Every finding on record at Nivera Enterprises, Inc.

Upon patient record review 1 of 14 (Patient #4) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 4: The SC did not complete a SC comprehensive assessment and has not seen the patient, patient refused SC. The RN nor Social Worker completed the content of the spiritual comprehensive assessment.

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1,2,3,4,5,6,7,8,9,10: Imminently dying was not assessed by RN within the admission comprehensive assessment or visit note.

Upon patient record review, 6 of 14 (Patient #4,5,7,8,9,10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 4: Current Medication list dated 09/16/25 contains orders for Norco 5mg-325mg 1 tab every 6 hours as needed for moderate-severe pain and Acetaminophen 650mg Suppository 1 supp rectally every 4-6 hours as needed for pain/fever. There is no directive not to exceed 4000mg in all forms daily of acetaminophen. Corrected on site, medication record updated. Patient 5: Current Medication list dated 09/16/25 contains orders for Norco 10mg-325mg 1 tab every 8 hours as needed for moderate-severe pain and Acetaminophen 650mg Suppository 1 supp rectally every 4-6 hours as needed for pain/fever. There is no directive not to exceed 4000mg in all forms daily of acetaminophen. Corrected on site, medication record updated. Patient 7: Current Medication list dated 9/16/25 contains an order for MiraLax Powder for solution 17g orally without diluent. Corrected on site, medication record updated. Patient 8: Current Medication list dated 9/16/25 contains order for Hydrocortisone 1% topical Cream topically to affected area twice daily as needed for itching. Order does not indicate location of application. Corrected on site, medication record updated. Patient 9: Current Medication list dated 9/16/25 contains an order for MiraLax Powder for solution 17g orally without diluent. Corrected on site, medication record updated. Patient 10: Current Medication list dated 9/16/25 contains order for Miconazole Nitrate 2% 1 application topically to affected area twice a day for indication of rashes. Order does not indicate location of application. Corrected on site, medication record updated.

Upon patient record review, 5 of 14 (Patient #1,3,4,5,6) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1: The POC dated 09/16/25 has a medication order for ASA (anticoagulant) without a risk for bleeding care plan with appropriate goals and interventions. Patient 3: The current POC dated 09/16/25 has a medication order for ASA (anticoagulant) without a risk for bleeding care plan with appropriate goals and interventions. Corrected on site, POC updated. Patient 4: The POC dated 09/16/25 has a medication order for Eliquis (anticoagulant) without a risk for bleeding care plan with appropriate goals and interventions. Corrected on site, POC updated Patient 5: The current POC dated 09/16/25 has a medication order for ASA daily (anticoagulant) without a risk for bleeding care plan with appropriate goals and interventions. Corrected on site, POC updated Patient 6: The current POC dated 09/16/25 has a medication order for Eliquis (anticoagulant) without a risk for bleeding care plan with appropriate goals and interventions. Corrected on site, POC updated

Upon patient record review, 1 of 14 (Patient #4) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 4: Record indicates patient has been seen monthly by SW since admission 12/31/24, visit frequency order remains prn monthly with no scope or frequency on the POC. Corrected on site, POC updated.

Upon patient record review, 6 of 14 (Patient #4,5,7,8,9,10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 4: The POC contains orders for Norco 5mg-325mg 1 tab every 6 hours as needed for moderate-severe pain and Acetaminophen 650mg Suppository 1 supp rectally every 4-6 hours as needed for pain/fever. There is no directive not to exceed 4000mg in all forms daily of acetaminophen. Corrected on site, POC updated. Patient 5: The POC contains orders for Norco 10mg-325mg 1 tab every 8 hours as needed for moderate-severe pain and Acetaminophen 650mg Suppository 1 supp rectally every 4-6 hours as needed for pain/fever. There is no directive not to exceed 4000mg in all forms daily of acetaminophen. Corrected on site, POC updated. Patient 7: The POC contains an order for MiraLax Powder for solution 17g orally without diluent. Corrected on site, POC updated. Patient 8: The POC contains order for Hydrocortisone 1% topical Cream topically to affected area twice daily as needed for itching. Order does not indicate who will apply or location of application. Corrected on site, POC updated. Patient 9: The POC contains an order for MiraLax Powder for solution 17g orally without diluent. Corrected on site, POC updated. Patient 10: The POC contains order for Miconazole Nitrate 2% 1 application topically to affected area twice a day for indication of rashes. Order does not indicate who will apply or location of application. Corrected on site, POC updated.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4: Record indicates patient has been seen monthly by SW since admission 12/31/24, visit frequency order remains prn monthly. Corrected on site, POC updated.

Upon patient record review, 3 of 14 (Patient #1,7,8) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable. Patient 1: Current Aide POC dated 8/8/25 does not include frequency for turn and reposition, record bowel movements or feeding assistance. Corrected on site, POC updated. Patient 7: Current POC dated 9/16/25 indicates a walker is required for ambulation. Current Aide POC dated 5/21/25 does not list walker as a required ambulatory device; lists the patient as bedbound and non ambulatory. Corrected on site, POC updated. Patient 8: Current Aide POC does not indicate frequencies for dressing,oral care or nail care. Shower chair is marked on Aide POC however shower, tub bath or bed bath are not indicated. Corrected on site, POC updated.

Upon patient record review 1 of 14 (Patient #5) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 5: The medical record indicates that an Aide supervisory visit was conducted on 5/01/25 and not again until 5/29/25. (27 days).

Based on observation, interview and record review, the hospice agency failed to ensure the Conditions of Participations regarding initial and Comprehensive Assessments of Patients were met as followed: 1. The hospice agency failed to perform an accurate comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) for four of seven sampled patients, Patients 1, 2, 4 and 7. (Refer to L 521). 2. The hospice agency failed to ensure the medication profile were reconciled with the current medications, for two of seven sampled patients (Patients 2, Patient 7). This had the potential to place the patients at risk for medication errors and adverse drug reactions. (Refer to L 530). 3. The hospice agency failed to notify the physician when there was no urine output after a coude catheter (a type of catheter that is slightly bent at the tip to help move past a blockage, to drain urine) was inserted, for one of seven patients, Patient 1, who had a diagnosis of benign prostatic hyperplasia (an enlarged prostate which presses on the bladder and urethra and blocks the flow of urine) and urinary retention (a condition in which the bladder is unable to empty all the urine). (Refer to L534). 4. The hospice agency failed to ensure the wound specimen was collected in a timely manner. The laboratory test was ordered by the physician on 7/20/2018 and was collected 7/25/2018, for 1 of seven patients, Patient 1. (Refer to L534). The cumulative effect of these systemic practices resulted in the patient not receiving adequate care and allowed the patient to have a negative outcome, and resulted in the patient, who was not qualified for the services to receive hospice care and services. --- .

Based on observation, interview, and record review, the hospice agency failed to perform an accurate comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) for four of seven sampled patients, Patients 1, 2, 4 and 7. These deficient practice resulted in the status of the wound/edema and identifying impediments to the healing process that can result in the patient not receiving adequate care and allow the patient to have negative outcome, such as delayed wound/disease healing, and resulted in the patient, who was not qualified for the services, to receive hospice care and services. --- c. A review of Patient 4's clinical record indicated Patient 4 was admitted to the hospice agency on 8/29/2022, with diagnoses that included senile degeneration of brain. A review of the Plan of Care/Comprehensive Assessment dated 8/29/2022 indicated Patient 4 was alert and disoriented/confused and required total assistance with all the activities of daily living. It indicated Patient 4 had one unstageable wound on the left heel which measured 2 cm by 1.5 cm and had serosanguineous drainage. A review of the physician's order dated 8/29/2022 indicated the Skilled Nurse (SN) was to visit once a week and three visits as needed. The hospice aide was to visit three times a week and two visits as needed. The Medical Social Worker (MSW) was to visit once a month and two visits as needed. The chaplain and the volunteer service were declined. The physician ordered to cleanse the wound with normal saline, pat dry, apply triple antibiotic ointment, cover with a dry dressing, and secure with tape. A review of the physician's order dated 8/30/2022 indicated to start wound evaluation and treatment by the Wound Masters (Wound Masters is a group of dedicated surgeons, physicians, physician assistants, and nurse practitioners who are specially trained to provide mobile wound). A review of the "Wound Master" dated 9/6/2022 indicated Patient 4 had a Stage IV pressure ulcer on the left lateral foot which measured 1 cm by 1.4 cm by 0.5 cm (pre debridement measurement). The wound doctor ordered to cleanse the wound with wound cleanser, pat dry, apply collagen, cover with Hydrocolloid, put roll gauze, and tape. The Wound Master indicated to change the dressing every 2-3 days or as needed. A review of the Skilled Nursing Clinical Note indicated Patient 4 had a pressure ulcer on the left heel as follows: 1. 9/12/2022: Stage III which measured 3 cm by 4 cm - there was no measurement of depth 2. 9/26/2022: Stage III which measured 1 cm by 2.5 cm - there was no measurement of depth 3. 10/10/2022: Stage IV which measured 1 cm by 1.3 cm - there was no measurement of depth During an interview with the Designee of Patient Care Services (DPCS), DPCS stated the depth of Patient 4's wound on the left heel should have been assessed. A review of the agency's policy titled "Wound Care Policy" dated 4/15/2021, indicated the patient's skin will be assessed at each visit. The wound assessment and documentation will include measurement of length, width, depth, undermining and tunneling if present. d. A review of Patient 7's clinical record indicated Patient 7 was admitted to the hospice agency on 5/14/2022, with diagnoses of Alzheimer's disease. On 10/12/2022, at 1:35 p.m., Patient 7's home visit was conducted with Licensed Vocational Nurse 2 (LVN 2) at the board and care facility. Patient 7 was sitting in a bench in the back yard, and Caregiver 2 was next to the patient. Patient 7 was alert and answered questions (such as how are you? "Fine" do you have any pain? "No") in non-dominant language when questioned by the surveyor. Caregiver 2, who spoke the same language as Patient 7 used, stated Patient 7 could not answer appropriately but stated Patient 7 did not have pain. Caregiver 2 stated Patient 7 could walk without using a cane or a walker, and even run. Caregiver 2 stated Patient 7 wanders around all over the house, and Patient 7 eats okay even though she made a mess while eating. While moving to the patient's room for a body checkup, Patient 7 was observed humming and walking without using any assistive device. During an interview with LVN 2 on 10/12/2022, at 1:55 p.m., she stated Patient 7 did not seem to have end stage Alzheimer's disease. A review of the Plan of Care/Comprehensive Assessment dated 9/29/2022, indicated Patient 7 required total assistance with all the activities of daily living (ADL) including transferring and ambulating. It also indicated the Palliative Performance Scale (PPS - scale intended for evaluating patients requiring palliative care) scored 40 percent (mainly in a bed, unable to do most activity). A review of the Local Coverage Determination [(LCD) - an assessment to determine patient's eligibility for hospice services)] provided by the agency - indicated the patient with dementia due to Alzheimer's disease will be in the terminal stage of dementia (life expectancy of six months or less) if the patient meets the criteria. One of the criteria was "Unable to ambulate without assistance" During an interview with the designee DPCS on 10/13/2022, DPCS stated the agency should have followed LCD guidelines for Patient 7. A review of the agency's policy titled "Admission Criteria and Process" revised May 2022 indicated the patient's life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary's Local Coverage Determinations (LCDs). Based on observation, interview, and record review, the hospice agency (HA) failed to conduct accurate and complete skin assessments for two of 7 sampled patients (Patient 1 and 2). This deficient practice had the potential for the delay in the progress of patient 1 and 2s delivery of the plan of care. a. A review of patient 1s admission record indicated the patient was admitted to the Hospice Agency (HA) on 5/23/18, with a primary diagnoses of Cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it. A lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), dementia without behavioral disturbance (It is a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), Parkinsons disease ( is a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination. Symptoms usually begin gradually and worsen over time. As the disease progresses, people may have difficulty walking and talking) and Dysphagia (Difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage). A review of patient 1s plan of care (POC)/Interdisciplinary group (IDG) Review dated 5/23/18 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed, Skilled Nurse (SN) routine visits twice a week and Certified Home Health Aide (CHHA) visits three times a week, Medical Social Worker (MSW) and chaplain visit once a week. A review of patient 1s clinical records from wound care surgeons notes (wound care specialist) that visits once a week, dated 11/2/2018, 11/9/18, 11/16/18 and 11/23/18 indicated documentations of multiple skin pressure injuries located at bilateral sacrum (located at the bottom of the spine and lies between the fifth segment of the lumbar spine and the tailbone) with stage 4 pressure injury (the pressure injury is very deep, reaching into muscle and bone and causing extensive damage to deeper tissues, tendons, and joints may occur), right posterior elbow with stage 4 pressure injury, left trochanter (is the bony knob near the top of the thighbone, where the upper thigh curves outward) with stage 4 pressure injury, right lateral upper leg with stage 4 pressure injury and left inferior buttock with stage 4 pressure injury. A review of patient 1s skilled nurse notes (SN) dated 11/1/18, 11/6/18, 11/8/18, 11/13/18, 11/15/18, 11/20/18, 11/21/18, 11/24/18 and 11/25/18 indicated a documentation of only one (1) skin pressure injury located at Sacro gluteal (located below the lumbar spine and above the tailbone) with stage 4 pressure injury, however, there were no indication of other skin pressure injuries that wound care surgeons documented. On 10/14/22, at 1:30 p.m., during an interview with the Director of Patient Care Services Designee (DPCSD), DPCSD stated that she reviewed all the wound care surgeons notes and saw all the additional skin findings, DPCSD stated that she reviewed SN notes and did not see any documentation of the new skin findings. DPCSD stated that it was a lapse in communication between wound care surgeons and agencys nurses, but SN should have been doing their own assessment of patients skin and should have been doing appropriate wound care on the additional skin findings. DPCSD stated that it is the SN responsibility to read the reports and to do a proper assessment to address all skin issues. DPCSD stated that per documentation, SN missed the additional findings for that period. At 2:00 p.m., during an interview with LVN 1, LVN 1 stated that he was assigned to care for patient 1 but does not remember for how long since it has been four years ago. LVN 1 stated that he cannot recall about the additional skin findings and honestly cannot remember. LVN 1 stated that wound care surgeons would not communicate well with the SN. LVN stated that he documented of what his findings was. b. A review of patient 2s admission record indicated the patient was admitted to the Hospice Agency (HA) on 4/22/22, with a primary diagnosis of Atherosclerotic heart disease of native coronary artery without angina pectoris (is caused by plaque buildup in the wall of the arteries that supply blood to the heart, plaque is made up of cholesterol deposits and buildup causes the inside of the arteries to narrow over time without a condition marked by severe pain in the chest). A review of patient 2s plan of care (POC)/Interdisciplinary group (IDG) Review dated 10/13/22 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed, Skilled Nurse (SN) routine visits once a week and Certified Home Health Aide (CHHA) visits three times a week. On 10/11/22, at 1:30 p.m., Patient 2s home visit was conducted with Licensed Vocational Nurse 1 (LVN1) at the board and care facility. Patient 2 was observed laying on her bed comfortably. Patient 2 was alert, oriented, and was able to communicate well, pleasant, and well groomed. Patient 2 has a swollen left arm with skin redness. LVN 1 stated that patient 2s left arm was swollen today, LVN 1 stated it has been communicated with Registered Nurse already and waiting for physicians order. Patient 2 stated she does not feel any pain on her left arm. A review of patient 2s SN notes dated 10/11/22 indicated that right arm was swollen and no documentation of a complete assessment of swollen left arm. A review of patient 2s physician order dated 10/11/22, indicated that DPCSD obtained a telephone order from the Medical Doctor (MD) to administer Lasix 20 milligrams (mg) 1 tablet by mouth daily for 5 days for pitting edema and fluid retention but did not specify the swollen body area. On 10/14/22, at 1:30 p.m., during an interview with LVN 1, LVN 1 stated that he must have a mistake of documenting the swollen arm. LVN 1 stated that it should have been documented as left swollen arm and not the right swollen arm. At 2:00 p.m., during an interview with the Director of Patient Care Services Designee (DPCSD), DPCSD stated that SN should be particular and careful with the documentation to prevent errors in providing care for patients. A review of facilitys policy and procedure titled, ";Ongoing Assessments", revised on May 2022, indicated that the nurse will assess each patient on each visit includes current treatment related to the identified symptoms/patients response, skin integrity, progress toward hospice goals/patient needs/problems Also indicated that based upon the findings of the assessment, change/verbal orders will be generated and forwarded to the physician or other authorized independent practitioner as needed.

Based on observation, interview and record review, the hospice agency failed to ensure the medication profile were reconciled with the current medications, for two of seven sampled patients (Patients 2, Patient 7). This deficient practice had the potential to place the patients at risk for medication errors and adverse drug reactions. --- b. A review of Patient 7's clinical record indicated Patient 7 was admitted to the hospice agency on 5/14/2022, with diagnoses of Alzheimer's disease. A review of the physician's order dated 5/14/2022 indicated the Skilled Nurse (SN) was to visit once a week and three visits as needed, the hospice aide was to visit three times a week and two visits as needed, The Medical Social Worker (MSW) was to visit once a month and two visits as needed. The chaplain and the volunteer service were declined. On 10/12/2022, at 1:35 p.m., Patient 7's home visit was conducted with Licensed Vocational Nurse 2 (LVN 2) at the board and care facility.Patient 7 was sitting in a bench in the back yard, and Caregiver 2 was next to the patient. At 2 p.m., during Patient 7's medication review with LVN 2 and comparison with the medication profile, the following medications were not found at the facility while it was indicated in the medication list. 1. Clotrimazole 1 % topical cream - apply a small amount to affected area twice a day.2. Dicyclomine 20 mg - one tablet by mouth every 6 hours as needed for abdominal pain.3. Hydroxyzine HCL 25 mg - one tablet by mouth every 4 hours as needed for itching/agitation4. Loperamide 2 mg - two tablet by mouth -two tablet by mouth followed by one tablet by mouth after each loose stool During a telephone interview with Licensed Vocational Nurse 1 (LVN 1), who was the routine SN for Patient 7, he stated he was not able to answer the above medications were discontinued.He stated he had checked Patient 7's medications and compared them with the medication list one month ago. LVN 1 stated he should have clarified with the physician and updated the medication list. A review of the agency's policy titled "Medication Profile" revised on May 2022 indicated the medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications.During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. The medication profile includes all current medications, date prescribed, name of medication, dose, frequency, drug classification, and the date discontinued. a. A review of patient 2s admission record indicated the patient was admitted to the Hospice Agency (HA) on 4/22/22, with a primary diagnosis of Atherosclerotic heart disease of native coronary artery without angina pectoris (is caused by plaque buildup in the wall of the arteries that supply blood to the heart, plaque is made up of cholesterol deposits and buildup causes the inside of the arteries to narrow over time without a condition marked by severe pain in the chest). A review of patient 2s plan of care (POC)/Interdisciplinary group (IDG) Review dated 10/13/22 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed, Skilled Nurse (SN) routine visits once a week and Certified Home Health Aide (CHHA) visits three times a week. On 10/11/22, at 1:30 p.m., Patient 2s home visit was conducted with Licensed Vocational Nurse 1 (LVN1) at the board and care facility. Patient 2 was observed laying on her bed comfortably. Patient 2 was alert, oriented, and was able to communicate well, pleasant, and well groomed. At 2:15 p.m., during patient 2s medication review with LVN 1 and comparison with the medication profile, the following medications had discrepancies and had expired dates. 1.Lisinopril 10 mg tablet – take 4 tablets by mouth once a day indicated in medication profile but Caregiver 1 (CG1) administering 2 tablets and old bottle labeled to take 2 tablets is on hand. 2.Pramipexole 0.25 mg tablet – take 1 tablet by mouth as directed in the morning and 3 tablets at bedtime. Bottle has expiration date of 9/17/22. At 2:30 p.m., during an interview with LVN 1 and CG1, LVN 1 stated he is not aware that there were some changes with patient 2s Lisinopril dosage. LVN 1 stated medication reconciliation is done once a month and if there are any changes, CG1 notifies the agency. LVN 1 stated he is not aware that pramipexole bottle is expired already. CG1 stated she coordinated it with the RN and SN regarding lisinopril dosage changes but not sure why it was not updated in patient 2s medication profile. CG1 stated she is not aware about the expiration date of pramipexole medication but has a new bottle on hand and will use it. On 10/14/22, at 1:30 p.m., during an interview with the Director of Patient Care Services Designee (DPCSD), DPCSD stated that visiting nurses should conduct medication reconciliation for patients on each visit.

Based on interview, and record review, the hospice agency (HA) failed to: 1. Notify the physician when there was no urine output after a coude catheter (a type of catheter that is slightly bent at the tip to help move past a blockage, to drain urine) was inserted, for one of seven patients, Patient 1. Patient 1 who had a diagnosis of benign prostatic hyperplasia (an enlarged prostate which presses on the bladder and urethra and blocks the flow of urine) and urinary retention (a condition in which the bladder is unable to empty all the urine). This deficient practice resulted to Patient 1s bladder to become distended that resulted to Patient 1s transfer to general acute care hospital for further interventions 2. Ensure the wound specimen was collected in a timely manner for 1 of seven patients, Patient 1. The laboratory test was ordered by the physician on 7/20/2018 and was collected 7/25/2018. This deficient practice resulted to the delay of treatment for the identified infection which can potentially cause a more serious health complication to Patient 1. --- A review of Patient 1s admission record indicated that Patient 1 was admitted to the Hospice Agency (HA) on 5/23/18, with a primary diagnoses of cerebral infarction (ischemic stroke), dementia without behavioral disturbance (memory problems), parkinsons disease (a disorder with uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and dysphagia (difficulty swallowing foods or liquids). The document titled, ";Hospice 90 Day Certification/ Recertification", for the period 5/23/2018 to 8/20/2018, indicated that Patient 1 had BPH (benign prostatic hyperplasia, an enlarged prostate which presses on the bladder and urethra and blocks the flow of urine), urinary retention (a condition in which the bladder is unable to empty all the urine). A review of patient 1s plan of care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers)/ Interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) review dated 5/23/18 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed, Skilled Nurse (SN) routine visits twice a week. The clinical record for Patient 1 indicated a home visit was conducted by LVN 1 and LVN 2 last 7/13/2018 at 8:30 a.m. During the review of the Skilled Nursing Visit notes by LVN 1 dated 7/13/2018 at 8:30 a.m., LVN 1 notes indicated the foley catheter was clogged and bleeding from the penis was observed and LVN 1 indicated that the bladder was flushed for several times until clear. The notes also indicated that LVN 1 had to leave at 11:30 a.m. and would come back with an unspecified type of equipment. During the review of the Skilled Nursing Visit notes by LVN 3 dated 7/13/2018 at 11 a.m., the notes indicated the foley catheter was not intact. LVN3 attempted to reinsert the regular foley catheter but was unsuccessful. LVN3 then called the agency to report with a request to reinsert the foley catheter. LVN3 documented a 150 cc of urine output, however, time was not indicated in the notes. Further review of Patient 1s physician order dated 7/13/18, untimed, indicated an order for a coude foley catheter (a type of catheter that is slightly bent at the tip to help move past a blockage, to drain urine), 16 Fr (French, size of catheter). On 7/13/18 at 4:30 p.m., LVN 1s documentation indicated that a coude catheter was inserted and had no urine output. LVN 1 left Patient 1s home with the coude catheter left inserted, however, there was no documentation that it was reported to the physician. On 7/14/18 at 10 a.m., LVN 1 returned to Patient 1s residence to follow up. Per LVN 1s notes, the catheter drainage bag was empty and Patient 1s abdomen was distended. LVN 1 then called the agency to report and was instructed to call ambulance to take Patient 1 to general acute hospital (GACH). LVN 1s notes, indicated that 911 (medical emergency phone number) was called and Patient 1 was transferred to GACH, time was not indicated. On 7/14/2018 at 11: 15 p.m., Patient 1 returned to the hospice agency on with a new French 20 foley catheter. During an interview on 10/14/2022, at 1:30 p.m., LVN 1 stated that he was assigned to care for Patient 1 and does not remember much of the care because this was four years ago, but stated he remember there was an issue with the foley catheter insertion on the last day before he was sent to the hospital. LVN 1 stated that he was having trouble inserting the foley catheter and he called the office to let them know. LVN 1 stated, the direction he got was to tell the boarding care to call the hospital and have Patient 1 transported. LVN 1 stated, the office told him to call 911 to transfer Patient 1 to the hospital for further evaluation. LVN 1 stated he was unsure of the procedure and the policy of the agency to have someone transported to the hospital for a foley catheter issue. During an interview on 10/14/22, at 1:30 p.m., the Director of Patient Care Services Designee (DPCSD) stated that she has been with the agency since 2011. DPCSD stated she is familiar with Patient 1 and it has been 4 years ago that there was an order written for a coude catheter on 7/13/18, and the agency had to order it because coude catheter was not in stock. DPCSD stated that since the coude catheter was not available at that time, LVN 3 inserted a regular foley catheter instead. DPCSD also stated that LVN 3 should have inserted the type of catheter that was ordered, but because it was not available, LVN 3 inserted the regular foley catheter. When asked, DPCSD stated that if a nurse tries to put in a foley catheter and is unable to go through, the nurse should have called the office and the doctor to let the team know what's going on. Another clinical review of Patient 1s physicians order dated 7/20/18, indicated an order for wound culture and sensitivity at the genitalia (genitals). A review of the faxed lab result dated 7/30/2018, was reviewed and indicated the specimen was collected on 7/25/2018 by the laboratory staff, with the source from a wound/ penis. The specimen was received on 7/26/2018 at 1:16 a.m. The laboratory result dated 7/30/2018 indicated presence Methicillin Staphylococcus Aureus (MRSA, an antibiotic resistant bacterial infection). During an interview on 10/14/22, at 1:30 p.m., the DPCSD stated that the doctor gave the order for wound culture and sensitivity at the genitalia on 7/20/2018 which she believed was a Friday. DPCSD stated that the laboratory staff are responsible to collect the specimen, however, the laboratory staff came on 7/25/2018 to collect the specimen. The nurses notes did not indicate reasons why the specimen was collected late. A review of the agencys undated policy titled, ";Provision of Care and Record Management", indicated the nurse will assess each patient on each visit for bowel sounds, elimination (urinary and bowel). Ongoing comprehensive assessments should focus on patients response to care, based upon the findings of the assessment, change/ verbal orders will be generated and forwarded to the physician as needed. The physician will be notified to verify any changes including treatment/ interventions that require physician approval.

Based on observation, interview, and record review, the Hospice Agency failed to meet the Condition of Participation for Inter-Disciplinary Group (IDG), Care Planning and Coordination of Care as follows: 1. Failed to develop a plan of care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) to address the swollen left arm for one of seven sampled patients, (Patient 2. This had the potential that the required interventions will not be provided timely and can delay the healing process of the swollen left arm. (Refer to L538) 2. Failed to ensure the wound specialist was included to participate in the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meeting to ensure the wound treatment plan and order for one of seven sampled patients, Patient 4, were communicated to the IDG group. (Refer to L539) 3. Failed to ensure the spiritual counsellor (a person responsible for the provision of spiritual care services to patients and families/caregivers, either directly or through coordination of care with the hospice team members), attended the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meetings to discuss any changes and progress, and to update the plan of care for the six of 22 patients, (Patients 2, 3, 4, 5, 6, 7). (Refer to L541) The cumulative effect of these systemic practices resulted in the agencies failure to ensure inter-disciplinary group (IDG), Care Planning and Coordination of Care improved patient care. --- .

Based on interview and record review, the hospice agency failed to develop a plan of care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) to address the swollen left arm for one of seven sampled patients, (Patient 2. This deficient practice had the potential that the required interventions will not be provided timely which can also delay the healing process of the affected patient's left arm. --- A review of the admission record indicated Patient 2 was admitted to the Hospice Agency (HA) on 4/22/22, with diagnosis that included atherosclerotic heart disease of native coronary artery without angina pectoris (a condition caused by a plaque buildup in the wall of the arteries that supply blood to the heart). A review of Patient 2s Plan of Care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) / Interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Review dated 10/13/22, indicated the following visits: a). Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed. b). Skilled Nurse (SN) routine visits once a week. c). Certified Home Health Aide (CHHA) visits three times a week but there was no indication of POC to address Patient 2s swollen left arm. A joint home visit was conducted with Licensed Vocational Nurse (LVN) 1 on 10/11//2022, at 1:30 p.m. Patient 2 was observed laying on her bed comfortably. During an interview, LVN 1 stated Patient 2s left arm was swollen and the Registered Nurse (RN) has been made aware and was just waiting for the physicians order. During an interview on 10/14/22, at 1:00 p.m., LVN 1 stated he was not aware that a care plan was needed for the swollen arm. It should have been created by the RN. During an interview on 10/14/22, at 1:10 p.m., the Director of Patient Care Services Designee (DPCSD) stated, the care plan for patients should have been formulated as soon as possible once a new problem has been acknowledged. DPCSD stated there should be good communication between skilled nurse (SN), RN, and the physician to address the problem. A review of the agency's policy and procedure titled "The Plan of Care" revised in May 2022 indicated the plan of care will identify the patient's needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patients and family/caregivers needs, goals, and outcome achievement.

Based on observation, interview and record review the hospice agency failed to include the wound specialist in the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) to participate in the IDG meeting and to communicate regarding wound treatment for one of seven sampled patients, Patient 4. This deficient practice resulted in staff providing treatment that was not in accordance with what was ordered by the wound specialist and placed the patient at risk of having a negative outcome, such as delayed wound healing, due to inappropriate treatment. --- A review of Patient 4's clinical record indicated Patient 4 was admitted to the hospice agency on 8/29/2022, with diagnoses that included senile degeneration of brain (loss of intellectual ability). A review of the Plan of Care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers)/Comprehensive Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) dated 8/29/2022, indicated Patient 4 was alert and confused, and required total assistance with all activities of daily Living (ADL). The assessment indicated Patient 4 had one unstageable wound [wound with full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed] on the left heel which measured 2 centimeters (cm) by 1.5 cm and had serosanguineous drainage (a thin and watery fluid). A review of the physician's order for Patient 4, dated 8/29/2022 indicated the following: a). The Skilled Nurse (SN) was to visit once a week and three visits as needed. b). The hospice aide was to visit three times a week and two visits as needed. c). The Medical Social Worker (MSW) was to visit once a month and two visits as needed. d). The chaplain and the volunteer service were declined. e). Cleanse the left heel wound with normal saline, pat dry, apply triple antibiotic ointment, cover with dry dressing, and secure with tape. A review of Patient 4s physician's order dated 8/30/2022, indicated, to start wound evaluation and treatment by the "Wound Masters". A review of the "Wound Master" notes dated 9/6/2022, indicated Patient 4 had a Stage IV pressure ulcer on the left lateral foot which measured 1 cm (centimeter) by 1.4 cm by 0.5 cm (pre debridement measurement). The wound doctor ordered to cleanse the wound with the wound cleanser, pat dry, apply collagen (type of dressing), cover with hydrocolloid (provide a moist and insulating healing environment which protects uninfected wounds while allowing the body's own enzymes to help heal wounds), put roll gauze, and tape, and to change the dressing every 2-3 days or as needed. On 10/12/2022, at 11:15 a.m., a home visit was conducted at Patient 4's residence with the Licensed Vocational Nurse 2 (LVN 2). Patient 4 was lying on a hospital bed in the room, with eyes closed eyes. The left foot had a dressing and Patient 4 was wearing foot protectors on both feet. Family member 1 and Caregiver 3 were in the room. At 11:25 a.m., LVN 2 removed the foot protector on the left foot and removed the old dressing and measured the wound. LVN 2 stated the wound was a Stage III (deep and painful wounds in the skin), which measured 2.25 cm by 1.5. cm by 0.1 cm. LVN 2 then sprayed the wound cleanser on a 4 x 4 gauze and cleaned the wound and pat dried. Then she applied collagen (a type of dressing) on the wound, put on a non-adhesive dressing, taped, and applied kerlix (a white bandage). When asked whether hydrocolloid (dressing that provide a moist and insulating healing environment) dressing was to be applied, LVN 2 stated she could not find any at the patient's house. During a concurrent interview with Caregiver 2, she stated the wound doctor visited the patient once a week and the agency's SN visits once a week. She stated the wound doctor had brought his own dressing, and the agency SN had been using the non-adhesive dressing that the family bought from the pharmacy. A review of the Nursing Visit Record for Patient 4 dated 9/6/2022, 9/20/2022, 9/29/2022, 10/6/2022, indicated LVN 1 documentations that he cleaned the wound with wound cleanser, pat dried, applied collagen and alginate, and covered with a kerlix roll. There was no documentation a hydrocolloid dressing was applied as per order by the wound specialist. During a telephone interview on 10/14/2022, at 2:30 p.m., LVN 1 stated he applied collagen and calcium alginate on the wound because he never saw the hydrocolloid dressing in Patient 4's house. He stated he should have clarified with the wound specialist and the agency and should have followed the wound specialist's order. A review of the Plan of Care/Comprehensive Assessment dated 9/1/2022, 9/15/2022, and 9/29/2022 indicated wound care for the unstageable wound on the left heel was done as prescribed; Cleanse wound with normal saline, pat dry, apply triple antibiotic ointment, cover with dry dressing and secure with tape. A review of the IDG attendance sign in sheet dated 9/1/2022, 9/15/2022, and 9/29/2022 indicated there were no signatures of the wound specialist. A review of Patient 4's clinical record indicated there was no documented evidence the wound specialist participated in an IDG meeting or the agency had communicated regarding Patient 4's wound treatment. On 10/14/2022, at 3:10 p.m., during an interview with the Designee Patient Care Services (DPCS), she stated the Plan of Care/Comprehensive Assessment dated 9/1/2022, 9/15/2022, and 9/29/2022 should have been updated with the wound specialist's input and participation. A review of the agency's policy titled "Interdisciplinary Group Plan of Care" revised in May 2022, indicated Care will be provided by an interdisciplinary group made up of physician, nurses, social workers, certified hospice aides, homemakers, clergy, counselors, volunteers, and therapists. Contract personnel will participate in preparation of the plan of care and participate in the interdisciplinary group meetings.

Based on interview and record review, the hospice agency failed to ensure the spiritual counsellor (a person responsible for the provision of spiritual care services to patients and families/caregivers, either directly or through coordination of care with the hospice team members), attended the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meetings to discuss any changes and progress, and to update the plan of care for the six of 22 patients, (Patients 2, 3, 4, 5, 6 and 7). This deficient practice had the potential to result in the patients' spiritual, emotional concerns to not be adequately addressed and patient goals will not be met. --- On 10/13/2022, at 4 p.m., during an interview with the designee Director of patient Care Services (DPCS), she stated the IDG members had been signing the Interdisciplinary Team Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) attendance on the paper. A review of the IDG attendance sign in sheet did not indicate a chaplain's signature on the following dates: 1. 1/6/2022 2. 1/20/2022 3. 2/3/2022 4. 2/17/2022 5. 3/3/2022 6. 3/17/2022 7. 3/31/2022 8. 4/14/2022 9. 4/28/2022 10. 5/12/2022 11. 5/26/2022 12. 6/9/2022 13. 9/29/2022 On 10/14/2022, at 3:20 p.m., during an interview with the designee DPCS, she was not able to provide the documented evidence the chaplain had participated in the IDG meeting on the above days and stated the chaplain should have participated in the IDG meeting. A review of the agency's policy titled "Interdisciplinary Group Plan of Care" revised May 2022 indicated care will be provided by an interdisciplinary group made up of physicians, nurses, social workers, certified hospice aides, homemakers, clergy, counselors, volunteers, and therapists. A review of the agency's policy titled "Interdisciplinary Group Meeting" revised in May 2022 indicated the hospice Medical Director and all hospice interdisciplinary group members will be present, and the members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice clinical supervisor.

Based on observation, interview and record review, the hospice agency failed to ensure the plan of care for one of seven patients, Patient 4, was revised to reflect the current physicians wound care treatment order. This deficient practice had the potential to result in the delay of wound healing when the current treatment order is not being followed. --- A review of Patient 4's clinical record indicated Patient 4 was admitted to the hospice agency on 8/29/2022, with diagnoses that included senile degeneration of brain (loss of intellectual ability). A review of the Plan of Care Comprehensive Assessment dated 8/29/2022 indicated Patient 4 was alert, disoriented and confused, and required total assistance with all the activities of daily Living (ADL). It indicated Patient 4 had one unstageable wound on the left heel which measured 2 cm by 1.5 cm and had serosanguineous drainage. A review of Patient 4s physician's order dated 8/29/2022 indicated the following: 1. Skilled Nurse (SN) was to visit once a week and three visits as needed. 2. The hospice aide was to visit three times a week and two visits as needed. 3. The Medical Social Worker (MSW) was to visit once a month and two visits as needed. 4. The chaplain and the volunteer service were declined. The physician ordered to cleanse the unstageable wound on the left heel with normal saline, pat dry, apply triple antibiotic ointment, cover with dry dressing, and secure with tape. A review of Patient 4s physician's order dated 8/30/2022, indicated to start a wound evaluation and treatment by the "Wound Masters". A review of the "Wound Master" document dated 9/6/2022 indicated Patient 4 had a Stage IV pressure ulcer on the left lateral foot which measured 1 cm by 1.4 cm by 0.5 cm (pre debridement measurement). The wound doctor ordered to cleanse the wound with a wound cleanser, pat dry, apply collagen, cover with Hydrocolloid, put roll gauze, and apply tape. The Wound Master indicated to change the dressing every 2-3 days or as needed. On 10/12/2022, at 11:15 a.m., a home visit was conducted with Licensed Vocational Nurse 2 (LVN 2) at Patient 4's residence. Patient 4 was lying on a hospital bed in the room with closed eyes. Patient 4 had a dressing on the left foot and was wearing a foot protector on both feet. Family member 1 and Caregiver 3 were in the room. At 11:25 a.m., LVN 2 removed the foot protector on the left foot, then removed the old dressing, and measured the wound. LVN 2 stated the wound was a Stage III, which measured 2.25 cm by 1.5. cm by 0.1 cm. LVN 2 sprayed the wound cleanser onto a 4 x 4 gauze and cleaned the wound, and pat dried. LVN 2 then applied collagen on the wound and applied a non-adhesive dressing, taped, and applied Kerlix. A review of the Plan of Care/Comprehensive Assessment dated 9/1/2022, 9/15/2022, and 9/29/2022 indicated wound care for the unstageable wound on the left heel was done as prescribed as follows: Cleanse wound with normal saline, pat dry, apply triple antibiotic ointment, cover with dry dressing and secure with tape. On 10/14/2022, at 3:10 p.m., during an interview with the Designee Patient Care Services (DPCS), DPCS stated the Plan of Care/Comprehensive Assessment dated 9/1/2022, 9/15/2022, and 9/29/2022 were incorrect and should have been updated. A review of the agency's policy titled "Interdisciplinary Group Meeting" revised in May 2022 indicated the patient's plan of care will be updated no less frequently than every 15 days or more frequently if the patient's condition requires.

Based on observation, interview and record review, the hospice agency (HA) failed to: 1 Ensure a physician order was obtained for wound treatment for one (1) of seven patients, Patient 2. The skilled nurse (SN) applied a Collagen dressing without an order from the doctor on Patient 2s Stage 2 pressure ulcer located on the right and left upper buttocks. 2 Ensure a physicians order was followed as indicated in the wound care order for 1 of seven sampled patients, Patient 4. The SN did not apply the hydrocolloid dressing as ordered and instead applied calcium alginate dressing on Patient 4s stage 3 pressure ulcer (sore gets worse and extends into the tissue beneath the skin, forming a small crater, fat may show in the sore, but not muscle, tendon, or bone) located on Patient 4s left foot. These deficient practices resulted in the patients not receiving appropriate wound care treatments and placed the patients wounds at risk for delayed healing. --- b. A review of Patient 4's clinical record indicated Patient 4 was admitted to the hospice agency on 8/29/2022, with diagnoses that included senile degeneration of brain. A review of the Plan of Care/Comprehensive Assessment dated 8/29/2022 indicated Patient 4 was alert and disoriented/confused required total assistance with all the activities of daily living. It indicated Patient 4 had one unstageable wound on the left heel sized 2 cm by 1.5 cm and had serosanguineous drainage. A review of the physician's order dated 8/29/2022 indicated the Skilled Nurse (SN) was to visit once a week and three visits as needed, the hospice aide was to visit three times a week and two visits as needed, the Medical Social Worker (MSW) was to visit once a month and two visits as needed. The chaplain and the volunteer service were declined. The physician ordered to cleanse the wound with normal saline, pat dry, apply triple antibiotic ointment, cover with dry dressing, secure with tape. A review of the physician's order dated 8/30/2022 indicated to start wound evaluation and treatment by the "wound masters". A review of the "wound master" dated 9/6/2022 indicated Patient 4 had Stage IV pressure ulcer on the left lateral foot sized 1 cm by 1.4 cm by 0.5 cm (pre debridement measurement). The wound doctor ordered to cleanse the wound with wound cleanser, pat dry, apply collagen, cover with Hydrocolloid (provide a moist and insulating healing environment which protects uninfected wounds while allowing the body's own enzymes to help heal wounds), put roll gauze, and tape. It indicated to change dressing every 2-3 days or as needed. On 10/12/2022, at 11:15 a.m., Patient 4's home visit was conducted with Licensed Vocational Nurse 2 (LVN 2) at Patient 4's residence.Patient 4 was lying in a hospital bed in the room, closed eyes. Family member 1 and Caregiver 2 were in the room. Patient 4 had dressing on the left foot, and was wearing foot protectors on both feet. At 11:25 a.m., LVN 2 removed the foot protector on the left foot, removed the old dressing, and measured the wound. LVN 2 stated the wound was Stage III, sized 2.25 cm by 1.5. cm by 0.1 cm. LVN 2 sprayed wound cleanser to 4 x 4 gauze and cleaned the wound, pat dried. Then she applied collagen on the wound put non adhesive dressing, taped and put kerlix. When asked LVN 2 whether Hydrocolloid dressing was to be applied, she stated she could not find it at the patient's house.During an interview with Caregiver 3 at the same time, she stated the wound doctor visited the patient once a week and the agency's SN visited once a week. She stated the wound doctor had brought his own dressing, and the agency SN had been using the non adhesive dressing that the family bought from the pharmacy. A review of the Nursing Visit Record dated 9/6/2022, 9/20/2022, 9/29/2022, 10/6/2022, indicated LVN 1 (Patient 4's routine nurse) documented that he cleaned the wound with wound cleanser, pat dried, applied collagen and alginate, and covered with kerlix roll. There was no documentation Hydrocolloid dressing was applied as the wound specialist ordered. On 10/14/2022, at 2:30 p.m., during a telephone interview with LVN 1, he stated he applied collagen and calcium alginate on the wound because he never saw the Hydrocolloid dressing at Patient 4's house. He stated he should have clarified with the wound specialist and the agency, and should have followed the wound specialist's order. A review of the agency's policy titled "Wound Care Policy" dated 4/15/2021 indicated the nurse will provide wound care per the physician's order and continue to implement and evaluate the plan of care. a. A review of patient 2s admission record indicated the patient was admitted to the Hospice Agency (HA) on 4/22/22, with a primary diagnosis of Atherosclerotic heart disease of native coronary artery without angina pectoris (is caused by plaque buildup in the wall of the arteries that supply blood to the heart, plaque is made up of cholesterol deposits and buildup causes the inside of the arteries to narrow over time without a condition marked by severe pain in the chest). A review of patient 2s plan of care (POC)/Interdisciplinary group (IDG) Review dated 10/13/22 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed, Skilled Nurse (SN) routine visits once a week and Certified Home Health Aide (CHHA) visits three times a week but no indication of wound order treatment for stage 2 pressure ulcer located at right and left upper buttocks areas. A review of patient 2s physician orders detail dated 10/11/22 with no indication of wound order treatment for stage 2 pressure ulcer located at right and left upper buttocks areas. During a joint home visit with LVN 1 on 10/11//22, at 1:30 p.m., Patient 2 was observed laying on her bed comfortably. Patient 2 was alert, oriented, and was able to communicate well, pleasant, and well groomed. LVN 1 performed hand hygiene before conducting wound care treatment to patient 2s stage 2 pressure ulcer at right and left buttocks areas. LVN 1 cleansed patient 2s stage 2 pressure ulcer at right and left buttocks areas with normal saline (is the chemical name for salt, it can reduce some types of bacteria and is used to clean out a wound), patted to dry and covered with collagen dressing. During an interview with LVN 1 on 10/14/22, at 1:00 p.m., LVN 1 stated he is not aware that an order is needed to cleanse the wounds with normal saline and to cover it with collagen dressings. During an interview with the Director of Patient Care Services Designee (DPCSD) on 10/14/22, at 1:10 p.m., DPCSD stated that physician orders are necessary to provide appropriate wound treatments to patients, SN should coordinate it first to Registered Nurse (RN) and to the doctor before conducting wound treatment. A review of the agency's policy and procedure titled, "Verification of Physician Orders" revised in May 2022, indicated that orders will be obtained from a licensed physician or authorized independent practitioner for care and services to be provided to hospice patients. A review of the agencys policy and procedure titled, ";Wound Care Policy" dated 04/15/21, indicated that nurse will provide wound care per physician orders and continue to implement and evaluate the plan of care based on the effectiveness of treatment regimen, response to treatment, effectiveness of interdisciplinary services, need for assessment by wound care specialist, patient/caregiver participation and identification of obstacles/risk factors interfering with wound healing.

Based on observation, interview and record review, the hospice agency failed to ensure proper infection control practices were observed prior to providing wound care to one of 7 sampled patients, (Patient 4). This deficient practice placed the patients wound at risk for potential wound infection. --- A review of Patient 4's clinical record indicated Patient 4 was admitted to the hospice agency on 8/29/2022, with diagnoses that included senile degeneration of brain (loss of intellectual ability). A review of the Plan of Care/Comprehensive Assessment dated 8/29/2022 indicated Patient 4 was alert and disoriented/confused required total assistance with all the activities of daily living. Patient 4 had one unstageable wound on the left heel which measured 2 cm by 1.5 cm and had serosanguineous drainage. A review of the physician's order dated 8/30/2022 indicated to start a wound evaluation and treatment by the "Wound Masters". A review of the "Wound Master" document dated 9/6/2022 indicated Patient 4 had a Stage IV pressure ulcer on the left lateral foot which measured 1 cm by 1.4 cm by 0.5 cm (pre debridement measurement). The wound doctor ordered to cleanse the wound with a wound cleanser, pat dry, apply collagen, cover with hydrocolloid, apply roll gauze, and tape and change the dressing every 2-3 days or as needed. On 10/12/2022, at 11:15 a.m., a home visit was conducted with Licensed Vocational Nurse 2 (LVN 2) at Patient 4's residence. Patient 4 was lying on a hospital bed in the room with closed eyes. Patient 4 had a dressing on the left foot and was wearing a foot protector on both feet. Family member 1 and Caregiver 3 were in the room At 11:25 a.m., LVN 2 sanitized her hands and put the new gloves on after she removed the old dressing from Patient 4's left foot. Then LVN 2 took a trash can from Caregiver 3 who was standing on the other side of the bed and handed the trash can over to LVN 2. Without changing gloves and sanitizing her hands, LVN 2 measured the wound, then cleansed the wound with the wound cleanser, applied collagen powder, then applied a non-adhesive dressing and Kerlix. During an interview with LVN 2 on 10/12/2022, at 12:15 p.m., she stated she should have changed the gloves and sanitized her hands after she touched the trash can, but she forgot. On 10/14/2022, at 1:30 p.m., during an interview with the designee Patient Care Services (DPCS), she stated the SN should have changed the gloves and sanitized her hands before treatment if she had touched the trash can. Upon request for the policy of changing gloves and hand washing, the agency provided the policy titled "Standard Precautions". A review of the agency's policy titled, "Standard Precautions ";revised May 2022, hand hygiene will be performed to prevent cross-contamination between patient and personnel.

Based on interview and record review, the hospice agency failed to ensure, four of seven patients, Patients 2,3,4 and 7, were provided ";Comfort Kits" (an emergency kit for hospice patients in distress at home) as per the agencys policy and procedure. This failure had the potential that patients with terminal illness who will experience any type of distress will not have the emergency medicines available to rapidly treat symptoms and can affect the comfort level of these patients under their care. --- c. A review of Patient 4's clinical record indicated Patient 4 was admitted to the hospice agency on 8/29/2022, with diagnoses that included senile degeneration of brain. A review of the Plan of Care/Comprehensive Assessment dated 8/29/2022 indicated Patient 4 was alert and disoriented/confused required total assistance with all the activities of daily living. On 10/12/2022, at 11:15 a.m., Patient 4's home visit was conducted with Licensed Vocational Nurse 2 (LVN 2) at Patient 4's residence.Patient 4 was lying in a hospital bed in the room, closed eyes. Family member 1 and Caregiver 2 were in the room. At 12 p.m., when the Patient 4's medications were reviewed with LVN 2, Comfort kit was not found at the patient's house. During an interview with LVN 2 and Caregiver 2 at the same time, they stated the agency did not provide it. d. A review of Patient 7's clinical record indicated Patient 7 was admitted to the hospice agency on 5/14/2022, with diagnoses of Alzheimer's disease. A review of the physician's order dated 5/14/2022 indicated the Skilled Nurse (SN) was to visit once a week and three visits as needed, the hospice aide was to visit three times a week and two visits as needed, the Medical Social Worker (MSW) was to visit once a month and two visits as needed. The chaplain and the volunteer service were declined. On 10/12/2022, at 1:35 p.m., Patient 7's home visit was conducted with Licensed Vocational Nurse 2 (LVN 2) at the board and care facility.Patient 7 was sitting in a bench in the back yard, and Caregiver 1 was next to the patient. At 2 p.m., during Patient 7's medication review with LVN 2 and Caregiver 1, Comfort kit was not found at the patient's house. During an interview with LVN 2 and Caregiver 1 at the same time, they stated the agency did not provide it. During an interview with the Designee Director of Patient Care Services (DPCS) on 10/13/2022, at 2:15 p.m., she stated the agency provides the comfort kit only when the patient shows sign and symptoms in order to prevent waste. She stated the medications in the comfort kit could be expired if the patients did not use them. She stated the agency's pharmacy could deliver the medications in the comfort kit to the patients within 2-4 hours. When asked how the patient/family would manage the symptoms while waiting for the delivery from the pharmacy for 2-4 hours, and when the patients showed symptoms at night, and the patients lived far away from the pharmacy, the designee of DPCS was not able to answer.When asked the Designee DPCS, she stated there were four patients provided the Comfort kits out of 22 active patients. A review of the agency's "Practice Location Information (CMS-855 A) indicated the agency's geographic area included San Bernadino County, Riverside County, Orange County, and Los Angeles County. A review of the agency's policy titled "Hospice Comfort Kits" dated 1/4/2020 indicated the hospice nurse performing the hospice admission will contact the hospice patient's physician or the Hospice Medical Director at the time of assessment , for orders about specific emergency medications to be supplied in a Comfort Kit for every patient admitted to the agency. The pharmacy will fill orders for Comfort kits. The pharmacy will deliver the Comfort kit. The hospice primary nurse will follow up with education to the patient and family and ensure the Comfort Kit medications are listed on the medication list in the patient's chart. a. A review of patient 2s admission record indicated the patient was admitted to the Hospice Agency (HA) on 4/22/22, with a primary diagnosis of Atherosclerotic heart disease of native coronary artery without angina pectoris (is caused by plaque buildup in the wall of the arteries that supply blood to the heart, plaque is made up of cholesterol deposits and buildup causes the inside of the arteries to narrow over time without a condition marked by severe pain in the chest). A review of patient 2s plan of care (POC)/Interdisciplinary group (IDG) Review dated 10/13/22 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed, Skilled Nurse (SN) routine visits once a week and Certified Home Health Aide (CHHA) visits three times a week. During a joint home visit with LVN 1 on 10/11//22, at 1:30 p.m., Patient 2 was observed laying on her bed comfortably. Patient 2 was alert, oriented, and was able to communicate well, pleasant, and well groomed. At 2:15 p.m. during medication reconciliation, LVN 1 stated patient 2 has no comfort kit currently. LVN 1 stated he does not know why it was not provided to patient 2. A review of patient 2's clinical record indicated there was no documented evidence the comfort kit was provided. The agency was not able to provide the documented evidence the comfort kit was provided to patient 2. During an interview with the Director of Patient Services Designee (DPCSD) on 10/13/22 at 10:00 a.m., DPCSD stated that they do not provide comfort kits to patients unless the patient is in transition of actively dying or on continuous care. b. A review of patient 3s admission record indicated the patient was admitted to the Hospice Agency (HA) on 8/2/22, with a primary diagnoses of Atherosclerotic heart disease of native coronary artery without angina pectoris (is caused by plaque buildup in the wall of the arteries that supply blood to the heart, plaque is made up of cholesterol deposits and buildup causes the inside of the arteries to narrow over time without a condition marked by severe pain in the chest), Hypertensive chronic kidney disease (chronic elevation of blood pressure which also involves a gradual loss of kidney function), Chronic Kidney disease (involves a gradual loss of kidney function) and Isolated proteinuria (is protein in urine without any abnormalities in urinary sediment, blood in urine, or a reduction in kidney filtration). A review of patient 3s plan of care (POC)/Interdisciplinary group (IDG) Review dated 10/13/22 indicated Registered Nurse (RN) visits once a week for initial assessment, ongoing comprehensive assessment and recertification and as needed and Certified Home Health Aide (CHHA) visits three times a week. During a joint home visit with DPCSD on 10/12/22, at 11:00 a.m., Patient 3 was observed laying on her bed comfortably. Patient 3 was alert, oriented and confused at times but was able to communicate well, pleasant, and well groomed. Patient 3 has a private caregiver that stays with her all the time. At 12:15 p.m. during medication reconciliation, DPCSD stated patient 3 has no comfort kit currently as she is not in transition to actively dying. A review of patient 3's clinical record indicated there was no documented evidence the comfort kit was provided upon admission to hospice. The agency was not able to provide the documented evidence the comfort kit was provided to patient 3 upon admission to hospice. A review of the agency's policy and procedure titled "Hospice Comfort Kit", dated 1/4/20, indicated all hospice patients not residing in a nursing home will receive a comfort kit containing emergency medication as ordered by the patients physician or the hospice medical director and with the procedure as follows: 1. The hospice nurse performing the hospice admission will contact the hospice patient's physician or hospice Medical Director at the time of admission for orders about specific emergency medications to be supplied in a Comfort Kit for every patient admitted at the agency. 2. The hospice nurse will complete the Comfort Kit order Sheet and fax the form to the pharmacy as soon as possible. 3. The hospice primary nurse will follow up with education to the patient and family and ensure the comfort kit medications are listed on the medication list in the patients chart. 4. After delivery, the visiting nurse will educate the patient and family on the use and storage of the Comfort Kit.

Upon observation, there was no evidence that the patient has the right: • To exercise his or her rights as a patient of the hospice • Have one's property and person treated with respect • To not be subjected to discrimination or reprisal for exercising his or her rights Patient 1: Patient rights with regards to privacy was not honored during visit to respect the patient in a dignified and respectful manner. The bedroom door was open to the hallway where other patients and visitors have access. Also the curtains were open to the courtyard right outside with a view into the patients room. The LVN requested for the patient to turn over to address a wound on sacrum while there was an unobstructed view into the patients room. Patient 2: Patient rights with regards to privacy was not honored during visit to respect the patient in a dignified and respectful manner. The bedroom door was open to the hallway where other patients and visitors have access. The curtains in the patients room were open to the front entrance area of the home where visitors and patients enter.

Upon patient record review, 8 of 11 (Patients #2, #5, #6, #7, #8, #9, #10, #11) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patients #2, 5, 6, 7, 8, 9, 10, 11: There is documentation at SOC in the medical record that the patient is using oxygen. Oxygen therapy is not included on the medication profile.

Upon patient record review, 11 of 11 (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11: There is no indication for a frequency for all disciplines, as order states "each discipline may visit as frequently as needed to meet the patients/families needs as approved by Hospice IDT".

Upon patient record review, 3 of 11 (Patient #1, #5 #9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: The record indicated a wound to the coccyx that nursing is to provide wound care to. There is no evidence of an order for the care of this wound. Corrected on site. Patient #5: Patient was admitted with a Foley on 6/30/22, there was no evidence in the medical record of an order pertaining to foley catheter care or changes. Patient #9: On 8/29/22, the record indicated an order to cleanse with wound cleanser and apply mepilex to the Left heel. The order did not identify a frequency for wound care.

Upon client record review, 1 of 11 (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #5: On 7/7/22 and 7/11/22 there is nursing documentation by LVN that wound care was provided to bilateral heels, there is no evidence of an order for the care of this wound.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 1: No designated clean and dirty area for equipment and supplies. Equipment was set on dirty area after cleaned. Clorox container fell onto the ground and was not cleaned and set back into area with clean equipment and equipment was then used on patient. Clinician used notebook that is carried into all visits with as an area to hold clean equipment at start of visit. Patient 2: Clinician did not wash hands with soap and water or hand sanitizer prior to start of visit or touching patient.