Every finding on record at Placid Path Hospice, LLC

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participations (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) regarding Patient Rights was met as followed: --- 1. The HA failed to ensure Patient 2 was free and protected from physical abuse (refers to abuse perpetrated through any action intended to cause physical harm or pain, trauma, or bodily harm [e.g., hitting, slapping, punching, kicking, pinching, etc.]) from Certified Home Health Aid (CHHA). 2.Ensure the HA conducted an investigation regarding the alleged physical abuse of Patient 2. 3. Ensure the HA reported the alleged physical abuse incident to the Department of Public Health and the Local law enforcement. 4. Ensure the HA conducted a thorough investigation on a complaint of CHHA being rude to Patient 8. As a result, Patient 2 experienced physical abuse and sustained red markings to her right arm when CHHA provided nursing care on 3/6/2024 at Patient 2s Skilled Nursing Facility (SNF), and Patient 8s complaint of CHHA being rude to her on 2/28/2024 and not investigated (Refer to L517). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated Federal compliance for Patients' Rights to ensure their rights are not violated and receive the highest quality of hospice care.

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to implement its Patient Care-Abuse and Grievances (complaint) policies for two of eleven sampled patients (Patient 2 and Patient 8) by failing to: 1.Ensure Patient 2 was free and protected from physical abuse (refers to abuse perpetrated through any action intended to cause physical harm or pain, trauma, or bodily harm [e.g., hitting, slapping, punching, kicking, pinching, etc.]) from Certified Home Health Aid (CHHA). 2.Ensure the HA conducted an investigation regarding the alleged physical abuse of Patient 2. 3. Ensure the HA reported the alleged physical abuse incident to the Department of Public Health and the Local law enforcement. 4. Ensure the HA conducted a thorough investigation on a complaint of CHHA being rude to Patient 8. As a result, Patient 2 sustained red markings to her right arm when CHHA provided nursing care on 3/6/2024 at Patient 2s Skilled Nursing Facility (SNF), and Patient 8s complaint of CHHA being rude to her on 2/28/2024 and not investigated. On 3/21/2024, at 3:30 p.m., the Department of Public Health called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the agencys Administrator (ADM) and the Branch Director related to the hospice agencys failure to ensure Patient 2 was free and protected from physical abuse, conduct an abuse investigation and report the alleged physical abuse to the Department of Public Health and the local law enforcement, and conduct a thorough investigation on a complaint of the CHHA being rude to Patient 8. On 3/22/2024, at 12 p.m., the HA gave the IJ Removal Plan (the facilitys plan of action to correct the deficient practices) to the surveyors in the hospice agency. The survey team reviewed the IJ Removal Plan and notified the ADM and the Branch Director the IJ Removal Plan was not accepted on 3/22/2024, at 12:50 p.m. On 3/22/2024, at 4 p.m., the survey team completed the survey tasks, and exited the HA with the IJ situation not removed. On 4/24/2024, the HA submitted an acceptable IJ Removal Plan as follow: 1. On 3/13/2024, Home hospice aide (HHA) was suspended from the field and placed on suspencion. 2. On 3/22/2024, the HHA was reinstated 03/19/2024 after investigation did not substantiate allegations. RN case manager (RNCM) completed full, in person assessments for all patients seen by Traditions HHA after he returned to work 03/19/2024. Visit notes are attached for Patient 2 and Patient 8. 3. On 3/18/2024, The Branch Director issued HHA a final written warning as the investigation's outcome into substantiated allegations of rudeness and unprofessional behavior at the facility 03/06/2024. 4. On 3/22/2024, Patients with aide care plans were reassigned from HHA to an RN with communication to appropriate patient, caregiver, and/or facility. 5. On 3/22/2024, The Branch Director reported potential patient abuse to the California Department of Health. Branch Director reported to the Ombudsman (an official appointed to investigate individuals' complaints against maladministration) and Adult Protective Services (APS) for Patient 2 and Patient 8. 6. From 3/26/2024 to 3/28, RNCM completed full, in-person assessments on all current patients of the branch, with no safety or abuse identified. 7.On 3/27/2024, Patient 8 was transferred to another hospice agency. The survey verified the IJ removal plan implementation onsite and removed the IJ on 4/24/2024, at 11am in the presence of the Branch Administrator. --- b. During a review of Patient 8's Patient Information, indicated a start of care on 2/14/2023, with diagnoses including dysphagia (difficulty swallowing) and dementia. The Patient Information indicated Skilled nurse (SN) visits effective 2/28/2024 twice a week for eight weeks and once a week for one week for symptom management. Medical Social worker (MSW) visits effective 3/3/2024 once a month for one month, twice a month for one month with three (PRN, as needed) for psychosocial needs. Hospice aide (HA) visits effective 2/28/2024 for three times a week for eight weeks and twice a week for one week. Chaplain visits effective 3/3/2024 for once a week for nine weeks with three prn for spiritual needs. A review of the HA's document titled " Employee Counseling Form," dated 3/18/2024 indicated the HA received a report from the RN Case manager on 3/8/2024 that the CHHA saw Patient 8 on 2/28/2024 and was told by Patient 8s family that CHHA was rude and used cold water during the shower and did not want him to return. During an interview on 3/21/2024, at 12 p.m., with the BD, the BD stated she was aware CHHA was rude to Patient 8 during the home visit and did not investigate. The BD stated there was no investigation, no reports, and no interviews. During an interview on 3/21/2024, at 1:08 p.m., with the Registered Nurse Case Manager (RNCM), the RNCM stated Patient 8 did not usually shower because her bathroom was too small. RNCM stated Patient 8 refused the visit because she wanted a female CHHA and that the CHHA who was rude to her. When asked if he conducted his investigation, RNCM stated " I just told the Branch Director. I do not have the privilege to do Administration job." A review of the agency's document titled " Administrative Policy Manual: Resolution of Patient/Client Conflicts, Grievances, or Complaints" indicated that The Agency will investigate complaints made by the patient/client, the representative (if any), the caregivers, and the family, including, but not limited to:A. Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriatelyB. Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient/client property by anyone furnishingservices on behalf of the AgencyC. Lack of respect for the patient's/client's property and/or person by anyone furnishing services on behalf of the AgencyD. Discrimination The Administrative Policy Manual: Resolution of Patient/Client Conflicts, Grievances, or Complaints, indicate the Agency will inform the patient/client, representative (if any), and/or caregiver in writing at the time of the initial assessment to notify the agency's Administrator, or designee, regarding any conflicts, grievances, or complaints and the time frames for initiation and resolution. The Agency will document the receipt of the complaint/grievance and initiate an investigation within 10 calendar days. Management will be Informed of the complaint. The Agency will complete the investigation and documentation of the resolution within 30 days after the receipt of the complaint unless the Agency has and documents reasonable cause for the delay. The Agency will involve the patient/client, caregiver, representative, and/or the patient's/client's healthcare provider as appropriate to reach a resolution. Findings: a. During a review of Patient 2's Patient Information Report (admission Record), the Patient Information Report indicated the HA admitted Patient 2 on 2/14/2024 with diagnoses including hypertensive heart disease with heart failure (heart disease due to unmanaged high blood pressure for a long time that causes added strain on the heart and leads to heart failure), and dementia (loss of memory and other mental abilities severe enough to interfere with daily life). During a review of Patient 2's Hospice Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Comprehensive Assessment and Plan of Care (POC, the process of identifying a patient's needs to ensure collaboration among nurses, patients, and other healthcare providers) Updated Report for benefit period 2/28/2024 to 4/27/2024, the IDG/POC indicated an order for the Skilled Nurse (SN) to provide SN to visit one time a week for one week, twice a week for eight weeks with three PRN (as needed) visits for symptom management. The IDG/POC indicated for the CHHA to visit twice a week for one week and three times a week for eight weeks. During a review of Patient 2's Skilled Nursing Visit dated 3/8/2024, indicated Patient 2 was lethargic (lack of energy)/drowsy(sleepy), confused lying in semi Fowlers (a position in which the individual lies on their back on a bed with the head of the bed elevated), skin warm dry, multiple fading black bruises (skin discoloration) on bilateral (both) hands distal (away from) to elbow, reviewed patient status with SNF. During a review of the HAs Employee Counseling Form dated 3/18/2024, the Employee Counseling Form indicated the CHHA was counselled on 3/18/2024, regarding Inappropriate behavior. During an interview on 3/19/2024, at 11:30 a.m., with the HAs Branch Director (BD), the Branch Director stated on 3/6/2024, at around 6 p.m., while at an out of state airport waiting for her flight home, she received a phone call from the HAs office staff (unidentified) who informed her of an incident regarding the CHHA that had just been reported to the HA by a SNF staff. The BD stated she followed up and spoke with the SNF Social Worker (SW) on 3/7/2024, via telephone, who informed her of CHHA physical abuse allegation with Patient 2 and that the SNF was filing a complaint with the Department of Public Health. The BD stated she interviewed the CHHA who indicated it was a dispute between him and the SNFs Certified Nursing Assistant 1 (CNA1). The BD stated per that interview with the CHHA, the HA unsubstantiated (not proven to be true) their side of the complaint. The BD stated she did not interview anyone else regarding the physical abuse allegation and the Registered Nurse (RN) Case manager, the chaplain (a religious leader), and the MSW visited Patient 2, at the SNF after the alleged physical abuse allegation. The BD stated the CHHA took online in-services regarding customer services (unidentified dates). The BD stated the CHHA was the only CHHA for the HA and was providing patient care. During an interview on 3/19/2024, at, 3p.m., with the CHHA in the HA office, the CHHA denied abusing Patient 2 and stated he worked for the HA providing patient care on 3/7/2024, 3/8/2024, 3/11/2024, 3/12/2024, and 3/13/2024, before the HA inform him while in the HA office on 3/13/2024, and after visiting a patient, that he was being suspended while the HA was to investigate the allegation. The HHA stated he had a zoom interview with the HAs Compliance and Human Recourses staff and that he returned to work on 3/18/2024. The HHA stated he refused to sign the Employee Counseling Form given to him by the HA because he did not abuse patient 2 and by signing the form is an admitting he did it. During a concurrent home visit observation and interview, on 3/20/2024, at 11:30 a.m., inside Patient 2s room at the SNF, with the HAs RN Case Manager (RNCM). Patient 2 was lying in a hospital bed and awake. Patient 2 spoke very softly and was unable to understand. The RNCM stated he received from CHHA on 3/6/2024, regarding a dispute at the SNF with the SNFs CNA. The RNCM stated he was informed by the BD of the allegations regarding the CHHA on 3/18/2023, and that he did not investigate the alleged incident as he did not get involved in administrative concerns and did not have administrative privileges. During an interview on 3/20/2024, at 11:30am, inside Patient 2s room with Patient 2s roommate, Patient 2s roommate stated, on 3/6/24, the CHHA went inside their room to provide care to Patient 2, slammed the room the door in a SNFs staffs (unidentified) face. Patient 2s roommate stated the SNFs CNA went in the room and asked the CHHA if he needed help and the CHHA stated ";no." Patient 2s roommate stated the SNF CNA was inside the room beside her (Patient 2s roommate) while CHHA bathed Patient 2 and they could hear the CHHA slamming drawers, and patient 2 was whimpering (sobbing). Patient 2s roommate stated the SNF CNA asked CHHA if he needed help, and they began arguing. Patient 2s roommate stated CHHA roughly snatched the curtain between the two patients (Patient 2 and Patient 2s roommate) and while moving around, CHHA hit her bedside table, which flew into Patient 2 who was sitting up in her bed striking her right upper arm. The CHHA was informed by the SNF CNA, that he knocked Patient 2s roommates bedside table into Patient 2 and the CHHA stated he did not know the table was there and never apologized to Patient 2 and left the room slamming the door to their room as he walked out. Patient 2s roommate stated the SNF CNA, checked on Patient 2 and noticed multiple red markings on her right arm, and Patient 2 was upset. Patient 2s roommate stated the SNF CNA went out of the room, got the SNF MSW and they checked Patient 2 and noticed red marking on her right arm. During an interview on 3/20/2024, at 2:30 p.m., with the SNFS Social worker Director and the Administrator in the SNFS Director of Nurse office, the SW stated on 3/6/2024, she was informed by SNF staff of the CHHA behavior to the SNFs CNA and Patient 2 had red spots on her right arm. The SW stated she asked Patient 2 in Spanish what happened, and Patient 2 brushed over her right hand which had the red marking. The SW stated she informed the HA, however, did not receive a call back from the BD until the next day on 3/7/2024. The SNF SW stated she followed up with the HAs via phone call one to two days letter to see what the HA had done regarding CHHA and was informed by the BD the CHHA had appealed the allegation, was still working and the investigation had not started yet. The SNF SW informed the HA. During a telephone interview with the SNF CNA on 3/21/20 24, at 4 p.m., the SNF CNA stated that on 3/6/2024, she was called in the room by a staff member (unidentified) who informed her that the CHHA had slammed the door in her face hitting her nose. The SNF CNA went to ask the CHHA if he needed help bathing Patient 2 and he stated no, and the SNF CNA went inside Patient 2s room to talk to Patient 2s roommate. The SNF CNA stated while she was talking with Patient 2s roommate, they could overhear Patient 2 whimpering as she was being bathed by the CHHA and the SNF CNA asked the HAs HHA, are you OK?" The SNF CNA stated the CHHA said back to her ";are you ok?" and the SNF CNA and the CHHA began to argue because she stated that she was also the nurse who took care of Patient 2. The SNF CNA stated the CHHA came up to her face while she was at the bedside of Patient 2s roommate and started yelling and arguing with her, and roughly snatched the curtains between the two patients and continued bathing Patient 2, while slamming drawers on Patient 2s side. The SNF CNA stated the CHHA knocked Patient 2s roommates bedside table striking Patient 2 in the right arm as she sat in her bed. The SNF CNA stated she told the CHHA, ";you just hit," Patient 2 with the table and the CHHA said he did not know the table was there. The SNF CNA stated the CHHA did not apologize, gathered his belongings, opened the door to the hallway and slammed it shut after he walked out. The SNF CNA stated she did not see him hit Patient 2 as the curtain was closed but heard Patient 2 whimpers during the bath. The SNF CNA stated she went to check on Patient 2 who was upset and holding her right hand and saw multiple small red marks on her arm that got darker the next day. The SNF CNA stated she went and got the facility social worker, who came and spoke to Patient 2 who just waved her left hand over the red marks on her right hand. During an interview on 3/21/2024, at 4:30 p.m., with the BD, the BD stated she did not do an investigation/interview the staff at the SNF due to her not knowing she could. The BD stated she did not notify the Department of Public Health of the physical abuse allegation regarding the CHHA to Patient 2. The BD stated she had not informed Patient 2s family regarding the incident because she thought the SNF informed them. During a review of the agencys policy and procedure titled, ";Patient Care-Abuse, Neglect, & Exploitation-PC15," dated 4/2022, under II.-A-indicated The Hospice Management will: Immediately investigate all alleged violations involving anyone furnishing services on behalf of the Hospice and immediately take action to prevent further potential violations while the alleged violation is being verified. Review of II.-E- of the same policy/procedure, indicates, immediately suspend any Hospice employee, representative or contractor suspected of abuse or neglect of a patient, or misappropriation of patient property. Review of G. The Hospice verify violations to local bodies having jurisdiction (including to the State Survey and Citification Agency) within five working days of becoming aware of the verified violations unless state regulations are more stringent.

Based on interviews and record reviews, the hospice agency failed to implement, maintain, and provide appropriate coordination of care and services for two of eleven sampled patients (Patient 7 and 8). This deficient practice resulted in an ineffective coordination and delayed delivery of care and services provided to Patient 2 and Patient 9 to meet their hospice care needs. --- 2. A review of Patient 7's ";Patient Information" sheet indicated a start of care (SOC) date on 2/29/2024, with a diagnosis including cerebral atherosclerosis (a disease that occurs when the arteries in the brain become hard, thick, and narrow due to the buildup of plaque (fatty deposits) inside the artery walls. This buildup decreases the amount of blood flow to certain areas of the brain) and essential hypertension(occurs when you have abnormally high blood pressure that's not the result of a medical condition). Skilled nurse (SN) visits effective 3/3/2024 once a week for eight weeks and three as needed (PRN "pro re nata" meaning as needed) for symptom management. Medical Social worker (MSW) visits effective 3/3/2024 once a month for one month, twice a month for one month with three prn for psychosocial needs. Hospice aide (HA) visits effective 2/29/2024 for once a week for one week, and three times a week for 8 weeks. Chaplain visit declined and No volunteer needs at this time. During a joint home visit on 3/20/2024 at 9:30 a.m., with the hospice aide at the patient's residence. Observed that Patient 7 was alert and oriented to name, person and place with periods of forgetfulness, denied pain and walks around the home using a cane or a walker. During an interview with the primary caregiver (PCG-daughter in law) on 3/20/2024 at 10:45 a.m., PCG exclaimed that Patient 7 did not have any hospice aide visits last week. PCG stated that I requested someone to do the visit because the patient had explosive diarrhea when the patient went to the garden and ate the fruit from the tree. PCG stated that she called the agency and waited for someone from the agency till 8 p.m., but no hospice aide came, so she had to bathe the patient herself and that it was already her bedtime. She received the call at 9 p.m., by that time PCG stated ";I already bathed her." PCG also stated that she had not spoken to a doctor since admission and would want to speak to a doctor to refer the patients increasing forgetfulness, wandering and stating that she wanted to die. PCG stated the patient was not clinically diagnosed with Alzheimers but would want the patient to be cognitively evaluated. 3. A review of Patient 8s ";Patient Information Sheet" indicated an SOC date of 1/31/2024 with the diagnosis of congestive heart failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs) and hypothyroidism (A condition in which the thyroid gland doesn't produce enough thyroid hormone). A review of the agencys ";Employee Counseling Form" that the Branch director (BD) wrote that on 3/8/2024 BD spoke to Registered Nurse Case Manager (RNCM) indicated that the PCG spoke to the RNCM on 2/28/2024 and stated that they were refusing the hospice aide to return. He had only seen this patient once, but the patient said the hospice aide was rude to her and when he turned on the shower she was hit with cold water. During an interview on 3/21/2024 at 12 noon with the BD, stated that when she knew about Patient 8s refusal of the HA service and the reason why she refused the service was that the HA was rude to her during the HV. When asked if she conducted an investigation of that complaint, BD stated ";No." During a phone interview with the RNCM on 3/21/2024 at 1:08 p.m., RNCM stated that he was familiar with Patient 8s case. RNCM stated that Patient 8 does not usually shower because her bathroom was too small. NCM stated that the patient refused the visit because she wants a female CNA and the patient state that the HA was rude during the home visit with her. RNCM stated that he informed the BD about it and did not conduct the investigation because he ";doesnt have the privilege to do administrative job." During an interview with the Nurse Practitioner (NP) on 3/22/2024 at 11:10 a.m., NP stated that she conducts the home visits for the agency under Doctor J. NP stated that Traditions Health tells her which patients are due to visit and she needs to go, she coordinates with the patients family/patients to let them know that she will visit them.NP stated that she attends the IDT ";when necessary" NP stated that she does not attend IDTs (Interdisciplinary Team Meeting- brings together knowledge from different health care disciplines to help people receive the care they need) every 14 days. NP stated that she sometimes sees Patient 7, 8 and 9 but does not remember when the last time she saw them. NP stated that she had not formally met MD2 and does not know who his patients were, but she calls MD1 if she has notable concerns for the patients. NP further stated that she does not know MD2 and if she has to report anything for the patients, she calls MD1. During an interview with the Medical Director (MD) on 3/22/2024 at 2:07 p.m., MD stated that he signed the agreement with the agency in December 2023 but officially started last February 2024. MD confirmed that he does attend IDT meetings but does not do the home visits for patients. MD stated an NP conducts the home visits. MD stated that he reviews the NPs assessments and adds it on his Certification for Terminal Illness (CTI- a brief narrative designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician). During an interview with the Branch Director (BD) on 3/22/2024 at 11:40 a.m., When asked who MD1 was, BD stated that he was the former Medical Director who left January 2024 and was replaced by MD2 the same month. A review of the agency document titled " Collaborative Practice Agreement for Nurse Practitioner" The purpose of this document is to describe the scope of practice for the nurse practitioner (NP) who signs this agreement, as well as provide written authorization by the supervising physician for the NP to initiate and provide psychiatric and medical care for the consumers of the agency. An NP is a collaborating physician, either primary, back-up or on-call, is continuously available to the NP, either in person or by telephone, for consultation. Upon employment or at the beginning of the collaborative relationship, the supervising physician and NP will meet initially every week for the first 4 weeks of employment to provide education, evaluate skills, or specific case consultation. These meetings may include discussion of clinical problems, progress toward improving outcomes, and recommendations, if any, for changes in treatment. After the first month, these meetings will occur at least monthly for the next five months of the collaboration and then at least once every six months. A short summary of these interactions will be documented and signed by both the physician and NP. Documentation of the collaborative practice agreement will be retained for five calendar years. The NP will document any consultation with a supervising physician for a specific case in the consumer's medical record. A review of the document titled "Job Description: Registered Nurse" indicated that primary functions are to administer care for clients of all ages in their place of residence, coordinate care with the interdisciplinary team, patient/family and referring agency; assume responsibility for coordination of care. A review of the agency document titled "Executive Director-Home Health/Hospice" Job summary: The Branch Director provides leadership for the branch and ensures quality of patient care in the home. The Branch Director is responsible for the overall leadership, direction, growth and culture of the home health/hospice branch. The primary function is for the overall administration of clinical and administrative departments and monitoring of appropriate staffing and productivity of the branch. Coordinates care with the interdisciplinary team, patient/family and referring agency. A review of the " Hospice medical director Agreement" dated 12/1/2023 indicated that Medical Director shall have the following responsibilities and duties ( collectively referred to as "Services''): (a) Assume overall responsibility for the medical component of the Hospice's patient care program.(b) Upon admission and on an ongoing basis, will collaborate with the patient's Attending Physician for the palliation and management of the patient's terminal illness and related conditions, as part of the Plan of Care (POC). If the Attending Physician is not available, the Physician (Medical Director) will be responsible for meeting the medical needs of the patient.(c) Provide supervision and oversight for physician employees and those under contract with Hospice.(d) Participate in Hospice orientation as well as ongoing Palliative Care education.(e) Provide services and visits to Hospice's patients according to the POC, only with the express authorization of Hospice. (f) Schedule patient/family visits through the Interdisciplinary Team meetings and in conjunction with the plan of care. (g) Act as a medical resource for the Hospice clinical staff and attend and participate as a member of the Interdisciplinary Team, providing input into the patient's Plan of Care.(h) Complete the "certification of terminal illness" and subsequent "recertification's" as required by state and federal regulations for patients on hospice, and in collaboration with Attending Physician as appropriate.(i) Provide input in the development and revision of Hospice policies and procedures.

Based on observation, interview, and record review the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to meet the Conditions of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Residents of Skilled Nursing Facilities (SNF/NF) or Intermediate Care Facilities for Individuals with Intellectual Disability (ICF/MR) as follows: --- The Hospice Agency failed to implement, maintain, and coordinate care and services for two of eleven sampled patients (Patient 2 and 9) who were residing at the skilled nursing facility (SNF). Refer to L777. The Hospice Agency staff failed to review all medications the patient was taking and update the medication profiles with the currently used medications for one of 11 sampled patients (Patient 9). Refer to L778. The Hospice Agency failed to ensure the Medical Director assumed overall the responsibility for the medical component of the hospice patient care program for four of 11 sampled patients (Patients 2, 7, 8, and 9). Refer to L781. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily (written law) mandated Federal compliance for Residents in SNF/NF or ICF/MR to ensure coordination of services does occur for patients certified to receive hospice services.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to implement, maintain, and coordinate care and services for two of eleven sampled patients (Patient 2 and 9) who were residing at the Skilled Nursing Facility (SNF). This deficient practice had the potential not to meet the care and needs of Patient 2 and Patient 9. --- 1 1. On 03/19/2024, at 11 a.m., a complaint validation survey was conducted regarding a reported allegation of abuse of a patient who resided in a skilled nursing facility allegedly being hit by the hospice aide providing care in the SNF on 3/6/2024, and the hospice agency being notified regarding the incident by the SNF staff on 3/6/2024. On 3/19/2024, at 11:15 a.m., during the entrance conference and interview in the hospice agency ,with the hospice Branch Director (BD), the Branch Director stated on 3/6/2024, at around 6 p.m., while at the out of state airport waiting for her flight home, she received a phone call from the HA office staff informing her of an incident regarding HAs home health aide (HHA) that had just been reported to the HA by a SNF staff. The Branch Director stated she followed up and spoke with the SNF Social Worker (SW) on 3/7/2024, via telephone, who informed here of the allegations against the hospice agency (HA) and that the SNF was filing a complaint with The Department of Public Health. The BD director stated she interviewed the HHA who indicated it was a dispute between he and the CNA of the SNF and that per that interview, the HA unsubstantiated their side of the complaint. The BD stated she never interviewed anyone else regarding the complaint and that the RN Case manager, the chaplain, and the MSW visited Patient 2, at the SNF after the alleged incident. The BD stated the HHA was here in the HA taking online in-services regarding customer services. On 3/19/2024, at 3 p.m., during an interview with the hospice agencys home health aide (HHA) in the HA office, he stated, that while he was at the SNF on 3/6/2024, the SNF CNA informed him that she had already bathed the patient that day however, Patient 2s hair looked crinkly (frizzy, curly) and she did not look being bathed already. The HHA stated at, the beginning of each week, he receives a schedule of the day he was to visit the patient to provide care from the HA on his cell phone. The HHA was asked if the HA arranges the time, he was to provide care at the SNF and the CHHA stated No, he just goes various times depending on how many patients he must bathe that day. The CHHA showed the surveyor his cell phone with the day/patients, facility to visit. There was no set time noted on the HHAs schedule. During a review of Patient 2's Patient Information Report (admission Record), indicated Patient 2 was admitted to the HA on 2/14/2024 with diagnoses including Hypertensive Heart Disease with Heart Failure (heart disease due to unmanaged high blood pressure for a long time that causes added strain on the heart and leads to heart failure), and Dementia (A group of thinking and social symptoms that interferes with). During a review of Patient 2's Hospice IDG Comprehensive Assessment and Plan of Care Updated Report (POC, the process of identifying a patient's needs to ensure collaboration among nurses, patients, and other healthcare providers) for benefit period 2/28/2024 to 4/27/2024, the POC indicated an order for the Skilled Nurse (SN) to provide SN to visit one time a week for one week, twice a week for eight weeks with three PRN (as needed) visits for symptom management .The HHA to visit twice a week for one week and three times a week for eight weeks. The MSW to visit starting on 3/3/2024, to visit Patient 2 one time a week for eight weeks with three PRN visits for Psychosocial needs and for the chaplain, effective 3/3/2024, to visit one a week for eight weeks with three PRN for spiritual needs. During a concurrent home visit, observation, and interview on 3/20/2024, at 11:30 a.m., was conducted at Patient 2s residence at the SNF, with RN -Case Manager (RNCM). Patient 2 was lying in a hospital bed patient in semi fowlers was awake, on oxygen via nasal cannula at 4 LPM (a unit of measure). Patient 2 spoke very softly and hard to understand. During an interview with RNCM, he stated he receive a call from the HHA that day (3/6/2024), regarding a dispute at the SNF with the SNF CNA. The RNCM stated he was informed by the Branch Director of the allegations regarding the HHA on 3/18/2023, and that he did not investigate the alleged incident as he does not get involved in administrative stuff and does not have administrative privileges. During an interview on 3/20/2024, at 2:30 p.m., with the SNF Administrator in the Director of Nurse office with the SW stated on 3/6/2024, she was informed by SNF staff of the HHA behavior, and that Patient 2 had red spots on her left hand. The administrator stated he was informed by SNF staff that on multiple occasions, in the HHA form the HA and the SNF CNA, had bathed Patient 2 on the same day which over exhausted the patient. The administrator stated he asked the RNCM on 3/8/2024, while he was visiting Patient 2, if the HA was going to provide some emotional support since the abuse/incident by the HA's HHA, and that the RNCM stated he would get back to him, and he has not heard from him or anyone at the HA. During an interview with the HAs Branch Director on 3/22/2024, at 3 pm, she stated that the HAs does send them a schedule to staff with the days they are to visit, and that the HA s staff should be communicating with the SNF so that the patient is not bathed twice in a day. Review of the HAs Policy and procedure on Hospice Care in a SNF/NF or ICF/11D disclosed: 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. The Hospice will ensure that those services are furnished in a safe and effective manner by qualified, competent persons. Review of the same policy and procedure under Coordination /Continuity of care section A-4, indicates, the Hospice will: Designate a member of each IDG/IDT that is responsible for a patient who is a resident of the facility. The designated member is responsible to: a. Provide overall coordination of the Hospice care of the patient with the facility representatives: b. Hold IDG/IDT meetings to which the staff of the facility is invited, to discuss the patient/family needs and develop, implement, and revise the POC in coordination with patient/family, facility, Medical Director, and Attending Physician. c. Maintain professional management responsibility and coordination of services to ensure services are furnished in a safe, timely, and effective manner, according to the POC. e. Monitor care provided by the facility as part of the Hospice Quality Assessment Performance Improvement (QAPI) process through frequent staff visits, satisfaction surveys and patient outcomes; and f. Maintain IDG/IDT communication with the facilitys Medical Director, patient's attending practitioner, facility staff, patient, family, and other physicians participating in the provision of care, as needed, to ensure coordination and documentation of care. 2. A review of Patient 8s ";Patient Information Sheet" indicated an SOC date of 1/31/2024 with the diagnosis of congestive heart failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs) and hypothyroidism (A condition in which the thyroid gland doesn't produce enough thyroid hormone). A review of the agencys ";Employee Counseling Form" that the Branch director (BD) wrote that on 3/8/2024 BD spoke to Registered Nurse Case Manager (RNCM) indicated that the PCG spoke to the RNCM on 2/28/2024 and stated that they were refusing the hospice aide to return. He had only seen this patient once, but the patient said the hospice aide was rude to her and when he turned on the shower she was hit with cold water. During an interview on 3/21/2024 at 12 noon with the BD, stated that when she knew about Patient 8s refusal of the HA service and the reason why she refused the service was that the HA was rude to her during the HV. When asked if she conducted an investigation of that complaint, BD stated ";No." During a phone interview with the RNCM on 3/21/2024 at 1:08 p.m., RNCM stated that he was familiar with Patient 8s case. RNCM stated that Patient 8 does not usually shower because her bathroom was too small. NCM stated that the patient refused the visit because she wanted a female CNA and the patient stated that the HA was rude during the home visit with her. RNCM stated that he informed the BD about it and did not conduct the investigation because he ";doesnt have the privilege to do administrative job." 3. A review of Patient 9's ";Patient Information" sheet indicated a start of care on 2/14/2023, with diagnoses including dysphagia (a medical term for difficulty swallowing) and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Skilled nurse (SN) visits effective 3/10/2024 twice a week for eight weeks and once a week for one week for symptom management. Medical Social worker (MSW) visits effective 3/17/2024 once a month for one month, twice a month for one month with three (PRN "pro re nata" meaning as needed) for psychosocial needs. Hospice aide (HA) visits effective 3/10/2024 three times a week for 8 weeks and twice a week for one week. Chaplain visit effective 3/10/2024 once a week for nine weeks with three prn for spiritual needs. No volunteer needs at this time. During a concurrent interview and record review with the Director of Nursing (DON) of the skilled nursing facility (SNF) on 3/21/2024 at 11:30 a.m., DON stated that the nurse practitioner (NP) does come from the hospice agency, and also the SNF nurse practitioner sees the patient. DON confirmed that the hospice NP came on the following dates 1/2/2024, 2/2/2023, 11/19/2023 from a different name NP form. DON also stated that that the hospice doctor does not come and visit the patient. During an interview with the Nurse Practitioner (NP) on 3/22/2024 at 11:10 a.m., NP stated that she conducts the home visits for the agency under MD1 stated that Traditions Health tells her which patents are due to visit and she needs to go, she coordinates with the patients family/patients to let them know that she will visit them.NP stated that she attends the IDT ";when necessary" NP stated that she does not attend IDTs (Interdisciplinary Team Meeting- brings together knowledge from different health care disciplines to help people receive the care they need) every 14 days. NP stated that she sometimes sees Patient 9 but does not remember when the last time was, she saw them. NP stated that she had not formally met MD2 and does not know who his patients were, but she calls MD1 if she has notable concerns for the patients. NP further stated that she does not know MD2 and if she has to report anything for the patients, she calls MD1. During an interview with the Medical Director 2(MD2) on 3/22/2024 at 2:07 p.m., MD2 stated that he signed the agreement with the agency in December 2023 but officially started last February 2024. MD confirmed that he does attend IDT meetings but does not do the home visits for patients. MD2 stated an NP conducts the home visits. MD2 stated that he reviews the NPs assessments and adds it on his Certification for Terminal Illness (CTI- a brief narrative designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician). MD further stated that he did not know anything about the incidents until the BD called him up this morning. A review of the agency's document titled " Coordination of Care" last reviewed 10/1/2021 indicated to ensure coordination of all care provided for patients receiving hospice services and/or services from other provider. The Hospice will provide for and ensure the ongoing sharing of information between disciplines providing care and services in all settings, whether the care and services are provided directly or, under arrangement, by the Hospice, or by other providers. The Hospice will provide for an ongoing sharing of information-with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. The Hospice will develop and maintain a system of communication with each provider of care to ensure development of an integrated, coordinated plan of care, achieving unduplicated services, and facilitating effective coordination of patient services. 1 Findings: 1. During a review of Patient 2's Patient Information Report (admission Record), indicated Patient 2 was admitted to the HA on 2/14/2024 with diagnoses including Hypertensive Heart Disease with Heart Failure (heart disease due to unmanaged high blood pressure for a long time that causes added strain on the heart and leads to heart failure), and Dementia (A group of thinking and social symptoms that interferes with). During a review of Patient 2's Hospice IDG Comprehensive Assessment and Plan of Care Updated Report (POC, the process of identifying a patient's needs to ensure collaboration among nurses, patients, and other healthcare providers) for benefit period 2/28/2024 to 4/27/2024, the POC indicated an order for the Skilled Nurse (SN) to provide SN to visit one time a week for one week, twice a week for eight weeks with three PRN (as needed) visits for symptom management .The HHA to visit twice a week for one week and three times a week for eight weeks. The MSW to visit starting on 3/3/2024, to visit Patient 2 one time a week for eight weeks with three PRN visits for Psychosocial needs and for the chaplain, effective 3/3/2024, to visit one a week for eight weeks with three PRN for spiritual needs. On 3/19/2024, at 11:15 a.m., during the entrance conference and interview in the hospice agency ,with the hospice Branch Director (BD), the Branch Director stated on 3/6/2024, at around 6 p.m., while at the out of state airport waiting for her flight home, she received a phone call from the HA office staff informing her of an incident regarding HAs home health aide (HHA) that had just been reported to the HA by a SNF staff. The Branch Director stated she followed up and spoke with the SNF Social Worker (SW) on 3/7/2024, via telephone, who informed here of the allegations against the hospice agency (HA) and that the SNF was filing a complaint with The Department of Public Health. The BD director stated she interviewed the HHA who indicated it was a dispute between he and the CNA of the SNF and that per that interview, the HA unsubstantiated their side of the complaint. The BD stated she never interviewed anyone else regarding the complaint and that the RN Case manager, the chaplain, and the MSW visited Patient 2, at the SNF after the alleged incident. The BD stated the HHA was here in the HA taking online in-services regarding customer services. On 3/19/2024, at 3 p.m., during an interview with the hospice agencys home health aide (HHA) in the HA office, he stated, that while he was at the SNF on 3/6/2024, the SNF CNA informed him that she had already bathed the patient that day however, Patient 2s hair looked crinkly (frizzy, curly) and she did not look being bathed already. The HHA stated at, the beginning of each week, he receives a schedule of the day he was to visit the patient to provide care from the HA on his cell phone. The HHA was asked if the HA arranges the time, he was to provide care at the SNF and the CHHA stated No, he just goes various times depending on how many patients he must bathe that day. The CHHA showed the surveyor his cell phone with the day/patients, facility to visit. There was no set time noted on the HHAs schedule. During a concurrent home visit, observation, and interview on 3/20/2024, at 11:30 a.m., was conducted at Patient 2s residence at the SNF, with RN -Case Manager (RNCM). Patient 2 was lying in a hospital bed patient in semi fowlers was awake, on oxygen via nasal cannula at 4 LPM (a unit of measure). Patient 2 spoke very softly and hard to understand. During an interview with RNCM, he stated he receive a call from the HHA that day (3/6/2024), regarding a dispute at the SNF with the SNF CNA. The RNCM stated he was informed by the Branch Director of the allegations regarding the HHA on 3/18/2023, and that he did not investigate the alleged incident as he does not get involved in administrative stuff and does not have administrative privileges. During an interview on 3/20/2024, at 2:30 p.m., with the SNF Administrator in the Director of Nurse office with the SW stated on 3/6/2024, she was informed by SNF staff of the HHA behavior, and that Patient 2 had red spots on her left hand. The administrator stated he was informed by SNF staff that on multiple occasions, in the HHA form the HA and the SNF CNA, had bathed Patient 2 on the same day which over exhausted the patient. The administrator stated he asked the RNCM on 3/8/2024, while he was visiting Patient 2, if the HA was going to provide some emotional support since the abuse/incident by the HA's HHA, and that the RNCM stated he would get back to him, and he has not heard from him or anyone at the HA. During an interview with the HAs Branch Director on 3/22/2024, at 3 pm, she stated that the HAs does send them a schedule to staff with the days they are to visit, and that the HA s staff should be communicating with the SNF so that the patient is not bathed twice in a day. 2. A review of Patient 9's ";Patient Information" sheet indicated a start of care on 2/14/2023, with diagnoses including dysphagia (a medical term for difficulty swallowing) and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Skilled nurse (SN) visits effective 3/10/2024 twice a week for eight weeks and once a week for one week for symptom management. Medical Social worker (MSW) visits effective 3/17/2024 once a month for one month, twice a month for one month with three (PRN "pro re nata" meaning as needed) for psychosocial needs. Hospice aide (HA) visits effective 3/10/2024 three times a week for 8 weeks and twice a week for one week. Chaplain visit effective 3/10/2024 once a week for nine weeks with three prn for spiritual needs. No volunteer needs at this time. During a concurrent interview and record review with the Director of Nursing (DON) of the skilled nursing facility (SNF) on 3/21/2024 at 11:30 a.m., DON stated that the nurse practitioner (NP) does come from the hospice agency, and also the SNF nurse practitioner sees the patient. DON confirmed that the hospice NP came on the following dates 1/2/2024, 2/2/2023, 11/19/2023 from a different name NP form. DON also stated that that the hospice doctor does not come and visit the patient. During an interview with the Nurse Practitioner (NP) on 3/22/2024 at 11:10 a.m., NP stated that she conducts the home visits for the agency under MD1 stated that Traditions Health tells her which patents are due to visit and she needs to go, she coordinates with the patients family/patients to let them know that she will visit them.NP stated that she attends the IDT ";when necessary" NP stated that she does not attend IDTs (Interdisciplinary Team Meeting- brings together knowledge from different health care disciplines to help people receive the care they need) every 14 days. NP stated that she sometimes sees Patient 9 but does not remember when the last time was, she saw them. NP stated that she had not formally met MD2 and does not know who his patients were, but she calls MD1 if she has notable concerns for the patients. NP further stated that she does not know MD2 and if she has to report anything for the patients, she calls MD1. During an interview with the Medical Director 2(MD2) on 3/22/2024 at 2:07 p.m., MD2 stated that he signed the agreement with the agency in December 2023 but officially started last February 2024. MD confirmed that he does attend IDT meetings but does not do the home visits for patients. MD2 stated an NP conducts the home visits. MD2 stated that he reviews the NPs assessments and adds it on his Certification for Terminal Illness (CTI- a brief narrative designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician). MD further stated that he did not know anything about the incidents until the BD called him up this morning. A review of the agency's document titled " Coordination of Care" last reviewed 10/1/2021 indicated to ensure coordination of all care provided for patients receiving hospice services and/or services from other provider. The Hospice will provide for and ensure the ongoing sharing of information between disciplines providing care and services in all settings, whether the care and services are provided directly or, under arrangement, by the Hospice, or by other providers. The Hospice will provide for an ongoing sharing of information-with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. The Hospice will develop and maintain a system of communication with each provider of care to ensure development of an integrated, coordinated plan of care, achieving unduplicated services, and facilitating effective coordination of patient services. Review of the HAs Policy and procedure on Hospice Care in a SNF/NF or ICF/11D disclosed: 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. The Hospice will ensure that those services are furnished in a safe and effective manner by qualified, competent persons. Review of the same policy and procedure under Coordination /Continuity of care section A-4, indicates, the Hospice will: Designate a member of each IDG/IDT that is responsible for a patient who is a resident of the facility. The designated member is responsible to: a. Provide overall coordination of the Hospice care of the patient with the facility representatives: b. Hold IDG/IDT meetings to which the staff of the facility is invited, to discuss the patient/family needs and develop, implement, and revise the POC in coordination with patient/family, facility, Medical Director, and Attending Physician. c. Maintain professional management responsibility and coordination of services to ensure services are furnished in a safe, timely, and effective manner, according to the POC. e. Monitor care provided by the facility as part of the Hospice Quality Assessment Performance Improvement (QAPI) process through frequent staff visits, satisfaction surveys and patient outcomes; and f. Maintain IDG/IDT communication with the facilitys Medical Director, patient's attending practitioner, facility staff, patient, family, and other physicians participating in the provision of care, as needed, to ensure coordination and documentation of care.

Based on observation, interview and record review, the hospice staff failed to review all medications the patient was taking and update the medication profiles with the currently used medications for one of 11 sampled patients (Patient 9). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. --- A review of Patient 9's ";Patient Information" sheet indicated a start of care on 2/14/2023, with diagnoses including dysphagia (a medical term for difficulty swallowing) and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Skilled nurse (SN) visits effective 3/10/2024 twice a week for eight weeks and once a week for one week for symptom management. Medical Social worker (MSW) visits effective 3/17/2024 once a month for one month, twice a month for one month with three (PRN "pro re nata" meaning as needed) for psychosocial needs. Hospice aide (HA) visits effective 3/10/2024 three times a week for 8 weeks and twice a week for one week. Chaplain visits effective 3/10/2024 for once a week for nine weeks with three PRN for spiritual needs. No volunteer needs at this time. A joint home visit with the Registered Nurse Came manager (RNCM) on 3/21/2024 at 9:05 a.m., observed Patient 9 was completely bedbound with upper and lower limb contractures (A limitation in the passive range of motion of a joint of the upper and lower limbs resulting from loss of elasticity in the periarticular tissues owing to structural changes of non-bony tissues, such as muscles, tendons, ligaments, joint capsules or skin making it hard to move) eyes were closed, Patient 9 grimaces upon touch and small movements, not in any respiratory distress, fair and clean in appearance. During a medication review on 3/21/2024 at 10:30 a.m., with the assigned facility medication nurse showed the following medications were not found during the home visit: Tylenol 325 milligrams (mg- unit of measurement) twice daily for pain. Amlodipine 10 mg once daily for high blood pressure Docusate sodium 100 mg twice daily for constipation Norco 5/325 mg 1 tablet every 4 hours as needed for pain Atropine Sulfate 0.1% 3 drops under the tongue for as needed excessive secretions Lorazepam 2 mg/ml (milliliter- unit for fluid measurement) give 0.25 ml every 2 hours under the tongue for as needed for agitation and restlessness. Morphine Sulfate 100 mg/5 ml, give 5 mg every 2 hours as needed for breakthrough pain During a concurrent interview with the RNCM, on 3/21/2024 at 11 a.m., RNCM stated ";I only ask the charge nurse of the facility if they need refills on medications and if there are new orders from the doctor. I dont review the medication cart; I am assuming that whatever in their list we have the same as their list." During an interview on 3/21/2024 at 12 noon, with the Director of Nursing (DON) of the nursing facility, DON stated, "If it is not on our list means it is not ordered and it will not be on our order summaries." DON stated, " for Patient 9, if it is covered by Hospice, the hospice will provide the medication, and if it is not, the nursing facility provides it for Patient 9." During an interview with the Branch Director (BD) on 3/22/2024 at 12 noon, BD stated that the RNCM should always check the medications with the facility and notify the office if there are new or discontinued medications. BD stated that the expectation is for them to review the medications to the list of the facility and the hospice medication list to confirm if the medications were correct. A review of the agencys document titled ";Coordination of Care" revised 10/1/2021, indicated to ensure coordination of all care provided for patients receiving hospice services and/or services from other providers. The Hospice will provide for and ensure the ongoing sharing of information between disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement, by the Hospice, or by other providers. The hospice will develop and maintain a system of communication with each provider of care to ensure development of an integrated, coordinated plan of care, achieving unduplicated services, and facilitating effective coordination of patient services. A review of the agencys document titled ";Hospice Care in a SNF (Skilled Nursing Facility)/NF (Nursing facility) revised 10/1/2021 indicated the hospice will provide the facility the following hospice information/documentation on admission and ongoing medication information specific to each patient. A review of the agency's document titled "Medication List and Monitoring" reviewed last 1/27/2023 indicated that to outline a process for ongoing medication monitoring. To ensure the hospice is compliant with the identification and management of high-alert and hazardous medications. The registered nurse (RN) will be responsible for coordinating the efforts of monitoring the medication regimen by compiling assessment data through a collaborative effort of all the hospice staff involved in the patient's care. The hospice will attempt to obtain a medication list from referral sources.

Based on interview and record review, the HA failed to ensure the Medical Director assume overall responsibility for the medical component of the hospices patient care program for 4 of 11 sampled patients (Patients 2, 7, 8, and 9). This deficient practice resulted in the patients care not being evaluated to ensure the care provided by the HA met the patients' and families' needs. --- 2. A review of Patient 7's ";Patient Information" sheet indicated a start of care (SOC) date on 2/29/2024, with a diagnosis including cerebral atherosclerosis (a disease that occurs when the arteries in the brain become hard, thick, and narrow due to the buildup of plaque (fatty deposits) inside the artery walls. This buildup decreases the amount of blood flow to certain areas of the brain) and essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition). Skilled nurse (SN) visits effective 3/3/2024 for once a week for eight weeks and three as needed (PRN "pro re nata" meaning as needed) for symptom management. Medical Social worker (MSW) visits effective 3/3/2024 once a month for one month, twice a month for one month with three prn for psychosocial needs. Hospice aide (HA) visits effective 2/29/2024 for once a week for one week, and three times a week for 8 weeks. Chaplain visit declined and No volunteer needs at this time. During a joint home visit on 3/20/2024 at 9:30 a.m., with the hospice aide at the patient's residence. Observed that Patient 7 was alert and oriented to name, person and place with periods of forgetfulness, denied pain and walks around the home using a cane or a walker. During an interview with the primary caregiver (PCG-daughter in law) on 3/20/2024 at 10:45 a.m., PCG exclaimed that Patient 7 did not have any hospice aide visits last week. PCG stated that I requested one to do the visit because the patient had explosive diarrhea when the patient went to the garden and ate the fruit from the tree. PCG stated that she called the agency and waited for someone from the agency till 8:00 p.m., but no hospice aide came, so she had to bathe the patient herself and that it was already her bedtime. She received the call at 9:00 p.m., by that time PCG stated ";I already bathed her." PCG also stated that she had not spoken to a doctor since admission and would want to speak to a doctor to refer the patients increasing forgetfulness, wandering and stating that she wanted to die. PCG stated the patient was not clinically diagnosed with Alzheimers but would want the patient to be cognitively evaluated. 3. A review of Patient 8s ";Patient Information Sheet" indicated an SOC date of 1/31/2024 with the diagnoses of congestive heart failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs) and hypothyroidism (A condition in which the thyroid gland doesn't produce enough thyroid hormone). A review of the agencys ";Employee Counseling Form" that the Branch director (BD) wrote that on 3/8/2024 BD spoke to Registered Nurse Case Manager (RNCM) indicated that the PCG spoke to the RNCM on 2/28/2024 and stated that they are refusing the hospice aide to return. He had only seen this patient once, but the patient said the hospice aide was rude to her and when he turned on the shower she was hit with cold water. During an interview on 3/21/2024 at 12 noon, with the BD, stated that when she knew about Patient 8s refusal of the HA service and the reason why she refused the service is that the HA was rude to her during the HV. When asked if she conducted an investigation of that complaint, BD stated ";No." During a phone interview with the RNCM on 3/21/2024 at 1:08 p.m., RNCM stated that he was familiar with Patient 8s case. RNCM stated that Patient 8 does not usually shower because her bathroom was too small. NCM stated that the patient refused the visit because she wants a female CNA and the patient state that the HA was rude during the home visit with her. RNCM stated that he informed the BD about it and did not conduct the investigation because he ";doesnt have the privilege to do administrative job." 4. A review of Patient 9's ";Patient Information" sheet indicated a start of care on 2/14/2023, with a diagnosis including dysphagia (a medical term for difficulty swallowing) and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Skilled nurse (SN) visits effective 3/10/2024 for twice a week for eight weeks and once a week for one week for symptom management. Medical Social worker (MSW) visits effective 3/17/2024 once a month for one month, twice a month for one month with three (PRN "pro re nata" meaning as needed) for psychosocial needs. Hospice aide (HA) visits effective 3/10/2024 for three times a week for 8 weeks and twice a week for one week. Chaplain visits effective 3/10/2024 for once a week for nine weeks with three prn for spiritual needs. No volunteer needs at this time. During a concurrent interview and record review with the Director of Nursing (DON) of the skilled nursing facility (SNF) on 3/21/2024 at 11:30 a.m., DON stated that the nurse practitioner (NP) does come from the hospice agency and the SNF nurse practitioner who also sees the patient. DON confirmed that the hospice NP came on the following dates 1/2/2024, 2/2/2023, 11/19/2023 from a different name NP form. DON also stated that the hospice doctor does not come and visit the patient. During an interview with the Nurse Practitioner (NP) on 3/22/2024 at 11:10 a.m., NP stated that she conducts the home visits for the agency under MD1. NP stated that Traditions Health tells her which patients are due to visit and she needs to go, she coordinates with the patients family/patients to let them know that she will visit them. NP stated that she attends the IDT ";when necessary" NP stated that she does not attend IDTs (Interdisciplinary Team Meeting- brings together knowledge from different health care disciplines to help people receive the care they need) every 14 days. NP stated that she sometimes sees Patient 7, 8 and 9 but does not remember when was the last time she saw them. NP stated that she had not formally met MD2 and does not know who his patients were, but she calls MD1 if she has notable concerns for the patients. NP further stated that she does not know MD2 and if she has to report anything for the patients, she calls MD1. During an interview with the Medical Director 2 (MD2) on 3/22/2024 at 2:07 p.m., MD2 stated that he signed the agreement with the agency in December 2023 but officially started last February 2024. MD2 confirmed that he does attend IDT meetings but does not do the home visits for patients. MD2 stated an NP conducts the home visits. MD2 stated that he reviews the NPs assessments and adds it on his Certification for Terminal Illness (CTI- a brief narrative designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician). During an interview with the Branch Director (BD) on 3/22/2024 at 11:40 a.m., When asked who MD1 was, BD stated that he was the former Medical Director who left January 2024 and was replaced by MD2 the same month. A review of the agency document titled " Collaborative Practice Agreement for Nurse Practitioner" The purpose of this document is to describe the scope of practice for the nurse practitioner (NP) who signs this agreement, as well as provide written authorization by the supervising physician for the NP to initiate and provide psychiatric and medical care for the consumers of the agency. An NP is a collaborating physician, either primary, back-up or on-call, is continuously available to the NP, either in person or by telephone, for consultation. Upon employment or at the beginning of the collaborative relationship, the supervising physician and NP will meet initially every week for the first 4 weeks of employment to provide education, evaluate skills, or specific case consultation. These meetings may include discussion of clinical problems, progress toward improving outcomes, and recommendations, if any, for changes in treatment. After the first month, these meetings will occur at least monthly for the next five months of the collaboration and then at least once every six months. A short summary of these interactions will be documented and signed by both the physician and NP. Documentation of the collaborative practice agreement will be retained for five calendar years. The NP will document any consultation with a supervising physician for a specific case in the consumer's medical record. A review of the document titled "Job Description: Registered Nurse" indicated that primary functions are to administer care for clients of all ages in their place of residence, coordinate care with the interdisciplinary team, patient/family and referring agency; assume responsibility for coordination of care. A review of the agency document titled "Executive Director-Home Health/Hospice" Job summary: The Branch Director provides leadership for the branch and ensures quality of patient care in the home. The Branch Director is responsible for the overall leadership, direction, growth and culture of the home health/hospice branch. The primary function is for the overall administration of clinical and administrative departments and monitoring of appropriate staffing and productivity of the branch. Coordinates care with the interdisciplinary team, patient/family and referring agency. A review of the " Hospice medical director Agreement" dated 12/1/2023 indicated that Medical Director shall have the following responsibilities and duties ( collectively referred to as "Services''): (a) Assume overall responsibility for the medical component of the Hospice's patient care program.(b) Upon admission and on an ongoing basis, will collaborate with the patient's Attending Physician for the palliation and management of the patient's terminal illness and related conditions, as part of the Plan of Care (POC). If the Attending Physician is not available, the Physician (Medical Director) will be responsible for meeting the medical needs of the patient.( c) Provide supervision and oversight for physician employees and those under contract with Hospice.( d) Participate in Hospice orientation as well as ongoing Palliative Care education.(e) Provide services and visits to Hospice's patients according to the POC, only with the express authorization of Hospice. (f) Schedule patient/family visits through the Interdisciplinary Team meetings and in conjunction with the plan of care. (g) Act as a medical resource for the Hospice clinical staff, and attend and participate as a member of the Interdisciplinary Team, providing input into the patient's Plan of Care.(h) Complete the "certification of terminal illness" and subsequent "recertifications" as required by state and federal regulations for patients on hospice, and in collaboration with Attending Physician as appropriate.(i) Provide input in the development and revision of Hospice policies and procedures. On 3/19/2024, at 11:15 a.m., during the entrance conference and interview in the hospice agency ,with the hospice Branch Director (BD), the Branch Director stated on 3/6/2024, at around 6 p.m., while at the out of state airport waiting for her flight home, she received a phone call from the HA office staff informing her of an incident regarding HAs home health aide (HHA) that had just been reported to the HA by a SNF staff. The Branch Director stated she followed up and spoke with the SNF Social Worker (SW) on 3/7/2024, via telephone, who informed here of the allegations against the hospice HHA and that the SNF was filing a complaint with The Department of Public Health. The branch director stated she interviewed the HHA who indicated it was a dispute between he and the CNA from the SNF and that per that interview, the HA unsubstantiated their side of the complaint. The Branch Director when asked, stated she never interviewed anyone else regarding the complaint and that the RN Case manager, the chaplain, and the MSW visited Patient 2, at the SNF after the alleged incident. The Branch Director stated the HHA was here in the HA taking online in-services regarding customer services. On 3/19/2024, at 3:00 pm. , during an interview with the hospice agencys home health aide in the HA office, he stated, the allegation did not occur and that he still worked for the HA providing patient care on 3/7/2024,3/8/2024, 3/11/2024,3/12/2024, and 3/13/2024, before the HA inform him while in the HA office on 3/13/2024, and after visiting a patient, that he was being suspended while the HA was to investigate the allegation. The HHA stated he had a zoom interview with the HAs Compliance and Human Recourses staff and that he returned to work on 3/18/2024. The HHA stated he refused to sign the Employee Counseling Form given to him by the HA because he did not abuse patient 2 and by signing the form is an admitting he did it. During a review of the HAs Employee Counseling Formed dated 3/18/2024, indicated the HHA was counselled on 3/18/2024, regarding Inappropriate behavior. The employee Counseling form included an incident reported by RN. 1. During a review of Patient 2's Patient Information Report (admission Record), indicated Patient 2 was admitted to the HA on 2/14/2024 with diagnoses including Hypertensive Heart Disease with Heart Failure (heart disease due to unmanaged high blood pressure for a long time that causes added strain on the heart and leads to heart failure), and Dementia (A group of thinking and social symptoms that interferes with). During a review of Patient 2's Hospice IDG Comprehensive Assessment and Plan of Care Updated Report (POC, the process of identifying a patient's needs to ensure collaboration among nurses, patients, and other healthcare providers) for benefit period 2/28/2024 to 4/27/2024, the POC indicated an order for the Skilled Nurse (SN) to provide SN to visit one time a week for one week, twice a week for eight weeks with three PRN (as needed) visits for symptom management .The HHA to visit twice a week for one week and three times a week for eight weeks. The MSW to visit starting on 3/3/2024, to visit Patient 2 one time a week for eight weeks with three PRN visits for Psychosocial needs and for the chaplain, effective 3/3/2024, to visit one a week for eight weeks with three PRN for spiritual needs. During a review of Patient 2's Skilled Nursing Visit dated 3/8/2024, under Narrative indicated, Patient 2 is lethargic/drowsy, confused lying in Semi Fowlers position, Skin warm dry, intact, multiple fading black bruises on bilateral hands distal to elbow, reviewed patient status with SNF SN. She denies any concerns. During a concurrent home visit, observation and interview on 3/20/2024, at 11:30 a.m., inside Patient 2s residence at the SNF, with RN -Case Manager (RNCM). Patient 2 was lying in a hospital bed patient in semi fowlers was awake, on oxygen via nasal cannula at 4 LPM (a unit of measure). Patient spoke very softly and was unable to understand. During an interview with RNCM, he stated he receive a call by the HHA that day (3/6/2024), regarding a dispute at the SNF with the SNF CNA. The RNCM stated he was informed by the Branch Director of the allegations regarding the HHA on 3/18/2023, and that he did not investigate the alleged incident as he does not get involved in administrative stuff and does not have administrative privileges. During a telephone interview with the HA's Nurse Practitioner on 3/22/2024, at 12pm, She stated she visits the patients when needed, and she communicates with Medical Director 1 if needed. The NP stated she has never met MD 2 . During a telephone interview with the medical director 9MD) on 3/22/2024, at 1pm, the MD 1 stated that he does not see, the hospice patients, and complete the patients Certification for Terminal Illness (CTI) form based on the HA's Nurse Practitioner's progress note. The MD 1 stated he was unaware of the abuse incident regarding the CHHA at the SNF until this telephone conversation. During an interview with the Branch Director in the HA on 3/22/2024, at 3Pm., she stated MD 1 has not worked for the HA's since some time last year and was unaware that the NP was communication with MD1 and did not know MD 2. 2. A review of Patient 7's ";Patient Information" sheet indicated a start of care (SOC) date on 2/29/2024, with a diagnosis including cerebral atherosclerosis (a disease that occurs when the arteries in the brain become hard, thick, and narrow due to the buildup of plaque (fatty deposits) inside the artery walls. This buildup decreases the amount of blood flow to certain areas of the brain) and essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition). Skilled nurse (SN) visits effective 3/3/2024 for once a week for eight weeks and three as needed (PRN "pro re nata" meaning as needed) for symptom management. Medical Social worker (MSW) visits effective 3/3/2024 once a month for one month, twice a month for one month with three prn for psychosocial needs. Hospice aide (HA) visits effective 2/29/2024 for once a week for one week, and three times a week for 8 weeks. Chaplain visit declined and No volunteer needs at this time. During a joint home visit on 3/20/2024 at 9:30 a.m., with the hospice aide at the patient's residence. Observed that Patient 7 was alert and oriented to name, person and place with periods of forgetfulness, denied pain and walks around the home using a cane or a walker. During an interview with the primary caregiver (PCG-daughter in law) on 3/20/2024 at 10:45 a.m., PCG exclaimed that Patient 7 did not have any hospice aide visits last week. PCG stated that I requested one to do the visit because the patient had explosive diarrhea when the patient went to the garden and ate the fruit from the tree. PCG stated that she called the agency and waited for someone from the agency till 8:00 p.m., but no hospice aide came, so she had to bathe the patient herself and that it was already her bedtime. She received the call at 9:00 p.m., by that time PCG stated ";I already bathed her." PCG also stated that she had not spoken to a doctor since admission and would want to speak to a doctor to refer the patients increasing forgetfulness, wandering and stating that she wanted to die. PCG stated the patient was not clinically diagnosed with Alzheimers but would want the patient to be cognitively evaluated. 3. A review of Patient 8s ";Patient Information Sheet" indicated an SOC date of 1/31/2024 with the diagnoses of congestive heart failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs) and hypothyroidism (A condition in which the thyroid gland doesn't produce enough thyroid hormone). A review of the agencys ";Employee Counseling Form" that the Branch director (BD) wrote that on 3/8/2024 BD spoke to Registered Nurse Case Manager (RNCM) indicated that the PCG spoke to the RNCM on 2/28/2024 and stated that they are refusing the hospice aide to return. He had only seen this patient once, but the patient said the hospice aide was rude to her and when he turned on the shower she was hit with cold water. During an interview on 3/21/2024 at 12 noon, with the BD, stated that when she knew about Patient 8s refusal of the HA service and the reason why she refused the service is that the HA was rude to her during the HV. When asked if she conducted an investigation of that complaint, BD stated ";No." During a phone interview with the RNCM on 3/21/2024 at 1:08 p.m., RNCM stated that he was familiar with Patient 8s case. RNCM stated that Patient 8 does not usually shower because her bathroom was too small. NCM stated that the patient refused the visit because she wants a female CNA and the patient state that the HA was rude during the home visit with her. RNCM stated that he informed the BD about it and did not conduct the investigation because he ";doesnt have the privilege to do administrative job." 4. A review of Patient 9's ";Patient Information" sheet indicated a start of care on 2/14/2023, with a diagnosis including dysphagia (a medical term for difficulty swallowing) and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Skilled nurse (SN) visits effective 3/10/2024 for twice a week for eight weeks and once a week for one week for symptom management. Medical Social worker (MSW) visits effective 3/17/2024 once a month for one month, twice a month for one month with three (PRN "pro re nata" meaning as needed) for psychosocial needs. Hospice aide (HA) visits effective 3/10/2024 for three times a week for 8 weeks and twice a week for one week. Chaplain visits effective 3/10/2024 for once a week for nine weeks with three prn for spiritual needs. No volunteer needs at this time. During a concurrent interview and record review with the Director of Nursing (DON) of the skilled nursing facility (SNF) on 3/21/2024 at 11:30 a.m., DON stated that the nurse practitioner (NP) does come from the hospice agency and the SNF nurse practitioner who also sees the patient. DON confirmed that the hospice NP came on the following dates 1/2/2024, 2/2/2023, 11/19/2023 from a different name NP form. DON also stated that the hospice doctor does not come and visit the patient. During an interview with the Nurse Practitioner (NP) on 3/22/2024 at 11:10 a.m., NP stated that she conducts the home visits for the agency under MD1. NP stated that Traditions Health tells her which patients are due to visit and she needs to go, she coordinates with the patients family/patients to let them know that she will visit them. NP stated that she attends the IDT ";when necessary" NP stated that she does not attend IDTs (Interdisciplinary Team Meeting- brings together knowledge from different health care disciplines to help people receive the care they need) every 14 days. NP stated that she sometimes sees Patient 7, 8 and 9 but does not remember when was the last time she saw them. NP stated that she had not formally met MD2 and does not know who his patients were, but she calls MD1 if she has notable concerns for the patients. NP further stated that she does not know MD2 and if she has to report anything for the patients, she calls MD1. During an interview with the Medical Director 2 (MD2) on 3/22/2024 at 2:07 p.m., MD2 stated that he signed the agreement with the agency in December 2023 but officially started last February 2024. MD2 confirmed that he does attend IDT meetings but does not do the home visits for patients. MD2 stated an NP conducts the home visits. MD2 stated that he reviews the NPs assessments and adds it on his Certification for Terminal Illness (CTI- a brief narrative designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician). During an interview with the Branch Director (BD) on 3/22/2024 at 11:40 a.m., When asked who MD1 was, BD stated that he was the former Medical Director who left January 2024 and was replaced by MD2 the same month. A review of the agency document titled " Collaborative Practice Agreement for Nurse Practitioner" The purpose of this document is to describe the scope of practice for the nurse practitioner (NP) who signs this agreement, as well as provide written authorization by the supervising physician for the NP to initiate and provide psychiatric and medical care for the consumers of the agency. An NP is a collaborating physician, either primary, back-up or on-call, is continuously available to the NP, either in person or by telephone, for consultation. Upon employment or at the beginning of the collaborative relationship, the supervising physician and NP will meet initially every week for the first 4 weeks of employment to provide education, evaluate skills, or specific case consultation. These meetings may include discussion of clinical problems, progress toward improving outcomes, and recommendations, if any, for changes in treatment. After the first month, these meetings will occur at least monthly for the next five months of the collaboration and then at least once every six months. A short summary of these interactions will be documented and signed by both the physician and NP. Documentation of the collaborative practice agreement will be retained for five calendar years. The NP will document any consultation with a supervising physician for a specific case in the consumer's medical record. A review of the document titled "Job Description: Registered Nurse" indicated that primary functions are to administer care for clients of all ages in their place of residence, coordinate care with the interdisciplinary team, patient/family and referring agency; assume responsibility for coordination of care. A review of the agency document titled "Executive Director-Home Health/Hospice" Job summary: The Branch Director provides leadership for the branch and ensures quality of patient care in the home. The Branch Director is responsible for the overall leadership, direction, growth and culture of the home health/hospice branch. The primary function is for the overall administration of clinical and administrative departments and monitoring of appropriate staffing and productivity of the branch. Coordinates care with the interdisciplinary team, patient/family and referring agency. A review of the " Hospice medical director Agreement" dated 12/1/2023 indicated that Medical Director shall have the following responsibilities and duties ( collectively referred to as "Services''): (a) Assume overall responsibility for the medical component of the Hospice's patient care program.(b) Upon admission and on an ongoing basis, will collaborate with the patient's Attending Physician for the palliation and management of the patient's terminal illness and related conditions, as part of the Plan of Care (POC). If the Attending Physician is not available, the Physician (Medical Director) will be responsible for meeting the medical needs of the patient.( c) Provide supervision and oversight for physician employees and those under contract with Hospice.( d) Participate in Hospice orientation as well as ongoing Palliative Care education.(e) Provide services and visits to Hospice's patients according to the POC, only with the express authorization of Hospice. (f) Schedule patient/family visits through the Interdisciplinary Team meetings and in conjunction with the plan of care. (g) Act as a medical resource for the Hospice clinical staff, and attend and participate as a member of the Interdisciplinary Team, providing input into the patient's Plan of Care.(h) Complete the "certification of terminal illness" and subsequent "recertifications" as required by state and federal regulations for patients on hospice, and in collaboration with Attending Physician as appropriate.(i) Provide input in the development and revision of Hospice policies and procedures. On 3/19/2024, at 11:15 a.m., during the entrance conference and interview in the hospice agency ,with the hospice Branch Director (BD), the Branch Director stated on 3/6/2024, at around 6 p.m., while at the out of state airport waiting for her flight home, she received a phone call from the HA office staff informing her of an incident regarding HAs home health aide (HHA) that had just been reported to the HA by a SNF staff. The Branch Director stated she followed up and spoke with the SNF Social Worker (SW) on 3/7/2024, via telephone, who informed here of the allegations against the hospice HHA and that the SNF was filing a complaint with The Department of Public Health. The branch director stated she interviewed the HHA who indicated it was a dispute between he and the CNA from the SNF and that per that interview, the HA unsubstantiated their side of the complaint. The Branch Director when asked, stated she never interviewed anyone else regarding the complaint and that the RN Case manager, the chaplain, and the MSW visited Patient 2, at the SNF after the alleged incident. The Branch Director stated the HHA was here in the HA taking online in-services regarding customer services. On 3/19/2024, at 3:00 pm. , during an interview with the hospice agencys home health aide in the HA office, he stated, the allegation did not occur and that he still worked for the HA providing patient care on 3/7/2024,3/8/2024, 3/11/2024,3/12/2024, and 3/13/2024, before the HA inform him while in the HA office on 3/13/2024, and after visiting a patient, that he was being suspended while the HA was to investigate the allegation. The HHA stated he had a zoom interview with the HAs Compliance and Human Recourses staff and that he returned to work on 3/18/2024. The HHA stated he refused to sign the Employee Counseling Form given to him by the HA because he did not abuse patient 2 and by signing the form is an admitting he did it. During a review of the HAs Employee Counseling Formed dated 3/18/2024, indicated the HHA was counselled on 3/18/2024, regarding Inappropriate behavior. The employee Counseling form included an incident reported by RN. 1. During a review of Patient 2's Patient Information Report (admission Record), indicated Patient 2 was admitted to the HA on 2/14/2024 with diagnoses including Hypertensive Heart Disease with Heart Failure (heart disease due to unmanaged high blood pressure for a long time that causes added strain on the heart and leads to heart failure), and Dementia (A group of thinking and social symptoms that interferes with). During a review of Patient 2's Hospice IDG Comprehensive Assessment and Plan of Care Updated Report (POC, the process of identifying a patient's needs to ensure collaboration among nurses, patients, and other healthcare providers) for benefit period 2/28/2024 to 4/27/2024, the POC indicated an order for the Skilled Nurse (SN) to provide SN to visit one time a week for one week, twice a week for eight weeks with three PRN (as needed) visits for symptom management .The HHA to visit twice a week for one week and three times a week for eight weeks. The MSW to visit starting on 3/3/2024, to visit Patient 2 one time a week for eight weeks with three PRN visits for Psychosocial needs and for the chaplain, effective 3/3/2024, to visit one a week for eight weeks with three PRN for spiritual needs. During a review of Patient 2's Skilled Nursing Visit dated 3/8/2024, under Narrative indicated, Patient 2 is lethargic/drowsy, confused lying in Semi Fowlers position, Skin warm dry, intact, multiple fading black bruises on bilateral hands distal to elbow, reviewed patient status with SNF SN. She denies any concerns. During a concurrent home visit, observation and interview on 3/20/2024, at 11:30 a.m., inside Patient 2s residence at the SNF, with RN -Case Manager (RNCM). Patient 2 was lying in a hospital bed patient in semi fowlers was awake, on oxygen via nasal cannula at 4 LPM (a unit of measure). Patient spoke very softly and was unable to understand. During an interview with RNCM, he stated he receive a call by the HHA that day (3/6/2024), regarding a dispute at the SNF with the SNF CNA. The RNCM stated he was informed by the Branch Director of the allegations regarding the HHA on 3/18/2023, and that he did not investigate the alleged incident as he does not get involved in administrative stuff and does not have administrative privileges. During a telephone interview with the HA's Nurse Practitioner on 3/22/2024, at 12pm, She stated she visits the patients when needed, and she communicates with Medical Director 1 if needed. The NP stated she has never met MD 2 . During a telephone interview with the medical director 9MD) on 3/22/2024, at 1pm, the MD 1 stated that he does not see, the hospice patients, and complete the patients Certification for Terminal Illness (CTI) form based on the HA's Nurse Practitioner's progress note. The MD 1 stated he was unaware of the abuse incident regarding the CHHA at the SNF until this telephone conversation. During an interview with the Branch Director in the HA on 3/22/2024, at 3Pm., she stated MD 1 has not worked for the HA's since some time last year and was unaware that the NP was communication with MD1 and did not know MD 2.

Observed in Patient Home. In 3 of 3 home visits conducted, the surveyor noted that during HV#1/RR#1, HV#2/RR#2, and HV#3/RR#3 that the patients did not have written policies or state specific laws on Advance Directives in their home folders. Findings were verified by the Branch Director who was present on the visits.

Observed in Record Review. In 3 of 10 patient records reviewed, for active patients it was noted by the nurse surveyor that for RR#4, RR#5, and RR#6 the bereavement risk assessment was not completed as part of the comprehensive assessment. This was verified by the Branch Manager.

Observed in Record Review. In 10 of 10 patient records reviewed, for active patients the nurse surveyor noted that the goals were not measurable. For example, “pain will be managed at a level acceptable to patient by the end of the certification period” and “O2 level will be maintained as appropriate by the end of the certification period.” Additionally, there were no short-term goals at start of care to address issues of immediate needs such as understanding medication management, symptom management, pain management, mobility or safety, most were to be achieved at the end of the recertification period. This was verified by the Branch Manager.

Observed in Record Review. In 1 of 10 patient records reviewed, for active patients the nurse surveyor noted that the plan of care was not complete. For RR#9 the patient had oxygen in the home yet there was no order for the oxygen nor was the use of oxygen addressed on the patient’s care plan. Finding was verified by the Branch Manager.

Observed in Patient Home. In 2 of 3 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned. For example, during HV#1/RR#1 the skilled nurse washed his hands with soap and water and donned gloves. He then set up his equipment and then began taking the patient’s vital signs without changing gloves. He then removed the patient’s sacral dressing and then removed his gloves without performing hand hygiene. He reached in his pocket for his phone, called the doctor, went into his nursing bag, and supply bag all without performing hand hygiene. He then donned a new pair of gloves without hand sanitizing, then cleaned the wound and applied a clean dressing all with the same gloves on. The skilled nurse hand sanitized after removing gloves, then applied a clean pair to take the patient’s foley catheter out. After the catheter removal, he washed his hands with soap and water then began to set up foley supplies. He opened package and donned sterile gloves then opened the catheter package and set up the rest of his supplies contaminating the sterile field. With sterile gloves on he touched the overbed table and the catheter tip hit the side of the tray that he had put lubricant in. After the foley insertion he gathered the trash up, threw it away, and removed his gloves without hand sanitizing. During HV#2 with a Home Health Aide, proper hand technique was broken. Upon arrival to the patient’s room in the facility, the Home Health Aide went into the patient’s bathroom and washed his hands. He then donned gloves. He proceeded to remove the gloves without performing hand hygiene. During the visit the home health aide donned and doffed gloves several times all without hand sanitizing per policy. The Branch Director was present during the home visits and also observed the breaks in technique per agency policy. Observed in Patient Home. In 1 of 3 home visits conducted, it was noted by the nurse surveyor that for HV#1/RR#1, the organization was using Normal Saline to irrigate the patient’s catheter. There was an open bottle of normal saline used for the catheter irrigation that did not have the date it was opened or the date that it would expire on it per agency policy. Finding was verified by Branch Director who was present on the home visit.

Observed in Record Review. In 1 of 10 patient records reviewed, for active patients it was noted by the nurse surveyor that for RR#5, the home health aide supervisory visit was completed 21 days after the previous home health aide supervisory visit, not the required 14 days per policy and regulation. This was verified with the Branch Director.

Observed in Record Review. In 1 of 10 patient records reviewed, for active patients, it was noted by the nurse surveyor that for HV#1/RR#1 and RR#4 the physician’s certificate of terminal illness (CTI) was blank and did not contain the required narrative. Findings were validated by the Branch Director and the Vice President of Regional Operations.

Observed in Patient Home. In 3 of 3 home visits conducted, it was noted by the nurse surveyor that for HV#1/RR#1, HV#2/RR#, and HV#3/RR#3, the patients did not have education related to pain management, education related to an emergency or a natural disaster, education regarding oxygen storage or safety or an individualized disaster plan in their home folders. Findings were verified by the Branch Director who was present on the visits.