on 7/25/24 at 4of 6/28/24e:54 PM with EI # 1 who confirmed the agency failed to ensure the physician and IDG were notified of the missed HA visits. 1. MR # 10 was admitted to the agency on 4/15/24 with diagnoses including Traumatic Subdural Hemorrhage with Loss of Consciousness Greater than 24 Hours without Return to Pre-existing Conscious Level with Patient Surviving, Subsequent Encounter, Personal History of Pneumonia (Recurrent), and Encounter for Attention to Gastrostomy. Review of the Hospice POC dated 4/15/24 to 7/13/24 revealed a Medical Social Worker (MSW) frequency to assess and evaluate from 4/11/24 to 4/16/24 and a hospice aide (HA) frequency of three times a week for twelve weeks. There was no documentation of a MSW frequency following the assess and evaluate frequency. Review of the MSW visit note dated 4/16/24 revealed a plan for the next visit was a face to face visit to follow up on coping strategies, to check on the caregiver to ensure the caregiver was coping normally, and to see if intervention by the MSW was needed to prevent caregiver burnout. There was no documentation of the MSW scope and frequency for future visits by the MSW on the patient POC. Review of the HA visit notes dated 5/1/24, 5/3/24, 5/22/24, and 6/3/24 revealed missed HA visits per the patient's family request. There was no documentation the physician was notified of the missed HA visits. Review of the HA visit notes for the week of 5/26/24, revealed two visits were completed, and not three as ordered. There was no documentation the physician was notified of the missed visit. Review of the IDG meetings dated 5/6/24, 6/3/24, and 6/17/24 revealed no documentation the physician and IDG were notified of the missed HA visits. Review of the MSW visit note dated 7/10/24 revealed a second MSW visit was completed. There was no documentation of the MSW scope and frequency on the patient POC. An interview was conducted on 7/25/24 at 4:09 PM with EI # 1, Director, who confirmed the agency failed to ensure the MSW scope and frequency was on the patient's POC and failed to ensure the physician and IDG were notified of the missed HA visits. 2. MR # 9 was admitted to the agency on 5/30/24 with a diagnosis of Unspecified Dementia, Severe, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. Review of the Hospice POC dated 5/30/24 to 8/27/24 revealed a HA frequency of three times a week for twelve weeks. Review of the HA visit notes dated 6/5/24, 6/12/24, 6/19/24, and 7/10/24 revealed missed HA visits per the patient's family request. There was no documentation the physician was notified of the missed HA visits. Review of the IDG Meetings dated 6/17/24, 7/1/24, and 7/15/24 revealed no documentation the physician and IDG were notified of the missed HA visits. An interview was conducted on 7/25/24 at 4:37 PM with EI # 1 who confirmed the agency failed to ensure the physician and IDG were notified of the missed HA visits. 3. MR # 11 was admitted to the agency on 5/17/24 with a diagnosis of Chronic Kidney Disease, Stage 3 Unspecified. Review of the Physician order dated 5/20/24 revealed a SN (Skilled Nurse) frequency of five times a week for 12 weeks and a HA frequency of five times a week for two weeks. Review of the Hospice POC dated 5/17/24 to 8/14/24 revealed no documentation of the five times a week frequency for the SN and HA. An interview was conducted on 7/25/24 at 2:57 PM with EI # 1 who confirmed the agency failed to ensure the discipline frequencies were included in the patient's POC.

Based on review of Medical Records (MR), agency policies and procedures, Potter and Perry Fundamentals of Nursing, Hospital A MR (hospital providing General Inpatient) and staff interview it was determined the agency failed to ensure: 1. Wounds were assessed per the agency policy. 2. IDG (Interdisciplinary Group) was notified of the presence of a new wound in order to determine the treatment necessary to the wound. 3. Wound care was provided per the physician order. This deficient practice did affect MR # 10, MR # 9, MR # 6, MR # 3, and Home Visit (HV) # 2, five out of 14 MR's reviewed and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Wound Care Policy Policy Number: HP-144 Effective Date: 8/21 Policy: ...The patient deserves consistent, effective wound care. The assessment, delivery of and evaluation of the wound will be as follows in the procedure. Procedure: 1. All wounds will be staged per the following criteria: Stage 1: ...observable pressure-related alteration of intact skin. (no break in the skin)... Stage 2: Partial thickness skin loss involving epidermis or dermis, or both. The wound is superficial and presents as an abrasion, blister, or shallow crater... 2. All wounds greater than a Stage 1 will be measured at least once a week. ...4. The wound will be documented in the nurse's note. The documentation will include at least the following: a. Measurement - done at least weekly (Stage 1 or greater). b. Color. c. Odor, if any. d. Drainage - color, amount... 7. Wound measurements will be done weekly and charted under wounds. Potter and Perry Fundamentals of Nursing 8th Edition Page 1216 Treating Pressure Ulcer Steps. ...7. Assess pressure ulcer(s)... a. Note color, type, and percentage of tissue type present in wound base... 8. Assess periwound skin; check for maceration, redness, denuded area. Agency Policy: Coordination of Care During GIP or Respite Policy Number: HP 007 Reviewed Date: 3/24 Policy: A patient who is admitted to a facility for pain and symptom management...will have their plan of care (POC) coordinated by the Hospice throughout their stay... Procedure: ...2. Services provided in an inpatient setting must conform to the written POC, coordinated by Hospice. The services must be reasonable and necessary for: Palliation or management of the terminal illness --- 5. HV # 2, was admitted to the Hospice Agency on 6/228/24 with diagnoses including Parkinson's Disease with Dyskinesia, with Fluctuations, Non-Rheumatic Aortic (valve) Stenosis, and Pulmonary Hypertension, Unspecified. Review of the Skilled Nursing Visit Notes dated 6/28/24 and 7/3/24 revealed documentation of a right forearm skin tear and right buttock skin tear. There was no documentation of a wound measurement, assessment of the wound base, and assessment of the peri-wound skin. An interview was conducted on 7/25/24 at 3:38 PM with EI # 1, Director, who confirmed the agency failed to ensure wounds were assessed and documented per the agency policy. 3. MR # 6, was admitted to the Hospice Agency on 6/21/24 with diagnoses including Unspecified Dementia, Severe, with Agitation, Essential Hypertension, and Chronic Obstructive Pulmonary Disease. Review of the Skilled Nursing Visit Notes dated 7/5/24 and 7/9/24 revealed documentation of blisters to the feet. There was no documentation of a wound measurement, assessment of the wound base, and assessment of the peri-wound skin. An interview was conducted on 7/25/24 at 2:56 PM with EI # 1, Director, who confirmed the agency failed to ensure wounds were assessed and documented per the agency policy. 4. MR # 3 was admitted to the agency on 9/14/23 with diagnoses including Vascular Dementia, Severe, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Tremor, and Type 2 Diabetes Mellitus. Review of the Skilled Nursing Visit Note dated 10/24/23 revealed an Unstageable Decubitus to the Coccyx was documented and orders were verbally obtained for care. Review of the Skilled Nursing Visit Note dated 10/31/23 revealed no documentation of a wound, wound measurement, assessment of the wound base, and assessment of the peri-wound skin. An interview was conducted on 7/25/24 at 4:19 PM with EI # 1, who confirmed the agency failed to ensure wounds were assessed and documented on per the agency policy 1. MR # 10 was admitted to the agency on 4/15/24, and recertified for continued care from 7/14/24 to 10/11/24, with diagnoses including Traumatic Subdural Hemorrhage with Loss of Consciousness Greater than 24 Hours without Return to Pre-existing Conscious Level with Patient Surviving, Subsequent Encounter, Personal History of Pneumonia (Recurrent), and Encounter for Attention to Gastrostomy. Review of the Hospice Plan of Care (POC) dated 4/15/24 to 7/13/24 revealed a Skilled Nurse (SN) frequency of once a week for one week, twice a week for one week, then once a week for 11 weeks. Review of the SN Visit Note dated 7/10/24 revealed the patient had a skin tear to the right buttock. There was no documentation of a wound measurement, assessment of the wound base, and assessment of the periwound skin. Review of the IDG Meeting dated 7/15/24 revealed no documentation the IDG was notified of the presence of a new wound in order to determine the treatment necessary to the wound. Review of the Hospice POC dated 7/14/24 to 10/11/24 revealed a SN frequency of once a week for 12 weeks. Review of the SN Visit Note dated 7/17/24 revealed the patient had a pressure sore to the right buttock. There was no documentation of a wound measurement, assessment of the wound base, assessment of the periwound skin, presence of odor, presence of drainage, and stage of the pressure sore. An interview was conducted on 7/25/24 at 4:09 PM with EI # 1 who confirmed the agency failed to ensure wounds were assessment per the agency policy and the IDG was notified of the presence of a new wound. 2. MR # 9 was admitted to the agency on 5/30/24 with a diagnosis of Unspecified Dementia, Severe, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. Review of the Hospice POC dated 5/30/24 to 8/27/24 revealed a SN frequency of once a week for one week then twice a week for 12 weeks. Review of the Patient Care Order dated 6/24/24 revealed a physician order to clean the a stage 2 pressure ulcer to the posterior buttocks with soap and water, pat dry, apply Chamosyn (Brand name) ointment, and cover with an Allevyn (Brand name) dressing every three days and as needed. Caregiver may provide care when SN is not in home. Review of the SN Visit Notes dated 6/27/24, 7/5/24, 7/9/24, 7/11/24, 7/15/24, and 7/18/24 revealed no documentation the posterior buttock wound was covered with an Allevyn dressing per the physician order. Review of the SN Visit Notes for the weeks of 6/30/24 and 7/14/24 revealed no documentation the posterior buttock wound was measured per the agency policy. Review of the SN Visit Note dated 7/10/24 revealed no documentation a wound assessment and wound care was performed for the posterior buttock wound per the agency policy and physician order. An interview was conducted on 7/25/24 at 4:37 PM with EI # 1 who confirmed the agency failed to ensure wound care was provided per the physician order and the posterior buttock wound was assessment per the agency policy.

Based on review of the medical record (MR), agency policy and procedure, and staff interviews it was determined the agency failed to update the plan of care with a change in level of care. This deficient practice did affect MR # 3 and MR # 11, two of two MRs reviewed with a change in level of care, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Coordination of Care During General Inpatient or Respite. Policy Number: HP 007 Reviewed Date: 3/24 Policy: A patient who is admitted to a facility for pain and symptom management or for respite care will have their plan of care coordinated by the Hospice throughout their stay. Hospice personnel will be available 24 hours a day for clinical consultation to facility personnel. Purpose: To define care coordination during general inpatient or respite care. Procedure: 1. The decision to admit the patient for general inpatient (GIP) or respite care will be made after consultation with the.. Medical Director and/or attending physician and other members of the IDG (Interdisciplinary Group) ...5. The Manager of Patient Care Services or Designee will: ...Consult with the physician and IDG members. Revise the plan of care as needed... --- 2. MR # 3 was admitted to the agency on 9/14/23 with diagnoses including Vascular Dementia, Severe, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, and Tremor. Review of the POC dated 9/14/23 to 12/12/23 and the IDG dated 10/23/23 revealed the patient was admitted in Monroe County Hospital (MHC) for a respite stay on 10/16/23. On 10/18/23 the patient was changed to GIP in MCH due to aspiration pneumonia. The Hospice agency failed to update the POC for the higher level of care. An interview was conducted on 7/25/24 at 4:19 PM with EI # 1 who confirmed the agency failed to update the POC for the higher level of care. 1. MR # 11 was admitted to the agency on 5/17/24 with a diagnosis of Chronic Kidney Disease, Stage 3 Unspecified. Review of the Review of the Skilled Nurse Admission Visit Note dated 5/17/24 revealed the patient was in GIP. Review of the Plan Of Care dated 5/17/24 to 5/26/24 and IDG Meeting dated 5/20/24 reveled no documentation of the patient's GIP status. Review of the MR revealed the patient was in GIP until 5/28/24. An interview was conducted on 7/25/24 at 2:57 PM with EI # 1, Director who confirmed the agency failed to update the POC for the higher level of care.

Based on observation, agency policies and procedures, and staff interviews it was determined the agency failed to ensure the staff: 1. Discarded a single dose vial (SDV) after use. 2. Used a new needle and syringe each time a SDV was re-entered per the agency policy. 3. Maintained a clean environment for prepared injections. 4. Performed hand hygiene per the agency policy. This did affect Home Visit (HV) # 3, one of one HV conducted for the observation of medication administration via injection, and had the potential to affect all patients requiring medication administration via injection. Findings included: Agency Policy: Medication Preparation Policy Number: MCHHP- 030 Reviewed Date: 2/24 Policy: Staff will prepare patient's medications safely. Purpose: To define processes for safe medication preparation. ...Procedure: ...3. Staff will utilize appropriate techniques during medication administration to avoid contamination including: Using a clean or sterile technique as appropriate. Maintaining a clean and uncluttered area to prepare the medication in an effort to decrease contamination... 4. Hospice will implement standardized practices for the use of SDV. Use a SDV for a single patient during the course of a single procedure. Discard the vial after this single use. If a SDV must be entered more than once during a single procedure for a single patient, use a new needle and new syringe for each entry. ...Do not store used SDVs for later use, no matter what the size of the vial. Agency Policy: Hand Hygiene Policy and Compliance Program Policy Number: MCHHP-014 Reviewed Date: 2/24 Policy: Hand hygiene will be done by all employee...to reduce the transfer of microbes to patients and to prevent the growth of microorganisms... Procedure: ...7. Hospice will follow the Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene: ...I. Indications for handwashing and hand antisepsis. ...Moving from contaminated patient body site to clean site during patient care... --- 1. HV # 3 was admitted to the agency on 7/16/24 with diagnoses including Cerebral Infarction, Unspecified, Personal History of Urinary (Tract) Infections, and Presence of Other Vascular Implants and Grafts. An observation was conducted on 7/23/24 at 1:39 PM to observe Employee Identifier (EI) # 5, Registered Nurse, administer an intramuscular (IM) injection to HV # 3. EI # 5 obtained a syringe and needle, Fortaz 2 grams/vial SDV, and an opened 50 ml (milliliter) vial of sterile water labeled as a SDV. EI # 5 used one of the two syringes and needles to insert the needle into the SDV of sterile water and withdrew 3 ml of sterile water. EI # 5 injected the 3 ml of sterile water into the Fortaz vial, then used the same syringe and needle to withdraw an additional 3 ml of sterile water from the sterile water SDV. EI # 5 failed to use a new syringe and needle when re-entering the sterile water SDV per the agency policy. EI # 5 then injected the second 3 ml of sterile water into the Fortaz vial to mix the Fortaz injection. After the Fortaz was mixed with the sterile water, EI # 5 withdrew 6 ml of Fortaz into two separate syringes and placed both syringes on the patient's bed, then administered both of the Fortaz filled syringes to the patient. EI # 5 failed to maintain a clean area for the Fortaz medication syringes prior to the administration of the injection per the agency policy. After the administration of the IM injection, EI # 5 assessed the patient's groin and penis and replaced the patient's diaper with gloved hands. EI # 5 then used the same gloves to adjust the patient's pillow under the patient's head. EI # 5 failed to remove gloves and perform hand hygiene when moving from a contaminated body site to a clean site during patient care per the agency policy. During the observation, EI # 5 was asked if the SDV of sterile water had been used prior to 7/23/24. EI # 5 verbalized the vial was opened on Friday, 7/19/24, and this visit was the fifth time the vial of sterile water had been used. EI # 5 failed to discard the used SDV and continued to store and use the SDV for a total of five days and five patient injections. An interview was conducted on 7/23/24 at 3:33 PM with EI # 1, Director, who confirmed EI # 5 failed to discard a SDV after use and not reuse the SDV, use a new needle and syringe each time a SDV was re-entered, maintain a clean environment of the prepared IM injection prior to administration of the injection, and perform hand hygiene per the CDC guidelines.

Based on review of Medical Records (MR), agency policy and procedure, and staff interviews it was determined the Hospice Aide (HA) failed to follow the Aide Plan of Care (POC). This deficient practice affected six out of 14 MRs reviewed with Hospice Aide (HA) services. MR # 10, MR # 11, HV # 1, MR # 3, HV # 2, and MR # 5, and had the potential to affect all patients who require HA services. Findings Include: Agency Policy: HA Services and Training Program Policy Number: HP 102 Reviewed Date: 3/24 ...Purpose: To define the scope of HA services... Procedure: ...4. The duties of the HA are to provide services that are ordered by the IDG (Interdisciplinary Group), included in the POC... --- 5. HV # 2 was admitted to the agency on 6/28/24 with diagnoses including Parkinson's Disease with Dyskinesia, with Fluctuations, and Non-Rheumatic Aortic (valve) Stenosis. Review of the Hospice POC dated 6/28/24 revealed a HA intervention to document a BM and report no bowel movements in three days to the nurse. Review of the HA visit notes dated 7/9/24, 7/12/24, and 7/22/24 revealed no documentation of the date of the patient's last BM. An interview was conducted on 7/25/24 at 3:38 PM with EI # 1 who confirmed the HA failed to document the patient's last BM. 6. MR # 5 was admitted to the agency on 6/13/24 with diagnoses including Dementia in Other Disease Classified Elsewhere, Unspecified Severity, with Agitation, Unspecified Asthma Uncomplicated, and Depression, Unspecified. Review of the Hospice POC dated 6/13/24 revealed a HA intervention to document a bowel movement BM and report no bowel movements in three days to the nurse. Review of the 20 HA visit notes dated 6/19/24 to 7/19/24 revealed no documentation of the date of the patient's last BM. An interview was conducted on 7/25/24 at 4:54 PM with EI # 1, who confirmed the HA failed to document the patient's last BM. 3. HV # 1 was admitted to the agency on 7/5/24 with diagnoses including Vascular Dementia, Moderate, with Mood Disturbance, Major Depressive Disorder, Adjustment Disorder with Depressed Mood. Review of the Hospice POC dated 7/5/24 revealed a HA intervention to document a BM and report no bowel movements in three days to the nurse. Review of the HA visit note dated 7/12/24, 7/15/24, 7/19/24, and 7/22/24 revealed no documentation of the date of the patient's last BM. An interview was conducted on 7/25/24 at 3:52 PM with EI # 1 who confirmed the HA failed to document the patient's last BM. 4. MR # 3 was admitted to the agency on 9/14/23 with diagnoses including Vascular Dementia, Severe. without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, and Tremor. Review of the Hospice POC dated 09/14/23 revealed a HA intervention to document a BM and report no bowel movements in three days to the nurse. Review of the 34 HA visit notes dated 9/15/23 to 11/7/23 revealed no documentation of the date of the patient's last BM. An interview was conducted on 7/25/24 at 4:19 PM with EI #1 who confirmed the HA failed to document the patient's last BM. 1. MR # 10 was admitted to the agency on 4/15/24 with diagnoses including Traumatic Subdural Hemorrhage with Loss of Consciousness Greater than 24 Hours without Return to Pre-existing Conscious Level with Patient Surviving and Subsequent Encounter, Personal History of Pneumonia (Recurrent). Review of the Hospice POC dated 4/15/24 to 7/13/24 revealed a HA intervention to document a BM and report no bowel movements in three days to the nurse. Review of the HA visit note dated 4/19/24, 4/22/24, 4/26/24, 4/29/24, 5/6/24, 5/8/24, 5/10/24, 5/13/24, 5/17/24, 5/20/24, 5/24/24, 6/5/24, and 6/19/24 revealed no documentation of the date of the patient's last BM. An interview was conducted on 7/25/24 at 4:09 PM with Employee Identifier (EI) # 1, Director, who confirmed the HA failed to document the patient's last BM. 2. MR # 11 was admitted to the agency on 5/17/24 with a diagnosis of Chronic Kidney Disease, Stage 3 Unspecified. Review of the HA POC dated 5/20/24 revealed a HA intervention to document a BM and report no bowel movements in three days to the nurse. Review of the HA visit note dated 5/20/24, 5/21/24, 5/23/24, 5/24/24, and 5/28/24 revealed no documentation of the date of the patient's last BM. An interview was conducted on 7/25/24 at 2:57 PM with EI # 1 who confirmed the HA failed to document the patient's last BM and there was no documentation of the care performed by the HA on 5/22/24.

Based on review of Medical Records (MR), agency policy and procedure, and staff interviews it was determined the agency failed to ensure the Hospice Aide (HA) reported changes in the patient's medical condition were reported to the Registered Nurse (RN). This deficient practice did affect MR # 9, one of 10 MR's reviewed with HA services and had the potential to affect all patient served by the agency requiring HA services. Agency Policy: HA Services and Training Program Policy Number: HP 102 Reviewed Date: 3/24 ...Purpose: To define the scope of HA services... Procedure: ...4. The duties of the HA are to provide services that are ordered by the IDG (Interdisciplinary Group), included in the Plan of Care (POC)...Reporting changes in the patient's medical, nursing, rehabilitative and social needs to a RN, as the changes related (relate) to the POC... --- 1. MR # 9 was admitted to the agency on 5/30/24 with a diagnosis of Unspecified Dementia, Severe, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. Review of the Hospice POC dated 5/30/24 to 8/27/24 revealed a HA frequency of three times a week for twelve weeks. Review of the HA visit notes dated 6/24/24 and 6/28/24 revealed documentation of a "sore" to the bottom of the right heel. There was no documentation the HA notified the RN of the sore to the right heel. An interview was conducted on 7/25/24 at 4:37 PM with Employee Identifier # 1,Director, who confirmed the agency failed to ensure the HA notified the RN of changes in the patient's medical condition.

Based on review of Medical Records (MR), agency policy and procedure, and staff interviews it was determined the Registered Nurse (RN) failed to supervise the Hospice Aide every 14 days. This deficient practice did affect two out of 14 MR reviewed with Hospice Aide (HA) services MR # 10, Home Visit HV # 2, and had the potential to affect all patients who require HA services. Findings Include: Agency Policy: Hospice Aide Supervision Policy Number: HP 103 Reviewed Date: 3/24 Policy: All Hospice Aide supervisory visits will be made at least every 14 days. Hospice will conduct the 14-day supervisory visit during and on-site visit, in person... Purpose: To Assure the appropriateness of Hospice Aide services and to maintain quality of care. Procedure: 1. Hospice Aides are closely supervised to ensure their competence in providing care. At least every 14 days the registered nurse (RN) makes and onsite home supervisory visit to assess relationships and determine whether goals are being met... --- 2. HV # 2 was admitted to the agency on 6/28/24 with diagnoses including Parkinson's Disease with Dyskinesia, with Fluctuations and Non-Rheumatic Aortic (valve) Stenosis. Review of the Hospice POC dated 6/28/24 revealed a HA order frequency of five times a week for 12 weeks and SN visits once a week for one week and then two times a week for eleven weeks. Review of the HA visit notes dated 7/1/24 to 7/5/24 revealed four HA visits were completed. Review of the SN Visit Notes dated, 7/3/24, 7/6/24, 7/7/24, 7/8/24, 7/11/24, 7/16/24, 7/17/24, and 7/22/24 revealed no documentation a HA supervisory visit was conducted. Review of the HA visit notes dated 7/8/24 to 7/12/24 revealed five HA visits were completed. An interview was conducted on 7/25/24 at 3:38 PM with EI # 1 who confirmed the SN failed to supervise the Hospice Aide every 14 days per Agency Policy. 1. MR # 10 was admitted to the agency on 4/15/24 with diagnoses including Traumatic Subdural Hemorrhage with Loss of Consciousness Greater than 24 Hours without Return to Pre-existing Conscious Level with Patient Surviving, Subsequent Encounter and Personal History of Pneumonia (Recurrent). Review of the Hospice Plan of Care (POC) dated 4/15/24 to 7/13/24 revealed a HA frequency of three times a week for twelve weeks and Skilled Nurse (SN) once a week for one week then twice a week for one week then once a week for eleven weeks. Review of the HA visit notes dated 4/18/24 to 5/8/24 revealed eight HA visits were completed. Review of the SN visit notes dated 4/20/24, 4/27/24, and 4/30/24 revealed no documentation a HA supervisory visit was conducted. Review of the HA visit notes dated 5/10/24 to 5/29/24 revealed seven HA visits were completed. Review of the SN visit notes dated 5/15/24 and 5/22/24 revealed no documentation a HA supervisory visit was conducted. Review of the HA visit notes dated 5/31/24 to 6/18/24 revealed seven HA visits were completed. Review of the SN visit notes dated 6/5/24 and 6/10/24 revealed no documentation of an HA supervisory visit was conducted. An interview was conducted on 7/25/24 at 4:09 PM with Employee Identifier (EI) # 1, Director, who confirmed the agency failed to ensure a nurse performed a HA supervisory visit every 14 days.

Based on review of the agency volunteer program, agency policy and procedure, and staff interview it was determined the agency failed to document and demonstrate viable and ongoing efforts to recruit volunteers. This deficient practice had the potential to affect all patients served by the agency. Findings include: Agency Policy: Volunteer Services Policy Number: HP106 Revised Date: 5/23 Policy: Hospice uses volunteers in administrative or direct patient care roles under the supervision of (the) Volunteer Coordinator. ...Procedure: Hospice will document active and ongoing efforts to recruit...volunteers... --- Review of the Volunteer program revealed the volunteer program had four volunteers. There was no documentation of the agency efforts to recruit volunteers for 2023 through July 2024. An interview was conducted on 7/25/24 at 1:42 PM with Employee Identifier (EI) # 3, Social Worker, Volunteer Coordinator, who confirmed there was no documentation of the agency efforts to recruit volunteers.

Based on review of the agency volunteer program, agency policy and procedure, and staff interview it was determined the agency failed to provide administrative and/or direct patient care services equal to five percent of the total patient care hours of all paid hospice employees and contract staff. This deficient practice had the potential to affect all patient served by the agency. Findings include: Agency Policy: Volunteer Services Policy Number: HP106 Revised Date: 5/23 Policy: Hospice uses volunteers in administrative or direct patient care roles under the supervision of (the) Volunteer Coordinator. ...Procedure: 2. Hospice will document and maintain a volunteer staff sufficient to provide administrative and/or direct patient care in an amount that, at a minimum, equals 5 % of the total patient care hours of all paid hospice employees and contract staff... --- Review of the agency volunteer program on 7/25/24 revealed the following quarterly volunteer hour percentages for 2023: 0.00 % was documented for quarter 1 and quarter 2. 2.32 % was documented for quarter 3. 0.8 % was documented for quarter 4. The agency failed to provide administrative and/or direct patient care services equal to five percent of the total patient care hours of all paid hospice employees and contract staff for the year of 2023. An interview was conducted with Employee Identifier (EI) # 3, Social Worker, Volunteer Coordinator, who confirmed the agency has failed to provide administrative and/or direct patient care services equal to five percent of the total patient care hours of all paid hospice employees and contract staff for the year of 2023. EI # 3 also verbalized prior to July 23 there were no volunteer hours for 2023.

Based on review of the agency on-call log, agency policy and procedure, and staff interviews the agency failed to document a nursing response in four of six patient on-call request. This deficient practice did affect Unsampled Patient (UP) # 1, UP # 2, and UP # 3, had the potential to affect all patients requiring on-call nursing services. Findings include: Agency Policy: After Hours Accessibility Policy Number: HP 070 Reviewed Date: 3/24 ...Purpose: To provide care to patient 24 hours/day, 7 days/week. Procedure: 1. Nursing services...are routinely available on a 24 hour basis 7 days a week... 4. The RN (Registered Nurse) and LPN (Licensed Practical Nurse) on-call is available at all times by telephone. 5. All calls are documented on an on-call form... 6. If a visit is made, a nursing visit report is completed... --- Review of the agency on-call log dated January 2024 to July 2024 revealed the following patient on-call request: 1. UP # 1 called the on-call service on 5/5/24 at 6:32 PM with a complaint of pain and on 6/8/24 at 3:12 PM with a question regarding pain medication. There was no documentation a nurse returned the patient's call or performed a nursing visit. 2. UP # 2 called the on-call service on 5/31/24 at 5:36 PM with a complaint of blood running out of the mouth. There was no documentation a nurse returned the patient's call or performed a nursing visit. 3. UP # 3 called the on-call service on 6/25/24 at 5:15 PM and asked to talk with a nurse. There was no documentation a nurse returned the patient's call or performed a nursing visit. An interview was conducted on 7/25/24 at 2:46 PM with Employee Identifier (EI) # 1, Director, who confirmed there was no documentation of a nursing response to UP # 1, UP # 2, and UP # 3 on-call request.