Every finding on record at Phoenix Home Care Inc

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure staff maintained an accurate/updated medication profile in two of five full records reviewed (Records/Patients #2 and #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the providers policy titled, ";Medication List and Monitoring," last reviewed 09/01/2024, showed in part: - The hospice will review, monitor, and maintain a current, accurate list of all prescription and over the counter (OTC) medications, herbal remedies and other alternative treatments that could affect drug therapy taken by the patient; and - The medication/drug profile will be updated as frequently as necessary to reflect changes in the medication regimen, keeping the profile accurate. --- RECORD/PATIENT #3: Review of the clinical record showed the patient elected hospice on 09/06/2024 with a terminal diagnosis of malignant neoplasm of the right kidney (kidney cancer that spread to other areas of the body). The patient had additional diagnoses of an infrarenal abdominal aortic aneurism (a ballooning of the wall in the abdominal aorta, below the kidney), surgical repair of a fractured left femur from a fall on 09/03/2024, chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), diabetes (a group of diseases that results in too much sugar in the blood) and hypertensive chronic kidney disease (impaired kidney function caused by high blood pressure). The patient lived in his/her home with help from family members and paid caregivers. Observation on 01/14/2025 at 10:30 AM, showed the following discrepancies between the providers medication profile and the patients home medications: - The providers medication profile showed acetaminophen (a non-narcotic pain reliever) 325 milligrams (mg), take two tablets every six hours as needed for pain. The patient had a bottle of acetaminophen that showed the dosage was 500 mg tablets, and the patient stated that they took two tablets two times a day; - The providers medication profile showed nitroglycerin sublingual tablets 0.4 mg take one tablet every five minutes as needed for chest pain. May take up to three doses. The patient stated that they were not taking this medication; - The providers medication profile showed Benadryl (brand) Allergy tablet 25 mg take one tab every eight hours as needed. The patient stated that they were not taking this medication; - The providers medication profile showed FML Liquifilm (brand) (steroid eye drops) 0.1% solution, use one drop two times daily. The patient stated that they were not taking this medication; - The providers medication profile showed azelastine nasal solution 137 micrograms (mcg) (for seasonal allergies), use two sprays into each nostril two times daily. The patient stated that they were not taking this medication; - The patient had a bottle of calcium 333 mg, magnesium 133 mg and zinc 5 mg with vitamin D-3 5 mcg supplement, take one tablet up to three times daily. The providers medication profile did not include this medication; - The patient had a bottle of vitamin E 268 mg, take one daily. The providers medication profile did not include this medication; - The patient had a bottle of iron complex (vitamin C 60 mg, folate 400 mcg, vitamin B-12 80 mcg, iron 25 mg, L-histidine 100 mg), take one capsule daily. The providers medication profile did not include this medication; and - The patent had a bottle of vitamin D-3, 125 mcg, take one daily. The providers medication profile did not include this medication. During an interview on 01/16/2025 at 11:30 AM, the administrator stated that he/she would expect the clinician to maintain an accurate and updated medication list and the clinician should review medications at least for every interdisciplinary group meeting. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 10/15/2024 with a terminal diagnosis of atherosclerotic heart disease (a condition that occurs when plaque builds up in the arteries and hardens, narrowing the blood vessels), type II diabetes (a group of diseases that results in too much sugar in the blood) with peripheral neuropathy (weakness, numbness, and pain from nerve damage), hypertension (elevated blood pressure) and chronic kidney disease (loss of kidney function). The patient resided in a long-term care facility (LTCF). Observation on 01/14/2025 at 12:15 PM, showed the following discrepancies between the providers medication profile and the patients facility medications: - The LTCF treatment administration record (TAR) showed lorazepam (antianxiety) 0.25 milligram (mg) / milliliter (ml), give 0.25 ml by mouth every 2 hours as needed for anxiety/increased restlessness. The providers medication profile showed 0.25 ml under the tongue every 4 hours as needed for agitation/anxiety; - The LTCF TAR showed apply skin prep (skin protectant) to stasis ulcer to anterior left lower extremity (LLE) daily until resolved every day shift. The providers medication profile did not include this medication; - The LTCF TAR showed apply skin prep to bilateral heels twice daily for skin integrity every shift. The providers medication profile did not include this medication; - The LTCF medication administration record (MAR) showed hydroxyzine (anti itching) 25 mg by mouth every 4 hours as needed for itching. The providers medication profile did not include this medication; and - The LTCF medication administration record (MAR) showed cetirizine (allergies) 10 mg tablet, give one tablet by mouth one time a day for allergies. The providers medication profile did not include this medication;

Based on policy review, record review, and interview, the hospice provider failed to develop an individualized plan of care (POC) in, one of five full records reviewed (Record/Patient #2). This deficient practice has a potential to affect all patients served by the provider. --- Findings included: Review of the providers policy titled, ";Plan of Care," dated 05/02/2024, showed:- Each patient/client must receive an individualized POC, including any revisions or additions; - The individualized POC must include the following;*The types of supplies, and equipment required; and- The POC should list required, non-routine supplies and equipment that are medically necessary for the patient's/client's care. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 10/15/2024 with a terminal diagnosis of atherosclerotic heart disease (a condition that occurs when plaque builds up in the arteries and hardens, narrowing the blood vessels), type II diabetes (a group of diseases that results in too much sugar in the blood) with peripheral neuropathy (weakness, numbness, and pain from nerve damage), hypertension (elevated blood pressure) and chronic kidney disease (loss of kidney function). The patient resided in a long-term care facility (LTCF). Review of the skilled nurse visit, dated 12/30/2024, showed the registered nurse (RN) documented the patient was able to stand and transfer to a wheelchair on admission, but he/she had lost all ability to stand and was currently using a Hoyer lift (a mechanical lift used for transferring patients) for transfers to a wheelchair. Review of the interdisciplinary group (IDG) meeting, dated 12/31/2024, showed the RN IDG re-cert (recertification) details: he/she was able to stand and transfer to a wheelchair on admission, but he/she had lost all ability to stand and was currently using a Hoyer lift for transfers to a wheelchair. Observation during the home visit on 01/14/2025 at 12:15 PM, showed a low air loss mattress on the patient's bed he/she was sitting on. During an interview during the home visit on 01/14/2025 at 12:30 PM, the patient stated that the facility staff were going to start using the Hoyer lift to take him/her to the beauty shop. Review of the patients POC, dated 01/13/2025 to 04/12/2025, failed to be individualized and show the Hoyer lift and the low air loss mattress as part of the patients durable medical equipment (DME). During an interview conducted on 01/16/2024 at 12:20 PM, the providers administrator stated that all the patients DME should be on the patients POC.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure the plan of care (POC) was updated with the correct urinary catheter size in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients with urinary catheters served by the provider. --- RECORD/PATIENT #1: Review of the clinical record showed the patient elected hospice on 11/27/2024 with a terminal diagnosis of malignant neoplasm of the connective and soft tissue of the left lower limb, including hip (cancer in the left leg that had spread to other parts of the body). The patient had additional diagnoses of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood), chronic kidney disease, urinary retention (difficulty urinating and completely emptying the bladder), and dementia (a decline in mental capacity). The patient lived in a long-term care facility (LTCF). Review of the clinical record, showed in part: - The initial assessment, dated 11/27/2024, showed the patients genito-urinary system was assessed, the urine was dark yellow, urinary incontinence was present, and the patient had a urinary catheter (a sterile tube placed in the bladder to drain urine) and the size of the catheter was a 16 French (Fr., refers to the catheters diameter) 10 ml (milliliter) bulb (refers to the volume of fluid needed to inflate the balloon at the tip of the catheter, chosen based on the patients needs and anatomy); - The POC, dated 11/27/2024, showed an order for a 16 Fr. 10 ml bulb urinary catheter for altered bladder elimination; - A skilled nurse (SN) visit note, dated 11/28/2024, showed the catheter was changed by the LTCF nurse and the size was 16 Fr. 5 (five) ml bulb; - A SN visit note, dated 12/03/2024, showed the urinary catheter size was 16 Fr. 5 ml bulb; - IDG/POC notes, dated 12/04/2024, showed an order for a 16 Fr. 10 ml bulb urinary catheter (the IDG failed to update the catheter size in the POC); - SN visit notes, dated 12/06/2024, 12/10/2024 and 12/13/2024, showed the catheter size was documented as 16 Fr. 5 ml bulb; - A SN visit note, dated 12/17/2024, showed the urinary catheter was last changed on 12/17/2024 and the size was 16 Fr. 5 ml bulb; - IDG/POC notes, dated 12/18/2024, showed an order for a 16 Fr. 10 ml bulb urinary catheter (the IDG failed to update the catheter size in the POC); - A SN visit note, dated 12/24/2024, showed the urinary catheter was changed on 12/23/2024 and the size was 16 Fr. 5 ml bulb; - The SN visit note, dated 12/30/2024, showed the catheter size was 16 Fr. 5 ml bulb; - IDG/POC notes, dated 12/18/2024, showed an order for a 16 Fr. 10 ml bulb urinary catheter (the IDG failed to update the catheter size in the POC); - A SN visit note, dated 12/31/2024, showed the catheter was changed on 12/31/2024, and the size was 16 Fr. 5 ml bulb; - A SN visit note, dated 01/03/2025 at 10:50 AM, showed the catheter was changed on 01/02/2025, and the size was 16 Fr. 5 ml bulb; - A SN SOAP note (an acronym for subjective, objective, assessment, and plan; a type of structured clinical documentation), dated 01/03/2025 at 3:35 PM, showed the hospice RN responded to a call from the LTCF requesting assistance with a catheter change. The hospice RN inserted a 16 Fr. 30 ml bulb urinary catheter. The SOAP note failed to document the reason a 30 ml bulb catheter was used; - On 01/07/2025, the SN note documented the presence of a 16 Fr. 5 ml bulb urinary catheter inserted on 01/02/2025 (the note failed to document the presence of the 16 Fr. 30 ml catheter inserted on 01/03/2025); and - IDG/POC notes, dated 01/08/2025, showed an order for a 16 Fr. 10 ml bulb urinary catheter (the IDG failed to update the catheter bulb size in the POC). Observation on 01/14/2025 at 1:00 PM, during the patients home visit, showed the patients urinary catheter size was 16 Fr. 30 ml bulb. During an interview on 01/16/2025 at 11:30 AM, the administrator stated that he/she would expect the clinician to accurately document the catheter size and the IDG to update the POC with the correct catheter size.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure the plan of care (POC) contained the durable medical equipment (DME) necessary to meet the needs of the patients in three of five full records reviewed (Record/Patient #2, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. --- Findings Included: Review of the providers policy titled, ";Plan of Care," dated 03/07/2022, showed the POC will include all services necessary for the palliation and management of the terminal illness and related conditions, including medical supplies and appliances necessary to meet the needs of the patient. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 04/12/2024 with a terminal diagnosis of dementia (decline in mental capacity), and secondary diagnoses which included, heart failure, and anemia (a blood disorder that occurs when the body doesn't have enough red blood cells to carry oxygen throughout the body). The patient resided in a long-term care facility (LTCF). Observation during the home visit on 01/14/2025 at 11:30 AM, showed a wheeled walker in the patients room labeled with the patients name. Review of the patients plan of care dated 01/03/2025 failed to show the wheeled walker as part of the patients DME. During an interview during the home visit on 01/14/2025 at 11:50 AM, Licensed Practical Nurse (LPN) D stated that the patient has had the wheeled walker since admission to the LTCF. During an interview conducted on 01/16/2024 at 12:20 PM, the providers administrator stated that the patients wheeled walker should be included as DME on the patients POC. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice services on 11/23/2024 with a terminal diagnosis of malignant neoplasm of the lung (lung cancer), and secondary diagnoses which included chronic kidney disease, (a condition where the kidneys gradually lose the ability to filter waste products from the body), and heart failure. The patient resided in a long-term care facility (LTCF). Review of the skilled nurse visit dated 12/23/2024 showed staff documented a cane, a scooter, and a Rollator (mobility aid that helps people with walking difficulties) as part of the patients DME. Review of the patients plan of care dated 01/03/2025 failed to show the patients cane, scooter, and rollator as part of the patients DME. During an interview conducted on 01/16/2024 at 12:20 PM, the providers administrator stated that all the patients DME should be on the patients POC. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 10/15/2024 with a terminal diagnosis of atherosclerotic heart disease (a condition that occurs when plaque builds up in the arteries and hardens, narrowing the blood vessels), type II diabetes (a group of diseases that results in too much sugar in the blood) with peripheral neuropathy (weakness, numbness, and pain from nerve damage), hypertension (elevated blood pressure) and chronic kidney disease (loss of kidney function). The patient resided in a long-term care facility (LTCF). Review of the skilled nurse visit dated 12/30/2024 showed the registered nurse (RN) documented the patient was able to stand and transfer to a wheelchair on admit, now he/she has lost all ability to stand and is a Hoyer lift for transfers to a wheelchair. Review of the interdisciplinary group (IDG) meeting dated 12/31/2024 showed the RN IDG re-cert details: he/she was able to stand and transfer to a wheelchair on admit, now he/she has lost all ability to stand and is a Hoyer lift for transfers to a wheelchair. Review of the patients plan of care dated 01/13/2025 to 04/12/2025 failed to show a Hoyer lift as part of the patients durable medical equipment (DME). During an interview during the home visit on 01/14/2025 at 12:30 PM, the patient stated that the facility staff were going to start using the Hoyer lift to take her to the beauty shop.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure staff followed established policies and procedures for reporting missing narcotic medication in one of four home visit interviews conducted (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the hospice providers undated policy titled, ";Home Use and Disposal of Control Substances Policy," located in the document titled, ";Patient Handbook," showed in part: - The registered nurse (RN) case manager or designee identifies and documents any misuse of controlled substances and notifies the attending or hospice physician, the pharmacist, and the director of hospice services for further intervention; and - An incident report is completed for suspected or actual diversion of controlled substances and the interdisciplinary group (IDG), in consultation with the hospice physician, the patients attending physician (if there is one) and the pharmacist determines the appropriate course of action, including reporting the diversion to the appropriate authorities. RECORD/PATIENT #3: Review of the clinical record showed the patient elected hospice on 09/06/2024 with a terminal diagnosis of malignant neoplasm of the right kidney (kidney cancer that spread to other areas of the body). The patient had additional diagnoses of an infrarenal abdominal aortic aneurysm (a ballooning of the wall in the abdominal aorta, below the kidney), surgical repair of a fractured left femur from a fall on 09/03/2024, chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), diabetes (a group of diseases that results in too much sugar in the blood) and hypertensive chronic kidney disease (impaired kidney function caused by high blood pressure). The patient lived in his/her home with help from family members and paid caregivers. Observation on 01/14/2025 at 10:30 AM, showed the patient had a locked box that contained Norco 5/325 milligrams (mg) (hydrocodone 5 mg / Acetaminophen 325 mg) take one tablet every eight hours as needed for pain. Per an interview conducted during observation, the patient and the patients daughter stated that the staff were addressing his/her pain needs and the only time he/she had a problem with the provider was when he/she ";first started hospice". He/she had a different nurse who also had a second nurse ";training" with them and while one nurse wrapped his/her feet, the other nurse counted his/her narcotics. The patient and daughter both stated that, sometime after that visit, they noticed the narcotic pain medications (Norco 5/325 mg) were missing. They reported the missing narcotics to the provider and another bottle was brought to the home. The patient was taking Tylenol (acetaminophen 500 mg) for pain and was not taking the Norco. On 01/14/2025 at 2:00 PM, this surveyor requested information regarding the investigation into the missing narcotics and the policies and procedures the provider had in place for the discovery of missing narcotics in the home. The administrator stated that he/she would have to look in the patients file and see what he/she could find. On 01/14/2025 at approximately 3:30 PM, the administrator produced the following: - A document titled, ";Incident Report," that showed the incident occurred on 02/06/2024 at 2:00 PM and the witness was (licensed practical nurse A, LPN-A). Details included ";medication bottle missing from the home see note attached" and the response to the incident was two attempts to call the patient both resulted in an inability to leave a message due to full voice mailbox and called and left message for daughter with no returned call. The incident note showed documentation that the patients daughter was notified on 02/05/2024 at 4:00 PM (one day before the medication was discovered to be missing). The RN coordinator was notified on 02/09/ (no year entered) (three days following the discovery). The incident report was completed by (registered nurse C, RN-C) on 02/08/2024; and - A typed document on plain white paper that showed (named nurse A) ";made a skilled nursing visit on 2/6/25 (date of occurrence was 02/06/2024) and documented that (he/she) was unable to find Norco bottle during (his/her) skilled nursing visit." (Registered nurse B, RN-B) ";made (his/her) skilled nursing visit and contacted this nurse (RN-C) that the Norco was no longer present in the home as the patient was unable to find it. It was discussed that the patient has 24/7 (referring to 24 hour a day, seven days a week) care with family and paid caregivers present. (RN-B) contacted (named physician) who re-ordered the medication to be replaced. It was discussed that a lockbox be placed in the home and all narcotics be placed in the box and the key kept with the patient. (RN-B) ordered the Norco to be refilled and discussed with the patient and (named daughter) that the medications to be placed in the lockbox on arrival and the key kept in a safe place. Both patient and daughter verbalize understanding. This nurse communicated with the daughter regarding the medications missing. (He/she) reports they have multiple caregivers in the home 24/7 and is unable to pinpoint who would have taken the medications however feels certain the patient or (named provider) was not responsible for taking the medications." The document was signed by (RN-C) on 02/08/2024. Review of the skilled nursing visit made by (LPN-A), dated 02/06/2024, showed the following entry: ";No refills needed at this time Xanax (a narcotic for anxiety) 13 tabs (tablets) unable to locate Norco." The note failed to show documentation that anyone was notified of the missing narcotic pain medication. Review of the skilled nursing visit made by (RN-B), dated 02/09/2024, showed/ the following entry: ";No refills needed at this time Xanax 10 tabs (tablets) Norco 325/5 mg (5/325 mg) 30 tabs (tablets) – placed in locked box." The note also showed two keys were in the patients possession and two more keys were placed in the kitchen cupboard. The patient verbalized an understanding on the use of the lock box. Review of the IDG meeting notes, dated 02/21/2024, failed to show documentation regarding the missing narcotics. During an interview on 01/15/2025 at 3:00 PM, the administrator stated that the policy located in the patient handbook was a current policy for the provider and he/she confirmed the incident report and attached document were written at the time of the incident. He/she would look for further documentation that showed the missing narcotics were discussed in the IDG meeting with the medical director and pharmacist or any reports made to the authorities. During an interview on 1/15/2024 at 3:45 PM, the administrator stated that he/she remembered discussing the missing narcotics in IDG, but nothing was written down in the IDG meeting notes. He/she did not have any documentation to show the missing narcotics were discussed with the hospice physician and pharmacist and they did not report the missing narcotics to any law enforcement officials. He/she stated that they should have documented the occurrence and reported the incident to the proper authorities per the providers policy.

Based on policy review, record review, and interview, the provider failed to ensure the registered nurse (RN) updated the assigned patient care duties for the hospice aide to reflect a change in the patients condition in one of four patient records receiving aide services reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients receiving aide services from the hospice provider. --- Findings included: Review of the providers policy titled, ";Implementing Care and Treatment," last reviewed 09/01/2024, showed in part: - The hospice designates a qualified RN who is a member of the interdisciplinary group (IDG), who will provide coordination of care to ensure the continuous assessment of each patients and familys needs; and - The RN will oversee the assignment of a hospice aide to a particular patient, initiating hospice aide services within the time frame to meet identified patients needs as identified in the plan of care (POC) and per physicians orders. RECORD/PATIENT #1: Review of the clinical record showed the patient elected hospice on 11/27/2024 with a terminal diagnosis of malignant neoplasm of the connective and soft tissue of the left lower limb, including hip (cancer in the left leg that had spread to other parts of the body). The patient had additional diagnoses of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood), chronic kidney disease, urinary retention (difficulty urinating and completely emptying the bladder), and dementia (a decline in mental capacity). The patient lived in a long-term care facility (LTCF). Review of the hospice aide care plan, dated 11/27/2024, showed the frequency of visits was two times a week and the aide was assigned the task to assist in transfer with one person assist every visit. Review of the skilled nursing (SN) visit, dated 11/28/2024, showed the RN documented the patient was a total lift. Review of the SN visits with dates ranging from 12/13/2024 to 01/09/2025, showed the RN documented the patient was a total lift requiring two staff. Review of the aide visit notes showed the following: - On 12/13/2024, 12/17/2024, and 12/19/2024 the aide documented completion of the one-person transfer per the care plan; - On 12/26/2024 and 12/30/2024, the aide documented the one-person transfer task as ";N/A" (not applicable), due to the patient did not get out of bed and the RN case manager was notified; - On 01/02/2025, the aide documented the one-person transfer was completed; and - On 01/06/2025, the aide documented the one-person transfer as ";N/A" due to the patient was not able to get out of bed. The RN case manager was notified. Review of the RN aide supervision notes with dates ranging from 12/17/2024 to 01/07/2025, and IDG meeting notes with dates ranging from 12/04/2024 to 01/08/2025, showed the RN failed to update the hospice aide care plan to reflect the bedbound status of the patient or that the patient required a total lift of two staff members for transfers. During an interview on 01/16/2024 at 11:30 AM, the administrator stated that he/she would expect the RN case manager to update the aide care plan to reflect the change in the patient's condition.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure the hospice plan of care (POC) identified which provider was responsible for changing the urinary catheter in one of two patients that reside in a long-term care facility (LTCF) (Record/Patient #1). This deficient practice has the potential to affect all hospice patients who reside in a LTCF. --- Findings included: Review of the providers policy titled, ";Hospice Care in a SNF/NF (Skilled Nursing Facility/Nursing Facility) or ICF/IID (Intermediate Care Facility/Individuals with Intellectual Disabilities)," last reviewed 09/01/2024, showed in part: - A hospice POC will be developed based on the patient/familys needs. A copy of the POC, which includes services furnished, will be provided to the facility; and - The POC will identify the care and services that are specifically needed and identify which provider is responsible for performing the respective functions that have been agreed upon and included in the POC. RECORD/PATIENT #1: Review of the POC, dated 11/27/2024, showed in part: - An order for a Foley (brand) urinary catheter (a sterile tube placed in the bladder to drain urine) and the size of the catheter was a 16 French (Fr., refers to the catheters diameter) 10 milliliter (ml) bulb (refers to the volume of fluid needed to inflate the balloon at the tip of the catheter, chosen based on the patients needs and anatomy); and - The order showed the catheter was to be changed every 30 days and as needed for blockage or patient removal. Review of the initial assessment, dated 11/27/2024, showed the patient had a urinary catheter and was last changed at the LTCF on 10/28/2024. Review of the skilled nursing (SN) visit notes showed in part: - On 11/28/2024, registered nurse-F (RN-F) documented the catheter was changed on 11/28/2024 by (named nurse – first name only was documented). The note failed to show whether the nurse was a LTCF nurse or a hospice nurse; - On 12/17/2024, RN-F documented the catheter was changed on 12/17/2024 (19 days since the previous change). The note failed to show the reason the catheter was changed early or whether it was changed by the LTCF nurse or the hospice nurse; - On 12/24/2024, RN-F documented the catheter was changed on 12/23/2024 (six days since the previous change). The note failed to show the reason the catheter was changed early or whether it was changed by the LTCF nurse or the hospice nurse; - On 12/31/2024, RN-F documented the catheter was changed on 12/31/2024 (eight days since the previous change). The note failed to show the reason the catheter was changed early or whether it was changed by the LTCF nurse or the hospice nurse; - On 01/03/2025 at 10:50 AM, RN-F documented the catheter was changed on 01/02/2025 (two days since the previous change). The note failed to show the reason the catheter was changed early or whether it was changed by the LTCF nurse or the hospice nurse; and; - On 01/03/2025 at 3:35 PM, a SOAP note (an acronym for subjective, objective, assessment, and plan; a type of structured clinical documentation), RN-F documented he/she responded to a call from the LTCF requesting assistance with a catheter change (one day after the previous change). The note failed to show the reason the catheter was changed one day after the previous change. Observation on 01/14/2025 at 1:30 PM, during the patients home visit, showed the coordinated task plan of care with the LTCF included the Foley catheter change with a 16 Fr. five ml bulb (the hospice order was for a 10 ml bulb) and the party responsible for changing the catheter was marked as both the hospice and the LTCF. The plan of care failed to give instruction as to when the LTCF should change the catheter versus when the hospice nurses were to change the catheter. Per an interview conducted during the observation, RN-F stated that the LTCF usually did the catheter changes, but they would call him/her if they had trouble inserting it. During an interview on 01/16/2025 at 11:30 AM, the administrator stated that the hospice nurse and the LTCF nurses usually do a verbal report of information, and he/she would expect the RN to document why the catheter was being changed and who had performed the changes.

Based on policy review, record review, home visit observation, and interview, the agency failed to maintain an accurate/updated medication profile/plan of care (POC) in, but not limited to, two (Records/Patients #2 and #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's undated policy titled, "Medication-Management," showed in part: - A medication profile is maintained for every patient and includes a listing of the current medication orders for each patient and specifies whether a medication is or is not related to the patient's terminal illness; - The medication profile includes all prescription medications, over the counter drugs, vitamins, and herbal and alternative supplements; and - The agency will use the medication list/profile to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies and contraindications. RECORD/PATIENT # 2: Observation on 06/06/2022 beginning at 2:00 PM, during the patient's home visit, showed the following discrepancies with the hospice medication profile: - The patient's caregiver stated that the patient used an Albuterol inhaler (bronchodilator) as needed for shortness of breath, Symbicort inhaler (corticosteroid) once daily, and Incruse Ellipta oral inhaler (anticholinergic) 62.5 milligram (mg) one inhalation daily. These were not included on the hospice medication profile; - Melatonin (hormone used to help sleep) 5 mg one at bedtime. The agency medication profile showed Melatonin 10 mg one tablet every night at bedtime; and - Lasix (diuretic) 20 mg once a day on Monday, Wednesday, and Friday and then as needed daily for increased swelling. The agency medication profile showed Lasix 20 mg once a day on Monday, Wednesday, and Friday. During an interview on 6/8/2022 at 9:35 AM the director of nursing (DON) stated that medication reconciliation should be completed monthly and that medications in the home should match the plan of care order. RECORD/PATIENT #3: Review of the clinical record showed the following discrepancy with the medication profile: - The patient had allergies/sensitivity to Morphine (narcotic) and Codeine (narcotic) on the plan of care. The pharmacy/drug review dated for 04/14/2022 showed NKDA (no known drug allergies). During an interview on 06/08/2022 at 8:45 AM, the DON stated that the drug review profile should list any allergies or sensitivities as stated on the plan of care.

Based on policy review, record review, and interview, the agency failed to document an ongoing comprehensive assessment that included all changes in the patient's condition and response to care and treatment provided in one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's undated policy titled, "Comprehensive Assessment - Updates," showed in part: - The interdisciplinary group (IDG) updates the comprehensive assessment and reassesses the patient's response to care on a regular basis; - An update of the comprehensive assessment is conducted by the IDG and includes identification of changes that have occurred and reassessment of the patient's response to care and progress toward desired outcomes; and - Documentation of the IDG's care planning meetings reflects the ongoing reassessment of the patient's status and needs. RECORD/PATIENT #1: Review of the skilled nurse (SN) visit notes showed on 03/15/2022, the patient had two small wounds directly over the bony prominence of the coccyx (tailbone). The SN notified the physician and obtained wound care orders. The wound assessment showed one wound was a Stage 1 (intact skin with non-blanchable redness) pressure ulcer that measured 0.3 x 0.3 x 0.0 centimeters (cm), the wound bed showed a light brown scab, no drainage or odor with surrounding skin intact. Cleansed and protective dressing applied. The patient had another wound to the coccyx that was a Stage 2 (an open break in the skin that is usually tender and painful) pressure ulcer that measured 0.3 x 0.3 cm, wound bed pink, no drainage or odor with surrounding tissue intact. Cleansed and protective dressing applied. Review of the IDG meeting note dated 03/16/2022, showed the patient had two small wounds to the coccyx-slightly reddened (this contradicts the SN note that showed the patient had a Stage 1 and Stage 2 pressure ulcer) skin over the bony prominence. The physician was notified and orders received. The plan of care (POC) showed a problem with alteration in skin integrity wound/lesion and interventions included to assess for changes in skin integrity. Review of the SN visit notes from 03/18/2022 through 05/26/2022, showed the SN's continued to document the patient had two small wounds to the coccyx but no further assessments were documented. Review of the IDG meeting notes showed: - On 03/30/2022 and 04/13/2022 no documented discussion regarding the patient's wounds; - On 04/27/2022 showed no new skin issues. No documentation regarding the status of the other wounds; and - On 05/11/2022 and 05/25/2022 no documented discussion regarding the status of the patient's wounds. During an interview on 06/08/2022, beginning at 9:05 AM, the director of nursing stated that he/she would expect the progress of the wounds to be discussed at the IDG meetings.

Based on policy review, record review, observation, and interview, the agency failed to: - Provide education and training for the caregiver as appropriate to their responsibilities (L544); - Develop an individualized plan of care (L545); - Develop an individualized written plan of care for each patient that included interventions to manage pain and symptoms (L546); - Implement plans of care that included anticipated measurable outcomes (L548); and - Ensure that the plan of care included all physicians orders for medications and treatments (L549). The cumulative effect of these deficient practices has the potential to affect all patients served by the agency.

Based on policy review, record review, home visit observation, and interview, the agency failed to provide education and training for the caregiver as appropriate to their responsibilities in one (Record/Patient #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's undated policy titled, "Medication-Management," showed in part: -The registered nurse (RN) Case Manager or designee provides and documents instruction to the patient/caregiver regarding safe administration of medications including possible side-effects and expected responses; and - Medications that are no longer needed are disposed of in accordance with accepted standards of practice. RECORD/PATIENT # 3: Observation on 06/07/2022 beginning at 2:00 PM, during the home visit, showed the following discrepancies with the hospice documentation of education provided: - The patient's caregiver stated that the patient had received a prescription for Norco (narcotic) on 05/06/2020 and had this prescription bottle stored in the patient's active medications; and - The patient's caregiver stated that it was discontinued on 05/07/22 and he/she kept it for emergencies. During an interview on 6/8/2022 at 8:45 AM, the director of nursing (DON) stated that the in home medication reconciliation should be completed weekly and that the medications in the home should match the plan of care order. He/she stated it was his/her expectation that the nurse would educate the patient/caregiver to dispose of the medication once discontinued and document the education provided as well as the patient/caregiver response to the education.

Based on policy review, record review, and interview the agency failed to develop an individualized plan of care (POC) in, but not limited to two (Records/Patients #2 and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #2: Review of the registered nurse (RN) initial assessment, dated 04/30/2022, showed the patient had a Foley catheter (a closed system to drain urine from the bladder) and the POC problems stated, "there are no problems to display for this section". Review of the POC dated 05/11/2022 and updated 05/25/2022 failed to show problems, goals, and interventions for the Foley catheter. During an interview on 06/08/2022 at 9:35 AM, the director of nursing (DON) stated that the POC should have included goals and interventions for the Foley catheter. RECORD/PATIENT #5: Review of the record showed the patient was admitted to hospice on 05/12/2022 with a terminal diagnosis of uterine cancer. Comorbidities included iron deficiency anemia (too little iron in the body). Review of the RN initial assessment, dated 05/12/2022, showed the patient was incontinent of urine. Review of the POC medication list showed: - Cyanocobalamin (hematopoietic agent) 1000 microgram (mcg) one tablet daily in the AM; and - Ferrous sulfate (hematopoietic agent) 325 milligram (mg) one tablet daily at bedtime. Review of the POC dated 05/18/2022 and updated 06/01/2022, failed to show problems, goals, and interventions for incontinence and anemia. During an interview on 06/08/2022 at 9:40 AM, the director of nursing (DON) stated that incontinence and anemia problems, goals, and interventions should have been on the POC. No further information was provided by the time of exit.

Based on policy review, clinical record review, and interview, the agency failed to develop an individualized written plan of care (POC) for each patient that included interventions to manage pain and symptoms in two (Records/Patients #4 and #5) of five full records reviewed. This deficient practice has the potential to affect the care provided to all of the agency's patients. Findings included: Review of the agency's undated policy titled, "Pain and Symptom Management," showed in part, the following: - The IDG (interdisciplinary group) ensures that patients receive effective pain management and symptom control from the hospice for the terminal illness and its related conditions; - The pain assessment is a distinct, easily identifiable, part of the initial assessment and is incorporated into other documentation's tool; - The patient's pain and other symptoms related to the terminal condition are thoroughly assessed during the comprehensive assessment of the patient by the RN (Registered Nurse) case manager or designee; - The patient's preference for pain management are reflected in the pain control measures selected; - Procedures and protocols for pain assessment and management are developed and implemented, using a numerical or other rating scale for pain assessment; - Pharmacological and non-pharmacological interventions are considered for the treatment of pain; and - Interventions to manage the patient's pain are included in the patient's plan of care. Review of the agency's undated policy titled, "Plan of Care," showed in part: -The Hospice written interdisciplinary POC is developed and individualized for each patient and family, reflects patient/family goals based upon problems identified in the initial/updated assessments, and includes all services necessary for palliation and management of the terminal illness and related conditions, including interventions to manage pain and symptoms; and - Measurable outcomes are anticipated from implementing and coordinating the plan of care for each patient by using data elements identified by the hospice and are used as part of the hospice's Quality Assurance and Performance Improvement (QAPI) program. RECORD/PATIENT #4: Review of the POC dated 04/03/2022, showed the following: - A POC problem titled pain with a goal listed that the patient will report pain at a level at or below patient's acceptable level of pain. The documentation failed to show an acceptable level of pain within the clinical record; and - A POC problem titled altered endocrine - diabetes with a goal listed that the patient's blood sugars would be as close to a normal range as possible. The documentation failed to show an intervention to monitor the blood sugar. During an interview on 06/08/2022 at 9:25 AM, the director of nursing (DON) stated that he/she would expect an acceptable patient pain level to be set in the POC. The DON also stated that he/she would expect an order to coincide with the goal of maintaining blood sugars within normal ranges. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice services on 05/12/2022 for a terminal diagnosis of uterine cancer. Review of the registered nurse (RN) initial assessment, dated 05/12/2022, showed: - Patient had generalized pain; - The pain was intermittent; - The pain was relieved by rest and medication; - The current medication for pain was Tylenol (analgesic); - The target pain goal was none; and - A pain level of "4" warranted further attention. Review of the POC dated 05/18/2022, showed the agency failed to document a goal for pain, to include Tylenol as the medication to use when having pain, and any non-pharmacological interventions the patient could use to help alleviate pain. During an interview on 06/08/2022 at 9:40 AM, the DON stated that he/she would expect the patient's pain POC to be individualized, include interventions the patient was utilizing for pain, and to include the patient's acceptable level of pain.

Based on policy review, record review, and interview, the agency failed to implement plans of care (POC) that included anticipated measurable outcomes in, but not limited to, one of (Record/Patient #5) of five full records reviewed. This deficient practice has the potential to affect the quality of care for all patients receiving services. Findings included: Review of the agency's undated policy titled, "Plan of Care," showed in part: - The interdisciplinary written POC is based on initial and updated patient-specific comprehensive assessments by members of the IDG and is developed with measurable goals and outcomes for planned interventions; and - The hospice written interdisciplinary POC is developed and individualized for each patient and family, reflects patient/family goals based upon problems identified in the initial/updated assessments, and includes all services necessary for palliation and management of the terminal illness and related conditions. Review of the agency's undated policy titled, "Plan of Care-Content," showed in part: - The POC must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments; and - The POC must include all services necessary for the palliation and management of the terminal illness and related conditions, including, but not limited to measurable outcomes anticipated from implementing and coordinating the plan of care. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice on 05/12/2022 with a terminal diagnosis of uterine cancer. Comorbidities included: iron deficiency anemia (too little iron in the body), hypertension (high blood pressure), and anorexia (an eating disorder). Review of the initial Registered Nurse (RN) assessment, dated 05/12/2022, showed the following: - The patient had three plus edema (refers to swelling caused by excess fluid, assessed by applying pressure on the area, the depth of the depression, and how long it lasts) to bilateral lower extremities; - The patient usually slept six to eight hours a day and used a sleep aide less than weekly; and - Appetite fair with weight loss anticipated. Review of the POC showed the following problems: - Altered cardiovascular system; - Vaginal bleeding; - Pain; - Altered sleep pattern; - Altered endocrine; - Altered nutrition; - Altered neurological system; and - The POC failed to include measurable goals for the above problems. During an interview on 06/08/2022 at 9:40 AM, the director of nursing (DON) agreed with the findings that the problems identified did not have measurable goals and he/she would expect them to have measurable goals.

Based on policy review, record review, home visit observation, and interview, the agency failed to ensure that the plan of care (POC) included all physicians orders for medications and treatments in two (Records/Patients #1 and #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's undated policy titled, "Plan of Care - Content," showed in part: - The hospice must develop an individualized written POC for each patient; - The POC must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments; and - The POC must include all services necessary for the palliation and management of the terminal illness and related conditions, including drugs and treatment necessary to meet the needs of the patient and medical supplies, equipment, and appliances necessary to meet the needs of the patient. RECORD/PATIENT #1: Review of the clinical record showed the following medication discrepancies between the current long term care facility (LTCF) medication orders, hospice medication profile, and the hospice plan of care (POC): - The LTCF current medication orders showed an order dated 04/16/2022, for Mucinex (cough and cold medicine) 600 milligrams (mg) one tablet twice a day. The hospice POC included this medication, but the hospice medication profile failed to include this medication; - The LTCF orders showed an order dated 05/04/2022 for lorazepam (anti-anxiety) intensol 0.5 milliliters (ml) every six hours. The hospice medication profile showed an order for lorazepam 0.5 ml every six hours as needed. The hospice POC showed an order for lorazepam 0.5 ml under the tongue every four hours as needed for anxiety; - The LTCF orders showed an order dated 05/04/2022, for morphine sulfate 0.5 ml every six hours. The hospice medication profile showed an order for morphine sulfate 0.5 ml every six hours as needed. The hospice POC showed an order for morphine sulfate 0.5 ml every four hours as needed for pain; - The hospice POC showed an order for Prednisone (reduces inflammation) 7.5 mg daily; The LTCF orders and hospice medication profile showed an order for Prednisone 10 mg daily; - The hospice POC showed an order for Colace (stool softener) one capsule twice daily. The LTCF orders and hospice medication profile did not include this order; - The hospice POC showed an order for Restoril 15 mg at bedtime for insomnia. The LTCF orders and hospice medication profile did not include this order; - The hospice POC showed an order for ergocalciferol (vitamin D) 1.25 mg one capsule every week. The LTCF orders and hospice medication profile did not include this order; and -The hospice medication profile showed an order for folic acid (vitamin B9) 1 mg daily. The LTCF orders and hospice medication profile did not include this medication. During an interview on 06/08/2022 beginning at 9:05 AM, regional vice president B stated that he/she did not know why the correct orders were not on the POC because the medication profile flowed to the POC. During an interview on 06/08/2022, at 2:15 PM, regional vice president A stated that the nurses check the charts at the LTCF every visit and update the medication profile with any changes in orders. The medication profile should flow to the POC. The DON thought they had a glitch in their computer system. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice on 04/12/2022 with a terminal diagnosis of malignant neoplasm (cancer) of unspecified site of left breast. Review of the initial assessment dated 04/12/2022, showed the patient had a wound under his/her left breast. Review of the record showed in part: - A physician's order dated 04/19/2022 for Calmoseptine (barrier cream) to be applied daily and as needed to affected breast; and -The documentation failed to show any further orders for additional treatments. Observation on 06/07/2022 beginning at 2:00 PM, during the patient's home visit, showed the following discrepancies with the hospice POC: - Registered Nurse (RN) C assessed the left breast by removing a bordered foam dressing, cleansing the site with wound cleanser, applying skin prep adhesive, and placing a new bordered foam; - RN C failed to place any Calmoseptine on the affected area as ordered; and - The caregiver stated that the cream and bordered foam were to be replaced every 3 days. During an interview on 6/8/2022 at 8:45 AM, the director of nursing (DON) stated that it was the expectation an order would be in the POC specifying what, if any treatments were appropriate for each wound and that the caregiver/patient was educated on the treatment and the ability to complete the treatment.

Based on home health standards, policy review, home visit observation, and interview, the agency failed to ensure that accepted standards of practice to prevent the transmission of infections and communicable diseases was followed in two (Records/Patients #1 and #3) of three home visits conducted. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of official reference: McGoldrick, M. (2015). Home Care Infection Prevention and Control Program. Saint Simons Island, GA: Home Health Systems, Inc. showed that equipment that had direct contact with environmental surfaces should be cleaned and disinfected before use on another patient. Review of McGoldrick, M. Home Care Infection Prevention and Control Program showed also that staff should use a surface barrier of a water-resistant material (e.g., plastic bag [tall kitchen size] on a roll, wax paper, disposable underpads [chux], etc.) under the bag and/or equipment used in patient care. Review of official reference: [Centers for Disease Control and Prevention] CDC (2022). Guidelines for Hand Hygiene in Healthcare Settings; Clinical indications for hand hygiene include: - Immediately before touching a patient; - After touching a patient or the patient's immediate environment; - After contact with blood, body fluid, or contaminated surfaces; and - Immediately after glove removal. Review of the agency's undated policy titled, "Infection Control- Hand Hygiene and Bag Technique," showed in part: - Wash hands- Hands must be washed before and after contact with each patient; - After the removal of all gloves; - After contact with non-intact skin and wound dressings; and - A disposable tape measure is used if the part measured is an open wound. RECORD/PATIENT #1: Observation on 06/07/2022, beginning at 9:00 AM, during the patient's home visit at a long term care facility (LTCF), showed the social worker (SW) lay his/her computer tablet on the seat of the patient's wheelchair without placing a barrier underneath. The SW left the patient's room without cleaning the computer tablet, then lay it on a cart at the nurses' station without a barrier underneath. The SW then left the facility without cleaning the computer. During an interview on 06/08/2022 beginning at 9:05 AM, the director of nursing (DON) stated that staff should have a clean area to sit their computers. If there was not a clean area, they should place a barrier. Regional vice president B stated that staff should clean their computers with a sanicloth wipe. RECORD/PATIENT #3: Observation on 06/07/2022, beginning at 2:00 PM, during the patient's home visit, showed Registered Nurse (RN) C assessed the patient's left breast by removing a bordered foam dressing, changed gloves (he/she failed to use hand sanitizer or wash his/her hands), cleansed the wound site with wound cleanser, changed gloves again (he/she failed to use hand sanitizer or wash his/her hands), applied skin prep adhesive, changed gloves again (he/she failed to use hand sanitizer or wash his/her hands), measured the wound, changed gloves (he/she failed to use hand sanitizer or wash his/her hands), placed a new bordered foam dressing, removed gloves, then completed hand hygiene. RN C used a reusable measuring tape to measure the patient's wound and cleaned the tape with a disinfectant wipe before placing the tape measure back into his/her bag. During an interview on 06/08/2022 at 8:45 AM, the DON stated that it was the expectation to use disposable paper measuring tape when measuring wounds and to complete hand hygiene as per the agency policy.

Based on policy review, job description, record review, home visit observation, and interview, the agency failed to ensure the nursing needs of the patient's were met in two (Records/Patients #1 and #2) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's undated policy titled, "Comprehensive Assessment - Content" showed in part, a complete pain and symptom assessment conducted at the time of admission based on policies and procedures and/or protocols for assessment and management of pain that includes, but is not limited to, history of pain, treatment and strategies, and factors that reduce pain. Review of the agency's undated policy titled, "Pain and Symptom Management," showed in part, pain is reassessed during every home visit, anytime a patient states that his/her pain level has changed, and whenever pain medications or dosages are changed. This information is documented in the clinical record. Review of the agency's undated job description titled, "Registered Nurse/Case Manager," showed in part, the Registered Nurse (RN) should: -Consult with the attending physician and Hospice Medical Director concerning changes in patient's condition requiring order changes and/or changes in the plan of care. During an interview on 06/08/2022 at 12:00 (noon), the regional vice president stated that they did not have a specific wound assessment policy. RECORD/PATIENT #1: Review of the skilled nurse (SN) visit notes showed: - On 02/22/2022, the hospice received a phone call from the LTCF (long term care facility, where the patient resided) that the patient was out of morphine sulfate extended release (MSER, pain medication) for the past two days. Upon arrival to the facility, the SN spoke to the charge nurse and CMT (certified medication technician). The charge nurse called the pharmacy while the SN was present to find out that they needed a script. The SN called the hospice office to resend the script to the pharmacy for medication delivery. Before leaving the facility, the SN had the CMT take his/her phone number to call if the medication did not arrive. The patient had been in pain and awake per facility staff. When the SN went to the patient's room, the patient slept soundly and did not wake him/her. Instructed LTCF staff to call the hospice 24 hours a day, seven days a week. The SN also gave staff his/her personal cell number; - No documentation of follow up regarding the medications until 02/25/202; - On 02/25/2022, the patient denied pain and pain management was effective. The LTCF nurse reported no problems at this time and would order medications through the facility pharmacy; - On 03/15/2022, the patient had two small wounds directly over the bony prominence of the coccyx (tailbone). The patient stated that the area was sore. The SN notified the attending physician and obtained wound care orders. The wound assessment showed one wound was a Stage 1 (intact skin with non-blanchable redness) pressure ulcer that measured 0.3 x 0.3 x 0.0 centimeters (cm), the wound bed showed a light brown scab, no drainage or odor with surrounding skin intact. Cleansed and protective dressing applied. The patient had another wound to the coccyx that was a Stage 2 (an open break in the skin that is usually tender and painful) pressure ulcer that measured 0.3 x 0.3 cm, wound bed pink, no drainage or odor with surrounding tissue intact. Cleansed and protective dressing applied; and - From 03/18/2022 through 05/26/2022, the SNs continued to document the patient had two small wounds to the coccyx but no further assessments were documented. Review of a hospice physician order dated 03/16/2022 showed an order to cleanse the wounds on the coccyx with wound cleanser, pat dry, apply a protective dressing every five days and as needed. Review of the plan of care (POC) dated 03/16/2022, showed: - A problem identified as alteration in skin integrity - wound/lesion and interventions included to assess for changes in skin integrity; - The POC failed to include the new treatment order; and - A problem identified with pain and interventions included to assess and monitor the patient's pain level and evaluate effectiveness of pain medication. Review of the SN visit notes showed: - On 03/18/2022, the patient had more pain today. The LTCF staff informed the SN that he/she did not have his/her MSER for two days (no call made to hospice). The problem had been solved, and the mediations would be delivered and resumed today. They reassured the SN that the medication was being delivered that day and would be given as soon as possible. The Roxanol (pain medication) was being given as ordered and as needed to provide relief. The pain assessment showed the patient had generalized pain/back at a level of five (pain is rated on a scale of 0-10 with 0 meaning no pain and 10 meaning the worst pain), not acceptable to the patient, pain intervention showed the SN talked with staff and progress toward goal was good. The pain assessment failed to address the patient's history of pain and how much and what pain medications the patient used for pain. The patient had missed doses of MS Contin (long acting pain medication) two days. The staff reported trouble getting the script signed; -No documentation of follow up regarding the medications until 03/23/2022; -On 03/23/2022, the pain assessment showed the same verbiage as the previous pain assessment even though the patient felt better and was eating better; - On 03/25/2022, the pain assessment showed the same verbiage. The patient discussed feeling better and more capable. The CNA (certified nursing assistant) was in the room and discussed that the patient was now able to get into his/her wheelchair independently; - On 03/29/2022, the pain assessment showed the same verbiage as the previous assessment except for in the comment section it showed MS Contin times two; and - From 04/02/2022 through 04/29/2022 the pain assessment showed the same verbiage. Per interview conducted during observation, on 06/07/2022, beginning at 9:00 AM, the patient denied pain and stated that he/she had good pain control. He/she felt much better since starting with the hospice and the LTCF. The patient knew what he/she took for pain and stated that the staff would give him/her extra medication if he/she needed it. He/she no longer had a sore on his/her bottom. During an interview on 06/07/2022, at 9:45 AM, the LTCF charge nurse stated that the patient had been doing well with his/her pain medications. The patient had switched physicians a while back. They order the medications through their pharmacy. If the medications were getting low, they let the physician know and he/she would send a script to the pharmacy. He/she could not remember the patient having a wound, but just redness. He/she stated that on 05/04/2022, they had an order to apply a dressing times five days then just as needed. He/she showed the surveyor the order which said for the dressing to be done every five days and as needed. When questioned regarding this, he/she stated that was his/her mistake and he/she should have written the order as times five days and as needed. During an interview on 06/08/2022, beginning at 9:05 AM, regional vice president A stated that the nurse should have followed up with the LTCF the day of the concerns with the medication. The director of nursing (DON) stated that the pain assessments should address whether as needed medications were used and the patient's history of pain in the last 24 hours. He/she did not know about the same verbiage on the assessment but would not expect that. He/she would look into it. No further information was provided. He/she expected skin assessments to be done at each visit and wound assessments including measurements to be done once a week. If a wound had healed, that should be documented. RECORD/PATIENT #2: Review of the clinical record showed: -On 5/20/2022 that an unstageable pressure wound (an area of full thickness tissue loss in which depth is obscured by slough or eschar) was first identified and measured on the right heel of the patient. The documentation failed to show that the attending physician and/or the hospice medical director were notified. The agency failed to update the plan of care; - On 5/24/2022 the skilled nurse's note identified an unstageable wound to the patient's right heel. The documentation failed to show that the physician was notified. The agency failed to update the plan of care; - On 5/27/2022 the skilled nurse's note identified an unstageable wound to the patient's right heel. The documentation failed to show that the physician was notified. The agency failed to update the plan of care and measure the wound; - On 5/31/2022 the skilled nurse's note identified an unstageable wound to the patient's right heel. The documentation failed to show that the physician was notified. The agency failed to update the plan of care; and - On 6/3/2022 the skilled nurse's note identified an unstageable wound to the patient's right heel. The documentation failed to show that the physician was notified. The agency failed to update the plan of care. During an interview on 6/8/2022 at 9:35 AM, the director of nurses (DON) stated that he/she would expect the physician to be notified of changes, the plan of care to be updated, and that pressure ulcer measurements should be completed weekly.

Based on policy review, record review, and interview the agency failed to ensure that accurate physician orders were obtained in one (Record/Patient #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's undated policy titled, "Physician Orders," showed in part some of the reasons orders are obtained from physicians include, but are not limited to: new medication, change in medication, discontinuance of medication, care, treatment and services. RECORD/PATIENT #4: Review of the medication profile dated 03/29/2022 showed an order for oxygen two liters per minute per nasal cannula continuously for dyspnea (shortness of breath). Review of the skilled nurse (SN) visits from 03/31/2022 through 05/09/2022 showed that the nurse documented that the patient wore oxygen at three liters per minute. Review of the SN visit from 05/12/2022 showed that the nurse documented that the patient wore oxygen at four liters per minute. Review of the SN visits from 05/16/2022 through 06/02/2022 showed that the nurse documented that the patient wore oxygen at three and a half liters per minute. Review of the clinical record failed to show: - An order for oxygen at three liters; - An order for oxygen at four liters; and - An order for oxygen at three and a half liters. Review of the clinical record also failed to show any attempts to contact the physician regarding the patient not following the physician's written order. During an interview on 06/08/2022 at 9:20 AM, the Director of Nursing (DON) stated that he/she would have expected there to be a new order if the patient was requiring higher flows of oxygen or he/she would expect the patient to follow the current physician order.

Based on policy review, record review, and interview, the agency failed to ensure documentation was accurate in, but not limited to, two (Records/Patients #1 and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's undated policy titled, "Documentation Requirements," showed in part: - Documentation must be legible, grammatically correct, accurate, and timely; and - All documentation contains complete, factual, essential, and accurate information. RECORD/PATIENT #1: Review of the skilled nurse (SN) visit notes showed: from 03/18/2022 through 03/25/2022 and from 04/22/2022 through 04/29/2022 the SN documented the same verbiage on the pain assessments. During an interview on 06/08/2022, beginning at 9:05 AM, the director of nursing stated that he/she did not know about the same verbiage on the assessment, but would not expect that. He/she would look into it. No further information was provided. RECORD/PATIENT #5: Review of the SN visit note dated 05/20/2022 showed there was a medication change since the last visit and in the comment section, it stated, "started Colace as the patient is on an iron supplement". Review of the skilled nurse visit notes, dated 05/24/2022, 05/27/2022, 05/31/2022, and 06/03/2022 all showed there was a medication change since the last visit and in the comment section, it stated, started Colace as the patient is on an iron supplement. During an interview on 06/08/2022 at 9:40 AM, the director of nursing (DON) stated that the visit notes from 05/24/2022, 05/27/2022, 05/31/2022, and 06/03/2022 were not accurate and should not have been marked to show there was a medication change. The DON stated that he/she would expect staff not to copy and paste in their documentation.

Based on policy review, clinical record review and interview, the hospice agency failed to document they supplied the inpatient provider with a copy of the patient's plan of care which included the respite services to be furnished by the long-term care facility, in one of one applicable case reviewed for respite (Record/Patient #9) and the contract failed to show the specified inpatient services to be furnished. This deficient practice has the potential to affect all patients admitted for respite care while receiving hospice services from the agency. Findings included: Review of the agency's undated policy titled, "Facility Contracts- Inpatient Care Short Term Care," showed in part that the hospice supplies the inpatient provider with a copy of the patient's plan of care and specifies the inpatient services to be furnished. RECORD/PATIENT #9: Review of the clinical record showed the patient was admitted to hospice services on 03/07/2022. The hospice staff failed to document they furnished the long-term care facility a current hospice plan of care that included the respite services to be provided from 03/12/2022 until 03/17/2022. During an interview on 06/08/2022 at 8:10 AM, regional vice president A stated there was no documentation to show the patient's care plan was provided or that it included the inpatient services to be furnished during respite care.

Based on policy review, review of a written agreement for respite services (inpatient care for caregiver relief), and interview the agency failed to ensure the agreement with the long term care facility (LTCF) included the requirement that the inpatient provider has established patient care policies consistent with the hospice in one (Contract B) of two respite contracts reviewed. This deficient practice has the potential to affect all respite patients served by the agency. Findings included: Review of the agency's undated policy titled, "Facility Contracts - Inpatient Care Short Term Care," showed in part that the contract would include that the inpatient provider has established patient care policies consistent with those of hospice. CONTRACT B: Review of a written agreement for respite services with a LTCF dated 04/03/2019, failed to include the provision that the inpatient provider has established patient care policies consistent with hospice. During an interview on 06/08/2022 at 8:10 AM, the director of nursing stated that he/she could not find the missing items.

Based on policy review, review of a written agreement for general inpatient care (GIP, short term care for symptom management)/inpatient respite services (inpatient care for caregiver relief), and interview the agency failed to ensure the agreement with the long term care facility (LTCF) included the requirement that the inpatient provider has identified an individual within the facility who is responsible for the implementation of the provisions of the agreement in two (Contract A and Contract B) of two inpatient contracts reviewed. This deficient practice has the potential to affect all respite patients served by the agency. Findings included: Review of the agency's undated policy titled, "Facility Contracts - Inpatient Care Short Term Care," showed in part that the contract would include that the inpatient facility had identified an individual within the facility who is responsible for the provisions of the agreement. CONTRACT A: Review of a written agreement for GIP/inpatient respite with a LTCF dated 11/10/2015, failed to include the provision that the inpatient provider has identified an individual within the facility who is responsible for the provisions of the agreement. CONTRACT B: Review of a written agreement for respite services with a LTCF dated 04/03/2019, failed to include the provision that the inpatient provider has identified an individual within the facility who is responsible for the provisions of the agreement. During an interview on 06/08/2022 at 8:10 AM, the director of nursing stated that he/she could not find the missing items.

Based on policy review, review of a written agreement for respite services (inpatient care for caregiver relief), and interview the agency failed to ensure the agreement with the long term care facility (LTCF) included the requirement that they provide space for family privacy after a patient's death in one (Contract B) of two respite contracts reviewed.. This deficient practice has the potential to affect all respite patients/famillies served by the agency. Findings included: Review of the agency's undated policy titled, "Facility Contracts - Inpatient Care Short Term Care," failed to include that the inpatient facility would provide space for family privacy after a patient's death. CONTRACT B: Review of a written agreement for respite services with a LCTF dated 04/03/2019, failed to include the provision that the inpatient provider would provide space for family privacy after a patient's death. During an interview on 06/08/2022 at 8:10 AM, the director of nursing stated that he/she could not find the missing items.

Based on policy review, record review, and interview, the agency failed to ensure the coordinated task plan of care (POC) with the long term care facility (LTCF) included the frequency of visits for the social worker and chaplain and failed to show coordination of wound care management in one (Record/Patient #1) of one record reviewed of patients that resided in a LTCF. Findings included: Review of the agency's undated policy titled, "Hospice Care for Nursing Facility Residents - Coordination of Services," showed in part that the hospice ensures that mechanisms are in place to provide for the coordination of all hospice services provided to patients residing in facilities. The hospice designates a member of each interdisciplinary group that is responsible for providing overall coordination of the hospice care of the resident with facility representatives. RECORD/PATIENT #1: Review of the skilled nurse (SN) visit notes showed on 03/15/2022, the patient had two small wounds directly over the bony prominence of the coccyx (tailbone). The SN notified the physician and obtained wound care orders. The wound assessment showed one wound was a Stage 1 (intact skin with non-blanchable redness) pressure ulcer and another wound to the coccyx that was a Stage 2 (an open break in the skin that is usually tender and painful) pressure ulcer. The nurse collaborated with the charge nurse. Review of the SN visit notes from 03/18/2022 through 05/26/2022, the SN's continued to document the patient had two small wounds to the coccyx but no further assessments were documented. Review of the coordinated task POC maintained in the LTCF hospice binder (first date on the form was 03/15/2022) failed to include the frequency of visits for the social worker and chaplain and failed to show coordination of wound care and assessment. The section for wound care schedule was blank. During an interview on 06/08/2022 beginning at 9:05 AM, the director of nursing (DON) stated that he/she expected the coordinated task plan to address who was responsible for wound care. During an interview on 06/08/2022 at 1:25 PM, the DON stated that he/she expected the coordinated task plan to include the frequency of visits for the social worker and chaplain.

Based on policy review, record review, home visit observation, and interview the agency failed to ensure the long term care facility (LTCF) hospice patient record contained a copy of all required hospice documents in one (Record/Patient #1) of one applicable record of patients that resided in a LTCF. This deficient practice has the potential to affect all patients that resided in a LTCF. Findings included: Review of the agency's undated policy titled, "Hospice Care for Nursing Facility Residents - Coordination of Services," showed in part that the hospice would provide the facility with the most recent hospice plan of care (POC) and hospice and attending physician orders specific to each patient. RECORD/PATIENT #1: Review of the hospice record maintained at the LTCF, during a home visit observation on 06/07/2022 beginning at 9:00 AM, showed it failed to contain the following required information: - Current hospice POC; and - Hospice physician and attending physician orders. The findings were reviewed with the director of nursing, regional vice president A, and regional vice president B on 06/08/2022, beginning at 9:05 AM. No further information was provided.

Based on review of Missouri state law, personnel file review, and interview, the agency failed to obtain the results of the employee disqualification list (EDL) check prior to hire in one (Employee #1) of seven personnel files reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of Section 192.2490.12 RSMo showed the statement, "No person, corporation, organization or association who received the employee disqualification list under subdivisions (1) to (5) of subsection 11 of this section shall knowingly employ any person who is on the employee qualification list." EMPLOYEE #1: - Date of hire: 12/07/2020; and - EDL check 12/10/2020. During an interview on 06/08/2022 at 12:00 PM, the Director of Nursing (DON) stated that he/she would expect the EDL to be checked prior to hire. The DON had no further information to present and agreed with the findings. The DON could not provide an agency policy relating to the EDL check prior to hire.