Every finding on record at Premier Hospice of Monroe, LLC

Based on record reviews and interview the provider failed to develop and maintain a system of communication and integration, in accordance with the providers own policies and procedures for 9 patients (#1, #2, #3, #4, #5, #6, #7, #8, #10, #11) out of 13 patient records reviewed (#1, #2, #3, #4, #5, #6, #7, #8, #9,#10, #11, #12, #13). Findings: Review of the providers Missed Visits Policy (undated) revealed: Purpose: To ensure that missed visits are documented and does not affect the quality of patient care. Policy: Missed visits will be communicated to the clinical supervisor and the patients physician. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. Procedure: If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. If a visit is missed and not rescheduled the clinician will: A. Notify the physician and the clinical supervisor of the missed visit and reason for missed visit. B. Document in the patients clinical record the following information: 1. Patient Name 2. Date and type of visit that was missed 3. Reason for the missed visit 4. Description of an y unmet needs and how the patients needs were met 5. Physician notification including date, time, physician name, method of notification and staff reporting the information 6. Other person(s) who were notified of the missed visit 7. Any other follow-up needed 8. Signature of staff member reporting the information If an aide visit is missed the aide will contact the case manager or clinical supervisor and the manager/supervisor will take the appropriate measures stated above. The clinical supervisor will track the number and reasons for missed visits to assess patterns and to assure that the plans of care contained the correct number of planned visits. If a patient is routinely refusing visits, the clinician and clinical supervisor should evaluate the appropriateness of eh pan of care and make adjustments to the plan of care with input from the patient and physician. Patient #1 Review of Patient #1s clinical record revealed a start of care date of 05/08/2024. Review of Patient #1s plan of care for certification period 11/04/2024 to 01/02/2025 revealed an order for Hospice Aide 3 times a week for 8 weeks, then 2 times a week for 1 week. Review of Patient #1s Hospice Aide notes for certification 11/04/2024 to 01/02/2025 revealed the following: -Week of 11/10/2024 to 11/16/2024: 1 missed Hospice Aide visit. -Week of 12/15/2024 to 12/21/2024: 1 missed Hospice Aide visit. -Week of 12/22/2024 to 12/28/2024: 1 missed Hospice Aide visit. Review of Patient #1s clinical record failed to reveal the physician and the clinical supervisor were notified of the missed visits and reason for missed visits. Patient #2 Review of Patient #2s clinical record revealed a start of care date of 12/03/2024. Review of Patient #2s plan of care for certification period 12/03/2024 to 03/02/2025 revealed orders for Hospice Aide visits 2 times a week for 1 week, then 3 times a week for 12 weeks. Review of Patient #2s Hospice Aide notes for the certification period 12/03/2024 to 03/02/2025 revealed the following: -Week of 12/22/2024 to 12/28/2024: 1 missed Hospice Aide visit Review of Patient #2s clinical record failed to reveal the physician and the clinical supervisor were notified of the missed visit and reason for missed visit. Patient #3 Review of Patient #3s clinical record revealed a start of care date of 07/19/2024. Review of Patient #3s plan of care for certification period 10/17/2024 to 01/14/2025 revealed an order for Nurse visits 1 time a week for 1 week, then 2 times a week for 12 weeks, and 1 time a week for 1 week. Further review of Patient #3s plan of care revealed an order for Hospice Aide visits 1 time a week for 1 week, then 3 times a week for 12 weeks and 1 time a week for 1 week. Review of Patient #3s Nurse and Hospice Aide notes for certification period 10/17/2024 to 01/14/2025 revealed the following: -Week of 10/20/2024 to 10/26/2024: 1 missed Hospice Aide visit. -Week of 11/10/2024 to 11/16/2024: 1 missed Nurse visit. -Week of 11/24/2024 to 11/30/2024: 1 missed Nurse visit. -Week of 12/22/2024 to 12/28/2024: 1 missed Nurse visit. Review of Patient #3s clinical record failed to reveal the physician and the clinical supervisor were notified of the missed visits and reason for missed visits. Patient #4 Review of Patient #4s clinical record revealed a start of care date of 03/15/2024. Review of Patient #4s plan of care for certification period 11/10/2024 to 01/08/2025 revealed an order for Nurse visits 2 times a week for 8 weeks, then 1 time a week for 1 week. Further review of Patient #4s plan of care revealed an order or Hospice Aide visits 3 times a week for 8 weeks, then 2 times a week for 1 week. Review of Patient #4s Nurse and Hospice Aide notes for certification period 11/10/2024 to 01/08/2025 revealed the following: -Week of 11/10/2024 to 11/16/2024: 1 missed Nurse visit. -Week of 11/24/2024 to 11/30/2024: 1 missed Nurse visit and 1 missed Hospice Aide visit. -Week of 12/01/2024 to 12/07/2024: 2 missed Hospice Aide visits. -Week of 12/15/2024 to 12/21/2024: 1 missed Nurse Visit and 1 missed Hospice Aide visit. -Week of 12/22/2024 to 12/28/2024: 1 missed Nurse visit and 1 missed Hospice Aide visit. Review of Patient #4s clinical record failed to reveal the physician and the clinical supervisor were notified of the missed visits and reason for missed visits. Patient #5 Review of Patient #5s clinical record revealed a start of care date of 07/09/2020. Review of Patient #5s plan of care for certification period 11/15/2024 to 01/13/2025 revealed an order for Nurse visits 1 time a week for 1 week, then 2 times a week for 8 weeks. Review of Patient #5s Nurse notes for certification period 11/15/2024 to 01/13/2025 revealed the following: -Week of 11/24/2024 to 11/30/2024: 1 missed Nurse visit. Review of Patient #5s clinical record failed to reveal the physician and the clinical supervisor were notified of the missed visit and reason for missed visit. Patient #6 Review of Patient #6s clinical record revealed a start of care date of 08/19/2024. Review of Patient #6s plan of care for certification period 11/17/2024 to 02/14/2025 revealed an order for Nurse visits 2 times a week for 13 weeks. Further review of Patient #6s plan of care revealed an order for Hospice Aide visits 3 times a week for 13 weeks. Review of Patient #6s Nurse and Hospice Aide notes for certification period 11/17/2024 to 02/14/2025 revealed the following: -Week of 11/24/2024 to 11/30/2024: 1 missed Nurse visit and 1 missed Hospice Aide visit. -Week of 12/2202024 to 12/28/2024: 1 missed Hospice Aide visit. Review of Patient #6s clinical record failed to reveal the physician and the clinical supervisor were notified of the missed visits and reason for missed visits. Patient #7 Review of Patient #7s clinical record revealed a start of care date of 08/11/2023. Review of Patient #7s plan of care for certification period 12/03/2024 to 01/13/2025 revealed an order for Hospice Aide visits 2 times a week for 9 weeks. Review of Patient #7s Hospice Aide notes for certification period 12/03/2024 to 01/13/2025 revealed the following: -Week of 12/15/2024 to 12/21/2024: 1 missed Hospice Aide visit. Review of Patient #7s clinical record failed to reveal the physician and the clinical supervisor were notified of the missed visit and reason for missed visit. Patient #8 Review of Patient #8s clinical record revealed a start of care date of 11/06/2024. Review of Patient #8s plan of care for certification period 11/06/2024 to 01/04/2025 revealed an order for Nurse visits 2 times a week for 9 weeks. Further Review of Patient #8s plan of care revealed an order for Hospice Aide visits 1 time a week for 1 week, then 3 times a week for 8 weeks. Review of Patient #8s Nurse and Hospice Aide notes for certification period 11/06/2024 to 01/04/2025 revealed the following: -Week of 11/10/2024 to 11/16/2024: 1 missed Hospice Aide visit. -Week of 12/15/2024 to 12/21/2024: 1 missed Nurse visit -Week of 12/29/2024 to 01/04/2024: 1 missed Hospice Aide visit. Review of Patient #8s clinical record failed to reveal the physician and the clinical supervisor were notified of the missed visits and reason for missed visits. Patient #10 Review of Patient #10s clinical record revealed a start of care date of 03/22/2023. Review of Patient #10s plan of care for certification period 11/11/2024 to 01/09/2025 revealed an order for Nurse visits 2 times a week for 8 weeks, then 1 time a week for 1 week. Further Review of Patient #10s plan of care revealed an order for Hospice Aide visits 2 times a week for 9 weeks. Review of Patient #10s Nurse and Hospice Aide notes for certification period 11/11/2024 to 01/09/2025 revealed the following: -Week of 11/10/2024 to 11/16/2024: 1 missed Nurse visit. -Week of 11/24/2024 to 11/30/2024: 1 missed Hospice Aide visit. -Week of 12/15/2024 to 12/21/2024: 1 missed Nurse visit. -Week of 12/22/2024 to 12/28/2024: 1 missed Nurse visit. -Week of 12/29/2024 to 01/04/2024: 1 missed Hospice Aide visit. Review of Patient #10s clinical record failed to reveal the physician and the clinical supervisor were notified of the missed visits and reason for missed visits. Patient #11 Review of Patient #11s clinical record revealed a start of care date of 03/08/2024. Review of Patient #11s plan of care for certification period 11/13/2024 to 01/11/2025 revealed an order for Nurse visits 1 time a week for 1 week, then 2 times a week for 2 weeks. Review of Patient #11s Nurse notes for certification period 11/13/2024 to 01/11/2025 revealed the following: -Week of 11/10/2024 to 11/16/2024: 1 missed Nurse visit. -Week of 12/15/2024 to 12/21/2024: 1 missed Nurse visit. Review of Patient #11s clinical record failed to reveal the physician and the clinical supervisor were notified of the missed visits and reason for missed visits. During an interview on 01/06/2025 at 3:10 p.m. S1 Director of Nursing and S2 Director of Clinical Operations reviewed Patient #1, #2, #3, #4, #5, #6, #7, #8, #10, and #11s clinical records and acknowledged the physician and the clinical supervisor were not notified of the missed visits and reason for missed visits.

Based on record reviews and interview the provider failed to ensure care and services were provided in accordance with patients plan of care by failing to make Nurse and Hospice Aide visits as ordered in the patients plan of care for 9 patients (#1, #2, #3, #4, #5, #6, #7, #8, #10, #11) out of 13 patient records reviewed (#1, #2, #3, #4, #5, #6, #7, #8, #9,#10, #11, #12, #13). Findings: Patient #1 Review of Patient #1s clinical record revealed a start of care date of 05/08/2024. Review of Patient #1s plan of care for certification period 11/04/2024 to 01/02/2025 revealed an order for Hospice Aide 3 times a week for 8 weeks, then 2 times a week for 1 week. Review of Patient #1s Hospice Aide notes for certification 11/04/2024 to 01/02/2025 revealed the following: -Week of 11/10/2024 to 11/16/2024: 1 missed Hospice Aide visit. -Week of 12/15/2024 to 12/21/2024: 1 missed Hospice Aide visit. -Week of 12/22/2024 to 12/28/2024: 1 missed Hospice Aide visit. Patient #2 Review of Patient #2s clinical record revealed a start of care date of 12/03/2024. Review of Patient #2s plan of care for certification period 12/03/2024 to 03/02/2025 revealed orders for Hospice Aide visits 2 times a week for 1 week, then 3 times a week for 12 weeks. Review of Patient #2s Hospice Aide notes for the certification period 12/03/2024 to 03/02/2025 revealed the following: -Week of 12/22/2024 to 12/28/2024: 1 missed Hospice Aide visit. Patient #3 Review of Patient #3s clinical record revealed a start of care date of 07/19/2024. Review of Patient #3s plan of care for certification period 10/17/2024 to 01/14/2025 revealed an order for Nurse visits 1 time a week for 1 week, then 2 times a week for 12 weeks, and 1 time a week for 1 week. Further review of Patient #3s plan of care revealed an order for Hospice Aide visits 1 time a week for 1 week, then 3 times a week for 12 weeks and 1 time a week for 1 week. Review of Patient #3s Nurse and Hospice Aide notes for certification period 10/17/2024 to 01/14/2025 revealed the following: -Week of 10/20/2024 to 10/26/2024: 1 missed Hospice Aide visit. -Week of 11/10/2024 to 11/16/2024: 1 missed Nurse visit. -Week of 11/24/2024 to 11/30/2024: 1 missed Nurse visit. -Week of 12/22/2024 to 12/28/2024: 1 missed Nurse visit. Patient #4 Review of Patient #4s clinical record revealed a start of care date of 03/15/2024. Review of Patient #4s plan of care for certification period 11/10/2024 to 01/08/2025 revealed an order for Nurse visits 2 times a week for 8 weeks, then 1 time a week for 1 week. Further review of Patient #4s plan of care revealed an order or Hospice Aide visits 3 times a week for 8 weeks, then 2 times a week for 1 week. Review of Patient #4s Nurse and Hospice Aide notes for certification period 11/10/2024 to 01/08/2025 revealed the following: -Week of 11/10/2024 to 11/16/2024: 1 missed Nurse visit. -Week of 11/24/2024 to 11/30/2024: 1 missed Nurse visit and 1 missed Hospice Aide visit. -Week of 12/01/2024 to 12/07/2024: 2 missed Hospice Aide visits. -Week of 12/15/2024 to 12/21/2024: 1 missed Nurse Visit and 1 missed Hospice Aide visit. -Week of 12/22/2024 to 12/28/2024: 1 missed Nurse visit and 1 missed Hospice Aide visit. Patient #5 Review of Patient #5s clinical record revealed a start of care date of 07/09/2020. Review of Patient #5s plan of care for certification period 11/15/2024 to 01/13/2025 revealed an order for Nurse visits 1 time a week for 1 week, then 2 times a week for 8 weeks. Review of Patient #5s Nurse notes for certification period 11/15/2024 to 01/13/2025 revealed the following: -Week of 11/24/2024 to 11/30/2024: 1 missed Nurse visit. Patient #6 Review of Patient #6s clinical record revealed a start of care date of 08/19/2024. Review of Patient #6s plan of care for certification period 11/17/2024 to 02/14/2025 revealed an order for Nurse visits 2 times a week for 13 weeks. Further review of Patient #6s plan of care revealed an order for Hospice Aide visits 3 times a week for 13 weeks. Review of Patient #6s Nurse and Hospice Aide notes for certification period 11/17/2024 to 01/14/2025 revealed the following: -Week of 11/24/2024 to 11/30/2024: 1 missed Nurse visit and 1 missed Hospice Aide visit. -Week of 12/22/2024 to 12/28/2024: 1 missed Hospice Aide visit. Patient #7 Review of Patient #7s clinical record revealed a start of care date of 08/11/2023. Review of Patient #7s plan of care for certification period 12/03/2024 to 01/13/2025 revealed an order for Hospice Aide visits 2 times a week for 9 weeks. Review of Patient #7s Hospice Aide notes for certification period 12/03/2024 to 01/13/2025 revealed the following: -Week of 12/15/2024 to 12/21/2024: 1 missed Hospice Aide visit. Patient #8 Review of Patient #8s clinical record revealed a start of care date of 11/06/2024. Review of Patient #8s plan of care for certification period 11/06/2024 to 01/04/2025 revealed an order for Nurse visits 2 times a week for 9 weeks. Further Review of Patient #8s plan of care revealed an order for Hospice Aide visits 1 time a week for 1 week, then 3 times a week for 8 weeks. Review of Patient #8s Nurse and Hospice Aide notes for certification period 11/06/2024 to 01/04/2025 revealed the following: -Week of 11/10/2024 to 11/16/2024: 1 missed Hospice Aide visit. -Week of 12/15/2024 to 12/21/2024: 1 missed Nurse visit -Week of 12/29/2024 to 01/04/2024: 1 missed Hospice Aide visit. Patient #10 Review of Patient #10s clinical record revealed a start of care date of 03/22/2023. Review of Patient #10s plan of care for certification period 11/11/2024 to 01/09/2025 revealed an order for Nurse visits 2 times a week for 8 weeks, then 1 time a week for 1 week. Further Review of Patient #10s plan of care revealed an order for Hospice Aide visits 2 times a week for 9 weeks. Review of Patient #10s Nurse and Hospice Aide notes for certification period 11/11/2024 to 01/09/2025 revealed the following: -Week of 11/10/2024 to 11/16/2024: 1 missed Nurse visit. -Week of 11/24/2024 to 11/30/2024: 1 missed Hospice Aide visit. -Week of 12/15/2024 to 12/21/2024: 1 missed Nurse visit. -Week of 12/22/2024 to 12/28/2024: 1 missed Nurse visit. -Week of 12/29/2024 to 01/04/2024: 1 missed Hospice Aide visit. Patient #11 Review of Patient #11s clinical record revealed a start of care date of 03/18/2024. Review of Patient #11s plan of care for certification period 11/13/2024 to 01/11/2025 revealed an order for Nurse visits 1 time a week for 1 week, then 2 times a week for 8 weeks. Review of Patient #11s Nurse notes for certification period 11/13/2024 to 01/11/2025 revealed the following: -Week of 11/10/2024 to 11/16/2024: 1 missed Nurse visit. -Week of 12/15/2024 to 12/21/2024: 1 missed Nurse visit. During an interview on 01/06/2025 at 3:10 p.m. S1 Director of Nursing and S2 Director of Clinical Operations reviewed Patient #1, #2, #3, #4, #5, #6, #7, #8, #10, and #11s clinical records and acknowledged there were missed visits as documented above.

Based on record reviews and interview the agency failed to ensure a criminal background check was obtained for 5 {S3 Registered Nurse (RN), S4 RN, S5 Licensed Practical Nurse (LPN), S6 Master of Social Work (MSW), and S7 Certified Nursing Assistant (CNA)} out of 10 (S1-S10) sampled employees who have direct patient contact or access to patient records. Findings: Review of S3 RN's employee record revealed a hire date of 1/21/22. S3 RN's employee record failed to reveal a criminal background check . Review of S4 RN's employee record revealed a hire date of 9/29/21. S4 RN's employee record failed to reveal a criminal background check. Review of S5 LPN's employee record revealed a hire date of 2/10/22. S5 LPN's employee record failed to reveal a criminal background check. Review of S6 MSW's employee record revealed a hire date of 2/10/22. S6 MSW's employee record failed to reveal a criminal background check. Review of S7 CNA's employee record revealed a hire date of 9/19/19. S7 CNA's employee record failed to reveal a criminal background check. During an interview on 2/22/22 at 2:00PM S2 Compliance Officer reviewed the employee records and confirmed there were not background checks for S3 RN, S4 RN, S5 LPN, S6 MSW, and S7 CNA. S2 Compliance Officer acknowledged these employees all had direct patient contact and could access patient records.

Based on record reviews and interview, the agency failed to comply with all applicable federal, state and local laws and regulations related to the health and safety of patients for 1 (S8 CNA{Certified Nursing Assistant}) of 10 (S1-S10) employees reviewed for criminal background as evidenced by the agency employing someone with a criminal background which would bar the person from employment as a healthcare personnel. Findings: Review of the employee record for S8 CNA revealed a hire date of 10/08/2015 and a criminal background check dated 10/15/2015. Further review of the criminal background check revealed the following charge for S8 CNA: Charge 1 R.S. 14:67 of theft over 500. Disposition: 3 YRS H/L SUSP. 5 YRS PROB $500 F/CC or 180 days-PROB Begins 6-10-97, Ends 6/10/2002 During an interview on 02/22/2022 at 11:18 AM, S2 Compliance Officer confirmed S8 CNA had a felony theft charge and acknowledged he could not provide any verification of it being expunged or dismissed.