Every finding on record at Procare Hospice Bakersfield

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview and observation. In 1 of 3 (33%) home visits observed, the agency did not ensure that clinical staff followed the agency's policy on hand hygiene. The agency's "Hand Hygiene" policy (Policy No. 7-009, Revised 07/2023) stated in part, "3. Hand decontamination using an alcohol-based hand rub should be performed: D. After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings... G. After removing gloves." HOME VISIT 1/CLINICAL RECORD 1: During a home visit observation with the Registered Nurse (RN) (Personnel Record 3) on 05/19/2026. The RN was observed performing wound care for a stage 2 pressure ulcer located on the patient's coccyx. The RN put on gloves and removed the dirty dressing, cleansed the wound with a wound cleanser, and applied a new dressing, without removing gloves after contact with the soiled dressing. The RN then removed the gloves and did not sanitize hands as per agency’s policy. The Administrator/Director of Patient Care Services (DPCS) (Personnel Record 1) was interviewed on 05/19/2026 and stated, "The nurse should disinfect her hands after removing the dirty dressing and after removing gloves."

It is required that Nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care; 1. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure Nursing care and services were provided by or under the supervision of a registered nurse and per the patient plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 01/13/2026 with a diagnosis of cerebrovascular disease and congested heart failure. A review of the clinical record revealed that a comprehensive assessment was completed on 01/13/2026. The Plan of Care (POC) dated 04/13/2026-07/11/2026 included an order for Skilled Nursing (SN) visits twice weekly. A verbal order dated 04/22/2026 was documented that stated in part, "Wound Care to stage 2 pressure ulcer coccyx area. Hospice RN to perform wound care during visits to stage 2 pressure ulcer to coccyx area using clean technique. Cleanse with wound cleanser, pat dry with 4x4 gauze, apply hydrocolloid dressing 3 times per week and as needed for torn, tattered, soiled, or dislodged dressing until wound is healed. The [ALF] staff in memory care is to perform wound care on non-SN visit days after a successful return demonstration PRN. Buddy code SN93 added for weekly measurements." The clinical record included skilled nursing (SN) visits provided twice weekly, 04/22/2026 through 05/21/2026, as ordered on the POC. The SN visit documentation did not provide evidence of weekly wound measurements as ordered on the POC. CLINICAL RECORD 4: The patient elected the hospice benefit on 03/20/2026 with a diagnosis of Parkinson’s disease and protein-calorie malnutrition. A review of the clinical record revealed that a comprehensive assessment was completed on 03/20/2026. The Plan of Care (POC) dated 03/20/2026-05/18/2026 included orders for Skilled Nursing (SN) visits with a frequency of 2 visits each week. The clinical record included a skilled nursing note dated 04/24/2026, that stated in part, "PT scratches herself and caused a scrape on right inner arm to bleed." The clinical record included a verbal order dated 04/24/2026, that stated in part, "Hospice SN to perform wound care during visits to right inner arm area. Using clean technique, cleanse with wound with wound cleanser, pat dry with 4x4 gauze, apply dressing 3 times per week. Perform same wound care PRN for torn, tattered, soiled or dislodged dressing until wound is healed. [ALF] staff in memory care to perform wound care on non-SN visit days after successful return demonstration PRN. SN to measure wound weekly." The clinical record included skilled nursing (SN) visits provided twice weekly, 04/24/2026 through 05/18/2026, as ordered on the POC. The SN visit documentation did not provide evidence of weekly wound measurements as ordered on the POC. CLINICAL RECORD 7: The patient elected the hospice benefit on 12/02/2025 and recertified for the service dates of 03/02/2026-05/30/2026 with a diagnosis of heart failure. The Plan of Care (POC) dated 03/02/2026-05/30/2026 included an order for Skilled Nursing (SN) with a visit frequency of 1 visit weekly. The clinical record included a skilled nursing note dated 04/25/2026, that documented that the patient's right big toenail had fallen off. The clinical record included an order dated 04/25/2026 that stated in part, "Hospice RN to perform wound care during visits to wound to right big toe (toenail has fallen off). Using clean technique, cleanse the wound with wound cleanser, pat dry with 4x4 gauze, apply dressing 3 times per week and as needed for torn, tattered, soiled, or dislodged dressing until wound is healed. [ALF] staff in memory care to perform wound care on non-SN days after successful return demonstration. SN to measure wound every 7 days...". The clinical record included documentation of weekly skilled nursing visits provided 04/25/2026 through 05/15/2026. The SN visit notes documented that the “wound has healed”, and an order was obtained to discontinue wound care on 05/15/2026. The SN visit documentation did not provide evidence of weekly wound measurements as ordered on the POC. The Administrator/Director of Patient Care Services (DPCS) (Personnel Record 1) reviewed the clinical records and verified that wound measurements were not documented as ordered. The Administrator/DPCS (Personnel Record 1) was interviewed on 05/20/2026 and stated, "We talked to the nurse. She has the measurements in her notebook, but she forgot to put them in the chart."

Based on interview and record review, the facility failed to ensure one of one sampled patient (Patient 1) had an accurate comprehensive assessment when Registered Nurse (RN) 1 did not document accurate information to reflect Patient 1s health condition. This failure resulted in Patient 1s physician (MD 1) receiving inaccurate information regarding Patient 1s health condition necessary to determine appropriate hospice election. --- Findings: During an interview on 7/13/23, at 1:01 p.m., with RN 1, RN 1 stated, the criteria for Patient 1 to be admitted to hospice included an oxygen saturation (amount of oxygen level in one's red blood cells normal is 97-100%) of less than 88%, signs and symptoms of Congestive Heart Failure (CHF-a condition when one's heart does not pump enough blood to meet the body's need), and oxygen and/or steroid (anti-inflammatory medications) dependent (uninterrupted steroid intake for more than a year). RN 1 stated, Patient 1 opened the door for her when she arrived to conduct the nursing visit on 5/5/23. RN 1 stated, Patient 1 was not wearing her oxygen. Patient 1 was short of breath, and she asked her to wear her oxygen. RN 1 was unable to provide documented evidence Patient 1s oxygen saturation was less than 88%. RN 1 stated, she did not check Patient 1's oxygen saturation during her visit on 5/5/23. RN 1 acknowledged she marked ";signs and symptoms of CHF." RN 1 acknowledged and stated her documentation of Patient 1's assessment on 5/5/23 indicated, the patient's ";lungs were clear, breathing 96 %, currently, no edema, and no abnormal cardiovascular findings. During a concurrent interview and record review on 7/13/23, at 1:30 p.m., Patient 1's medication list was reviewed. Patient 1's list of medication did not include any steroid medications. RN 1 stated, she listed all the medications Patient 1 was taking and RN 1 confirmed Patient 1 was not on steroid medication. During a concurrent interview and record review, on 6/21/23, at 2:15 p.m., with MD 1, Patient 1s Visit Notes Report (VNR), dated 5/5/23, was reviewed. MD 1 acknowledged RN 1s documentation and stated, Patient 1 was not on steroid medication, was not diagnosed with CHF and there was no documented evidence of patient being diagnosed with CHF in the medical record; Patient 1 did not have edema and no abnormal cardiovascular findings. MD 1 stated, CHF symptoms are completely different from Chronic Obstructive Pulmonary Disease (COPD-chronic lung disease that causes obstructed airflow from the lungs). MD 1 stated, ";I dont know where the CHF diagnosis came from, but the primary diagnosis for hospice care was COPD." During an interview on 6/30/23, at 1:12 p.m., with Patient 1s Nurse Practitioner (NP), NP stated, NP 1 stated, ";[Patient 1] has never been diagnosed with CHF. Sometimes, her shortness of breath is from her anxiety and panic attack. [Patient 1] has COPD, but not CHF." During a review of the facilitys policy and procedure (P&P) titled, ";Documentation Expectations," dated 2/2023, the P&P indicated, ";The employee providing direct patient care services will: 1. Demonstrate capability of entering data accurately, appropriately, and efficiently regarding patient related condition/status in the interviewing/assessment process. 2. Provide adequate data entry regarding patient-related condition/status during the course of care."

Based on interview and record review, the facility failed to: 1. Ensure a physician's order for one of one sampled patient (Patient 1)'s admission to hospice was obtained timely and appropriately. This failure resulted in Patient 1's admission to hospice without proper approval for hospice admission. 2. Ensure one of one sampled patient (Patient 1) had a physician order written to address the use of Emergency Kit, continuation of previous medications, or medications Hospice did not cover. This failure had the potential for adverse consequences, which could be detrimental to Patient 1s medical care. --- Findings: 1.During an interview on 6/13/23, at 8:45 a.m., with Family Member (FM), FM stated, [Patient 1]s Nurse Practitioner received a faxed document from Hospice on 5/4/23, requesting her to sign agreement to admit [Patient 1] to hospice care, but [NP] did not sign the request. During an interview on 6/20/23, at 3:11 p.m., with Accounts Executive (AE), AE stated, she received a call from the property manager of a seniors apartment, she was informed Patient 1 was declining in health and could use hospice care. AE stated, she visited Patient 1, explained what hospice was all about, gathered her information, and submitted them to the Office. AE stated, ";I dont do clinical stuff. I just handed the release form to the Office and at that point my task is done." During a concurrent interview and record review, on 6/21/23, at 1 p.m., with MD 1, Patient 1s ";Physicians Order (PO)," dated 5/5/23, was reviewed. The PO indicated Verbal Certification obtained by RN 1 on 5/5/23. Hospice verbal certification by Medical Director on 5/5/23, at 7:28 p.m. MD 1 stated, ";I did not write the order." MD 1 stated, the order description did not appear how physicians order were normally written. The facility may have a template that generated physicians order once the nurse entered Patient 1s medical information in the electronic health record (EHR). During a concurrent interview and record review, on 6/21/23, at 1:53 p.m., Patient 1s Physicians Order (PO), dated 5/6/23, was reviewed. The PO indicated, ";Eval (evaluate) for hospice, admit if appropriate. DX (diagnosis) COPD." MD 1 stated, ";I wrote this order on 5/6/23." MD 1 stated, he was not aware Patient 1s primary care physician refused hospice care and stated, ";Had I known, I would not have admitted the patient [for hospice care]. Instead, the patient should be evaluated in the Emergency Department and the physician should refer the patient to hospice. There must be a transfer of care from the primary care physician to the hospice physician. I dont know how we got the referral from a property manager." During a review of the facilitys policy and procedure (P&P) titled, ";Hospice Intake & Admission," dated 4/2022, the P&P indicated, ";Admission to Hospice Care: (a) The hospice admits a patient only on the recommendation of the medical director in consultation with or with input from, the patients attending physician (if any). . .Instructions for entering a Lead into HCHB. . .6. Physicians Order: a medical directors order must be obtained to initiate hospice services. Physicians (sic) may communicate a verbal order to a licensed nurse." 2. During a concurrent interview and record review, on 6/20/23, at 1:58 p.m., with Registered Nurse (RN) 1, Patient 1s Medication Report (MR), dated 5/5/23, was reviewed. The MR indicated the following emergency kit medications and patients own medications: From the Emergency Kit (Ekit contains oral medications and suppositories): Acetaminophen (medication for mild pain, fever) 650 mg (milligram, a unit of measure) rectal suppository (medications by insertion into a body orifice where it dissolves or melts to exert local or systemic effects), Bisacodyl (laxative) 10 mg rectal suppository, Hyoscyamine (used to treat a variety of stomach/intestinal problems such as cramps) 0.125 mg sublingual (under the tongue) tablet, Lorazepam (medication used to treat anxiety) 0.5 mg tablet, Morphine (narcotic pain medication)15 mg tablet, Nystatin (antifungal) 100,000 units/ml (milliliter, a unit of measure) oral suspension, Ondansetron (medication to prevent nausea and vomiting) HCL 4 mg tablet. Patient 1s own medications: Ferosul (iron medication) 325 mg one tablet daily Loratadine (medication to treat hay fever, pollen allergy) 10 mg one tablet by mouth daily Meloxicam (medication to treat arthritis, reduce pain, swelling, and stiffness of the joints)15 mg one table by mouth daily Movantik (laxative) 25 mg one tablet by mouth daily Omeprazole (medication to treat heartburn or acid reflux) 40 mg one tablet by mouth daily Ropinirole (medication to improve symptoms like shaking (tremors), slowness and stiffness) 1 mg one tablet by moth three times daily During an interview on 6/15/23, at 10:35 a.m., with Patient 1's Caregiver, Caregiver stated, Patient 1 takes Norco 10/325 mg (milligram, a unit of measure) one tablet three times a day. During a review of Patient 1s medication profile, Patient1's pain medication Norco (narcotic pain medication) 10/325 mg was not listed. RN 1 stated, Patient 1 handed over her medications from the drawer to me. ";I did not see the pain medication. I did not call the family to discuss Patient 1s medications. I did not call the doctor. We know what medications [MD 1] would be okay with." During a concurrent interview and record review on 6/21/23, at 2 p.m., with MD 1, Patient 1s ";Medication Order" was reviewed. MD 1 stated, he reviewed Patient 1s medications, but did not write medication orders. MD 1 stated, he did not write physicians orders for the use of emergency kit. MD 1 stated, ";Almost every hospice patient receives an Ekit. Patients may have some shortness of breath; they can have morphine." MD 1 also stated, ";Patient 1 had medications not covered by Medicare. We should have informed the family of those medications, if continued, will have to be shouldered by the family, out of pocket. For example, Patient 1 was on Movantik and Ropenirole; these medications are not covered by Medicare." MD 1 stated, he did not write orders for the medications Patient 1 had to continue while on hospice care. During an interview on 6/13/23, at 9 a.m., with Family Member (FM), FM stated, no one called me regarding the Ekit they left for my mother, nor provided me education regarding the medications, and hospice care." During a concurrent interview and record review, on 6/13/23, at 10:56 a.m., with Administrator, Administrator stated, Ekits are standing order for our office. Every patient on hospice receives an Ekit. Administrator was unable to provide any protocols or policies /procedures on the use of Ekits. During a review of the facilitys policy and procedure (P&P) titled, ";Medication List and Monitoring-PC-85," dated 4/2022, the P&P indicated, ";I. The Hospice will maintain a current, accurate Medication Profile of all prescription, over the counter (TC), sample and investigational medications, herbal and home remedies taken by the patient, alternative treatments that could affect drug therapy, and drug therapy currently associated with laboratory testing. . .III. The medication profile will include. . .F. Reconciliation with physician order. IV. The RN will compare the medication information (list) the patient is currently taking with the medications ordered to identify and resolve discrepancies, to include omissions, duplications, contraindications, unclear information, and changes."

Based on interview and record review, the facility failed to ensure one of one sampled patient (Patient 1)'s discharge summary from Hospice was sent to Patient 1's primary care physician. This failure resulted in the patient's primary physician being unaware of a change in the resident's care. --- Findings: During a concurrent interview and record review on 6/20/23, at 2:17 p.m., with Medical Social Worker (MSW), MSW stated, when she visited [Patient 1] on 5/9/23, [Patient 1] stated, she did not want to be on hospice, instead, Patient 1 wanted to be on pain management. MSW stated, [Patient 1] signed the revocation paper to revoke (stop) hospice care. During an interview on 6/21/23, at 2:40 p.m., with Medical Director (MD), MD stated, he received a text message informing him [Patient 1] revoked hospice care on 5/9/23. I did not write the discharge order. The Interdisciplinary group (IDG- a group of health care professionals from diverse fields who work collaboratively toward a common goal for patients) met on 5/17/23, but I did not write the discharge order or the discharge summary. During a concurrent interview and record review, on 6/30/23, at 1:33 p.m., with Patient 1's Nurse Practitioner (NP), Patient 1's clinic record was reviewed. NP was unable to find documentation of a physician discharge summary from Hospice. NP stated, "I have not received a discharge summary from the hospice physician (MD) 1. I have not received any form of communication from [MD] 1 regarding Patient 1's hospice care." During a review of the facilitys policy and procedure (P&P) titled, ";Patient Revocation-PE 35," dated 4/2022, the P&P indicated, ";VI. The Hospice will forward copies of the following information to the patients attending physician: A. The Hospice discharge summary that includes but is not limited to: 1. A summary of the patients care (pain management, symptoms and treatments); 2. The patients plan of care, including current medication profile; 3. The latest physician orders; and 4. Any other documentation requested or that may assist with the patients post discharge continuity of care."

Based on interview and record review, the facility failed to ensure one of one sampled patient (Patient 1) had a completed physician discharge summary written by the hospice physician after Patient 1 revoked election of hospice care. This failure resulted in Patient 1's primary care physician not receiving the summary of hospice care for continuum of care. --- Findings: During a concurrent interview and record review on 6/21/23, at 2:30 PM, with Medical Director (MD) 1, Patient 1s medical record was reviewed. MD 1 was unable to find a physician discharge summary (a clinical report prepared by a health professional at the conclusion of a hospital stay or series of treatments). MD 1 stated, he was informed of Patient 1s revocation of hospice care on 5/9/23 and the Interdisciplinary Group (IDG- a group of health care professionals from diverse fields who work collaboratively toward a common goal for the patient) met on 5/17/23. MD 1 stated, we discussed about Patient 1 and learned she revoked her election to hospice care. I should have written the discharge summary at that time. MD 1 stated, ";I did not write the discharge summary. I did not write the discharge order." During a review of the facilitys policy and procedure (P&P) titled, ";Patient Revocation-PE 35," dated 4/2022, the P&P indicated, ";VI. The Hospice will forward copies of the following information to the patients attending physician: A. The Hospice discharge summary that includes but is not limited to: 1. A summary of the patients care (pain management, symptoms and treatments); 2. The patients plan of care, including current medication profile; 3. The latest physician orders; and 4. Any other documentation requested or that may assist with the patients post discharge continuity of care." During a review of the facilitys policy and procedure (P&P) titled, ";Interdisciplinary Group Meeting," dated 3/2022, the P&P indicated, ";Conducting IDG Meeting: 4. All core team members will be prepared to contribute. . .c. The hospice physician will complete his/her IDG Notes during the meeting, in collaboration with the IDG members as each patient is discussed. . .ii. The Medical Director/hospice physician must type, or speak-to-text their IDG Notes, Physician Narratives, and CTI documentation; no other team member may type this information for them."

Based on interview and record review, the facility failed to ensure one of one sampled patient (Patient 1) was assessed and determined capable of self-administration of medication by the Interdisciplinary Group (IDG- a group of health care professionals from diverse fields who work collaboratively toward a common goal for the patient). This failure had the potential for adverse consequences. --- Findings: During an interview on 6/13/23, at 8:43 a.m., with Family Member (FM), FM stated, ";[Patient 1] was signed up for hospice care without me and her caregiver knowing. Hospice nurse left her several medications: 15 morphine (narcotic pain medication) pills, five lorazepam (medication to treat anxiety), and some suppositories. [Patient 1] had taken nine of the morphine pills and consumed the lorazepam in 36 hours. When the caregiver picked her up for her doctors appointment, [Patient 1] was very drowsy. We are managing her medications once a week. I put her meds, a weeks worth, in her pill box and the caregiver gives her medications because she is not able to manage her own medications." During an interview on 6/15/23, at 10 a.m., with Patient 1s Caregiver (PC), PC stated, ";I was not aware she got signed up for hospice care. They brought her morphine and other medications. [Patient 1] does not take her medications properly. Her daughter and I manage her medications. I come every day to give [Patient 1] her medications. Her NP told us she could not take any more pills than what we give her. It was a mess." During a concurrent interview and record review, on 6/20/23, at 2:10 p.m., with Registered Nurse (RN) 1, Patient 1s medical record was reviewed. RN 1 was unable to provide documentation of an IDG assessment for Patient 1s self-administration of medication and stated, ";Its not here." During an interview on 6/30/23, at 10:30 a.m., with Administrator, Administrator stated, IDG meeting occurs on the 14th day of admission. Administrator stated, the IDG for Patient 1 occurred on 5/17/23, eight days after Patient 1 revoked hospice care on 5/9/23. Administrator acknowledged there was no IDG for Patient 1s self-administration of medication. During a review of the facilitys policy and procedure (P&P) titled, ";Medication List and Monitoring," dated 4/2022, the P&P indicated, ";IV. The Interdisciplinary Group/Team (IDG/IDT), as part of the review of the Plan of Care (POC), will determine the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient at home."

Observed in Record Review. In 8 of 8 patient records reviewed, for active patients, it was noted by the nurse surveyor that for HOSHV#1/RR#1, HOSHV#2/RR#2, HOSHV#3, RR#4, RR#5, RR#6, RR#7, and RR#8 the interdisciplinary group meeting notes did not document decline, revisions to plans of care and goals. Findings were discussed with the Administrator.

Observed in Record Review. In 8 of 8 patient records reviewed, for active hospice patients the nurse surveyor noted that the goals were not measurable. For example, “pain will be managed at a level acceptable to patient by on-going” and “Patient’s constipation is controlled.” 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 did not have a timeframe for completion. Findings were verified by the Clinical Team Lead and the Administrator.

Observed in Record Review. In 8 of 8 patient records reviewed, for active patients, the nurse surveyor noted that for HOSHV#1/RR#1, HOSHV#2/RR#2, HOSHV#3, RR#4, RR#5, RR#6, RR#7, and RR#8 the visit frequency as established by the IDG (interdisciplinary group) included PRN visits for the skilled nurse, the medical social worker, and the chaplain. There were no indications stated or reasons documented for the extra PRN visits as required by regulation. Finding was verified by the Administrator.

Observed in Patient Home. In 3 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 per policy “Hand Hygiene – IC15”. For example, during HOSHV#1/RR#1 the Social Worker entered the home, signed in and then proceeded to go over and talk to the patient, touching her at intervals. At one point during the visits she did walk over to the entry table and hand sanitize. When asked if she carried hand sanitizer with her into the home, she said she kept a bottle in her car and she used it prior to entering the home. HOSHV#2/RR#2 the hospice aide did not change her gloves or perform hand hygiene per policy. She removed the patient’s urine soaked briefs and pads, then bathed him, and applied cream to his private parts and bottom without changing gloves or performing hand hygiene between tasks. After applying the cream, she changed gloves and hand sanitized, she then put clean briefs on patient, and clean pads under him and positioned him in bed, she then proceeded to put toothpaste on his toothbrush and assist him with mouth care with the same gloves on. HOSHV#3/RR#3 the skilled nurse had numerous breaks in hand hygiene policy, she did not change gloves between touching the patient and touching other items, when she did she change gloves she did not hand sanitize prior to putting clean gloves on. She then set up the patient’s medi planner and reconciled her meds without performing hand hygiene or changing gloves between touching the pills and the bottles. The Clinical Team Lead was present during the home visits and also observed the breaks in technique per agency policy.

Based on interview and record review, the agency failed to follow its policy and procedure (P&P) to document and initiate an investigation for one of 13 sampled patients (Patient 8) with multiple skin discoloration [bruises]. This failure had the potential for possible mistreatment and/or abuse. Findings: During a review of Patient 8's "Visit Note Report" (VNR), dated 10/26/21, the "VNR" indicated, "Head to toe assessment done both under the eyes, right side of hip and right side of breast brusse [bruises] noted. . . " During an interview on 1/3/22, at 2 PM, with Registered Nurse Case Manager (RNCM) 2, RNCM 2 stated, "This place [Patient 8's home] is not a good place. When she [Patient 8] was first admitted [10/26/21] she had multiple bruises on her eyes, breast area and hip. They [facility staff] said she [Patient 8] had a fall." During a concurrent interview and record review on 1/4/22, at 10:15 AM, with Executive Director (ED), ED was unable to find documentation the agency investigated Patient 8's multiple bruises dated 10/26/21. ED was unable to find a follow up investigation regarding the bruises. During an interview, on 1/4/22, at 1:55 PM, with Director of Clinical Services (DCS)and ED, DCS stated, an Occurrence Report should be completed when there was a fall, bruises, and injuries. ED stated, it should have been followed up. During a review of the agency's policy and procedure (P&P) titled "Abuse, Neglect, and Exploitation," dated 3/1/21, the P&P indicated, "II. Hospice Management will: A. Initiate an Investigation of the situation. . . VIII. . . "Regarding alleged abuse. . . the Hospice must. . . B. 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. Investigation and /or documentation of all alleged violations must be conducted in accordance with established procedures."

Based on observation, interview, and record review, the agency failed to perform medication reconciliation for one of 13 sampled patients (Patient 1) when the Licensed Vocational Nurse (LVN) 1 did not reconcile Patient 1's medications and did not educate Caregiver (CG) 3 of Patient 1's medication administration. These failures had the potential for Patient 1 not being given the correct medications and had the potential to result in adverse health outcomes. Findings: During an observation on 1/3/22, at 1 PM, in Patient 1's home, LVN 1 performed wound dressing changes to Patient 1, checked Patient 1's vital signs (blood pressure, pulse rate, and temperature), asked CG 3 if there were changes in conditions (a change in what is normal [baseline] for a particular patient's condition when the patient first comes in) and if Patient 1 was taking new medications. LVN 1 did not check and reconcile Patient 1's medications. LVN 1 left Patient 1's home. During a concurrent observation and interview on 1/3/22, at 1:20 PM, with CG 3, in Patient 1's home, CG 3 stated, she prepared and gave Patient 1's medications. CG 3 stated, "I decide which medications I give her. There are medications I do not give her because she [Patient 1] does not need them." CG 3 showed three plastic bags containing bottles of medications. CG 3 stated, she only gave those medications in the first bag, the second bag contains medications which Patient 1 no longer takes, and the third bag were "extra". CG 3 showed which current medications she was giving. During a review of Patient 1's current medications in the bag, with CG 3, the following current medications were reviewed: a. Senna Lax (stool softener) 8.6 mg (milligram-unit of measurement) b. Clonazepam (medication for anxiety) 1 mg c. Memantin (medication for memory loss) 5 mg d. Banophen (anti-allergy) 25 mg e. Paroxetine (medication for depression) 40 mg f. Olanzapine (medication for mental disorder) 10 mg g. Donepezil (medication for memory loss) 5 mg h. Diphenhydramine (anti-allergy) 25 mg i. Acetaminophen (medication for pain and fever) tablet 325 mg j. Bactrim DS (antibiotic) k. Morphine liquid (strong medication for pain) 0.5mg/ml (milliliter-unit of measurement) During a review of Patient 1's "Medications" List, dated 12/8/21, the "Medications" List indicated: a. Acetaminophen 650 rectal suppository b. Banophen 25 mg c. Bisacodyl (stool softener) 10 mg rectal suppository d. Donepezil 5 mg e. Folic Acid (supplement) 1 mg f. Levsin (medication for stomach cramps) 0.125 mg g. Lorazepam (medication for anxiety) 1 mg/0.5 ml h. Memantin 5 mg i. Milk of Magnesia liquid (stool softener) j. Morphine 0.5 mg/ml k. Olanzapine 10 mg l. Paroxetine 40 mg m. Senna Lax 8.6 mg n. Zofran (medication for nausea and vomiting) 4 mg During an interview on 1/4/22, at 1:52 PM, with LVN 1, LVN 1 stated, she did not do the medication reconciliation because she asked CG 3 if there were changes. LVN 1 stated, CG 3 said no change. LVN 1 stated, "Sometimes, they [caregivers] don't like us telling them about their medications." LVN 1 stated, "Caregiver [CG 3] was holding medications when Patient 1 had low blood pressure." LVN 1 stated, she should have educated CG 3 regarding medication administration and reconciled Patient 1's medications. During a review of Patient 1's "Hospice Certification and Plan of Care" (HCPC), dated 12/8/21, the "HCPC" indicated, "Hospice nurse to assess medication response and instruct on schedule, actions, purpose, side effects, compliance and need to report side effects to hospice staff." During a concurrent interview and record review on 1/4/22, at 11:40 AM, with Director of Clinical Services (DCS), Patient 1's "Medication List," dated 12/8/21, was reviewed. DCS stated, the last medication reconciliation was upon admission on 12/8/21. DCS stated, licensed nurses should update the medication profile. During a review of agency's policy and procedure (P&P) titled, "Medication List and Monitoring," dated 1/1/21, the P&P indicated, "I. The Hospice will maintain a current and accurate Medication Profile of all prescription, over-the-counter (OTC), sample and investigational medications, herbal and home remedies taken by the patient, alternative treatments that could affect drug therapy, and drug therapy currently associated with laboratory testing. IV. The Registered Nurse will compare the medication information (list) the patient is currently taking with the medications ordered to identify and resolve discrepancies, to include omissions, duplications, contraindications, unclear information, and changes. VI. Hospice nursing staff will assess on an ongoing basis the patient's medication safety as well as their response to the medication and the patient/caregiver's compliance with the medication regimen. The hospice pharmacist may be consulted. VII. Hospice nursing staff will assess on an ongoing basis the patient's response to the medication and the patient/caregiver's compliance with the medication regimen."

Based on interview and record review, the agency failed to provide services in accordance with the plan of care (POC) for five of 13 sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13). This failure had the potential to negatively impact the quality of care received by the patients. Findings: 1. During a concurrent interview and record review on 1/3/22, at 4:10 PM, with Executive Director (ED), Patient 8's "Hospice Certification and Plan of Care (HCPOC)," dated 10/26/21, was reviewed. HCPOC indicated, "Frequency/Duration of Visits ...MSW [Medical Social Worker] 1Wk [one time per week] ... CH [Chaplain] 1Wk ... " ED was unable to find documented evidence MSW and the Chaplain did the home visits to Patient 8 as indicated in the POC on the following weeks: 10/31/ to 11/6/21 - No MSW and no Chaplain home visits. 11/7/21/ to 11/13/21 - No MSW home visit. 11/14/21 to 11/20/21 - No MSW home visit. 11/21/21 to 11/27/21 - No MSW and no Chaplain home visits. 11/28/21 to 12/4/21 - No MSW home visit. 12/5/21 to 12/11/21 - No MSW and no Chaplain home visits. ED stated, home visits by the MSA and the Chaplain should have been completed in accordance with the POC. 2. During a concurrent interview and record review on 1/4/22, at 11:35 AM, with ED, Patient 9's HCPOC, dated 2/8/21 was reviewed. HCPOC indicated, "Frequency/Duration of Visits ... MSW 1 Wk . . CH 1 Wk ... " ED was unable to find documented evidence MSW and the Chaplain did the home visits to Patient 9 as indicated in the POC on the week of 2/14/21 to 2/20/21. No additional information was provided. ED verified the findings. 3. During a concurrent interview and record review on 1/4/22, at 12:05 PM, with ED, Patient 10's HCPOC, dated 12/7/20 was reviewed. HCPOC indicated, "Frequency/Duration of Visits ... MSW 2 Wk ... CH 1 Wk ... " ED was unable to find documented evidence MSW and Chaplain did the home visits to Patient 10 as indicated in the POC on the following weeks: 12/13/20 to 12/19/20 - No MSW and no Chaplain home visits. 12//20/20 to 12/26/20 - No Chaplain home visit. 12/27/20 to 1/2/21 - No Chaplain home visit. 1/3/21 to 1/9/21 - No Chaplain home visit. ED verified the findings. 4. During a concurrent interview and record review on 1/4/22, at 4:40 PM, with ED, Patient 12's HCPOC, dated 8/14/20 was reviewed. HCPOC indicated, "Frequency/Duration of Visits ... SN [Skilled Nursing (Registered Nurse - RN or a Licensed Vocational Nurse - LVN)] 2 Wk ... MSW effective 8/16/20 2 Wk ... CH effective 8/16/20 1 Wk ... " ED was unable to find documented evidence the RN, MSW and Chaplain completed the home visits to Patient 12 as indicated in the POC on the following weeks: 8/16/20 to 8/22/20 - One SN home visit. SN did not do the second home visit for the week. 8/23/20 to 8/29/20 - No MSW and no Chaplain home visits. 9/6/20 to 9/12/20 - No MSW home visit. 9/20/20 to 9/26/20 - One SN home visit. SN did not do the second home visit for the week. 9/27/20 to 10/3/20 - No SN home visits. ED verified the findings. 5. During a concurrent interview and record review on 1/5/22, at 8:55 AM, with ED, Patient 13's HCPOC, dated 3/24/20 was reviewed. HCPOC indicated, "Frequency/Duration of Visits ...SN 2x Wk ..." Ed was unable to find documented evidence home visits were completed for Patient 13 as indicated in the POC on the following weeks: 3/29/20 to 4/4/20 - One SN home visit. SN did not do the second home visit for the week. 4/5/20 to 4/11/20 - One SN home visit. SN did not do the second home visit for the week. 4/12/20 to 4/18/20 - One SN home visit. SN did not do the second home visit for the week. ED stated, "I don't have it in the list that she [Patient 13] refused the home visits from the SN. During a review of the facility's policy and procedure (P&P) titled, "Plan of Care," dated 5/1/19, the P&P indicated, " I. All hospice care and services furnished to patients and their families will follow an individualized written Plan of Care (POC) established by the hospice interdisciplinary group ... "

Based on interview and record review, the agency failed to develop an individualized plan of care for one of 13 sampled patients (Patient 1) when Licensed Vocational Nurse (LVN) 1 documented Patient 1 had bruises but did not develop a plan of care. This failure had the potential to result in Patient 1's bruises to be uninvestigated, not addressed, and not monitored. Findings: During a review of Patient 1's "Visit Note Report (VNR)", dated 1/3/22, the "VNR" indicated, "Abnormal integumentary assessment findings: bruising. Indicate location of bruising: arms." During an interview on 1/4/22, at 1:54 PM, with LVN 1, LVN 1 stated, Patient 1's bruises had been there for a long time. LVN 1 stated, "She [Patient 1] hits her arms during transfers." LVN 1 stated, she did not develop a plan of care for the bruises. LVN 1 stated, "It is the responsibility of the RN [Registered Nurse] Case Manager to develop a plan of care." During an interview on 1/5/22, at 11:09 AM, with RN Case Manager (RNCM) 1, RNCM 1 stated, "She [LVN 1] can also create a plan of care. RNCM 1 stated, she saw those bruises but did not create a plan of care nor documented the cause of the bruises." During a review of agency's policy and procedure (P&P) titled, "Plan of Care", dated 5/1/19, the P&P indicated, "The hospice will develop and individualized written POC (Plan of Care) for each patient. The POC must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions."

Based on observation, interview, and record review, the agency failed to ensure oxygen supplies were provided and readily available for use at home for one of 13 sampled patients (Patient 8). This failure had the potential for Patient 8 not to receive oxygen as needed for respiratory difficulty and had the potential to result in respiratory distress. Findings: During a review of Patient 8's "Hospice Certification and Plan of Care" (HCPOC), dated 10/26/21, the "HCPOC" indicated, "Medications. . . Oxygen 2 liter[s] as needed. . . " During a concurrent observation and interview on 1/3/22, at 2:15 PM, with Registered Nurse Case Manager (RNCM) 2, in the living room where Patient 8 was living, RNCM 2 was checking for oxygen supplies (oxygen tanks [used to store gas for breathing] and nasal oxygen cannula [a device used to deliver supplemental oxygen to a patient in need of respiratory help]). RNCM 2 was unable to find oxygen supplies were provided and readily available as needed for Patient 8's use. RNCM 2 stated, the oxygen supplies should have been readily available for use at all times when needed by Patient 8. During a review of the agency's policy and procedure (P&P), titled, "Equipment Safety/Safe Medical Device," dated 5/1/19, the P&P indicated, "Procedure. . . A. All legend medical devices must be obtained for each patient pursuant to a physician's prescription. . . " During a review of the agency's policy and procedure (P&P), titled, "Plan of Care Process," dated 5/1/20, the P&P indicated, "VI. The POC includes, but is not limited to ...E. Medical supplies, equipment and appliances necessary to meet the needs of the patient."

Based on observation, interview, and record review, the agency failed to coordinate care with other disciplines for two of 13 sampled patients when: 1. The Licensed Vocational Nurse (LVN) 1 did not coordinate care with the Registered Nurse Case Manager (RNCM) 1 regarding Patient 1's bruises. 2. Medical Social Worker (MSW) did not follow up on Patient 2's complaint of high blood pressure (pressure of circulating blood against the walls of blood vessels). These failures had the potential for these patients not receiving the necessary care and had the potential to result in adverse health outcomes. Findings: 1. During a review of Patient 1's "Visit Note Report (VNR)", dated 1/3/22, the "VNR" indicated, "Abnormal integumentary assessment findings: bruising. Indicate location of bruising: arms." During an interview on 1/4/22, at 1:54 PM, with LVN 1, LVN 1 stated, Patient 1's bruises had been there for a long time. LVN 1 stated, "She [Patient 1] hits her arms during transfers." LVN 1 stated, she did not tell RNCM 1 about Patient 1's bruising. LVN 1 stated, RNCM 1 could read her documentation and should have followed through. During an interview on 1/5/22, at 11:09 AM, with RNCM, RNCM 1 stated, she did not read LVN 1's visit notes. RNCM 1 stated, "I know she had bruises, but it was not due to abuse. This is the first time I heard I should document the reasons for the bruises." 2. During a concurrent observation and interview on 1/3/22, at 3 PM, in Patient 2's home, with Patient 2 and MSW. Patient 2 stated (to the MSW), "My blood pressure is high, and I feel dizzy." During a review of Patient 2's "VNR" dated 1/3/22, the "VNR" indicated, " ... Patient [2] says he experiences dizziness. MSW will follow up with Chaplain and Nurse." During a concurrent interview and record review, on 1/4/22, at 11:40 AM, with Director of Clinical Services (DCS), Patient 2's "VNR" was reviewed. DCS stated, she could not find documentation the Patient 2's complaint was followed up by a nurse. DCS stated, she did not receive a report from the MSW regarding Patient 2's high blood pressure concern. During a review of the agency's policy and procedure (P&P) titled, "Implementing Care and Treatment," dated 10/1/20, the P&P indicated, "The Hospice will assign appropriate disciplines needed to provide care/treatment."

Based on observation, interview, and record review, the agency failed to ensure infection control practices were implemented when: 1. Licensed Vocational Nurse (LVN) 1 did not change her gloves during dressing changes when she touched a dirty dressing and a clean dressing without changing her gloves for Patient 1. 2. Caregiver (CG) 3 assist LVN 1 in wound dressing changes for Patient 1 without wearing gloves or performing hand hygiene. 3. LVN 1 did not maintain a clean and dirty area during Patient 1's wound dressing. 4. LVN 1 disposed her gloves and used wound dressings into the trash bin at Patient 1's bedside without double bagging. 5. LVN 1 used a hand sanitizing wipes to disinfect medical equipment. 6. A biohazard (medical waste) sharps disposal container which was approximately one half filled with used needles and syringes was stored in the clean storage area in between the clean supplies. These failures had the potential to result in spreading germs and infectious diseases to the patient, caregiver, staff, and visitors. Findings: 1. During a concurrent observation and interview on 1/3/22, at 12:50 PM, in Patient 1's home, with LVN 1, LVN 1 was wearing gown, mask, face shield and gloves. LVN 1 opened Patient 1's brief and removed a wound dressing from Patient 1's right buttock. LVN 1 did not change her gloves and did not perform hand hygiene after removing the dressing. CG 3 handed LVN 1 a clean gauze dressing. LVN 1 sprayed the wound with a wound cleansing spray. CG 3 continued to hand clean wound dressings and ointment for the wound to LVN 1. CG 3 was not wearing gloves and was not observed performing hand hygiene. CG 3 touched a clean dressing and placed an ointment onto the dressing and handed the dressing to LVN 1. LVN 1 continued to touch the clean dressing and placed it on the wound without changing her gloves and without performing hand hygiene. There was no separation of clean and dirty areas. LVN 1 placed the used wound dressing in Patient 1's brief. LVN 1 and CG 3 changed Patient 1's brief and placed the used brief into the trash bin at the bedside. LVN 1 changed her gloves after changing Patient 1's brief, but did not perform hand hygiene. LVN 1 removed the dressing on Patient 1's left heel. LVN 1 cleansed the wound on Patient 1's heel with spray and clean gauze. CG 3 handed LVN 1 a clean dressing with ointment. LVN 1 did not change her gloves and did not perform hand hygiene. CG 3 continued to touch clean dressings without performing hand hygiene and without wearing gloves. 2. During a concurrent observation and interview on 1/3/22, at 1 PM, in Patient 1's home, with CG 3, CG 3 did not perform hand hygiene and did not wear gloves during direct patient care. CG 3 stated, "I should have worn gloves." During a review of the agency's policy and procedure (P&P) titled, "Exposure Control Plan," the P&P indicated, "Tips: Always use gloves when performing patient care. 2. Proper hand hygiene by healthcare personnel at the beginning and end of each visit, and after any procedure considered as occupational risk. 3. Gloves must be worn at all times when a reasonable potential for contamination of the employee by blood or bloody fluids exists." 3. During a concurrent observation and interview on 1/3/22, at 1:05 PM, in Patient 1's home, with LVN 1, LVN 1 changed the wound dressing in Patient 1's right buttock wound without providing a clean area for the celan (type of dressing) wound dressings. There was not a separate dirty area for the used/dirty wound dressings. LVN 1 stated, she should have placed a chux (clean disposable underpad) to provide a clean area to prevent contamination of clean wound dressing. During an interview on 1/4/22, at 2:15 PM, with Director of Clinical Services (DCS), DCS stated, the agency did not have a policy on wound dressing. 4. During an observation on 1/3/22, at 1:10 PM, in Patient 1's home, LVN 1 disposed her gloves into the trash bin at Patient 1's bedside without placing in a bag. During an interview on 1/4/22, at 1:52 PM, with LVN 1, LVN 1 stated, "I should have put it [used gloves and wound dressings] in a bag." During a review of the facility's policy and procedure (P&P) titled, "Disposal of Dressings", dated 2/1/21, the P&P indicated, "II. Discard old and soiled dressing and gloves in a plastic bag. III. Plastic bag will be double bagged and placed in the patient's trash container. If the patient's trash container has a plastic liner, this may serve as a second bag." 5. During an observation on 1/3/22, at 1:15 PM, in Patient 1's home, LVN 1 checked Patient 1's blood pressure, temperature, oxygen saturation (oxygen level in the blood), and pulse rate. LVN 1 wiped the blood pressure cuff, oxygen saturation monitor, and stethoscope (medical instrument used in listening to sounds produced within the body) with hand sanitizing wipes and immediately placed the equipment in her bag. During an interview on 1/4/22, at 1:52 PM, with LVN 1, LVN 1 stated, "I forgot to use the wipes with virucide [chemical agent that destroys viruses]." During an interview on 1/4/22, at 2:15 PM, with DCS, DCS stated, LVN 1 should have used the disinfectant with virucide to wipe medical equipment, not the alcohol hand sanitizing wipes. During a review of agency's policy and procedure (P&P) titled, "Exposure Control Plan", dated 10/1/21, the P&P indicated, "Equipment that can not be left at home will be thoroughly cleaned and disinfected with appropriate disinfectant." 6. During a concurrent observation and interview on 1/5/22, at 4:20 PM, with Executive Director (ED), in the clean storage room, one biohazard sharp disposal container which was approximately one half filled with used needles/sharps and syringes was stored in the clean storage area in-between the clean supplies (a box of drainage bag, a box of 60 milliliter of clean syringes, and a box of incontinent pads). ED stated, the sharps container should not be stored in the clean storage area. ED stated, the sharps container should have been picked up for disposal by the biohazard company. During a review of the agency's policy and procedure (P&P), titled "Exposure Control Plan," dated 10/1/21, the P&P indicated, ". . . D. Work Practice Controls. . . 4. . . All nurses are to take biohazard sharps containers into the home for disposal of needles used for venipunctures. . . When the containers are approximately 2/3 full, the nurse is to transport the container to the office to be disposed of in an approved manner for destruction."

Based on interview and record review, the agency failed to ensure the medical social worker's (MSW) services were provided in a timely manner for one of 13 sampled patients (Patient 8) for an allegation of an unsafe physical environment. This failure had the potential for a negative psychosocial outcome to Patient 8. Findings: During a review of Patient 8's "Visit Note Report" (VNR), dated 12/29/21, the "VNR" from the Registered Nurse Case Manager (RNCM) 2 indicated, " ...Pt [patient] wants to speak something and she looks scared ... Caregiver [CG 1] and [CG 2] started arguing and yelling at [sic] my visit with each other ... DON [Director of Nursing - Director of Clinical Services] notified ... Pt's [sic] are not safe in that kind of environment ... " During an interview on 1/3/22, at 2:15 PM, with RNCM 2, RNCM 2 stated, "I told the Social Worker [MSW] [regarding staff yelling at each other]." During an interview on 1/4/22, at 2:40 PM, with Director of Clinical Services (DCS), DCS stated, "There wasn't an MSW visit on 12/29/21. There's nothing in there [MSW documentation regarding staff yelling at each other]. I expected the MSW to follow-up on that which we discussed during the IDG [Interdisciplinary Group - a hospice care team that includes the physician, registered nurse, social worker, volunteer and spiritual caregiver] meeting." During a review of Patient 8's "VNR," dated 1/4/22 from the MSW, the "VNR" indicated, "MSW addressed with caregiver [CG 1] incident reported ... of arguments between her and another coworker. Caregiver admitted the incident and the argument was over job responsibilities. MSW addressed with caregiver keeping a safe environment in professional setting. MSW addressed with caregiver the incident could be viewed as elderly abuse due to unsafe environment. Caregiver understood ... " During an interview on 1/5/22, at 2:36 PM, with MSW, MSW stated, "I was made aware yesterday [1/4/22] [regarding the incident on Patient 8 on 12/29/21]. I just went there. It [caregivers yelling at each other] was not an unsafe environment. I addressed it with the caregiver. I didn't see a reason for it to be reported. It happened one time." During a review of the agency's "Job Description/Performance Evaluation" titled, "Hospice Medical Social Worker" (HMSW), dated 6/1/20, the "HMSW" indicated, " ... Social work services will be based on the patient's psychosocial assessment ... Provides an environment which promotes respect for patients and their privacy and property." During a review of the agency's policy and procedure (P&P) titled, "Abuse, Neglect, and Exploitation," dated 3/1/21, the P&P indicated, "Regarding alleged abuse ... the Hospice must ... B 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 ... "

Based on observation, interview, and record review, the agency failed to provide Chaplain (priest, religious leader, or a lay representative of a religious tradition who seek to build a relationship of trust through compassionate presence and thereby offer help and support) services for three of 13 sampled patients (Patient 2, Patient 3, and Patient 4) when there was no Chaplain services provided according to the plan of care. This failure had the potential for not meeting patients' spiritual needs during end of life. Findings: 1. During an observation on 1/3/22, at 3 PM, in Patient 2's home, Patient 2 was in bed, seemed very happy when the social worker went to visit him. Patient 2 was using communication board due to hearing impairment. Patient 2 was verbally responsive and communicated well with his visitors. During an interview on 1/3/22, at 3:20 PM, with Caregiver (CG) 4, CG 4 stated, "He [Patient 2] enjoys visits but I have not seen a Chaplain in a while. I only see the nurse, the aide, and the social worker but no Chaplain." During a review of Patient 2's "Hospice POC [Plan of Care] Report (HPR)" dated 5/6/20 (one year and eight months ago), the HPR indicated, "Hospice Chaplain evaluation performed. Additional visits to be provided." During a concurrent interview and record review on 1/4/22, at 10:49 AM, with Director of Clinical Services (DCS), the Patient 2's Chaplain Notes, dated 2/12/21, was reviewed. DCS stated, "The last Chaplain visit was on 2/12/21 (11 months ago). There were no more visits after that. There is no physician's order to discontinue [chaplain visits] ." 2. During a review of Patient's 3's "Hospice POC [Plan of Care] Report (HPR)" dated 5/10/21 (eight months ago), the HPR indicated, "Hospice Chaplain evaluation performed. Additional visits to be provided." During a concurrent interview and record review on 1/4/22, at 10:49 AM, with DCS, the Patient 3's Chaplain Notes, dated 5/10/21 was reviewed. DCS stated, "The last Chaplain visit was on 5/10/21 (eight months ago). There were no more visits after that. It [Chaplain Notes] is not indicated it [Chaplain visits] was discontinued. I am not sure what happened with that [missed Chaplain visits]." 3. During a concurrent interview and record review on 1/4/22, at 10:49 AM, with DCS, Patient 4's clinical record was reviewed. DCS stated, "The last Chaplain visit was on 2/18/21 (11 months ago). The order was twice a month, but there was no Chaplain visit recently. There was no order to discontinue." During an interview on 1/4/22, at 1:24 PM, with Chaplain 1, Chaplain 1 stated, "I got sick in April and was off for five months. It could be overwhelming for the other Chaplain [2] because they did not hire anybody to replace me." Chaplain 1 stated, he was not sure why he did not visit the patients recently. Chaplain 1 stated, "Probably because of the virus [Covid-19 pandemic]. The nurses in facilities were not letting us in." Chaplain 1 was asked if he could provide spiritual counseling via telephone, he stated, "Yes, I could." During an interview on 1/4/22, at 4:48 PM, with Chaplain 2, Chaplain 2 stated, "The computer did not let me know I needed to visit these patients. I was busy. It [patients to visit] did not get assigned to me." Chaplain 2 stated, he was aware Chaplain 1 was on medical leave and the agency assigned him some patients but was not aware Patient 2, Patient 3, and Patient 4 needed to be visited. During a review of the facility policy and procedure (P&P) titled, "Counseling Services", dated 10/1/21, the P&P indicated, "Counseling services are available to the patient and family to assist the patient and family in minimizing the stress and problems that arise from the terminal illness, related conditions, and the dying process. Counseling services must include, but are not limited to bereavement counseling, dietary counseling, and spiritual counseling."

Based on interview and record review, the agency failed to ensure: 1. The plan of care (POC) for the frequency of Home Health Aide (HHA) visit was updated when there was a change in the frequency of visits for one of 13 sampled patients (Patient 13). This failure had the potential for unmet care needs for Patient 13. 2. A plan of care for skin discoloration was developed for one of 13 sampled patients (Patient 8). This failure had the potential for Patient 8 to have skin discoloration (bruises) unmonitored and new skin discoloration undetected. Findings: 1. During a review of Patient 13's "Hospice Certification and Plan Of Care" (HCPOC), dated 3/24/20, the "HCPOC" indicated, "Frequency/Duration of Visits ... HHA [Home Health Aide] 2X/Week [two times per week] ... " During a concurrent interview and record review on 1/5/22, at 8:55 AM, with Executive Director (ED), Patient 13's HHA home visits were reviewed. ED stated, Patient 13 was visited by HHA three times a week instead of two times a week as indicated in the POC. It started on the week of 4/6/20 per Patient 13's daughter request. ED was unable to find the licensed nurses' documentation for an updated POC. ED stated, the POC should have been updated to reflect the HHA home visits to three times a week. 2. During a review of Patient 8's "Visit Note Report" (VNR) by Registered Nurse Case Manager (RNCM) 3, dated 10/26/21, the "VNR" indicated, " ... Head to Toe Assessment Done. Both under the eyes, right side of hip, and right side of breast brusse (sic) [bruises] noted ... " During a concurrent interview and record review on 1/5/22, at 11:23 AM, with RNCM 3, Patient 8's Hospice Certification And Plan Of Care (HCPOC) dated 10/26/21 was reviewed. Patient 8's "Start of Care" (SOC) was on 10/26/21. RNCM 3 was unable to find a POC for the bruises under Patient 8's eyes, right side of hip, and right side of breast on the initial POC dated 10/26/21. RNCM 3 stated, "We didn't have a care plan for the bruises." During a review of the agency's policy and procedure (P&P) titled, "Plan of Care," dated 5/1/19, the P&P indicated, " ... II. The hospice will develop an individualized written POC for each patient. The POC must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions."

Based on interview and record review, the agency failed to ensure patients' clinical record contained Advanced Directives (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) for three of 13 sampled patients (Patient 8, Patient 11, and Patient 12). This failure had the potential for the patient's end of life preferences/choices to be not honored during an emergency or dying process. Findings: 1. During a concurrent interview and record review on 1/3/22, at 4:35 PM, with Executive Director (ED), Patient 8's clinical record was reviewed. ED was unable to find an Advance Directive was completed for Patient 8 upon admission to the hospice agency. ED was unable to find a documented attempt to obtain an Advance Directive for Patient 8. 2. During a concurrent interview and record review on 1/4/22, at 2:55 PM, with ED, Patient 11's clinical record was reviewed. ED was unable to find an Advance Directive was completed for Patient 11 upon admission to the hospice agency. ED was unable to find a documented attempt to obtain an Advance Directive for Patient 11. ED stated, "They [staff] should try to obtain one. Usually the Medical Social Worker (MSW) will follow-up on that." ED stated, "It's everybody's responsibility." 3. During a concurrent interview and record review on 1/4/22, at 4:30 PM, with ED, Patient 12's clinical record was reviewed. ED was unable to find an Advance Directive was obtained for Patient 12 upon admission to the hospice agency. ED was unable to find a documented attempt to obtain an Advance Directive for Patient 12. During a review of the agency's policy and procedure (P&P) titled, "Advance Directives," dated 5/1/19, the P&P indicated, "Purpose 1. To ensure that adult patients and their legal representatives are informed of patient rights under federal and state law to make and direct decisions concerning medical care ... and the right to formulate Advance Directives such as a "Living Will," "Medical Power of Attorney," and "Do-Not-Resuscitate (DNR) ... Procedure ... IV. Agency staff will inquire whether the patient has an Advance Directive at the time of the initial assessment. If an Advance Directive is not in place and the patient expresses the desire to establish an Advance Directive, then a medical social services referral may be initiated to facilitate the proper execution of the documents."

Based on observation, interview, and record review, the agency failed to ensure its policy and procedure related to the safe management of controlled medications (narcotic medications with potential for abuse or addiction) was implemented for one of 13 sampled patients (Patient 8). This failure resulted in an undetermined amount of controlled medications provided to Patient 8's anxiety, pain, and sleep and potential to result in drug diversion. Findings: During a review of Patient 8's "Hospice Certification and Plan of Care" (HCPOC), dated 10/26/21, the "HCPOC" indicated, Patient 8 was on the following controlled medications: 1. Lorazepam [used for the treatment of anxiety disorders] 0.5 mg [milligram - a unit of measurement] tablet 1 tablet ... every 6 hours /PRN [as needed] 2. Morphine [used to treat severe pain] 10 mg/5 ml [milliliter - a unit of measurement] oral solution 5 mg ... every 4 hours PRN 3. Temazepam [used to treat sleep problem] 15 mg capsule 1 capsule ... daily. During a concurrent observation and interview on 1/3/22, at 1:42 PM, with Registered Nurse Case Manager (RNCM) 2, in Patient 8's home with the caregivers, Patient 8's controlled medications were kept in a locked cabinet. There was no documentation of a narcotic count. RNCM 2 stated, "The staff [Caregiver 1 (CG 1) and CG 2] from the home where Patient 8 lived] don't sign if they give the medicine. RNCM 2 stated, "They don't chart. They just give the medications. They only have two patients here." During an interview on 1/3/22, at 2:15 PM, with RNCM 2, RNCM 2 stated, "We have no way of knowing when the PRN medications were given [by the caregivers]. Only verbal information." During an interview on 1/3/22, at 3:28 PM, with CG 1, CG 1 stated, "We [CG 1 and CG 2] both have access to the medications in the locked cabinet. My boss never told me to chart when I give the medications." During a review of the agency's policy and procedure (P&P), titled, "Disposal of Controlled Substances," dated 3/1/21, the P&P indicated, " ... IX. Recommendations for safe storage and managing controlled substances in the home: A. Counting controlled substance at each visit for each patient, regardless of the risk of diversion in their home. This practice is helpful for many reasons not just identification of possible diversion but may help to identify diversion early. "