Every finding on record at Pathways Healthcare, LLC

Upon patient record review, 3 of 19 (Patient #2, #4, #13) 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 #2, #4, #13: Two forms of bathing were assigned on the Aide plan of care.

Based on records reviewed and interviews for two of five sampled patients (Patient #2 and Patient #5) whose Plans of Care included Hospice Aide home visits, the Agency failed to ensure they consistently followed established Plans of Care related to the provision of Hospice Aide services. --- 2)Patient #5 was admitted to Hospice in August 2022, diagnoses included senile degeneration of the brain, diabetes mellitus, chronic ischemic heart disease, and acute kidney failure. Review of Patient #5s Physicians Orders, dated 5/09/23, indicated he/she was to receive HHA services, effective 5/07/23 four times a week for one week and then five times a week times three weeks. Review of Patient #5s Hospice Certification of Plan of Care, for certification period 4/05/23 to 8/03/23 and dated as effective 6/05/23, indicated he/she was to receive HHA services three times a week for nine weeks. Review of Patient #5s Patient Calendar, dated 05/08/23 through 06/16/23, indicated he/she had been scheduled for twenty-six HHA visits and indicated that twenty-two of those visits were missed by an HHA. During an interview on 9/06/23 at 12:34 P.M., Social Worker #1 said she felt that the Agency had difficulty scheduling HHA visits for patients due to staffing issues when Patient #5 was receiving Hospice services. Social Worker #1 said Family Member #1 asked for more assistance with Patient #5s personal care as time went on and he/she began to functionally decline, because it was becoming too much for Family Member #1 to care for him/her. Social Worker #1 said she told Family Member #1 that the Hospice Agency was unable to provide additional HHA visits to assist him/her at that time and said that was when she discussed placing Patient #5 in a Skilled Nursing Facility. During an interview on 09/06/23 at 1:17 P.M., Nurse #2 said when she arrived at Patient #5s home on 5/09/23, he/she was incontinent of a large amount of urine, and she assisted with his/her personal care and Nurse #2 said that was when she put in the recommendation for a HHA five times a week daily. Nurse #2 said she told Case Manager #3 that Patient #5 needed an HHA. During an interview on 9/06/23 at 2:07 P.M., Clinical Manager #3 said that an HHA had been scheduled by the Agency for Patient #5, but Family Member #1 refused the HHA services on three occasions in May 2023. Case Manager #3 said she had not been aware that after the refused visits in May, that Family Member #1 still wanted HHA services to assist her with his/her care. Clinical Manager #3 said she thought because the visits were missed in May, that there were no additional HHA services needed for Patient #5, therefore no further attempts to provide an HHA for Patient #5 were attempted after that. During an interview on 8/30/23 at 12:44 P.M., the Clinical Director said Patient #5 did not receive any HHA visits for the months of May and June 2023. The Clinical Director said he did not know why Patient #5 did not receive HHA services during that timeframe because there was an HHA scheduled. The Clinical Director said Patient #5 should have received visits by an HHA according to his/her Plan of Care Findings Include: The Agency Policy titled The Plan of Care, undated, indicated the care provided to the patient must be in accordance with the plan of care. The Policy indicated the Plan of Care would identify the patients needs and services to meet those needs. 1) Patient #2 was admitted to Hospice in May 2022, diagnoses included prostate cancer, acute respiratory failure, epilepsy, and protein calorie malnutrition. Review of Patient #2s Hospice Certification and Plan of Care, for certification period 05/25/22 to 08/22/22 and dated as ordered on 05/25/23, indicated he/she was to receive Hospice Home Health Aide (HHA) services three times a week for twelve weeks. The Hospice Certification and Plan of Care indicated HHA services would be provided to Patient #2 for assistance with personal care and activities of daily living (ADLs) secondary to functional limitations which prevented self-care. Review of Patient #2s Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update Report, dated as IDG meeting date, 06/02/22, indicated Patient #2s daughter was his/her full time care-giver and indicated he/she was fully dependent for all ADL care. The Report indicated that Patient #2 was to have an HHA three times a week for twelve weeks. Review of Social Worker #2s Visit Note, dated 06/02/22, indicated he/she lived with two daughters and many other family members and that one daughter was his/her primary care giver. The Note indicated an outside community agency provided sixteen hours of in-home support for Patient #2 but indicated Patient #2s care giver was in need of a break and increased support. Review of Patient #2s Nurse Visit Note, dated 07/18/22, indicated Nurse #6 provided a visit to him/her and that he/she remained at home comfortable with his/her aide. Review of Patient #2s Nurse Visit Note, dated 07/27/23, indicated Nurse #6 provided a visit to him/her and that he/she was home with his/her aide. Review of Patient #2s Medical Record indicated there was no documentation to support that a Hospice Agency HHA documented any visit notes or documented any ADL care provided to Patient #2. During an interview on 09/06/23 at 2:09 P.M., Nurse #6 said she provided Hospice home visits for Patient #2. Nurse #6 said that when she made visits to Patient #2s home, there was often an HHA there and said that, to her knowledge, the HHA had provided some personal care for Patient #2. Nurse #6 said although she documented in her Visit Notes that an HHA was present with Patient #2 during some of her visits, said she did not know if the HHA was provided by the Hospice Agency, another outside agency, or privately paid for by his/her Family. During an interview on 09/06/23 at 1:10 P.M., Social Worker #2 said that due to the length of time that had passed since Patient #2 had been admitted to Hospice, she did not remember if the Hospice Agency provided or did not provide Patient #2 with an HHA. The Social Worker said Patient #2 had received some services from an outside community agency but said the Hospice Agency should also have provided Patient #2 with HHA services also, for more overall support. During an interview on 09/06/23 at 2:49 P.M., the Clinical Director said the Hospice Agency did not provide Patient #2 with an HHA due to a computer glitch. The Clinical Director said the Hospice Agencys Plan of Care indicated the Hospice Agency was to provide Patient #2 with an HHA three times a week for twelve weeks and said although Patient #2 had received support from an outside community agency which had provided him/her with a home health aide, the Hospice Agency should have also provided Patient #2 an HHA as indicated in his/her Plan of Care.

Upon patient record review, 6 of 11 (Patient #1, #3, #5, #6, #9, #10) did not have evidence the plan of care includes specific orders for all medications and treatments. Patient #1, #3, #5, #6, #9 -Each of the patient's have orders to update the plan of care on record for Acetaminophen 650 mg supp 1 q6h prn pain and Morphine 20 mg/ml .25ml (5mg) q3h prn pain without differentiation in pain levels to determine which medication to administer. Patient #1- The 12/14/21 plan of care includes Latanoprost .005% eye drop 1 gtt qpm and Brimonidine .2% eye gtt three times daily. The plan does not specify which eye(s) for administration. Patient #5-The 11/03/21 plan of care includes orders to provide instruction related to pressure ulcer care. The orders are not specific for actual care to be provided. Patient #9- The 10/24/21 plan of care includes orders for skilled nurse to instruct/reinforce trach care/including stomal care /suctioning and dressing change. The orders are not specific for the actual care to be provided. The 10/28/21 nursing orders to update the plan of care are to change dressing to Pleural Drain weekly on Wednesdays. The complete dressing change to be performed is not included in the orders (sterile technique, cleansing agent, specific type of dressing). Patient #10- The 08/19/21 plan of care includes orders for skilled nurse to instruct/reinforce trach care/including stomal care /suctioning and dressing change. The orders are not specific for the actual care to be provided.

Upon patient record review 3 of 4 applicable (Patient #4, #9, #10) did not evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group and included in the plan of care. Patient #4-The Aide care plan assigned the Aide to perform the following tasks each visit: hair care, oral care, perineal care, shampoo, shaving and change linen. The tasks were not performed on aide visits between 09/10/21 and 12/08/21. Patient #9- The Aide care plan assigned the Aide to change linen each visit. The task was not performed on the 11/01/21 visit. Patient #10- The Aide care plan assigned the Aide to transfer the patient , shampoo hair, provide perineal care and oral care each visit. The tasks were not performed 09/17/21-10/08/21.

Upon patient record review, 4 of 11 (Patient #1, #4, #9, #10) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #1, #4, #9, #10- The records contained paper visit notes prepared by the Aides. The signatures on record were incomplete, illegible and/or did not contain credentials.

Upon patient record review, 1 of 1 applicable live discharge (Patient #9) did not have evidence that the discharge summary includes all required information. Patient #9- The patient revoked and was admitted to the hospital 11/4/21 to seek aggressive care. The Discharge summary does not include a summary of the patient's stay, including treatments, symptoms and pain management. The discharge summary only documents the patient transferred to a short term hospital for inpatient care.

Upon patient record review, 11 of 11 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) did not have documentation in the record that the written policies and procedures for managing controlled drugs was provided and discussed.