Every finding on record at Phoenix Home Care LLC

Based on policy review, clinical record review, home visit observation, and interview, the hospice provider failed to ensure clinicians maintained an accurate/updated medication profile/POC (plan of care) in, but not limited to, two of five full records reviewed (Records/Patients #3 and #4). This deficient practice has the potential to affect all the providers patients. --- RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 08/09/2024 with primary diagnosis of other specified degenerative diseases of nervous system (neurodegenerative disease), dementia (decline in mental capacity), atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), and hypertension (Elevated arterial blood pressure). The patient lived at home with his/her spouse as primary caregiver. Observation and interview on 10/01/2024 at 11:00 AM, during the patient's home visit, showed the following discrepancies: - The medication profile showed the patient took metoprolol (treats high blood pressure) extended release (ER) 24 hour 25 milligrams (mg) one half a tablet daily. Review of the medication bottle showed 50 mg take a half a tablet daily. The spouse stated he/she takes it like the medication bottle directions; - The medication profile showed the patient took cyanocobalamin (vitamin B12) 100 micrograms (mcg) tablet daily. Review of the medication bottle showed 2500 mcg daily. The spouse stated he/she takes it like the medication bottle; - The medication profile showed the patient took Vitamin D3 25 mcg tablet daily. Review of the medication bottle showed 125 mcg daily. The spouse stated he/she takes it like the medication bottle; - The medication profile showed the patient took Vitamin C chewable 500 mg daily. Review of the medication bottle showed vitamin C 2000 mg, zinc 40 mg, rose hip 50 mg daily. The spouse stated he/she takes one a day; - The medication bottle showed Sentry Senior Vitamin (comparable to Centrum Silver) one daily. The spouse stated he/she takes one daily. The medication profile failed to include the sentry Senior Vitamin; and - The spouse stated the patient takes Dulcolax (laxative) suppositories as needed for constipation. The spouse stated he/she administered two suppositories to the patient this morning and one on Sunday. The medication profile failed to include the Dulcolax suppositories. Per interview conducted during the observation, RN B stated that he/she would notify the physician and get the discrepancies clarified. During an interview on 10/03/2024 starting at 4:59 PM, the administrator stated that he/she would expect medications to be reconciled every visit and expected all medications the patient was taking to be on the medication profile. Findings included: Review of the providers policy titled, ";PC.85 Medication List and Monitoring," last reviewed 09/01/2024, showed in part: - A medication/drug profile will be maintained on all patients; - Medication monitoring will include appropriate data/information to develop an accurate patient medication history and a current, complete medication profile; - The Hospice will review, monitor and maintain a current, accurate list of all prescription and over the counter medications, herbal remedies and other alternative treatments that could affect drug therapy taken by patient; - The medication will be documented on the medication/drug profile; - The medication/drug profile will also include: ** Dosage, frequency, and route; and **administration schedule. - Changes in the medication/drug regimen will be documented in the medical record either on the medication profile, or a verbal order plan of care, as well as communicated to the patient and/or caregiver; 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 was admitted to hospice services on 07/11/2024 with a primary diagnosis of Parkinson's disease without dyskinesia, without mention of fluctuations (a neurological disorder that causes unintended or uncontrollable movements or stiffness, but currently without involuntary muscular movements or fluctuations). The patient resided in a long-term care facility (LTCF). Review of SN (skilled nurse) visit note dated 07/30/2024 showed ";received call from facility nurse that the patient had a bleeding, open wound to his/her groin. The medical director was notified and was okay with barrier cream (a product applied directly to the skin surface to help maintain the skins physical barrier, providing protection from irritants and preventing the skin from drying out) application and to reassess at the next routine SN visit 7/31/2024". (A physician order for the barrier cream failed to be documented). Review of the SN visit note dated 7/31/2024 showed ";redness in groin, barrier cream present in perianal area upon assessment". Review of the SN visit note dated 8/3/2024 showed ";redness in groin improved- barrier cream present- education provided". Review of POC order dated 08/15/2024 showed under the GU (genitourinary)/Urinary elimination problem section in the POC: barrier cream present- education provided (it failed to have any further directions). Further review of the clinical record failed to show a physician order for barrier cream. Review of the provider's current medication profile report provided to the surveyor failed to show Cetaphil moisturizing cream (a cream used to heal and soothe extremely dry skin, chapped lips, cracked hands and heels and other minor skin irritations), nystatin powder (anti-fungal used to treat fungal infections of the skin), or barrier cream. Observation on 10/01/2024, starting at 2:00 PM, the patients medications were reconciled utilizing the current medication profile report supplied to the surveyor by the provider and the 10/01/2024 physician order review provided by the LTCF. The following discrepancies were noted: - Each failed to show barrier cream listed; - The LTCF physician orders dated 10/01/2024 showed Cetaphil moisturizing cream apply to back twice daily as needed and Nystatin powder apply to abdominal folds topically twice daily as need. (These failed to be listed on the providers current med profile report. During an interview on 10/03/2024 at 1:30 PM the administrator stated that he/she: - Was unable to find an order for the barrier cream; - The physician had been notified and an order was received and the facility was notified of the new order; and - The medications should match. (facility/hospice provider)

Based on policy review, record review, home visit observation, and interview, the hospice provider failed to follow an individualized plan of care (POC) in, three of five full records reviewed (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice service on 03/29/2024 with a primary diagnosis of malignant neoplasm (a cancerous tumor) of upper lobe of the right lung. The patient resided at his/her home with his/her daughter. Review of the patients ";Plan of Care" dated for benefit period 06/27/2024 to 09/24/2024 and 09/25/2024 to 11/23/2024 showed in part, the patient/caregiver was able to administer tube feeding and provide care for tube insertion site. Observation on 10/01/2024 at 11:35 AM showed that the patient did not have a feeding tube. Review of the patient's interdisciplinary group (IDG) meeting notes dated 09/12/2024 showed in part RN (registered nurse) recertification details that bottom was excoriated and barrier cream applied daily as needed. Review of the patients ";Plan of Care" dated 09/26/2024 failed to show orders for zinc oxide (a barrier cream used to protect skin from moisture) and application instructions. Review of the patients ";Aide Care Plan Instructions" dated 10/01/2024 failed to show instructions to apply zinc oxide. Observation on 10/01/2024 at 11:45 AM showed the hospice aide (HA)-A applied zinc oxide to the patients coccyx wound. As the HA-A applied the zinc oxide he/she stated that he/she would ";let the nurse know." HA-A failed to contact the case manager nurse before applying the zinc oxide. Review of the patients ";Plan of Care" dated 09/26/2024 for the benefit period of 09/25/2024 to 11/23/2024 showed the hospice aide frequency for two times per week. Review of the patients interdisciplinary group meeting notes dated 09/26/2024 showed the hospice aide frequency for two times per week. Review of the patients ";Aide Care Visit" notes dated 10/01/2024 showed the hospice aide frequency for three times per week. During an interview on 10/01/2024 at 12:15 PM, the HA-A stated that the patient is scheduled for a bed bath three times per week. HA-A stated that he/she reads the care plan to know how many times a week he/she visits the patient. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice service on 12/28/2023 with a primary diagnosis of Wernickes encephalopathy (a degenerative brain disorder caused by the lack of vitamin B1). The patient resided at a long term care facility (LTCF). Review of the patients ";Plan of Care" dated 12/29/2023, 08/15/2024, 08/29/2024, 09/12/2024, and 09/26/2024 showed in part the following the patient/caregiver was able to administer tube feeding and provide care for tube insertion site. During an interview on 10/01/2024 at 10:35 AM, the assistant director of nursing (ADON)-A stated that the patient was never administered tube feeding. Findings included: Review of the hospice provider's policy titled, "PC.P50 Plan of Care," with a copyright date of 2021, showed in part: - The interdisciplinary written plan of care is based on initial and updated patient specific comprehensive assessments by members of the IDG (interdisciplinary group) and is developed with measurable goals and outcomes for planned interventions; - The care and services provided/delivered to patients and their families are in accordance with an individualized, written plan of care established by the hospice IDG in collaboration with the patients attending physician, the patient and/or his or her representative and the primary caregiver in accordance with the patients needs if any of them so desire; and - Care provided to an individual patient is in accordance with the plan of care. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 07/11/2024 with a primary diagnosis of Parkinson's disease without dyskinesia, without mention of fluctuations (a neurological disorder that causes unintended or uncontrollable movements or stiffness, but currently without involuntary muscular movements or fluctuations). The patient resided in a long-term care facility. Review of the POC orders dated 07/18/01 and 08/01/2024 showed: cleanse area to medial back with wound cleanser, pat dry, apply xeroform gauze (a nonadherent primary dressing that maintains a moist wound environment) to wound bed and cover with dry dressing once daily. Review of the SN (skilled nurse) visit notes dated 07/22/2024 and 08/02/2024 failed to show documentation that the wound care was performed. During an interview on 10/03/2024 at 4:56PM, the administrator stated that he/she would expect the wound care to be completed/documented. During an interview on 10/03/2024 at 5:22PM, the RN/Regional Executive Director stated that documentation that wound care was provided would be expected.

Based on policy review, record review, and interview, the hospice provider failed to ensure coordination of care when the on-going sharing of information between all disciplines providing care failed to be provided in a discharge summary during a respite stay in, one of one record reviewed for respite care (Record/Patient #6) and failed to involve the interdisciplinary group (IDG) when one patient chose to revocate for aggressive treatment in, one of two records reviewed for revocation (Record/Patient #8). This deficient practice has the potential to adversely affect communication and care to all the provider's patients in respite care and patients that choose to revocate. --- Findings included: Review of the policy titled, ";PC.C90 Coordination of Services" dated 2012, showed in part: - The hospice will maintain a system of communication and integration, in accordance with the hospice's own policies and procedures, to provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement; and - An assigned hospice registered nurse (RN) Case Manager coordinates the patients plan of care (POC) and facilitates the ongoing sharing of information with the attending physician, contracted facilities, vendors, other members of the IDG and non-hospice healthcare providers. RECORD/PATIENT #6: Review of the clinical record, showed in part: - The patient was admitted to hospice services on 02/06/2024 with a primary diagnosis of alcohol dependence with alcohol-induced persisting dementia; - The patient lived at home with his/her spouse as primary caregiver; - The patient was admitted to a long-term care facility (LTCF) for a respite stay on 03/26/2024 to 03/30/2024; and - The clinical record failed to include record that the discharge summary was provided to the hospice provider after discharge from his/her respite stay at the LTCF. During an interview on 10/02/2024 at 3:35 PM, the Regional Executive Director (Governing Body Designee)-A, stated that the discharge summary was missing, and they should have already had it from the LTCF. During an interview on 10/03/2024 at 1:25 PM, the hospice team coordinator stated no facility sends discharge summaries to the provider when they go in for respite. RECORD/PATIENT #8: Review of the clinical record, showed in part: - The patient was admitted to hospice on 08/29/2024 with a primary diagnosis of hypertensive heart disease without heart failure (long-term high blood pressure, which causes the heart to work harder and thicken over time); and - The patient lived at a LTCF. Review of the Medicare Hospice Benefit Revocation dated 08/30/2024, showed the reason for revoking the benefit was for aggressive treatment. Review of the revocation statement documented by the skilled nurse (SN) dated 08/30/2024, showed in part: - Comments: Patient was being transported to his/her daughter's home by family in a private vehicle from a LTCF, when the family decided to take the patient to the hospital for aggressive treatment; - The SN coordinated with the pharmacy and the durable medical equipment (DME) provider; and - The SN coordinated with the patients daughter and the hospital emergency department staff. Review of the clinical record failed to show the SN coordinated the revocation information with the IDG. During an interview on 10/03/2024 at 12:56 PM, the hospice team coordinator stated an email was sent to the billing department on 08/30/2024, but did not include the entire IDG.

Based on policy review, record review, and interview the hospice provider failed to ensure nursing followed policy and procedure for wound care in one of five full records reviewed (Patient/Record #3). This deficient practice has the potential to adversely affect wound management for all the provider's patients with wounds. --- RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice service on 03/29/2024 with a primary diagnosis of malignant neoplasm (a cancerous tumor) of upper lobe of the right lung. The patient resided at his/her home with his/her daughter. Review of the electronic wound assessments provided by the administrator dated 07/03/2024, 07/18/2024, 07/31/2024, 08/14/2024, 08/28/2024, 09/11/2024, and 09/25/2024 showed the registered nurse failed to document wound measurements every 14 days. Findings included: Review of the hospice providers undated policy titled, ";PC.C60.1 Skin Assessment Policy- Addendum", showed, in part: - ";Named Hospice" will assess/evaluate any wound/skin issues in coordination with patient/caregiver/facility staff; - Any skin impairment issues will be evaluated/assessed by the hospice skilled nurse at lease every 14 days and as needed; - Wound measurements are to be completed on any skin impairment issue at time of admission and at least with every comprehensive nursing assessment to assess response to ordered interventions; and - Documentation of wounds/skin issues will be documented per the wound assessment provided via the electronic medical record system. Review of the hospice providers policy titled, ";PC.D25 Documentation Requirements", with a copyright date of 2021, showed, in part: - Members of the interdisciplinary group document the interventions provided to the patient/caregiver, their response to care, services provided, and the goals or outcomes achieved; - Documentation is completed by all Hospice staff and volunteers whenever patient/caregiver visits occur; and - The patient record documentation provides patient information specific to care and services/products provided, current patient status, and progress toward goals and outcomes of care. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 07/11/2024 with a primary diagnosis of Parkinson's disease without dyskinesia, without mention of fluctuations (a neurological disorder that causes unintended or uncontrollable movements or stiffness, but currently without involuntary muscular movements or fluctuations). The patient resided in a long-term care facility (LTCF). Review of the SN (skilled nurse) visits dated 07/22/2024 and 08/03/2024 failed to show any wound description documented. During an interview on 10/03/2024 at 5:15PM, the RN/regional executive director stated that: - The providers policy was for wound measurements to be documented every 14 days; and - He/She would expect some sort of wound description documented at each SN visit.

Based on volunteer record review and interview, the provider failed to provide volunteer administrative and/or direct patient care services in the amount at a minimum, equaling five percent of the total patient care hours of all paid hospice employees and contract staff during 2023/2024 (the past 12 months). This deficient practice has the potential to affect the provider's ability to provide volunteer services to patients. --- Findings included: Review of the policy titled, ";Volunteers - Services" dated 2021, showed in part: - The Volunteer Program is designed to meet Federal regulations for the provision of volunteer services to hospice patients and their caregivers. The Volunteer Program is monitored on a continuous basis to ensure it is functioning as intended and meeting the needs of the hospice program and its patients; - Volunteers are used in defined roles to support ancillary, administrative and/or patient care services and are treated as employees; and - Active and ongoing recruitment and retention efforts are sufficient to ensure that the hospice has enough volunteers to meet the needs of patients and families and the requirements of Federal regulations. Documentation is kept regarding these efforts. Review of the volunteer records for 2023 and 2024 (combined total for the past 12 months) showed the actual combined percentage of administrative and direct patient care by trained volunteers equaled 1.6% of the total patient care hours of all paid hospice employees and contracted staff. During an interview on 10/03/2024 at 10:30 AM, the administrator stated that he/she had noticed a problem with the volunteer program when he/she started as the administrator approximately two months ago and he/she educated the volunteer coordinator. The volunteer coordinator did not do what was required and a new volunteer coordinator was hired. The new coordinator is doing good and is reaching out to increase the volunteer program.

Based on policy review, record review, and interview, the hospice provider failed to ensure all visit entries were completed and authenticated in, but not limited to, one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the providers patients. --- Findings included: Review of the providers policy titled ";Documentation Requirements" copyright 2021, showed in part, documentation was: - Completed by all hospice staff whenever the patient visit occurred; and - Accurate and timely. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice service on 03/29/2024 with a primary diagnosis of malignant neoplasm (a cancerous tumor) of upper lobe of the right lung. The patient resided at his/her home with his/her daughter. Review of the skilled nursing (SN) visit dated 09/20/2024 showed the right buttock wound was ";resolved" on 09/29/2024 (nine days after visit date) and treatment to the coccyx (tailbone) wound and left hip wound was ";performed" on 09/29/2024. The registered nurse failed to use accurate dates. Review of the SN visit notes dated 09/23/2024 showed the catheter was ";inadvertently" removed and left out. Review of the ";Aide Care Plan Instructions" comments dated 09/25/2024 showed catheter care was ";completed." Review of the ";Aide Care Plan Instructions" comments dated 10/01/2024 showed the catheter care was ";declined", and the patient did not have a catheter. During an interview on 10/03/2024 at 1:30 PM the administrator stated that he/she would expect the aide care plan to be updated and the provider's policies to be followed.

Based on policy review, record review, and interview, the hospice provider failed to ensure a discharge summary was provided to the patients attending physician upon discharge from the hospice when a patient moved out of the hospice service area and was admitted to a non-contracted facility, in one of one applicable record reviewed (Record/Patient #10). This deficient practice has the potential to adversely affect the post discharge continuity of care for all the live patients discharged by the provider. --- Findings included: Review of the provider's policy titled, ";Patient Discharge" last reviewed on 09/01/2024, showed in part: - The Hospice will forward copies of the following to the patients attending physician upon discharge from the Hospice's services; * The Hospice discharge summary which includes but is not limited to: * A summary of the patient's care (pain management, symptoms and treatments); * The patient's current plan of care (POC), including the current medication profile; * The latest physician orders; and * Any other documentation requested or that may assist with the patients post-discharge continuity of care. RECORD/PATIENT #10: Review of the clinical record, showed in part: - The patient was admitted to hospice services on 04/23/2024 with a primary diagnosis of malignant neoplasm of upper lobe, right bronchus or lung (cancer of the right bronchus or lung); - The patient resided at a long-term care facility (LTCF); - The patient was transported via emergency medical systems (EMS) to a medical center after attempting suicide by cutting his/her wrists; - Hospice was notified at 10:30 AM on 05/28/2024; - The hospital verbalized the patient was now under admitted status as of 05/28/2024 for suicide observation with no outside contact; and - The clinical record failed to include record that the discharge summary was provided to the patients attending physician after discharge from hospice services. During an interview, on 10/03/2024, beginning at 1:23 PM the hospice team coordinator stated that there was no proof the discharge summary had been sent to the attending physician.

Based on policy review, record review, observation, and interview the hospice provider failed to ensure coordination of responsibility for wound care between the hospice provider and the long-term care facility (LTCF) in one of two records reviewed of patients that resided in a LTCF (Record/Patient #3). This deficient practice has the potential to adversely affect all hospice patients residing in a LTCF. --- Findings included: Review of the hospice providers policy titled, ";Hospice care in a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facilities for individuals with intellectual disabilities,) dated last reviewed 09/01/2024, showed in part: - The hospice will assume responsibility for professional management of the patient's hospice services provided, in accordance with the hospice plan of care (POC) and the hospice conditions of participation and make any arrangements necessary for hospice related inpatient care; - A Hospice POC will be developed based on the patient's/familys needs. The POC will be written in collaboration with the interdisciplinary group/team (IDG/ IDT), facility staff, patient and/or the family, and the attending physician. 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 plan of care. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 07/11/2024 with a primary diagnosis of Parkinson's disease without dyskinesia, without mention of fluctuations (a neurological disorder that causes unintended or uncontrollable movements or stiffness, but currently without involuntary muscular movements or fluctuations). The patient resided in a LTCF. Review of the POC orders dated 07/18/2024 and 08/01/2024 showed: cleanse area to medial back with wound cleanser, pat dry, apply xeroform gauze (a nonadherent primary dressing that maintains a moist wound environment) to wound bed and cover with dry dressing once daily. (The POC failed to show who was responsible for the dressing changes (hospice or the facility). Review of the coordinated task plan dated 07/11/2024, in the facility binder, showed the portion under the wound care schedule was left blank. Per interview conducted during observation, on 10/01/2024 at 2:00 PM RN A stated that he/she did not see where the coordinated task plan identified who was changing the dressing or when. During an interview on 10/03/2024 at 4:56 PM, the administrator stated that he/she would expect the wound portion on the coordinated task plan to be filled out and who was responsible and when.

Based on policy review and interview, the provider failed to ensure orientation of long-term care facility (LTCF) staff caring for hospice patients on the hospice philosophy, including hospice policies and procedures regarding methods of comfort, pain control, symptom management, as well as principals about death and dying, individual responses to death, patient rights, appropriate forms and record keeping requirements. This deficient practice has the potential to affect all patients residing in a LTCF. --- Findings included: Review of the policy titled ";PC.H50 Hospice Care for Nursing Facility Residents – Coordination of Services" dated 2021, showed in part: - The hospice provider ensures that mechanisms are in place to provide for the coordination of all hospice services provided to patients residing in facilities; - Hospice staff provide orientation to skilled nursing facility (SNF) staff furnishing care to hospice patients which includes: * Hospice philosophy, including hospice policies and procedures regarding methods of comfort, pain control and symptom management; * Principles about death and dying and individual responses to death; * Patient rights; * Appropriate forms; and * Record keeping requirements. During the survey entrance on 09/30/2024 at 10:30 AM, evidence that hospice philosophy training was offered to SNF/nursing facilities (NF) was requested from the provider administrator. The provider failed to provide evidence of training offered to the SNF/NF facilities. During an interview on 10/03/2024 at 2:35 PM, the administrator stated there was nothing prior to the SNF/NF being offered education on hospice philosophy. He/she did not know it was to be done, and it should have been done.

Based on review of the agency's Emergency Preparedness (EP) binder, and interview, the agency failed to ensure contact information was included and updated for federal emergency preparedness staff. This deficient practice has the potential to adversely affect the care and safety of all patients served by the agency during an emergency. Findings included: Review of the agency's EP binder showed no contact information for federal EP staff. During an interview on 04/12/2022 at 4:47 PM, the administrator and director of nursing stated that there was no federal emergency management agency (FEMA) contact information in the EP binder.

Based on policy review, personnel file review, and interview, the agency failed to ensure one (Employee #4) employee received emergency preparedness training every two years as required of seven personnel files reviewed. This deficient practice has the potential to affect the care and services provided to all patients during an emergency. Findings included: Review of the agency's policy titled, "Emergency Disaster Preparedness Training and Testing Program," (undated), showed in part: - All current employees, and new employees (upon hire), will be oriented to the emergency disaster preparedness program and will participate in agency planned inservices, training and/or completed self-study modules annually; - Agency employees will actively participate in emergency preparedness practice drills and and testing, both internal and community-wide drills (if available) annually; - The agency will maintain documentation of all employee training and testing for at least three years; - The facility will update the training and testing program annually based on any lessons learned from the most recent exercises; - All current employees, including prn (as needed) or per-diem staff, and volunteers will attend a facility planned inservice for initial training in emergency preparedness; - Employees will complete assigned self-study modules annually; and - Current employees will annually participate in a planned full-scale exercise. EMPLOYEE #4: - Date of hire: 07/17/2017; and - No evidence of emergency preparedness training between 11/08/2018 and 2021. During an interview on 04/13/2022 at 11:50 AM, the human resource manager stated that they did not have documentation that the employee received emergency preparedness training between 2018 and 2021.

Based on policy review, record review, home visit observation, and interview, the agency failed to maintain an accurate/updated medication profile 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 policy titled, "Comprehensive Assessment - Content," (undated), showed in part: - The comprehensive assessment must include a review of medications; and - The comprehensive assessment must include a drug profile, including prescription, over-the-counter drugs, herbal remedies and alternative treatments which included the identification of effectiveness of drug therapy, drug side effects, actual/potential drug interactions, duplicate drug therapy, and drug therapy related to laboratory monitoring. RECORD/PATIENT #1: A home visit observation on 04/12/2022 beginning at 10:00 AM, showed the following discrepancies with the hospice medication profile: -The patient stated that he/she took Preservision (eye/vision supplement) two soft gels daily, folate (vitamin B9 supplement) 800 micrograms (mcg) daily, iron 325 milligrams (mg) daily, vitamin D3 25 mcg daily, B12 1000 mcg daily, and calcium 600 plus vitamin D3 20 mcg one tablet in the morning and one tablet in the evening. The patient stated that he/she had took these for a long time. These were not included on the hospice medication profile; and - The patient had a bottle dated 02/09/2022, of hycosamine (used to treat stomach/intestinal disorders) 0.125 mg one every four hours under the tongue as needed. The patient stated that he/she had not had to use this. This was not included on the hospice medication profile. During an interview on 04/13/2022, beginning at 9:30 AM, the administrator stated that at admission the nurse reviews the medications. The medications are also reviewed at the IDG (interdisciplinary group) meetings. If there are discrepancies or changes they would call the physician to clarify, reconcile the medications, and update the medication profile. During an interview on 04/13/2022 at 12:05 PM, the director of nursing stated that the hycosamine had been discontinued. The nurse did not generate the order to discontinue the medication. The nurse was going today to do a medication reconciliation. RECORD/PATIENT #2: Review of the long term care facility (LTCF) order summary report as of 04/12/2022, showed the following discrepancies with the hospice medication profile: -The hospice medication profile showed an order for famotidine 10 mg daily for GERD (gastroesophageal reflux disease). The facility orders did not include this medication; and -The hospice medication profile showed an order for zinc oxide ointment 20% apply topically to the peri area after incontinent episodes as needed to promote skin integrity. The facility orders showed an order for zinc oxide ointment 10% apply to buttocks topically if soiled and an order for zinc oxide 10% apply to buttocks topically two times a day for skin condition. During an interview on 04/13/2022, beginning at 9:30 AM, the administrator stated that weekly the nurse would get an updated medication list to compare to the facility orders. If there are discrepancies they would clarify the orders with the medical director and facility.

Based on policy review, record review, and interview, the agency failed to incorporate the bereavement assessment into the plan of care (POC), identify/document all potentially bereaved individuals during the initial bereavement assessment, and document contact with the bereaved to complete the assessment in one (Record/Patient #2) of five full records reviewed. This deficient practice has the potential to affect all bereaved individuals served by the agency. Findings included: Review of the agency's policy titled, "Comprehensive Assessment - Content," (undated), showed in part the comprehensive assessment must include the bereavement component that includes a bereavement assessment that considers the needs of the patient's family and other individuals, and focuses on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death; information gathered from the initial bereavement assessment is incorporated into the POC and is considered in the bereavement POC. Review of the agency's policy titled, "Bereavement - Care Planning," (undated), showed in part, that during the initial bereavement assessment, the interdisciplinary group (IDG) identified family members, caregivers, or significant others who may be significantly impacted by the patient's death. Review of the agency's policy titled, "Bereavement - Services," (undated), showed in part, that bereavement services are available to the family and other individuals in the bereavement POC. Bereavement services also extends to residents and facility staff when appropriate and identified in the bereavement POC. RECORD/PATIENT #2: Review of the social work assessment dated 03/25/2022, showed: - The patient lived in a long term care facility (LTCF); - He/she was supported by two nephews, who are both powers of attorney; - One lives out of the country and checks on the patient regularly and the other lived in another state; - One nephew visits every year and checks in with the patient at the facility; and - The patient's nephew reported the patient had been in a LTCF since 2020. Review of the initial bereavement assessment conducted by the bereavement coordinator dated 03/28/2022, listed one nephew as the bereaved. The assessment showed a score of seven which was documented as high risk. The assessment failed to include both family members identified by the social worker or the staff that cared for the patient at the LTCF. Review of the IDG (interdisciplinary group) meeting notes dated 03/28/2022 and 04/11/2022 showed the bereavement coordinator documented the initial visit and bereavement assessment had been completed and would continue to visit once a month to update the record and offer support. Review of the POC dated 03/28/2022 and 04/11/2022 failed to show the bereavement assessment had been incorporated into the POC. During an interview on 04/14/2022 beginning at 9:15 AM, the bereavement coordinator stated that the initial bereavement assessment had been done with the patient. He/she was able to answer the questions on the assessment. They usually try to contact the family member for the assessment. He/she could not think of why he/she did not talk with the named family member and could not find documentation of why. When he/she does the initial bereavement assessment, they make it part of the POC. It is uploaded and documented as part of the ongoing POC. The bereavement assessment for Patient #2 had not been incorporated into the POC. During an interview on 04/14/2022 beginning at 11:30 AM, the administrator stated that when the initial bereavement assessment is performed, the bereavement coordinator talks to the patient, patient's family, and anyone providing support for the patient. This would include facility staff caring for the patient. The initial chaplain assessment is incorporated into the POC. The initial bereavement assessment should be incorporated into the POC.

Based on policy review, record review, and interview, the agency failed to ensure the plan of care (POC) was followed and/or updated with the current visit frequency when visits were not completed as ordered on the POC in one (Record/Patient #1) of five full record reviews reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Plan of Care," (undated), showed in part: - Care is provided to an individual patient in accordance with the POC; and - The POC is revised as needed. RECORD/PATIENT #1: Review of the POC dated 02/08/2022 through 04/11/2022 showed the patient was admitted to hospice service on 02/08/2022. The patient's terminal diagnosis was malignant neoplasm (cancer) of the esophagus. The chaplain was to visit two times a month. Review of the record showed only one chaplain visit in February and March, 2022. Review of a missed visit form dated 02/28/2022 and 03/31/2022, showed the chaplain documented that his/her supervisory was informed to do a missed visit due to two orders in the system for February and March. Review of the IDG (interdisciplinary group) meeting notes showed from 02/14/2022 through 03/28/2022 the chaplain documented he/she would visit one time a month. On 04/11/2022 the chaplain documented that a routine visit was completed and would continue to visit to update chart and offer support. The POC had not been updated to reflect that the chaplain would visit one time a month. During an interview on 04/13/2022 beginning at 9:30 AM, the administrator stated that the POC should be updated with any changes in visit frequency.

Based on policy review, record review, and interview, the agency failed to develop an individualized plan of care (POC) in four (Records/Patients #2, #3, #4 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 policy titled, "Plan of Care," (undated) showed in part: - The 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; - Care is provided to an individual patient in accordance with the POC; and - The POC is revised as needed. RECORD/PATIENT #2: Review of the registered nurse (RN) initial assessment dated 03/22/2022, showed: - The patient resided in a long term care facility (LTCF); - The patient was cachectic (a general state of ill health involving weight and muscle loss) with significant fat and muscle wasting and food intake was poor; - Skin is fragile with vertebrae and hip bones protruding; and - Has a healed wound to the right heel but skin is fragile. Preventative ABD (large, thick pad) and Kerlex (gauze wrap) applied. Review of the LTCF order summary report as of April 12, 2022, showed: - Fortified food plan. Ice cream to be served with lunch and dinner; - Med pass 2.0 (nutritional supplement) 120 milliliters (ml) four times a day for weight loss; - Pudding for lunch and dinner; and - Apply skin prep (protective barrier) to both heels daily to prevent skin breakdown. Cushion boots to be worn while in bed. Review of the POC dated 03/28/2022 and updated 04/11/2022, showed: - Terminal diagnosis of subarachnoid hemorrhage (bleeding in the brain), other diagnoses included protein calorie malnutrition (inadequate protein and calorie intake); - The nutrition portion showed a goal that the patient/caregiver would be able to administer tube feedings and provide care for the tube insertion site (The patient did not have a tube feeding); - Did not include the interventions for fortified food plan, ice cream and pudding at lunch and dinner, med pass 2.0 four times a day; and - Did not include problems, goals and interventions for skin integrity. During an interview on 04/13/2022 beginning at 9:30 AM, the administrator stated that skin integrity and nutritional interventions should be included on the POC. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice on 02/09/2022, with a terminal diagnosis of COVID-19 acute respiratory disease with a co-morbidity of pneumonia (infection in lungs) due to coronavirus disease. Per interview conducted during the patient's home visit, on 04/13/2022 at 9:00 AM, the patient's family member stated that the COVID-19 and pneumonia had resolved. The family member stated that patient was still on hospice due to brain cancer. Review of the POC dated 04/11/2022 showed the agency failed to update the POC to show the COVID-19 and pneumonia was resolved. During an interview 04/13/2022 at 11:50 AM, the administrator stated that the terminal illness should have been changed after the COVID-19 and pneumonia were resolved. RECORD/PATIENT #4: Review of the RN initial assessment dated 03/25/2022, showed: - The patient resided in a LTCF; - The patient's primary diagnosis was senile degeneration of the brain (mental deterioration of the brain); and - Marital status showed widow/widower. Review of the master of social work (MSW) assessment dated 03/29/2022, showed the patient's marital status as widowed. Review of a refusal of visits form dated 03/24/2022 showed the patient elected to refuse service of volunteer. Review of the POC dated 03/25/2022 to 06/22/2022, showed: - Coordination of care - Care type - Volunteer - provide caregiver relief to husband per POC (the patient was widowed and had declined volunteer services). During an interview on 04/13/2022 at 2:40 PM, the director of nursing stated that the POC should be individualized. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice on 02/24/2022 with a terminal diagnosis of other chronic osteomyelitis (infection of the bone), other site. Review of the POC dated 04/11/2022 showed: - Comorbidities included abnormal weight loss and anorexia; and - No interventions regarding the abnormal weight loss and anorexia. During an interview on 04/13/2022, at 12:00 PM, the administrator stated that the comorbidities should have addressed on the POC.

Based on nationally-recognized standards, policy review, record review, and interview the agency failed to ensure the nursing needs of the patient were assessed and met in, but not limited to, one (Patient #5) of five full records reviewed. This deficient practice has the potential to adversely affect wound management for all the agency's patients with wounds. Findings included: Review of the article by Karen S. Clay, RN, BSN, CWCN Copyright 2008 titled, "Evidence Based Pressure Ulcer Prevention: A Study Guide for Nurses," showed the following: "The standard of practice requires at least weekly measurement of the wound. In addition, every time you change the dressing, assess peri-wound skin, wound margins, wound tissue, drainage, odor, pain, and any other relevant issues. (http://www.hcpro.com/content/76944.pdf Chapter 9-Wound Healing-Page 95) Review of the agency's policy titled, "Comprehensive Assessment," dated 2021, showed in part, the comprehensive assessment is a thorough evaluation of the patient's physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions. Review of the agency's policy titled, "Documentation Requirements," dated 2021, showed in part, members of the interdisciplinary group document the interventions provided to the patient/caregiver, their response to care, services provided, and the goals or outcomes achieved. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice on 02/24/2022 with a terminal diagnosis of other chronic osteomyelitis, other site. Review of the registered nurse (RN) initial assessment dated 02/24/2022 showed a wound to the right mandible (jaw) measuring 3.5 centimeters (cm) in length and 2.4 cm in width with a depth of 0.4 cm. Review of the plan of care (POC) dated 02/24/2022, showed: - Skilled nurse visits three times per week; and - Wound care orders included to right mandible owund , clenase with wound cleanser, pat dry, apply skin barrier cream to peri wound, place calcium aliginati, to wound bed cover with 4 x 4 dressing and caregiver to perform on days hospice not present. Review of the SN visits dated 02/25/2022, 02/28/2022, 03/11/2022, 03/25/2022, 03/28/2022, 04/01/2022, and 04/04/2022 failed to show an assessment of the wound. During an interview on 04/13/2022 at 12:00 PM, the director of nursing stated that there should have wound documentation on these visits.

Based on policy review and record review, and interview, the hospice aide failed to follow the aide care plan as assigned by the registered nurse (RN) in two (Records/Patients #1 and #4) of three records that received aide services. This deficient practice has the potential to affect all patients that received aide services. Findings included: Review of the agency's policy titled, "Hospice Aide Assignments and Duties," (undated), showed in part, that hospice aides are assigned to specific patients by a hospice RN that is a member of the interdisciplinary group and follow written patient care instructions in providing care to assigned patients. RECORD/PATIENT #1: Review of the plan of care (POC) dated 02/08/2022, showed the patient was admitted to hospice with a terminal diagnosis of malignant neoplasm (cancer) of the esophagus. The aide frequency was two times a week. Review of the aide care plan dated 02/08/2022, showed the aide was to visit the patient two times a week. Review of the aide visits showed the aide visited once the week of 02/08/2022. The findings were reviewed with the administrator on 04/13/2022, beginning at 9:30 AM. No further information was provided. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice service on 3/24/2022 with a primary diagnosis of senile degeneration of the brain (mental deterioration of the brain). The patient resided in a skilled nursing facility. Review of the POC dated 03/25/2022 to 06/22/2022 showed hospice aide visit frequency was two times a week. Review of the aide care visit note was dated 3/28/2022 during the second week of hospice service. During a interview on 04/13/2022 at 10:37 AM, the director of nursing (DON) stated there was no order to miss the first week of service for the aide visit. The findings were reviewed with the hospice administrator and DON on 04/13/2022 at 2:23 PM. The DON stated the agency weeks are Sunday to Saturday, and the aide did not do visits the first week because the patient admitted on a Thursday or Friday.

Based on record review, policy review, and interview, the agency failed to include in the patient's clinical record a copy of the patient's advance directive in one, (Record/Patient #4) of five full records reviewed. This deficient practice has the potential to affect the end of life care for all the agency's patients. Findings included: Review of the agency's policy titled, "PC.A35 Advance Directives," dated Patient Care copyright 2021, showed, in part, the patient's physician signs do not resuscitate (DNR) orders and a copy is placed in the patient's clinical record. RECORD/PATIENT #4: Review of the clinical record showed: - The patient was admitted to hospice services on 03/24/2022 for a primary diagnosis of senile degeneration of the brain (mental deterioration of the brain); - The admission nursing assessment dated 03/25/2022 documented patient code status is a DNR; and - No signed copy of the DPOA form. During an interview on 04/13/2022 3:09 PM, director of nursing stated there was no copy of the DNR on file.

Based on policy review and record review, the agency failed to ensure physician orders were obtained in, but not limited to, two (Records/Patients #3 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 policy titled, "Physician Orders," dated 2021, showed in part, that verbal orders are received, processed, confirmed in writing and countersigned by the physician in accordance with state/federal laws and regulations. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice on 02/09/2022 with a terminal diagnosis of COVID-19 acute respiratory disease. Review of the medication profile dated for the period of 02/09/2022-05/09/2022 showed, oxygen (shortness of air) per nasal cannula for shortness of air and comfort. Titrate for comfort. (No flow rate) Review of the skilled nurse visit, dated 03/22/2022, showed the nurse ordered an oxygen concentrator and nebulizer treatment. Review of the clinical record failed to show the following physician orders: - 02/09/2022 Oxygen flow rate order; and - 03/22/2022 Nebulizer order. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice on 02/24/2022 with a terminal diagnosis of other chronic osteomyelitis, other site. Review of the medication profile dated for the period 02/24/2022-04/24/2022 showed, oxygen per nasal cannula for shortness of air and comfort. Titrate for comfort. (No flow rate) Review of the clinical record failed to show a physician order for the oxygen flow rate. During an interview on 04/13/2022 at 11:50 AM, the director of nursing stated that there should be a flow rate for oxygen orders.

Based on policy review, record review, and interview, the agency failed to document a transfer summary that included a summary of the patient's stay including treatments, symptoms, and pain management in one (Record/Patient #8) of one transfer record reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Discharge from Hospice," (undated), showed in part, when a patient is discharged from hospice (by discharge, transfer, or revocation), the hospice provides a copy of the clinical record (if requested) and the hospice discharge summary to the patient's attending physician and any new agency providing care, if applicable. The discharge summary is filed in the clinical record and includes: *The date and reason for discharge; *Any instructions or referral information given to the patient or family; *Patient identifying information; *Hospice diagnosis; *Significant health history; *Discharge orders, instructions, medication profile, and allergies, if discharge other than patient death; *Status of patient at time of discharge; *Brief description of services provided and ongoing needs that cannot be met; *A copy of the patient's current plan of care, including the current drug profile; *Presence of advance directives; *End of life decisions; and *Any other documentation that will assist in post-discharge continuity of care or is requested by the attending physician or receiving facility. RECORD/PATIENT #8: Review of a discharge form dated 03/16/2022 showed the patient transferred to another hospice in another state to live with his/her family. Review of the transfer paperwork showed no transfer summary that included a summary of the patient's stay including treatments, symptoms, and pain management. During an interview on 04/14/2022, at 10:52 AM, the administrator stated that a referral packet was sent to the receiving hospice but not a written summary that summarized the patient's stay.

Based on review of the written agreement for respite services, record review, and interview, the agency failed to obtain a discharge summary from the skilled nursing facility (SNF) that provided respite services (inpatient care for caregiver relief) for one (Record/Patient #6) of one patient record reviewed for respite care. This deficient practice has the potential to affect coordination of care for hospice patients who receive respite care. Findings included: Review of the written agreement for respite services with the SNF that provided Patient #6's respite care, showed the facility must provide a discharge summary to the hospice agency at the time of discharge. RECORD/PATIENT #6: Record review showed the patient received respite care from 03/21/2022 to 03/26/2022. The record failed to include a discharge summary for the respite stay. During an interview on 04/14/2022 at 11:29 AM, the administrator stated that they did not have a discharge summary from the facility and placed a call 04/13/2022 to the facility to get a discharge summary.

Based on record review and interview, the agency failed to ensure the coordinated plan of care included the frequency of visits for all disciplines and the days of the week the nurse and aide would visit in two (Records/Patients #2 and #4) of two records reviewed of patients that resided in a long term care facility (LTCF) and failed to ensure the disciplines were named in one (Record/Patient #4) of two records reviewed of patients that resided in a long term care facility (LTCF). This deficient practice has the potential to affect the coordination of care of all patients residing in a LTCF. Findings included: RECORD/PATIENT #2: Review of the LTCF coordinated task plan dated 03/22/2022, failed to include the frequency of visits for all disciplines and failed to include which days of the week the hospice nurse and aide would visit the patient. During an interview on 04/13/2022, beginning at 9:30 AM, the administrator stated that after admission, the next case manager that saw the patient should update the visit frequency on the coordinated task plan. RECORD/PATIENT #4: Review of the LTCF coordinated task plan dated 03/25/2022, failed to include the names for all disciplines and failed to include which days of the week the hospice nurse and aide would visit the patient. During record review on 04/13/2022 at 2:40 PM, the director of nursing stated the disciplines names should be on the coordinated task plan and the days of the visits should be identified.

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 #2) of two applicable records 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 policy titled, "Hospice Care for Nursing Facility Residents - Coordination of Services," (undated), showed in part, the hospice will provide the following information to the facility: - The most recent hospice plan of care specific to each patient; - Hospice election form and any advance directives specific to each patient; - Physician certification and recertification of the terminal illness specific to each patient; and - Hospice physician and attending physician orders specific to each patient. RECORD/PATIENT #2: Review of the hospice record maintained at the long term care facility (LTCF), during a home visit observation on 04/12/2022 beginning at approximately 12:20 PM, showed it failed to contain the following required information: - Physician certification; - Advance directive information; and - Hospice physician and attending physician orders. The findings were reviewed with the administrator on 04/13/2022 beginning at 9:30 AM. No further information was provided.

Based on review of Missouri state law, policy review, personnel file review, and interview, the agency failed to obtain the results of the employee disqualification list (EDL) checks prior to hire in four (Employee #1, #2, #3, and #7) 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." Review of the agency's policy titled, "Criminal Background Checks," (undated), showed in part: - Prior to an offer of employment to personnel and volunteers, the agency will conduct a Missouri criminal background check and make an inquiry to the department of health and senior services whether the person is listed on the employee disqualification list. EMPLOYEE #1: - Date of hire: 05/19/2021; and - EDL check 05/19/2021. EMPLOYEE #2: - Date of hire: 11/03/2020; and - EDL check 11/03/2020. EMPLOYEE #3: - Date of hire: 05/04/2021; and - EDL check 05/04/2021. EMPLOYEE #7: - Date of hire: 09/07/2021; and - EDL check 09/07/2021. During an interview on 04/13/2022 at 11:15 AM, the human resource manager stated that they do all the EDL checks on the day of hire.

Based on federal law and Missouri state law review, personnel file review, and interview, the agency failed to assure Alzheimer's training was provided annually and included all the requirements to two hospitality specialist (Hospitality Specialist #1 and #2) that communicate with Alzheimer patients in person and on the phone and one employee (Employee #4) of seven personnel files reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of 19 CSR 30-35.010 (2) (M) 1. B. (xiii) requires: "Alzheimer's disease and related dementias. Hospice agencies shall provide dementia-specific training about Alzheimer's disease and related dementias to their employees and those persons working as independent contractors who provide direct care to or may have daily contact with residents, patients, clients or consumers with Alzheimer's disease or related dementias. (a) At a minimum, the training required shall address the following areas: A. An overview of Alzheimer's disease and related dementias; B. Communicating with persons with dementia; C. Behavior management; D. Promoting independence in activities of daily living; and E. Understanding and dealing with family issues. (b) Employees or independent contractors who do not provide direct care for, but may have daily contact with, persons with Alzheimer's disease or related dementias shall receive dementia-specific training that includes, at a minimum: A. An overview of Alzheimer's disease and related dementias; and B. Communicating with persons with dementia. (c) Dementia-specific training about Alzheimer's disease and related dementias shall be incorporated into orientation for new employees with direct patient contact and independent contractors with direct patient contact. The training shall be provided annually and updated as needed." HOSPITALITY SPECIALIST (HS) #1: During interview on 4/13/2022 at 12:07 PM, HS #1 stated he/she had no Alzheimer's training and that he/she answers phone calls from patients and their family members with Alzheimer's. HS #2: During interview on 4/13/2022 at 1:33 PM, HS #2 stated he/she had some Alzheimer's training with human resources when he/she first started and that he/she was in orientation training with caregivers and probably heard some information on Alzheimer's training then. He/she talks to patients on the phone and occasionally patients come into the agency, but mostly talks to them on the phone. During interview on 4/13/2022 at 11:15 AM, the human resources manager stated the two hospitality specialist at front desk of the agency answer calls from patients and families and they do not do any type of Alzheimer's training. The findings were reviewed with the hospice administrator on 04/13/2022 at 2:23 PM. He/she stated that there was no annual Alzheimer's training for the hospitality specialist. EMPLOYEE #4: - Date of hire: 08/17/2017; and - No evidence of annual Alzheimer's dementia training since November, 2018. During an interview on 04/13/2022 at 11:50 AM, the human resource manager stated that they did not have documentation of the employee's annual Alzheimer's dementia training after 2018. During an interview on 04/14/2022 at 1:05 PM,, the vice president of hospice stated that he/she could not find a specific policy for Alzheimer's and dementia training.