Every finding on record at Pella Regional Health Center

Based on agency staff interview, clinical record review and policy review, the hospice failed to ensure the patient received information about the services covered under the hospice benefit for 1 of 1 sampled patients (Patient #13) requesting the information at the time of admission to hospice care. Failure of the hospice to ensure the patient received information about the services covered under the hospice benefit increased the risk that patients did not receive appropriate services to meet assessed needs. --- Findings include: According to the agency policy titled Patient Rights, dated 3/2024, patients have the right to be advised prior to initiation of cares of the extent to which payment may be required from the patient. Patient liability for payment will be given orally and in writing. During an interview with the Administrator on 3/11/25 at 2:30 PM, stated on the Medicare Hospice Election Form, completed at the time of admission to hospice services, there is a box to be checked whether the patient would like to receive the addendum with the itemized list of non covered items, services or drugs. The Administrator acknowledged if the patient or family checks the box indicating they wish to receive the addendum, the nursing staff are knowledgeable on how to complete the addendum. Administrator could not locate an addendum form or verify one had been completed for Patient #13. Patient #13 had a start of care date of 2/14/25 and a death date of 2/18/25 and received hospice services inpatient in the hospice house. Clinical record review revealed : a. The Hospice Benefit Form, dated 2/14/25, patient marked yes to receive the addendum listing conditions, items, services and drugs the hospice agency determined to be unrelated to the terminal illness and thus not covered by Medicare. b. The clinical record lacked evidence this form was completed and given to the patient at the start of care. The agency failed to provide the patient with the requested addendum for conditions, items, services and drugs that would not be covered financially by Medicare. The above findings were reviewed with the Administrator.

Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure the provision of care in accordance with the patient's plan of care for 1 of 2 sampled patients with wounds (Patient #14). Failure to follow the patient's plan of care as directed by the Interdisciplinary Group (IDG) put the patients at risk of inconsistent care that may not meet the needs of the patient. Findings include: --- According to the agency policy, titled Care Planning Process, revised 3/2022, the hospice interdisciplinary group, in consultation with the attending physician will prepare a written plan of care for each patient. The primary care registered nurse will provide coordination of care and ensure continuous assessment of each patient and family's needs and implementation of the interdisciplinary plan of care. All hospice care and services furnished to patients and their families will follow an individualized plan of care. During an interview on 3/5/25 at 11:00 AM, the Administrator stated wound assessments and measurements are to be completed weekly. Patient #14 had a hospice admission date of 4/23/24, a death date of 9/14/24 and received services while residing in a private residence. a. Plan of Care (POC), dated 7/22/24 to 10/19/24, identified the patient had diagnoses of Alzheimer's disease, Nonrheumatic aortic valve stenosis and Type II diabetes mellitus without complications. The POC included orders for skilled nursing services to monitor and measure wounds weekly. b. The skilled nurse visit note, dated 8/5/24, completed by Staff C, Registered Nurse (RN), identified the patient had the following wounds: 1) Unstageable, circular pressure ulcer to right heel covered by eschar measuring 1 centimeters (cm) by 1 cm by 0 cm. Wound edges are attached to wound bed, no drainage noted and no signs or symptoms of infection. 2) Unstageable, circular pressure ulcer to left heel covered by eschar measuring 3 cm by 3 cm by 0 cm. Wound edges are attached to wound bed, no drainage noted and no signs or symptoms of infection. 3) Unstageable pressure ulcer to right, lateral leg, 90% covered with slough measuring 4 cm by 1.8 cm by 0.1 cm. Wound edges are attached to wound bed, scant amount of bright red drainage and no signs or symptoms of infection. 4) Unstageable pressure ulcer to right, lateral leg below bigger wound, 100% slough covered measuring 1.5 cm by 0.8 cm by 0 cm. Wound edges are attached to wound bed, no drainage and no signs or symptoms of infection. 5) Unstageable pressure ulcer to left calf, covered by eschar measuring 17 cm by 1 cm by 0 cm. Wound edges are attached to wound bed, no drainage and no signs or symptoms of infection. 6) Unstageable pressure ulcer to sacrum-midline, 100% covered by slough measuring 3.5 cm by 1.5 cm by 0 cm. Wound edges are attached to wound bed, moderate amount of tan drainage and no signs or symptoms of infection. c. The skilled nurse visit note, dated 8/13/24, completed by Staff C, RN, identified the patient had the following wounds: 1) Unstageable, circular pressure ulcer to right heel covered by eschar measuring 1 cm by 1.3 cm by 0 cm. No drainage noted, tissue bed color black and no signs or symptoms of infection. 2) Stage 1 pressure ulcer to left heel improving, measuring 1.7 cm by 1 cm by 0 cm. Wound edges are attached to wound bed, no drainage noted and no signs or symptoms of infection. 3) Stage 2 pressure ulcer to left calf, has three black areas in bottom half of wound that are eschar measuring 15 cm by 1 cm by 0 cm. Wound edges are attached to wound bed, no drainage and no signs or symptoms of infection. 4) Stage 2 pressure ulcer to right, lateral leg, 20% eschar measuring 8 cm by 3 cm by 0.1 cm. Wound edges are attached to wound bed, scant amount of light brown drainage and no signs or symptoms of infections. The agency failed to provide weekly wound assessments and measurements per the POC for the unstageable pressure ulcer to the right lateral leg below the bigger wound and for the unstageable pressure ulcer to the sacrum. The above findings were reviewed with the Administrator.

Based on home observation visits, staff and patient interviews, clinical record review and agency policy review, the agency failed to ensure the hospice plan of care, included all necessary medications and treatments and/or physicians orders for all medications and treatments to meet the needs of the patients in 3 of 3 sampled patients (Patient #1, #2 and #3) with home observation visits. Failure to update the plan of care with with medication changes and/or failure to obtain physicians orders for all medications the patient is taking, increased the potential for medications errors, possible adverse interactions and inaccurate provision of care. --- Findings include: According to the agency policy titled Care Planning Process, dated 3/2022, the hospice will develop an individualized Plan of Care for each patient. The Plan of Care will reflect patient and family goals and interventions based on the problems identified on the comprehensive and updated comprehensive assessments. These goals must have time frames and measurable outcomes. The Plan of Care must include all services necessary for management of the terminal illness and related conditions, including the following: Interventions to manage pain and symptoms, a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs, measurable outcomes anticipated from implementing and coordinating the Plan of Care, medications and treatments necessary to meet the needs of the patient, and medical supplies and appliances necessary to meet the needs of the patient. 1.Patient #1 had a start of care date of 2/19/25 and received hospice services in a private home. Home observation visit and clinical record revealed the following: a. The Plan of Care (POC), dated 2/19/25 to 5/19/25, included physician orders for services, treatments and medications. b. During the home observation visit on 3/3/25, with Staff B, Registered Nurse (RN), the surveyor noted the bottle with the medication Zofran (used to help prevent nausea) had been refilled at the pharmacy on 2/18/25 with directions to take 8 milligrams (mg), every 8 hours as needed. The POC failed to include an updated order for the medication and indicated an order for 4mg every 8 hours as needed for nausea. The agency failed to update the POC with current physician orders for medication. 2. Patient #2 had a start of care date of 1/10/25, and received hospice services in a private home. Home observation visit and clinical record review revealed the following: a. The POC, dated 1/10/25 to 4/9/25 , included physician orders for services, treatments and medications. b. During a home observation visit on 3/3/25, with Staff B, RN, the patient stated that instead of taking aspirin 325 mg, when a new bottle was purchased patient started taking 3 tablets of aspirin with 81 mg in each tablet instead. The POC failed to include an updated order for the aspirin as patient indicated was self administering. The agency failed to update the POC with current physician orders for medication. 3. Patient #3 had a start of care date of 8/2/24 and received hospice services in the home. Home observation visit and clinical record review revealed the following: a. The POC, dated 1/29/25 to 3/29/25, included physician orders for services, treatments and medications. b. During a home observation visit on 3/4/25 with Staff C, RN, the surveyor noted patient was taking Mucinex (expectorant) one tablet every day, which the patient verified. The POC failed to include the medication Mucinex as a current medication order. Failure to update the POC with all current medications increased the potential for medication errors, possible adverse interactions and inaccurate provision of care. The above findings were reviewed with the Administrator.

Based on home observation visits, patient interviews, clinical record reviews and agency policy review, the agency failed to ensure accurate completion of all components comprising the Plan of Care, including all supplies/equipment used by the patient for 3 of 14 sampled patients. (Patient #1, #2 and #12) Failure to maintain complete and accurate Plans of Care with current orders placed patients at risk to not receive services, supplies and/or treatments according to assessed needs and physician orders. --- 3. Patient #12 had a start of care date of 1/9/25, a revocation date of 1/31/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. POC, dated 1/9/25 to 4/8/25, identified the patient had a primary diagnosis of Chronic diastolic (congestive) heart failure and identified the patient required use of the following medical supplies and equipment: bedrail/bed cane, walker, portable heater, lifeline, elevated toilet seat, stair chair, shower bench, nebulizer, handheld shower and grab bars. b. The start of care assessment, completed by Staff C, Registered Nurse (RN), identified the patient's medication is set up in a medication cassette. c. The IDG meeting note, dated 1/22/25 identified no additional medical supplies and equipment used by the patient. The POC and the IDG meeting notes to update the POC failed to identify all medical supplies and equipment used by the patient, including medication cassette. The above findings were reviewed with the Administrator. Findings include: According to the agency policy titled Care Planning Process, dated 3/2022, the hospice will develop an individualized Plan of Care for each patient. The Plan of Care will reflect patient and family goals and interventions based on the problems identified on the comprehensive and updated comprehensive assessments. These goals must have time frames and measurable outcomes. The Plan of Care must include all services necessary for management of the terminal illness and related conditions, including the following: Interventions to manage pain and symptoms, a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs, measurable outcomes anticipated from implementing and coordinating the Plan of Care, medications and treatments necessary to meet the needs of the patient, and medical supplies and appliances necessary to meet the needs of the patient. 1.Patient #1 had a start of care date of 2/19/25 and received hospice services in a private home. Home observation visit and clinical record revealed the following: a. The POC, dated 2/19/25 to 5/19/25 , identified the patient had the following medical equipment and supplies: Hospital bed and lift chair. b. During the home observation visit on 3/3/25, with Staff B, Registered Nurse (RN), the surveyor noted the patient was weighed by the nurse on a scale and the patient had gastrostomy tube supplies, and oral mouth swabs in the home. The patient did not have a hospital bed in the home. The POC failed to identify all the supplies the patient utilized in the home. c. The Interdisciplinary Group (IDG) meeting note dated 2/19/25 identified no additional medical equipment and supplies used by the patient. The POC, and IDG meetings to update the POC, failed to identify the additional DME of weight scale, gastrostomy tube supplies, and oral mouth swabs as medical supplies used by the patient and incorrectly identified a hospital bed the patient did not have in the home. 2. Patient #2 had a start of care date of 1/10/25, and received hospice services in a private home. Home observation visit and clinical record review revealed the following: a. The POC, dated 1/10/25 to 4/9/25 , identified the patient had the following medical equipment and supplies: Hospital bed and lift chair, humidifier and oxygen equipment. b. During a home observation visit on 3/3/25, with Staff B, RN, the surveyor noted the patient did not have a hospital bed or a lift chair in the home. c. The Interdisciplinary Group (IDG) meeting notes dated 1/22/25, 2/5/25 and 2/19/25 identified no additional medical equipment and supplies used by the patient. The POC, and IDG meetings to update the POC, failed to identify the additional DME of weight scale, gastrostomy tube supplies, and oral mouth swabs as medical supplies used by the patient and incorrectly identified a hospital bed the patient did not have in the home.

Based on staff interview and clinical record review the hospice failed to ensure the hospice staff sent a copy of the patient's discharge summary to the attending physician for 1 of 2 sampled discharged patients (Patient #12) who revoked the hospice benefit. Failure to ensure the hospice staff included the attending physician in the process of imminent discharge placed the patient at risk for not receiving ongoing medical care and services to meet the needs of the patient. Findings include: --- Patient #12 had a hospice admission date of 1/9/25, received hospice services while residing in a private residence and revoked hospice services on 1/31/25. a. Plan of Care (POC), dated 1/9/25 to 4/8/25, identified the patient had a primary diagnosis of Chronic diastolic (congestive) heart failure. The POC included orders for skilled nursing services. b. Clinical record review lacked documentation the discharge summary was completed or forwarded to the patient's attending physician. c. During an interview on 3/11/25 at 3:00 PM, the Administrator stated the agency failed to send a discharge summary to the patient's attending physician following the patient's revocation from hospice services. The above findings were reviewed with the Administrator.

Based on observation and interview, the facility failed to maintain sprinklers in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-5.2.1.1.1 and Section-5.2.1.1.2), 2011 Edition. These deficient practices affect all residents, staff, and visitors throughout the facility. This facility has a capacity of 6 and a census of 3. Observation and interview on 2/14/25 at 09:28 a.m., revealed in the family room a sprinkler with excessive debris on the sprinkler bulb.

Based on record review and interview, the facility is not conducting fire drills at least quarterly on each shift in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.7.1.6), 2012 Edition. This deficient practice affects all residents, staff, and visitors as the lack of drills can affect the abilities of staff to respond in the event of an actual emergency. This facility has a capacity of 6 and a census of 3. Findings include: Observation and interview, on 2/2/14/25, at 09:15 a.m. that a 3rd quarter night shift fire drill had not been conducted. This was verified by the secretary and maintenance supervisor.

Based on observation and interview, the facility is not segregating empty and full cylinders in accordance with National Fire Protection Association (NFPA) 99, Healthcare Facilities Code (Section-11.6.5.2), 2012 Edition. This deficient practice affects all residents who require oxygen. This facility has a capacity of 6 and a census of 3. Observation and interview on 2/14/25 at 09:40 a.m., revealed that the upstairs oxygen storage room contained full oxygen cylinders that were intermingled with 1 partially used cylinder that were placed in an oxygen cart marked empty. The nursing staff and secretary verified this observation at the time of the survey process.

Based on clinical record review, hospice policy review, hospice admit packet review, patient interview, family interview and staff interview, the hospice failed to ensure hospice staff allowed the patient to exercise his/her rights without fear of reprisal for 1 of 6 sampled patients (Patient #5). Failure to ensure the hospice staff allowed the patient and/or patient's family to exercise his/her rights and respect their property resulted in the patient's family not allowed to make decisions in disposition of unused medications. Findings include: --- According to the hospice policy titled Patient Rights, dated July 2023, the patient and his/her family have the right to respectful care and services that are within the capability and mission of hospice and comply with regulations. Hospice will not discriminate in any way in the provision of services. Patient's personal property will be treated with respect. Any damage to property in the course of hospice care or lack of respect for patient property or person, may be reported by the patient/family to the hospice for follow-up and investigation. Patients have the right to be free form mental, physical, sexual,, and verbal abuse, neglect and exploitation. According to the hospice policy titled Medication Management, dated 4/1/19, when a home medication order is changed or discontinued, medication will be retained for a reasonable period of time in care medication is reordered by the physician. Changed/discontinued medication will be kept in separate, safe location from current medications. When patient expires in a home setting, any remaining hospice medications will be properly disposed by the family or by the Registered Nurse in the presence of the family. Family will be strongly encouraged to dispose of all other prescribed medications formerly used by the patient. Clinical record shall note disposal instructions given to family/primary caregiver. According to the hospice policy, titled Disposal of Prescription and Over The Counter Medications, dated January 2023, when medications are prescribed and are in the home they are the property of the patient. Patients and caregivers should be informed of the personal and environmental safety issues for proper disposal of prescription and over the counter medications. Initial teaching on proper medication disposal should begin when medications are prescribed and when medications are discontinued. For hospice patients who reside in their homes, this education begins upon admission to hospice and concludes with proper medication disposal per caregiver in the home at the time of death. Patient #5 had and admission date of 1/18/23 and date of death of 1/29/23 and received hospice services in a private residence. The Plan of Care, dated 1/18/23 to 4/17/23, included orders for skilled nursing services. The POC included orders for the medications Hydromorphone 4 mg and Lorazepam 0.5 mg. The admission skilled nurse visit note, dated 1/81/23, included documentation the RN gave the patient a copy of the FDA handout for drug disposal of unused medication, policy and procedure for Drug Disposal and gave verbal education. The Discharge/Postmortem Checklist included documentation Hydromorphone 4 milligrams (mg) 20 tablets and Lorazepam 0.5 mg 13 tablets were discarded by Staff D RN. The action witnessed by Staff F Registered Nurse (RN). Review of the Pharmacy Drug Usage Report, dated 1/19/23, the patient had Hydromorphone 4 mg, 60 tablets filled. During an interview on 10423 at 9:-5 AM. the Director stated she received a complaint from the patient's family that Staff D, RN removed Lorazepam and Hydromorphone from their home without permission. The family thought the count should have been more pills than there was. The director checked with the pharmacy who filled the script and they had a partial fill as the pharmacy did not have enough pills on hand and the count appeared to be correct. A report was made at a later date that additional medications, not narcotics, were taken from the home also. The hospice policy to destroy the narcotic medication in the home with the patient's family. Our policy was not clear but was vague. We clarified the policy and completed re-education to staff. During an interview on 10/4/23 at 10:07 AM Staff F, RN stated she works the night shift on the weekends in the hospice house. She stated the nurses take call for the home patients and that averages about 3 times a month. She reported she has had a death in the homes that I have been called out on. The hospice changed the policy of disposal of narcotics and destroy in the patient's homes. Before the policy change, staff took the medication out of the patient's home and destroyed the medication in the hospice house with another nurse witness. She stated she did not remember the specifics of the patient's medications due to the fact they destroyed medications all the time. During an interview on 10/4/23 at 10:19 AM Staff D, RN, stated she was at the patient's home at the time of death. She further stated she removed the Hydromorphone and Lorazepam from the home and did not tell the patient's family she took the medications. She brought the medication to the hospice house and destroyed the medications while witnessed by Staff F, RN. She further stated she took no other medications from the home. During an interview on 10/4/23 at 1:25 PM Staff E, RN, stated she did take calls-in home but worked mainly in the hospice house. When a patient expires, I would gather the narcotics and a family member-usually the Power of Attorney (POA) and count the medications in front of the POA. I place the narcotic into bags while the family watches me, add water and then threw the bag with the narcotics away in the home. I have always done it that way and have not brought them to the hospice house to destroy with another nurse. During an interview on 10/4/23 at 3:37 PM the patient's spouse stated Staff D, RN removed the medications from his/her home. Staff D had discussed she and the RN would count the medications, sign a paper and destroy the medications after the patient's death. He/She further stated he/she gave no one permission to take the medication out of the home. He/she further stated on a later date other medications noted to be missing including Gabapentin and Morphine from the bowl of medications no longer used stored in the home. The above information identified to the Director and no further information provided prior to the end of the survey.

Based on observation and staff interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association, NFPA 72, 2010 edition. The primary power supply for the fire alarm system shall be mechanically protected. The facility has a capacity of 6 with a census of 1 resident. Findings include: Observation and staff interview on 3/10/22 at 1:19 p.m., revealed the circuit breaker labeled as the primary power supply for the fire alarm system was not mechanically protected. The lock mechanism for the circuit breaker was located on top of an electrical panel in the Mechanical Room. Maintenance staff verified observations during the survey process.

Based on record review and staff interview, the facility failed to provide a policy regarding the procedures to be taken in the event the sprinkler system is out of service for more than 10 hours in any twenty-four hour period in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 9.7.6. and NFPA 25, 2011 Edition. The facility has a capacity of 6 with a census of 1 resident. Findings include: Record review and staff interview on 3/10/22 at 1:13 a.m., revealed the facility sprinkler system outage policy did not include all language and information as required as follows: 1. The sprinkler system outage policy did not include language indicating that the extent and expected duration of the impairment has been determined. 2. The sprinkler system outage policy did not include language indicating that the areas or buildings involved have been inspected and increased risks determined. 3. The sprinkler system outage policy did not include language indicating that recommendations have been submitted to management or the property owner. 4. The sprinkler system outage policy did not include language indicating that the supervisors in the areas to be affected have been notified. 5. The sprinkler system outage policy did not include language indicating that a tag impairment system has been implemented. 6. The sprinkler system outage policy did not include language indicating that all necessary tools and materials have been assembled on the impairment site. 7. The sprinkler system outage policy did not include language addressing all of the following conditions of impairment: System leakage. Interruption of water supply. Ruptured piping. Equipment failure. 8. The sprinkler system outage policy did not include the required content of language and language as required in the following order: "When the sprinkler system is out of service for more than 10 hours in a 24 hour period, the Impairment Coordinator shall arrange for one of the following: a) Evacuation of the building or portion of the building affected by the outage. b) An approved fire watch. c) Establishment of a temporary water supply. d) Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire." Maintenance Staff verified record review during the survey process.

Observation and staff interview revealed an annunciator panel for the generator set is not installed at a location site observable by personnel in accordance with National Fire Protection Association, NFPA 110, 2010 Edition and NFPA 99, 2012 Edition. The facility has a capacity of 6 with a census of 1 resident. Findings include: Observation and staff interview on 3/10/22 at 1:28 p.m., revealed an annunciator panel for the generator set is not installed at a location site observable by personnel as required. The annunciator panel was installed in the Basement Mechanical Room. Maintenance staff verified observations during the survey process.

Based on record review and staff interview, the facility failed to maintain and test the generator set in accordance with National Fire Protection Association, NFPA 110, 2010 Edition. A monthly test under load shall be conducted. The facility has a capacity of 6 with a census of 1 resident. Findings include: Record review and staff interview on 3/10/22 at 11:04 a.m., revealed available documentation of monthly tests under load of the generator set did not contain all required information as follows: 1. Available documentation of monthly tests under load of the generator set did not contain start and stop times. 2. Available documentation of monthly tests under load of the generator set did not contain start and stop meter readings. Maintenance Staff verified record review during the survey process.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the drug regimen review (DRR) included the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy and drug therapy currently associated with laboratory monitoring for 6 of 11 sampled patients (Patients #3, #4, #7, #8, #9 and #10). Failure to ensure the interdisciplinary group (IDG) members involved in the assessment of patient needs identified actual or potential issues when performing the drug regimen review in relation to drug therapy associated with laboratory monitoring with each update to the comprehensive assessment increased the risk of the patient developing an undetected a side effect or adverse reaction in relation to medication therapy. Findings include: Review of the hospice policy, titled Medication Management, dated 2/2022, identified the pharmacist and hospice nurse will review all medications a patient may be taking on admission to hospice services and as new medications are added to the medication profile. Review shall include possible ineffective drug therapy, adverse reactions, significant side effects, drug allergies, relevant laboratory results, contraindications due to drug incompatibility or patient's physical/mental status, potential food/drug interactions, pregnancy, or lactation. This review will be completed on the "Drug Regimen Review" form and will be addressed by the IDG. All actual or potential issues will be listed on every DRR, even if there is no clinically significant issues currently present with the patient. Duplicate therapies may be listed as such: 'duplicate hypertensives', 'duplicate inhalers'. The clinical record must reflect the DRR was reviewed by the IDG. If significant interactions are identified by the DRR, the nurse will consult with the pharmacist first, and then the nurse or pharmacist will contact the ordering physician if intervention is indicated. Any unresolved, or significant concerns about the medication will be discussed with the patient's physician or prescriber. Each patient will be monitored on an ongoing basis for medication effectiveness, actual or potential medication-related problems, and patient compliance. Assessment will be based on overall observation of symptom management and patient comfort level. Information gathered is maintained in the clinical record. Significant problems encountered with medication regime will be reported to the physician if intervention is needed. All information will be documented in the clinical record concerning reactions to medications. 1. Patient #7 had a hospice admission date of 2/16/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 2/16/22 to 5/16/22, included Interdisciplinary Group (IDG orders for skilled nursing services and a physician order for Zoloft 100 milligrams (mg) daily by mouth to treat anxiety. b. The comprehensive assessment completed by a registered nurse (RN), dated 2/16/22, included documentation which identified the patient's medications were effective with the exception of Zoloft, which the patient took to relieve anxiety. The nurse reported a plan to contact the patient's physician to order Lorazepam, a medication used to treat anxiety. c. The DRR, dated 2/16/22, included documentation by the RN which identified all of the patient's medications were effective. The DRR failed to include the information about the ineffectiveness of the Zoloft. d. The initial IDG meeting, dated 2/23/22, included documentation which identified the patient was started on Lorazepam due to anxiety related to dyspnea. The IDG meeting notes included documentation the patient had taken Lorazepam 0.5 mg to ease anxiety from coughing and fatigue due to a stressful day of family visiting for several hours. The IDG and related DRR, dated 2/23/22, lacked any documentation about the patient's reports of ineffectiveness with taking Zoloft. On 3/10/22 at 8:19 AM, during an interview, the Administrator reported the nurse did identify the patient was taking Lorazepam for anxiety, but agreed the nurse did not mention the effectiveness of Zoloft. 2. Patient #9 had a hospice admission date of 8/9/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 11/7/21 to 2/4/22, included IDG orders for skilled nursing services and physician orders for Furosemide (a diuretic medication) 80 mg daily 1 tablet twice daily and Metolazone (a diuretic) 2.5 mg 1 tablet daily as needed both to treat the retention of excess fluid. The POC, dated 2/5/22 to 4/5/22, included orders for Furosemide 80 mg 1 tablet daily and a second tablet as needed for fluid retention, Metolazone 2.5 mg 1 tablet as needed for excess fluid retention and Biofreeze topical gel one application as needed to both feet and lower legs as needed for pain. b. The skilled nursing visit note, dated 1/31/22, included documentation which identified the diuretic medications were only minimally effective in relieving the patient's bilaterally lower leg fluid retention (edema). The RN described the patient had hard, non-pitting edema from toes to mid-calf bilaterally. She documented the patient reported the Biofreeze was effective for a few days, but now it's not. c. The subsequent DRR, dated 2/9/22, and associated with the IDG meeting, dated 2/9/22, included documentation signed by the patient's RN Case Manager, Medical Director and Pharmacist that the patient did not have any ineffective medications. The IDG meeting lacked any mention of the ineffective Biofreeze, but did identify the patient had hard, pitting edema in the feet and lower legs that was most recently hard and non-pitting at the last visit. 3. Patient #3 had a hospice admission date of 9/24/2020 and received hospice services while residing in a nursing home. a. The Plan of Care, dated 9/19/21 to 11/17/21, identified orders for melatonin 5 milligrams (mg) 2 capsules as need at bedtime for sleep, Trazodone 50 mg at bedtime for sleep, milk of magnesia 30 milliliters daily for constipation, senna plus 8.6 mg/50 mg daily for bowels and bisacodyl 10 mg rectal suppository daily as needed for constipation. b. The IDG updates to the Plan of Care (POC), dated 9/22/21, documented duplicate drug therapy for antidepressants and analgesics, however, lacked documentation of duplicate sleep medications and duplicate bowel medications as part of the drug regimen review (DRR). c. The Plan of Care, dated 1/17/22 to 3/17/22, identified orders for melatonin 5 milligrams (mg) 2 capsules as need at bedtime for sleep and Trazodone 50 mg at bedtime for sleep. d. The IDG updates to the Plan of Care, dated 1/26/22, documented duplicate drug therapy for antidepressants, analgesics, antiemetics, and laxatives, however, lacked documentation of duplicate sleep medications \as part of the drug regimen review (DRR). 4. Patient #4 had a hospice admission date of 2/2/2022 and received hospice services while residing in a nursing home. a. The initial Plan of Care, dated 2/2/22 to 5/2/22, identified orders for dulcolax suppository 10 mg daily as needed for constipation, fleet enema daily as needed for constipation, docusate sodium 100 mg twice daily for constipation, polyethylene glycol 17 grams daily as needed for constipation, Tylenol extra strength 1000 mg every 6 hours for pain, oxycodone-acetaminophen 5 mg/325 mg 1/2 tablet twice daily for pain, ondansetron 4 mg every 8 hours as needed for nausea, and promethazine 25 mg every 6 hours as needed for nausea. b. The initial drug regimen review, dated 2/2/22, documented no duplicate drug therapy. The assessment lacked identification of duplicate bowel, pain, and nausea medications as part of the drug regimen review. 5. Patient #8 had a hospice admission date of 1/19/2022 and received hospice services while residing in a private home residence. a. The initial Plan of Care, dated 1/19/22 to 4/18/22, identified orders for clearlax 17 grams twice per day for bowels, docusate sodium 100 mg every other day for bowels, Tylenol extra strength 500 mg 2 tablets as needed for pain, and morphine concentrate 5 mg every 30 minutes as needed for pain. b. The initial drug regimen review, dated 1/20/22, documented antidepressants as duplicate drug therapy. The assessment lacked identification of duplicate bowel and pain medications as part of the drug regimen review. The IDG updates to the Plan of Care, dated 1/26/22, 2/9/22, and 2/23/22, documented duplicate drug therapy for antidepressants, however, lacked documentation of duplicate bowel and pain medications as part of the drug regimen review. 6. Patient #10 had a hospice admission date of 2/6/2022, received hospice services while residing in a private home residence and died on 2/23/2022. a. The initial Plan of Care, dated 2/6/22 to 5/6/22, identified orders for fentanyl patch 50 micrograms(mcg) per hour apply every 72 hours for pain, morphine concentrate 5 mg every 30 minutes as needed for mild pain, 10 mg every 30 minutes for moderate pain, and 20 mg every 30 minutes for severe pain, ondansetron 8 mg daily for nausea and prochlorperazine 10 mg every 5 hours for nausea. b. The initial drug regimen review, dated 2/6/22, documented no duplicate drug therapy. The assessment lacked identification of duplicate pain and nausea medications as part of the drug regimen review. The above findings were reviewed with the Hospice Administrator/Clinical Manager. Hospice staff provided no additional information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the provision of care in accordance with the patient's plan of care for 2 of 11 sampled patients (Patients #5 and #8). Failure to follow the patient's Plan of Care (POC) as directed by the Interdisciplinary Group (IDG) puts the patient at risk for inconsistent, unsafe care that may not meet the needs of the patient. Findings include: Review of the hospice's policy, titled Medication Management, dated 2/2022, a physician's order will be obtained for all medications the patient is taking, medications will be documented in the patient's electronic clinical record in medication profile on admission and with each medication change. Medication list will be updated with new/changed drugs as they are ordered. Changes will be reviewed at IDG meeting and communicated to other hospice staff caring for the patient. 1. Patient #5 had a hospice admission date of 2/11/22 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The POC, dated 2/11/22 to 5/11/22, included orders for hydrocodone/acetaminophen 5/325 milligrams (mg), 1 tablet every 4 hours if needed for pain. b. Skilled nurse phone call visit note, dated 2/13/22, included documentation the patient had pain and had not utilized the hydrocodone/acetaminophen today. The skilled nurse encouraged the patient to take 1.5 tablets of hydrocodone/acetaminophen now and see if that helps. c. Skilled nurse phone call visit note, dated 2/14/22, included documentation the nurse called the clinic requesting order change for hydrocodone/acetaminophen tablets and received a call back with new orders. d. The Medication Profile included hydrocodone/acetaminophen 5/325 mg, 1 tablet every 4 hours if needed for pain, 2 tablets every 4 hours if 1 tablet not effective for pain, with an effective date of 2/14/22. The clinical record lacked documentation the skilled nurse contacted the physician on 2/13/22 prior to instructing the patient to use 1.5 tablets of hydrocodone/acetaminophen. 2. Patient #8 had a hospice admission date of 1/19/2022 and received hospice services while residing in a private home residence. Clinical record review revealed: a. The Plan of Care (POC), dated 1/19/22 to 4/18/22, included orders for skilled nursing services weekly. b. The skilled nurse visit note, dated 2/1/22, documented a communication text was sent to the attending physician notifying the physician the patient had wax buildup in the ears and the nurse tried to flush the ears with no results. The nurse documented questioning the attending physician if Debrox drops could be used and then the nurse would reattempt flushing the ears the next day. c. The skilled nurse visit note, dated 2/2/22, documented the nurse instilled Debrox ear drops and left for 10 minutes before flushing with a bulb syringe. Interview on 3/9/22 at 3:40 AM with Staff G, Registered Nurse (RN), revealed the nurse documents communication with the physician in the communication section of the note. The nurse revealed she is not good about documenting physician's response to the communications and confirmed she did not have an order for the Debrox drop and to flush the patient's ears. Hospice staff furnished services to the patient without collaborating with the attending physician and receiving an order for the Debrox and for the nurse to flush the patients ears. The above findings were reviewed with the Hospice Administrator/Clinical Manager. Hospice staff provided no additional information prior to the end of the survey.

Based on clinical record review, agency policy review, observation, family interview and staff interview, the hospice failed to ensure the hospice Interdisciplinary Group (IDG) developed an individualized plan of care which addressed the assessed dietary needs of the patient for 2 of 11 sampled patients (Patients #1 and #4). Failure to establish individualized plans of care which addressed assessed needs related to the patient's dietary needs increased the potential hospice staff wound not meet the dietary needs of the patient or cause harm by not following the patient's dietary restrictions. Findings include: Review of the hospice's policy, titled Care Planning Process, dated 2/2022, identified the hospice IDG will develop an individualized, written Plan of Care (POC) which addresses interventions to manage pain and symptoms based on the comprehensive assessment and includes the patient's dietary needs. 1. Patient #1 had a hospice admission date of 3/3/22 and received hospice services while residing in the hospice's inpatient unit. Review of the clinical record revealed the following: a. The POC, dated 3/3/22 to 5/31/22, identified a diagnosis of a perforated bowel and included IDG orders for skilled nursing, hospice aide, social work and spiritual counseling services. The POC included orders for oral medications. The POC failed to identify if the patient was on any type of special diet or had any oral intake restrictions. b. The initial comprehensive assessment completed by a registered nurse, dated 3/3/22, identified the patient had a small bowel obstruction and free flowing fluid throughout the abdominal and pelvic cavity. The nurse documented the patient "receives no PO (by mouth) intake." c. A skilled nursing visit note, dated 3/4/22, included documentation which identified the patient was "NPO" (nothing by mouth) due to a bowel perforation. The nurse educated the family on concerns that anything the patient takes in orally would probably go through the bowel perforation into the patient's abdomen and cause increased pain and nausea. On 3/7/22 at 2:38 PM, during an interview, a family member of the patient reported the patient was not able to eat or drink due to the patient's bowel perforation. On 3/9/22 at 12:30 PM, during an observation of the hospice's IDG meeting, hospice staff read a report from the patient's primary nurse, Staff B, Hospice House RN, who could not be present for the meeting. The report identified the patient was not eating and actively dying, but did not identify if the patient had any dietary restrictions. On 3/10/22 at 8:21 AM, during an interview, the Administrator reported the patient did not have a physician's order for NPO. The Medical Director ordered the patient can be NPO except medications and sips of water. The Administrator explained the nurse thought she had added this to the orders and was getting an order for this now. 2. Patient #4 had a hospice admission date of 2/2/2022 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care , dated 2/2/2022 to 5/2/2022, identified the patient's nutrition status as regular diet as tolerated. b. The nursing home Medication Administration Report and Treatment Administration Report, for the months of February and March, documented the patient's diet as mechanical soft with ground meat texture, regular consistency. The Plan of Care lacked identification of the prescribed diet the patient was receiving at the nursing home. During surveyor observation of the IDG on 3/9/2022, the IDG did discuss the patient's altered diet. The above findings were reviewed with the Hospice Administrator/Clinical Manager. Hospice staff provided no additional information prior to the end of the survey.

Based on clinical record review, hospice policy review, Interdisciplinary Group meeting observation and staff interview, the hospice failed to ensure the hospice plan of care included a complete order for all medications and treatments to meet the needs of the patient and failed to ensure physician's signed the Plans of Care in a timely manner. (Patients # 7 & 9) Failure to ensure the plan of care included physician orders for all necessary medications and complete orders for medications placed patients at risk to receive inappropriate treatment of symptoms. Findings include: Review of the hospice's policy, titled Care Planning Process, dated 2/2022, identified the hospice Interdisciplinary Group (IDG) will develop an individualized, written Plan of Care (POC) which will include treatments and medications used by the patient. 1. Patient #7 had a hospice admission date of 2/16/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 2/16/22 to 5/16/22, included two conflicting orders for oxygen, one order for oxygen 2 liters per minute per nasal cannula as needed and an order for oxygen 6 liters per minute continuously and titrate up to 8 liters per minute for comfort. b. The comprehensive assessment completed at the start of care by a registered nurse (RN), dated 2/16/22, identified the patient was oxygen dependent but did not identify a flow rate used. On 3/9/22 at 12:30 PM, observation during the IDG meeting revealed the patient's nurse reported to the IDG members the patient was currently using 8 liters of oxygen continuously. On 3/9/22 at 3:53 PM, during an interview, the Administrator reported the oxygen order for 2 liters per minute per nasal cannula as needed for comfort was a standing order and should not have been on the patient's POC. The POC failed to include orders for all medications used by the patient and had conflicted oxygen orders. 2. Patient #9 had a hospice admission date of 8/9/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 8/9/21 to 11/6/21, included two conflicting orders for oxygen, one order for oxygen 2 liters per minute per nasal cannula as needed for comfort and an order for oxygen 2 to 4 liters per minute as needed for shortness of breath, may titrate up to 4 liters. b. The POC, dated 11/7/21 to 2/4/22, included an order for oxygen 2 to 4 liters per minute as needed for shortness of breath, may titrate up to 4 liters. An interim physician order, dated 1/26/22, included orders to discontinue the oxygen. An IDG meeting, dated 1/26/22, identified hospice staff had removed the oxygen from the patient's home. The POC, dated 2/5/22 to 4/5/22, included an order for oxygen 2 liters per minute per nasal cannula as needed for comfort. On 3/9/22 at 12:30 PM, observation during the IDG meeting revealed Staff B, RN, reported the patient did not have oxygen in the home. On 3/9/22 at 3:40 PM during an interview, Staff B, RN, explained the patient was not using oxygen and the order should not have been on the POC, dated 2/5 to 4/5/22. The Hospice Administrator/Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, home visit observation, family interview and hospice staff interview, the hospice failed to ensure the Plans of Care for 8 of 11 sampled patients (Patients #1, #2, #3, #4, #5, #8, #9 and #11) identified all medical equipment and supplies necessary to meet identified patient needs. Failure to include all needed items of medical equipment and supplies the patient used on the Plans of Care placed the patients at risk of unanticipated decline or injury and of needs not met. Findings include: Review of the hospice's policy, titled Care Planning Process, dated 2/2022, the hospice will develop an individualized plan of care for each patient. The Plan of Care (POC) must include medical supplies and appliances necessary to meet the needs of the patient. The hospice Interdisciplinary Group (IDG) will review, revise and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. 1. Patient #2 had a hospice admission date of 2/28/22 and received hospice services while residing in a private home. a. Clinical record review revealed the POC, dated 2/28/22 to 5/28/22, included documentation the patient had all equipment as needed: including hospital bed, lift chair, etcetera; as medical equipment used by the patient. b. During a home observation visit on 3/7/22 at 10:00 AM, with Staff D, Registered Nurse (RN), surveyor observed the patient using a heating pad while sitting in a recliner chair. The patient reported no other medical equipment used in the home at this time. The POC failed to identify all necessary medical equipment and supplies used by the patient. 2. Patient #5 had a hospice admission date of 2/11/22 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The POC, dated 2/11/22 to 5/11/22, included documentation the patient had all equipment as needed: including hospital bed, lift chair, etcetera, and oxygen, as medical equipment used by the patient. b. The Initial Skilled Nursing Assessment note, dated 2/11/22, included documentation the patient had a CPAP [(continuous positive airway pressure) machine to help make breathing easier during sleep] in the home. c. The IDG meeting note, dated 2/23/22, identified oxygen supplies, 4 wheeled walker, oxygen carrying pack, wheelchair and shower chair as medical equipment and supplies used by the patient. The POC and IDG meeting note failed to identify all necessary medical equipment and supplies used by the patient. 3. Patient #1 had a hospice admission date of 3/3/22 and received hospice services while residing in the hospice's inpatient unit. Review of the clinical record revealed the following: a. The POC, dated 3/3/22 to 5/31/22, identified the patient used the following medical equipment and supplies: a general statement for all equipment as needed including a hospital bed, lift chair, etc..., oxygen and a Foley urinary catheter. b. An undated hospice aide assignment identified the patient used adult incontinent briefs. On 3/7/22 at 2:28 PM, observation with Staff C, Hospice House Registered Nurse (RN), revealed the patient was using a hospital bed, pressure relieving air mattress, over bed table and urinary catheter. The surveyor observed the nurse put the head of the bed up with medication administration. On 3/7/22 at 2:38 PM, during an interview, a family member reported the patient had been using a hospital bed, air mattress, catheter, over bed table since admission. The patient was bed bound and not using the lift chair, grab bars or handheld shower in the bathroom. The patient had been, but was not currently using oxygen. On 3/9/22 at 12:30 PM, during an observation of the hospice's IDG meeting, hospice staff read a report from the patient's primary nurse, Staff B, Hospice House RN, who could not be present for the meeting. The report identified the patient was using a hospital bed, call light, over bed table, catheter and an incontinent brief. The POC and IDG meeting failed to identify the patient used an air mattress. On 3/9/22 at 3:53 PM, during an interview, the Administrator explained the general statement on the POC for all equipment as needed including a hospital bed, lift chair, etc... was on all of the patient's POCs and was a goal statement. The hospice staff list the actual medical equipment and supplies in the goal section of the POC. If no supplies are listed, the patient does not use any. She reported being unaware of the need to list all of the equipment in the hospice house rooms on the patient's POC. 4. Patient #9 had a hospice admission date of 8/9/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 2/5/22 to 4/5/22, identified the patient used the following medical equipment and supplies: all equipment as needed including a hospital bed, lift chair, etc..., oxygen supplies, Roho cushion, bedside commode, wheelchair, ramps, shower chair, chair cushion and pill planner. b. A skilled nursing visit, dated 1/17/22, identified the patient also used grab bars in the bathroom. c. An interim physician order, dated 1/26/22, included orders to discontinue the oxygen. d. An IDG meeting, dated 1/26/22, identified hospice staff had removed the oxygen from the patient's home. e. The POC, dated 2/5/22 to 4/5/22, included an order for oxygen 2 liters per minute per nasal cannula as needed for comfort. On 3/9/22 at 12:30 PM, observation during the IDG meeting revealed Staff B, RN, reported the patient did not have oxygen in the home. On 3/9/22 at 3:40 PM during an interview, Staff B, RN, explained the patient was not using oxygen and the order should not have been on the POC, dated 2/5 to 4/5/22. The POC failed to identify the patient used grab bars in the bathroom and incorrectly identified the patient used oxygen supplies. 5. Patient #11 had a hospice admission date of 12/10/21, received hospice services while residing in a private residence and discharged hospice services due to revocation on 1/11/22. Review of the clinical record revealed the following: a. The POC, darted 12/20/21 to 3/9/22, identified the patient used the following medical equipment and supplies: all equipment as needed including a hospital bed, lift chair, etc..., oxygen supplies, hospital bed, walker, shower chair, wheelchair, suction cup, hand holds, lift chair and syringes. b. The IDG meetings, dated 12/15 and 12/29/21, did not identify the use of any additional medical equipment and supplies. b. A skilled nursing visit note, dated 12/20/21, identified the patient used compression socks. c. A skilled nursing visit note, dated 12/30/21, identified the patient used disposable briefs and a family member "set up" the patient's medications. On 3/9/22 at 2:55 PM, during an interview, Staff G, RN, reported the patient did use disposable briefs and a medication planner since prior to admission. The hospice did not supply the briefs, because the patient wanted a specific brand that the hospice did not offer. She denied the patient used compression socks. The POC and IDG meetings failed to identify all medical supplies needed and used by the patient. 6. Patient #3 had a hospice admission date of 9/24/2020 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POCs, dated 9/19/21 to 11/7/21 and 11/18/21 to 1/16/22, identified the patient used the following medical equipment and supplies: recliner, seated walker, hospital bed, overbed table, bedside table, call light, and wheelchair. b. The POC dated, 1/17/22 to 3/17/22, identified the patient used the following medical equipment and supplies: recliner and seated walker. c. A skilled nursing visit notes, dated 1/3/22, 1/6/22 1/12/22, 1/13/22, 1/24/22, 1/31/22, , included documentation the patient wears disposable briefs. During hospice visit observation at the nursing home on 3/9/22 beginning at 3:00 PM, with Staff G, Registered Nurse (RN), the hospice nurse reported the patient 's use of disposable briefs for urinary incontinence for about a year. d. The IDG meeting updates to the POC, dated 1/26/2022, 2/9/2022 and 2/23/22, lacked identification of the patient's use of incontinence supplies as equipment needed to meet the patient's needs. During the same hospice visit observation, the surveyor observed the patient sitting in a wheelchair. The patient reported use of the wheelchair since moving to the nursing home about one year ago. e. The IDG meeting updates to the POC, dated 1/26/2022, 2/9/2022 and 2/23/22, lacked identification of the patient's use of the wheelchair as equipment needed to meet the patient's needs. During the same hospice visit observation, the surveyor observed the patient had two foam cushions, one on the floor by the patient's bed and another in the patient's recliner. The patient reported use of the foam cushions for the past 5 to 6 months. f. The IDG meeting updates to the POC, dated 1/26/2022, 2/9/2022 and 2/23/22, lacked identification of the patient's use of the foam cushion as equipment needed to meet the patient's needs. During the same hospice visit observation, the surveyor observed a hospital bed in the patient's room. The patient reported use of the hospital bed since moving to the nursing home about one year ago. g. The IDG meeting updates to the POC, dated 1/26/2022, 2/9/2022 and 2/23/22, lacked identification of the hospital bed as equipment needed to meet the patient's needs. During the same hospice visit observation, the surveyor observed an over the bed next to the hospital bed in the patient's room. The patient reported use of the over the bed table since moving to the nursing home about one year ago. h. The IDG meeting updates to the POC, dated 1/26/2022, 2/9/2022 and 2/23/22, lacked identification of the over the bed table as equipment needed to meet the patient's needs. The agency lacked identification of all medical equipment and supplies being used by the patient. 7. Patient #4 had a hospice admission date of 2/2/2022 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 2/22/22 to 5/2/22, identified the patient used the following medical equipment and supplies: all equipment as needed including hospital bed, lift chair, etc. b. The initial skilled nursing visit note, dated 2/2/2022, included documentation the patient used side rails with bed, compression hose, and disposable briefs. c. The skilled nursing visit note, dated 2/7/2022, included documentation the patient used compression hose, and grab bars around toilet. d. The skilled nursing visit note, dated 2/10/2022, included documentation the patient used bed side rails with bed. e. The skilled nursing visit note, dated 2/21/2022, included documentation the patient used bed side rails and grab bars around the toilet. f. The nursing home Medication Administration Report (MAR) and Treatment Administration Report (TAR) for the month of February 2022 and March 2022 included orders for application of compression hose every morning and removed every evening beginning 2/2/2022. g. The IDG meeting updates to the POC, dated 2/9/22 and 2/23/22, lacked identification of the patient's use of side rails, compression stockings, grab bars with toilet and disposable briefs as equipment needed to meet the patient's needs. During interview with Staff G, RN on 3/10/2022 at 3:45 PM, the RN reported the patients use of side rails, hospital bed, compression hose and disposable briefs since admission. The nurse thought the patient was no longer using the compression stockings. The surveyor informed the nursing facility staff continues to document application and removal of compression stockings. The agency lacked identification of all medical equipment and supplies being used by the patient. 8. Patient #8 had a hospice admission date of 1/19/2022 and received hospice services while residing in a private home residence. Clinical record review revealed: a. The POC, dated 1/19/22 to 4/18/22, identified the patient used the following medical equipment and supplies: all equipment as needed including hospital bed, lift chair, etc. and a four wheeled walker. b. The initial skilled nursing visit note, dated 1/19/2022, included documentation the patient used an electric scooter, grab bars around the toilet, and a medication planner. c. The skilled nursing visit notes, dated 1/24/2022 and 2/1/2022, included documentation the patient's caregiver set up medications for the patient and the patient had a Lifeline medical alert. d. The skilled nursing visit note, dated 2/08/2022, included documentation the patient's caregiver set up medications for the patient, had a Lifeline medical alert, incontinence briefs, and grab bars around the toilet. Telephone interview on 3/9/2022 at 7:56 AM with patient's caregiver reported the caregiver used a medication planner to set up the patient's medications. The caregiver also reported the patient uses the electric scooter, does have a Lifeline alert device, incontinence briefs, and uses grab bars around the toilet. During surveyor observation of IDG on 3/9/2022 at 1:05 PM, the medical director questioned the nurse if the patient had a medical alert device and the nurse confirmed use of the device. During interview on 3/10/22 at 3:45 PM with Staff G, RN, the nurse confirmed the patient's use of medication planner, Lifeline alert for past 5 years per patient report, disposable briefs for past 5 years per patient report, electric scooter for past 5 years per patient report, and grab bars around toilet for 8 years when moved to current home. e. The IDG meeting updates to the POC, dated 1/26/22, and 2/9/22 and 2/23/22, lacked identification of the patient's use of grab bars around the toilet, electric scooter, medication planner, Lifeline medical alert, and incontinence briefs as equipment needed to meet the patient's needs. The agency lacked identification of all medical equipment and supplies being used by the patient. The above findings were reviewed with Hospice Administrator/Clinical Manager. Hospice staff provided no additional information prior to the end of the survey.

Based on surveyor observation, record review, policy review and staff interview, the hospice failed to maintain hazard free environment free of access to chemicals for all patient, staff, visitors and children in the hospic's own in-patient unit (L724) The systemic practice resulted in the failure of the hospice to ensure hospice staff promoted an environment which would maintain the health and safety of patients, their families and other visitors, including children during the course of the delivery of care and services in the hospice house.

Based on surveyor observation, review of chemical Safety Data Sheets and interview with hospice staff, the hospice failed to ensure its own in-patient unit environment was free of hazardous materials accessible to patients, family and visitors. The hospice house had 1 patient in the hospice in-patient unit at the time of the survey. Failure to keep all hazardous materials properly secured, placed any confused patients and/or visiting children at risk for injury from accidental consumption of the hazardous materials. Findings include: On 3/8/22, beginning at 8:38 AM, during a tour of the hospice house facility with the Administrator, the Director of Facilities, Maintenance Supervisor and Facilities Specialist, the surveyor identified the following concerns through observation of an unlocked, lower cabinet to right of the sink in the patient/ family kitchen: a. An opened bottle of Finish Jet Dry rinsing aide 16 fluid ounces and with a warning label to avoid eye contact and keep out of reach of children. b. 1 open, partially used bag of Seventh Generation dishwasher tabs, 12.6 ounces, 20 pods per bag and 2 unopened bags of the same chemical. The warning label advised to keep out of reach of children. c. An open spray bottle of Multi-Purpose Cleaner, 1 quart, still mostly full. The chemical bottle had a warning to keep out of reach of children. d. An open, almost empty bottle of Weiman Cook Top Daily Cleaner, 4 fluid ounces, and an unopened bottle of the same chemical, 15 ounces. Both bottles had the same warning to keep out of reach of children. e. An open, almost empty bottle of Cerama Bryte Cook Top Cleaner, 2.5 fluid ounces, and a warning to keep out of reach of children. f. An open spray bottle of Ecolab Greasestrip Plus gel, 32 fluid ounces, and a warning to keep out of reach of children. Hospice staff removed the chemicals immediately from patient/family/visitor access. In an interview, during the same observation tour, the Administrator reported a plan to put a lock on the cabinet where staff had been keeping the chemicals. On 3/8/22, the Administrator provided the following Safety Data Sheets: a. The Finish Jet Dry chemical Safety Data Sheet identified the product as an eye irritant. The Safety Data Sheet advised to wash hands thoroughly after handling and rinse eyes for several minutes if the product got in the eyes. b. The Seventh Generation dishwasher tabs chemical Safety Data Sheet identified the product causes severe eye irritation, may cause breathing difficulties if inhaled and advised to contact poison control center or physician immediately if swallowed. c. The Excelente Multi-Purpose Cleaner chemical Safety Data Sheet identified the product as highly flammable and to avoid skin and eye contact. The Safety Data Sheet identified the product may be harmful if swallowed and may cause skin and eye irritation. d. The Weiman Cook Top Daily Cleaner chemical Safety Data Sheet identified the product causes severe eye damage, may be harmful if swallowed, can cause skin and respiratory tract irritation. e. The Cerama Bryte Cook Top Cleaner chemical Safety Data Sheet identified the product may cause skin, eye or gastrointestinal irritation (if swallowed). f. The Ecolab Greastrip Plus chemical Safety Data Sheet identified the product causes severe skin and eye burn damage. The Safety Data Sheet advised to call poison control immediately if swallowed, inhaled or if the product got in the eyes. On 3/8/22 at 10:58 AM, during an interview, Staff E, Hospice House Aide, reported her awareness of the chemicals being in the lower cabinet by the sink in the patient/family kitchen. She did not know how long the chemicals had been there, and guessed maybe for the last year. On 3/8/22 at 4:05 PM, during an interview, Staff C, Hospice House Aide, confirmed she worked at the hospice house and reported being aware of and using the chemicals located in the lower cabinet by the sink in the patient/family kitchen. She reported using the dishwasher cleaner (Jet Dry) and they had just switched over to using the dishwasher pods (Seventh Generation). She reported she had also known about the stove top cleaner and had used the chemical. She was unaware of any other chemicals. She reported the chemicals had been kept in the lower cabinet to the right of the sink in the kitchen for as long as she had worked at the hospice house. She reported she started working at the hospice house when it opened. On 3/9/22 at 3:52 PM, during an interview, the Administrator reported the hospice house had admitted 210 patients since January 2020. The Hospice Administrator/Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, patient interview and hospice staff interview, the hospice failed to: 1) Ensure hospice must report all alleged violations to the nursing home facility administrator within 24 hours of the hospice becoming aware of the alleged violation is documented in facility contract (see L0771), 2) Ensure hospice must provide a written plan of care (see L0773), 3) Ensure hospice plan of care must specifically identify which provider is responsible for performing the respective services (see L0774), 4) Ensure hospice plan of care reflects participation of the hospice, nursing home facility staff, and the patient and family to the extent possible (see L0775), 5) Ensure hospice must provide overall coordination of hospice care of patients residing in a nursing home facility with the nursing home facility staff (see L0778), 6) Ensure hospice communicates with the nursing home facility staff to ensure quality of care (see L0779), 7) Ensure hospice must provide the nursing home with required documentation specific to each hospice patient (see L0781), and 8) Ensure hospice staff in coordination with nursing home facility staff provide training in hospice philosophy (see L0782). The cumulative effects of these systemic practices resulted in the failure of the hospice personnel to ensure overall coordination of safe and comprehensive patient care to their hospice patients in the nursing home setting.

Based on review of written contracts for long-term care facilities (nursing homes) and staff interview, the hospice failed to maintain a written contractual agreement with a nursing home which included a provision for hospice staff to report, to the nursing home administrator, specifically within 24 hours, of any knowledge of alleged mistreatment, neglect or abuse perpetrated by non-hospice staff against nursing home residents. The survey identified this deficient practice with 1 of 2 sampled contracted nursing homes. The hospice had separate written agreements contracts with a total of 2 nursing homes and had one patient in each of the nursing homes at the time of the survey. Failure to include this provision with a specified time frame of notification within 24 hours in the contractual agreement increased the potential of unreported acts and/ or failure to investigate allegations of abuse, mistreatment or neglect against residents in a nursing homes in a timely manner. Findings include: Review of the written agreement with a nursing home in Newton, dated 1/31/22, identified a provision to address the need for the hospice to report all allegations of abuse by non hospice staff immediately to the facility administrator. The contract failed to include the required specified time frame of "within 24 hours". On 3/9/22 at 8:55 AM, during an interview, the Administrator explained the nursing home made her change the contract language to state "immediately" rather than "within 24 hours". She planned to contact the nursing home to get this changed. The Hospice Administrator/Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, review of hospice records in nursing facilities and staff interview, the hospice failed to update medication and treatment orders on the plan of care in consultation with nursing facility staff to ensure that the orders with both entities were coordinated for 2 of 2 sampled patients residing in a nursing home(Patients #3 and #4). Failure to ensure that both the hospice and the nursing facility have the same medication and treatment orders placed the patients at risk for not receiving needed and/or prescribed medications and/or treatments. Findings include: 1. Patient #3 had an admission to hospice on 9/24/2020 and received services in a long term care facility. The terminal diagnosis was Pancreatic Cancer. Review of the long term care (LTC) facility MAR/TAR (medication administration record/treatment administration record) for the months of January 2022, February 2022, and March 2022, and the hospice's current medication profile revealed the following: a. The hospice medication profile included orders for hydroxyzine HCl 25 milligrams (mg) every 6 hours as needed for itching with a start date of 7/23/21. The facility MAR/TAR lacked identification of an order for the hydroxyzine. b. The MAR included an order for trazodone 50 mg daily with a start date of 11/9/21. The hospice medication profile documented trazodone 100 mg daily starting 11/4/21. c. The MAR included an order for oxygen 2 liters as needed with a start date of 11/5/21. The hospice medication profile included an order for oxygen 2 liters as needed and included orders the oxygen may be titrated up to 6 liters as needed for patient comfort. d. The hospice medication profile included an order for nitroglycerin 0.3 mg sublingual 1 tablet every 5 minutes for 3 times as needed for chest pain with a start date of 12/20/21. The MAR lacked an order for the nitroglycerin. e. The hospice medication profile included orders for hydrocortisone cream 1% topical cream to be applied twice daily for rash with a start date of 3/30/21. The MAR included an order for hydrocortisone cream 0.5% as needed for rash with a start date of 6/28/21. f. The hospice medication profile included orders for capsicum topical cream 0.025% to be applied four times per day for pain with a start date of 11/4/2020. The MAR lacked identification of an order for capsicum. g. The hospice medication profile included orders for Lidocaine Pain Relief 4% topical cream applied for 12 hours then removed and off for 12 hours with a start date of 7/18/21. The MAR lacked identification of an order for Lidocaine Pain Relief patches. h. The hospice medication profile included orders for Tylenol 325 mg with orders to take 2 tablets (650 mg) daily for pain with a start date of 9/3/21. The MAR included an order for 650 mg twice per day with a start date of 9/3/21. i. The hospice medication profile included orders for Norco 10-325 mg 1-2 tablets as needed every 4 hours for pain with a start date of 7/29/21. The MAR included an order for Norco 10-325 mg 1 tablet every 4 hours as needed for pain. j. The hospice medication profile included orders for Zostrix-HP 0.1% topical cream applied for four times daily for pain with a start date of 9/13/21. The MAR lacked identification of an order for Zostrix-HP 0.1% topical cream. Interview on 3/9/22 at 3:36 PM with Staff G, Registered Nurse (RN), reported the agency does not provide information to the facility, including current Plan of Care or updates, and medication list. The nurse reported she has the doctor fax the nursing home orders if any new orders are received. Interview on 3/9/22 at 3:47 PM with Facility Administrator reported agency staff does not bring facility list of current hospice medications. 2. Patient #4 had an admission to hospice on 2/2/2022 and received services in a long term care facility. The terminal diagnosis was Frontotemporal dementia. Review of the long term care (LTC) facility MAR/TAR (medication administration record/treatment administration record) for the months of February 2022, and March 2022, and the hospice's current medication profile revealed the following: a. The MAR included an order for lactobacillus 20 billion cells daily with a start date of 2/1/2022. The hospice medication profile documented lactobacillus 10 billion cells daily with a start date of 2/2/2022. b. The MAR included an order for Senna S 8.6/50 mg two times daily with a start date of 2/21/22. The hospice medication profile lacked documentation of an order for Senna S. c. The MAR included an order for compression hose to be applied every morning and off every evening with a start date of 2/2/22. The hospice medication profile lacked orders for the compression hose to be applied and removed. Interview on 3/9/22 at 8:24 AM with Facility Administrator reported the hospice staff does not provided any documentation to the agency and is not good at stopping and updating staff after visits. Interview with Facility RN on 3/9/22 at 8:30 AM reported the hospice nurse does not leave any paperwork at the facility regarding hospice orders and information. The above findings were reviewed with the Hospice Administrator/Clinical Manager. Hospice staff provided no additional information prior to the end of the survey.

Based on clinical record review and hospice policy review, the hospice failed to delineate on the hospice plan of care responsibilities between the hospice and nursing home staff for 2 of 2 sampled patients receiving services while residing in a nursing home facility (Patients #3 and #4). Failure to delineate which provider had specific responsibilities for patient care to patients residing in a nursing home increased the risk that patients failed to receive adequate care and treatments according to physician's orders and the plan of care. Findings include: According to the hospice policy, titled, Care Planning Process, dated 2/2022, the IDG is responsible for establishing, implementing, reviewing and revising the patient's care plan. The IDG is responsible for providing and coordinating care and services in accordance with the patient's plan of care and reviewing goals. The primary care registered nurse (RN) is responsible for coordinating the care, ensuring continuous assessment of patient/caregiver needs and implementing the interdisciplinary plan of care. 1. Patient #3 had a hospice admission date of 9/24/2020 and received hospice services while residing in a nursing home. The Plan of Cares (POC), dated 9/19/21 to 11/17/21, 11/18/21 to 1/16/22, and 1/17/22 to 3/17/22, included IDG orders for skilled nursing and social worker services. The POC lacked identification and delineation of services to be provided by the facility staff. The POCs lacked identification the nursing home staff were responsible for administration of medications. The POCs and IDG updates to the POC failed to delineate any responsibilities in order to determine which services the hospice planned to provide and which services the facility was responsible to provide. 2. Patient #3 had a hospice admission date of 2/22/2022 and received hospice services while residing in a nursing home. The Plan of Care (POC), dated 2/2/22 to 5/2/22, included IDG orders for skilled nursing and social worker services. The POC lacked identification and delineation of services to be provided by the facility staff. The POCs lacked identification the nursing home staff were responsible for administration of medications. The POCs and IDG updates to the POC failed to delineate any responsibilities in order to determine which services the hospice planned to provide and which services the facility was responsible to provide. Interview on 3/9/22 at 3:45 PM with Staff G, Registered Nurse (RN) reported the nurse puts in her assessments the facility is administering medications, but does not include the information on the Plan of Care or updates to the Plan of Care with IDG. The above findings were reviewed with the Hospice Administrator/Clinical Manager. Hospice staff provided no additional information prior to the end of the survey.

Based on clinical record review, hospice staff interview and nursing home staff interview, the hospice failed to include participation of nursing facility staff when establishing the Plan of Care for 2 of 2 patients receiving hospice services while residing in a nursing home facility (Patient #3 and 4). Failure to involve and consult with nursing home personnel, when establishing the Plan of Care for hospice patients who resided in a nursing home, increased the risk that patients failed to receive adequate care and treatments according to physician's orders and the plan of care. Findings include: 1. Patient #3 had a hospice admission on 9/24/2020 and received routine hospice care while residing in a nursing home. The terminal diagnosis was Pancreatic Cancer. The Plans of Care, dated 11/18/21 to 1/16/22 and 1/17/22 to 3/17/22, included medications ordered by the physician, durable medical equipment the patient used/needed and outcome goals for the patient to attain from hospice services. The Plan of Care and documentation from IDG (Interdisciplinary Group) meeting to update the Plan of Care, dated 1/12/22, 1/26/22, 2/9/22, and 2/23/22, lacked any evidence the hospice staff and nursing home personnel coordinated to establish the Plan of Care for Patient #3 or collaborated in the delineation of the specific responsibilities expected of each provider when delivering care to the patient to meet all assessed needs. 2. Patient #3 had a hospice admission on 2/2/2022 and received routine hospice care while residing in a nursing home. The terminal diagnosis was Frontotemporal Dementia. The Plan of Care, dated 2/2/22 to 5/2/22, included medications ordered by the physician, durable medical equipment the patient used/needed and outcome goals for the patient to attain from hospice services. The Plan of Care and documentation from IDG (Interdisciplinary Group) meeting to update the Plan of Care, dated 2/9/22, and 2/23/22, lacked any evidence the hospice staff and nursing home personnel coordinated to establish the Plan of Care for Patient #3 or collaborated in the delineation of the specific responsibilities expected of each provider when delivering care to the patient to meet all assessed needs. Interview with Facility Administrator on 3/9/22 at 8:24 AM, reported agency staff does not communicate with the facility regarding hospice services. The above findings were reviewed with Hospice Administrator/Clinical Manager. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, nursing home medication and treatment administration records, hospice policy review, nursing home staff interview and hospice staff interview, the hospice failed to ensure hospice staff provided overall coordination of the hospice care with the nursing home for 2 of 2 sampled patients (Patient #3 and #4) with an on-site visit to the patient's nursing home residence. Failure to ensure the hospice staff provided overall coordination of patient care with the nursing home placed the patient at risk for not receiving care and/or treatment according to the hospice philosophy. Findings Include: According to the hospice policy, titled, Care Planning Process, dated 2/2022, the IDG is responsible for establishing, implementing, reviewing and revising the patient's care plan. The IDG is responsible for providing and coordinating care and services in accordance with the patient's plan of care and reviewing goals. The primary care registered nurse (RN) is responsible for coordinating the care, ensuring continuous assessment of patient/caregiver needs and implementing the interdisciplinary plan of care. Interview on 3/9/22 at 3:36 PM with Staff G, Registered Nurse (RN), reported the nurse asks the doctor's office to fax new orders to the facility and the nurse does not provide the facility with a current medication list. 1. Patient #3 had a hospice admission date of 9/24/2020 and received hospice services while residing in a nursing home. The Plans of Care (POC), dated 11/18/21 to 1/16/22 and 1/17/22 to 3/17/22, included IDG orders for skilled nursing and social worker services. On 3/9/22 at 3:47 PM, during an on-site visit to the patient's nursing home, the Administrator provided a copy of the patient's medication and treatment administration records for January 2022, February 2022, and March 2022. Review of the nursing home's medication administration record (MAR) and treatment administration record (TAR) for January 2022, February 2022, and March 2022 compared to the hospice's medication profile list, dated 3/8/22, identified several medication and treatment discrepancies (see G 773). 2. Patient #4 had a hospice admission date of 2/2/2022 and received hospice services while residing in a nursing home. The Plans of Care (POC), dated 2/2/22 to 5/2/22, included IDG orders for skilled nursing, social worker, and spiritual care services. On 3/9/22 at 8:24 AM, during an on-site visit to the patient's nursing home, the Director of Nursing provided a copy of the patient's medication and treatment administration records for February 2022 and March 2022. Review of the nursing home's medication administration record (MAR) and treatment administration record (TAR) for February 2022 and March 2022 compared to the hospice's medication profile list, dated 3/8/22, identified medication and treatment discrepancies (see G 773). he above findings were reviewed with the Hospice Administrator/Clinical Manager. Agency staff provided no additional information prior to the end of the survey.

Based on patient clinical record review and review of hospice documentation in nursing facilities, the hospice failed to communicate with long term care staff to ensure quality care for 1 of 2 sampled patient (Patient #4) living in a long term care facility visited during the survey. Failure to effectively communicate with long term care (LTC) facility staff where a patient resides potentially reduces the opportunity for adequate coordination and exchange of information to ensure appropriate updates to the patient's plan of care and provision of services by the two entities. Findings include: Patient #3 had a hospice admission on 2/22/2022. The patient's terminal diagnosis was Frontotemporal Dementia. On 3/9/22 at 8:24 AM, the surveyor visited the LTC facility where Patient #4 resides. Staff at the LTC facility reported not having a cohesive relationship with the hospice staff. Per LTC staff, the LTC facility doesn't usually receive phone calls or faxes from the hospice or collaborate on the patient's care plan. Interview with the Director of Nursing reported hospital staff are "not the greatest" and the nurse never stops to talk to staff about the hospice services. Interview on 3/9/22 at 3:36 PM with Staff G, Registered Nurse (RN), states if anything is out of the ordinary during hospice visit, the nurse will notify facility staff. The above findings were reported with the Hospice Administrator/Clinical Manager. Hospice staff provided no additional information prior to the end of the survey.

Based on hospice clinical record review, long term care (nursing home) clinical record review, nursing home staff and hospice staff interview, the hospice failed to ensure the nursing home where hospice patients resided received all required hospice documentation for 2 of 2 sampled patients who received an on-site record review at the facility (Patient #3 and #4). Failure to communicate hospice information to nursing home staff placed patients at risk to not receiving necessary care and services. Findings include: 1. Patient #3 had an admission to hospice on 9/24/2020 and received services while residing in a nursing home. During an onsite visit on 3/9/22 at 3:00 PM, Staff G, Registered Nurse, (RN), reported has never taken any hospice document to the facility, other than a magnet that includes the hospice phone number, hours of operation and a 24 hour call number. During the visit, the Facility Administrator assisted the surveyor in the review of the patient's nursing home record. The patient's nursing home clinical record lacked a copy of the hospice Plan of Care or most recent update, hospice benefit election form, advanced directive information, certification and recertification of terminal illness, name of hospice personnel to contact, or a medication list. 2. Patient #4 had an admission to hospice on 2/2/2022 and received services while residing in a nursing home. During onsite visit to facility on 3/9/22 at 8:24 AM, the Director of Nursing assisted the surveyor in the review of the patient's nursing home record. The patient's nursing home clinical record lacked a copy of the hospice Plan of Care or most recent update, hospice benefit election form, advanced directive information, certification and recertification of terminal illness, name of hospice personnel to contact, or a medication list. During an interview on 3/9/22 at 3:36 PM, Staff G, Registered Nurse, (RN), reported has never taken any hospice document to the facility, other than a magnet that includes the hospice phone number, hours of operation and a 24 hour call number. The above findings were reviewed to Hospice Administrator/Clinical Manager. The Administrator reported the hospice has not been seeing hospice patients in nursing homes until these two patients were admitted. Hospice staff provided no further information prior to the end of the survey.

Based on patient clinical record review and review of hospice documentation in nursing facilities, and hospice and facility staff interviews, the hospice failed to assess the education and training needs for staff of a long term care facility where 2 of 2 sampled patient (Patients #3 and #4) residing in a long term care facility at the time of the survey. Failure to educate and train the long term care (LTC) facility staff where a patient resides potentially puts the patient as risk for receiving substandard hospice philosophy based care. Findings include: 1. Patient #3 had a hospice admission on 9/24/2020 and received care at a LTC facility. The patient's terminal diagnosis was Pancreatic Cancer. During onsite visit to facility on 3/9/22 at 3:47 PM, the surveyor discussed staff training with the Administrator. The Administrator denied having any training from hospice staff about the hospice philosophy and hospice management. Review of the Hospice Services Contract with the facility, dated 11/1/2013, indicated the hospice shall provide orientation and training to facility staff, as well as ongoing in-service education, sufficient in the judgement of the hospice, to acquaint the facility's staff with the hospice concept and with protocols for symptom management. 2. Patient #4 had a hospice admission on 2/2/2022 and received care at a LTC facility. The patient's terminal diagnosis was Frontotemporal Dementia. During onsite visit to facility on 3/9/22 at 8:24 AM, the surveyor discussed staff training with the Director of Nursing . The Director of Nursing denied receiving any training from hospice staff about the hospice philosophy and hospice management. Review of the Hospice Services Agreement with the facility, dated 1/31/22, revealed facility staff responsible for providing services to residents who have elected hospice will completed orientation and inservice education programs in hospice principles and philosophy. The orientation and inservice education programs will provide facility staff with an understanding of hospice and their responsibilities under this agreement. On 3/10/22 at 8:30 AM, the surveyor reviewed the above findings with the Hospice Administrator/Clinical Manager. The Administrator reported the hospice did not provide any orientation to the facility staff and stated the nursing home should be able to provide their staff with their own education. Hospice staff provided no additional information prior to the end of the survey.