Every finding on record at Procare Hospice, LLC (Lancaster)

Observed in Record Review. In 5 of 10 patient records reviewed, for active patients, the nurse surveyor noted that for HOSHV#2/RR#2, HOSHV#3/RR#3, RR#4, and RR#6, the RN did not visit the hospice patient every 15 days to conduct an assessment, the LVN conducted the assessment visits for periods of time that were greater than 15 days over the last two months. For RR#7, the RN did not visit the hospice patient every 15 days to conduct an assessment, the LVN conducted the assessment visits for a period of time that were greater than 15 days over the last month. Findings were verified by the Clinical Team Leader.

Observed in Record Review. In 10 of 10 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” and “changes in neurologic status will be addressed appropriately.” Additionally, there were a few short-term goals at start of care to address issues of immediate needs with a complete time of a few days after admission but most other goals did not have a timeframe for completion. Findings were verified by the Clinical Team Lead.

Observed in Record Review. In 10 of 10 patient records reviewed, the nurse surveyor noted that for HOSHV#1/RR#1, HOSHV#2/RR#2, HOSHV#3/RR#3, RR#4, RR#5, RR#6, RR#7, RR#8, RR#9, and RR#10 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 Clinical Team Leader.

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 per policy “Hand Hygiene – IC15”. For example, during HOSHV2/RR#2 the hospice aide washed hands upon arrival to board and care and donned gloves. She then went into patient room and gathered supplies and clean clothes. She then got patient up to the wheelchair and wheeled her into bathroom. She then assisted patient to take her clothes off. The hospice aide did not change her gloves or perform hand hygiene per policy while performing all of the above-described tasks. 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. The skilled nurse completed the entire patient head to toe assessment to include assessing the patient’s bottom all with the same pair of gloves on. Additionally, she documented with a pen on her clipboard intermittently during the patient assessment and did not perform hand hygiene. She also did not have a clean and dirty barrier for her equipment. The Clinical Team Lead was present during the home visits and also observed the breaks in technique per agency policy.

Observed in Record Review. In 3 of 10 patient records reviewed, for active patients with the hospice aide, It was noted by the nurse surveyor that for HOSHV#2/RR#2 the hospice aide care plan was not updated to reflect a change in bath types. The care plan indicated a bed bath; however, the hospice aide was providing a shower. Additionally, the patient was on oxygen prn and the care plan did not address the hospice aide’s responsibility for the oxygen if the patient was using it at the time of the shower. HOSHV#3/RR#3, the hospice aide care plan instructed the hospice aide to provide a shower and assist to the bathroom, however the patient was now bedbound and unable to tolerate a shower. The hospice aide care plan had not been updated to reflect the change in condition. RR#4, the patient had a gastrostomy tube, however, there were no instructions on the hospice aide care plan as to what the hospice aide’s responsibilities were in regard to the tube. All findings were verified by the Clinical Team Lead.

Observed in Patient Home. In 2 of 3 home visits conducted, it was noted by the nurse surveyor that the hospice aide did not provide care according to the hospice aide plan of care. for HOSHV#2/RR#2, the hospice aide care plan instructed the hospice aide to provide a bed bath however, during the home visit the hospice aide took the patient to the bathroom to give her a shower. HOSHV#3/RR#3, the hospice aide care plan instructed the hospice aide to give the patient a shower and to assist her up to the bathroom, however, on the home visit with the skilled nurse it was noted that the patient was completely bedbound and mostly unresponsive. During record review it was noted that the hospice aide documented that she was providing the patient with a shower. Findings were verified by the Clinical Team Lead who was present during the visits.

Observed in Record Review. In 5 of 10 patient records reviewed, for active patients with the HHA it was noted by the nurse surveyor that Hospice Aide Supervisory visits were not documented the required every fourteen days per regulation. HOSHV#2/RR#2, there was no documented Hospice Aide Supervisory visit for a period of 30 days for the prior recertification period. HOSHV#3/RR#3, there was 24 days between the last documented Hospice Aide Supervisory visits during the current recertification period. RR#4, the first Hospice Aide Supervisory visit was completed 41 days after the Hospice Aide first saw the patient. There has not been another Hospice Aide Supervisory visit since, which has been 17 days ago. RR#6, no documented Hospice Aide Supervisory visit for the last 6 weeks. RR#7, there was no documented Hospice Aide visit for the last month. Findings were verified with the Clinical Team Leader.

Based on interview and record review the facility failed to ensure the Interdisciplinary Group (IDG) were involved in the completion of the comprehensive assessment within 5 days after election of hospice care for 5 of 13 patients (Patients 1, 4, 7, 10, and 11). This failure had the potential to result in the delay to develop the plan of care identifying patient's physical, psychosocial, spiritual, and emotional needs. Findings: 1. A review of Patient 1's "Patient Information Report" indicated the patient was admitted to hospice on 4/15/2022, with a diagnosis of chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). A review of Patient 1's "Hospice Certification and Plan of Care" dated 4/15/2022 to 7/13/2022, indicated skilled nursing (SN) visits 2 times per week for 12 weeks. A concurrent interview and record review on 6/10/2022 at 1:14 p.m. with Administrator (ADM) of Patient 1's electronic medical record indicated a start of care date of 4/15/2022. The IDG meeting was conducted on 4/27/2022, twelve (12) days after the patient's election for hospice services. 2. A review of Patient 4's "Patient Information Report" patient was admitted to hospice on 6/3/2022 with a diagnosis of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Patient 4's "Hospice Certification and Plan of Care" dated 6/3/2022 to 8/31/2022, indicated Skilled Nursing (SN) visits 2 times per week for 13 weeks, and 1 visit per week for 1 week. Home Health Aide (HHA) visits 2 times per week for 12 weeks, and 1 visit per week for 1 week. During a concurrent interview and record review on 6/10/2022, at 1:14 p.m., of Patient 4's electronic medical record with Administrator (ADM), indicated no evidence of IDG meeting to complete the patient's comprehensive assessment. The ADM stated," They had a stand-up process, which is a team meeting. We go over deaths, visits, new patients. They fill out a report daily of who they talked about". A review of facility's TEAM meeting report indicated there were no signatures of attendees and no patient information discussed. A review of facility's policy titled, "Patient Assessment" reviewed 1/1/2020 indicated the IDG in consultation with the patient's attending physician (if any), will complete the comprehensive assessment no later that five (5) calendar days after the election of the hospice benefit. A review of facility's policy titled, "Inter-Disciplinary Group Meeting" (IDG) dated 3/2022 indicated core IDG members required are: 1. Medical Director, 2. Registered Nurse (RN) Case Manger, 3. Chaplain, and 4. Social Worker; team members should make a final review of their IDG notes within 24 hours of IDG. It also indicted that the Branch Director/Clinical Team Lead (BD/CTL) will ensure that the signatures dates of each clinician are compliant and in line with Centers for Medicare Services (CMS) rules. The hospice physician will complete his/her IDG note during the meeting, in collaboration with the IDG members as each patient is discussed. All notes should be completed by the conclusion of IDG unless there are exceptional circumstances. 3. A review of Patient 7's "Hospice Certification and Plan of Care" indicated, a start of care (SOC) date of 5/3/22, with a diagnosis that included Alzheimer's disease (it is a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). Further review of the record indicated the certification period from 5/3/22 to 7/1/22 included an order for skilled nurse (SN), Medical Social Worker (MSW) and Home Health Aide (HHA). Patient 7's start of care (SOC) was on 5/3/22 . The first IDG meeting was on 5/11/22, eight days (8) after the SOC. 4. A review of Patient 10's "Hospice Certification and Plan of Care" indicated, a start of care (SOC) date of 5/16/22, with a diagnosis that included end stage renal disease (kidneys not functioning permanently). Further review of the record indicated the certification period from 5/16/22 to 7/14/22 included an order for skilled nurse (SN), Medical Social Worker (MSW), Home Health Aide (HHA) and Chaplain (CH). Patient 10's SOC was on 5/16/22. The first IDG meeting was 6/1/22, sixteen days (16) after the SOC. 5. A review of Patient 11's "Hospice Certification and Plan of Care" indicated, a start of care (SOC) date of 5/2/22, with a diagnosis that included unspecified severe protein-calorie malnutrition. Further review of the record indicated the certification period from 5/2/22 to 7/30/22 included an order for skilled nurse (SN), Medical Social Worker (MSW), Home Health Aide (HHA) and Chaplain (CH). Patient 11's SOC date was on 5/2/22. The first IDG meeting was 5/11/22 nine (9) days after the SOC. On 6/10/22, at 1:15 p.m., the administrator (ADM) stated the process of comprehensive care planning and care plan development as follows: a Registered Nurse (RN) sees the patient at the start of care (SOC). The RN assess and gathers information from the first visit and consults with the patient's doctor for the development of the plan of care. Initially, the nurse and the doctor set up the plan of care to individualize the patient's care. Then it is discussed during the IDG meeting at the 14th day or sooner. The ADM stated the other disciplines assess the patients by the 5th day of the SOC, then a care plan is developed using all their assessments. The ADM further stated whenever there is a new patient, the staff communicate using an electronic application where they share patient information. The IDG do consult during those first 5 days using that form of communication. A review of the HA's electronic communication titled "Traditions Health-threads", printed on 6/10/22, did not indicate the doctor, registered nurse, social worker, and chaplain discussed the patients' needs and consulted in the development of the plan of care. A review of the HA's electronic communication titled "Traditions Health Stand Up Report", printed on 6/10/22, did not indicate the doctor, registered nurse, social worker, and chaplain discussed the patients' needs and consulted in the development of the plan of care.

Based on observation, interview, and record review, the hospice agency (HA) failed to maintain an accurate and current medication profile for 1 of 13 patients (Patient 7). This failure has the potential in placing the patient at risk for medication errors and adverse drug reactions. Findings: A review of Patient 7's "Hospice Certification and Plan of Care" indicated, a start of care (SOC) date of 5/3/22, with a diagnosis that included Alzheimer's disease (it is a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). Further review of the record indicated the certification period from 5/3/22 to 7/1/22 included an order for skilled nurse (SN) to visit 2 times a week and 3 additional visits per week as needed for 9 weeks. During a home visit on 6/7/22, at 2:10 p.m., Registered Nurse 1 (RN 1) was observed reviewing the medications Patient 7 was taking. Medication "Lactulose" (used to help relieve constipation) was not located in the home. On 6/7/22, at 2:16 p.m., the caregiver (CG) stated, "I stopped giving that a long-long time ago. He goes to the bathroom (bowel movement) 3 times a day". On 6/7/22, at 2:25 p.m., RN 1 stated "Yeah, I was supposed to remove it from the list (medication list), but for some reason I forgot. I will remove it now". On 6/8/22, at 1:34 p.m., the administrator (ADM) stated the medications should be reviewed every visit. The ADM stated it is important to review medications for the patient's safety; whatever was written on the medication profile should be checked to make sure that information was accurate. A review of Patient record titled "Medication List", printed on 6/7/22, indicated the patients active medication use to include "Lactulose 10 gm(grams)/15 ml (milliliters, unit of measurement) oral solution 30 ml, 2 times daily for constipation." A review of facility's policy titled, "Medication list and Monitoring" dated 1/1/2021 indicated medication monitoring will include appropriate date/information to develop an accurate patient medication history and a current, complete medication profile. This data will be available to all Hospice staff involved in the patient care. The Hospice will maintain a current, accurate Medication Profile of all prescription and over the counter (OTC) medications taken by the patient."

Based on interview and record review, the hospice agency failed to ensure care and services are furnished in accordance to the plan of care (POC) for 3 of 13 patients (Patients 6, 11, and 13). This deficient practice has the potential to result in not meeting the patient's care needs identified in the POC. Findings: 1. A review of Patient 6's "Patient Information Report" indicated patient was admitted on 3/10/2022, with a diagnosis of malignant neoplasm of unspecified site of female breast (breast cancer). A review of Patient 6's "Hospice Certification and Plan of Care" dated 3/10/2022 to 6/7/2022 indicated Skilled Nursing (SN) visits once per week for 1 week, then 2 times per week for 12 weeks, and 1 visit per week for 1 week. Home Health Aide (HHA) visits 2 times per week for 12 weeks, and 1 visit per week for 1 week. A review of Patient 6's physician order dated 4/14/2022, at 2:51 p.m., indicated HHA visit 3 times a week and SN visits to 3 times per week. During a concurrent interview and record review on 6/10/2022, at 1:14 p.m. with Administrator (ADM) of Patient 6's electronic medical record indicated missing HHA visits the week of 3/13/2022, 4/17/2022, 4/24/2022, 5/1/2022, and 5/29/2022. SN missing visits the week of 4/17/2022 and 4/24/2022. ADM stated, "I don't have a communication note" for the week of 3/13/2022. ADM stated, "reason for missed visit were undocumented" for week of 4/24/2022. ADM stated, "one visit was missed" for week of 4/24/2022. A review of facility's policy titled, "Plan of Care" dated 4/2022 indicated each patient/client must receive the home health services that are written in an individualized plan of care that identifies patient/client specific measurable outcomes and goals ... 2. A review of Patient 11's "Hospice Certification and Plan of Care" indicated, a start of care (SOC) date of 5/2/22, with a diagnosis that included unspecified severe protein-calorie malnutrition. Further review of the record indicated the certification period from 5/2/22 to 7/30/22 included an order for Home Health Aide (HHA) twice a week. During an interview on 6/10/22, at 1:44 p.m., the administrator (ADM) stated the home health aide (HHA) was supposed to visit Patient 11, two times a week. It was scheduled 5/4/22 and 5/5/22. The HHA did not add a note. The HHA was supposed to document in the patient's record. 3. A review of Patient 13's "Hospice Certification and Plan of Care" indicated, a start of care (SOC) date of 5/7/22, with a diagnosis including chronic obstructive pulmonary disease (a chronic lung condition, making breathing difficult). Further review of the record indicated the certification period from 5/7/22 to 8/4/22 included an order HHA twice a week. During an interview on 6/10/22, at 1:44 p.m., the administrator (ADM) stated the HHA had a visit scheduled on 5/17/22 for Patient 13 and the patient refused. The HHA did not add a note. The HHA was supposed to document in the patient's record. During an interview on 6/10/22, at 1:44 p.m., the administrator (ADM) stated the process of missed visits was if patient refuses the visit, the information comes back to the schedule, then office staff re-schedule it within the same week so the visit is not missed. If patient refuses the visit staff must document it in the patient record, to include and explanation why the visit was missed. A review of the hospice policy and procedure titled, "Plan of Care", dated 4/22 , indicated "each patient/client must receive the home health services that are written in an individualized plan of care ..."

Based on observation, interview, and record review, the hospice agency failed to ensure all medications in the comfort kit are readily available for use to meet the patients needs during the end of life process for 1 of 13 patients (Patient 7). This failure has the potential to place the patient at risk to manifest unmitigated signs and symptoms of discomfort or pain during the end of life process. Findings: A review of Patient 7's "Hospice Certification and Plan of Care" indicated, a start of care (SOC) date of 5/3/22, with a diagnosis that included Alzheimer's disease (it is a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). Further review of the record indicated the certification period from 5/3/22 to 7/1/22 included an order for skilled nurse (SN) to visit 2 times a week and 3 additional visits per week as needed for 9 weeks. A review of Patient record titled "Hospice Certification and Plan of Care", for certification period 5/3/22-7/1/22, indicated hospice comfort kit will be provided to the patient. During a home visit on 6/7/22, at 2:10 p.m., Registered Nurse 1 (RN 1) was observed reviewing the medications in the comfort kit (medications used to treat symptoms during the end-of-life process). Medication named "Acetaminophen (to treat fever/pain), Bisacodyl (to treat constipation), and Haloperidol (to treat anxiety/agitation)" were not present in the comfort kit. On 6/7/22, at 2:20 p.m., RN 1 stated she ordered rest of comfort kit medications on 6/7/22, and expected to be delivered on 6/8/22. RN 1 agreed the following medications were not in patient's home, but listed on profile "Acetaminophen, Bisacodyl, and Haloperidol". On 6/8/22, at 1:34 p.m., the administrator (ADM) stated the hospice policy is that all patients get a comfort kit upon admission. The only exception is if patient/family refuses. Then the HA would document about the refusal. The ADM stated there was no documentation the family or patient had refused the comfort kit. On 6/10/22, at 3:20 p.m., the ADM stated, "the hospice did not have a policy regarding comfort kits and only had form titled ". A review of the hospice form titled "The Enclara Pharmacia Comfort Pak", dated 2022, indicated the following medications listed in the comfort kit: "Acetaminophen suppositories 650 mg (unit of measurement), Bisacodyl suppositories 10 mg, Haloperidol Liquid 2mg/ml ..."

Based on observation, interview, and record review, the facility failed to ensure staffs were screened for signs and symptoms for COVID19 infection (an infectious respiratory disease caused by the SARS-CoV-2 virus.). This failure had the potential to result in placing all patients and staffs at risk of spreading COVID19 infection. Findings: An observation on 6/7/2022, at 10 a.m., it was observed the survey team upon arrival were not screened for COVID19 signs and symptoms. An observation on 6/8/2022 at 9 a.m., upon arrival the survey team were not screened for COVID19 screening. An interview on 6/8/2022 at 10:25 a.m. with Administrator (ADM), ADM stated, "COVID19 screening generates thru email it's a form (5 questions) that staff answer online, goes back to the branch, and we log it. It will come back as a red flag if staff answers that they feel sick or have a temperature. We then question it and do a form tracer. Staff does not need to log in on paper when they come into the office. We do it as an extra precautions to sign in when coming into the office. It's not mandatory for staff, they can either do it online or when they come in". ADM stated that she would like for staff to ask outside vendors to log in. An interview on 6/8/2022, at 12:50 p.m., with ADM, ADM stated that office staff was supposed to screen any body that walks in hospice facility. ADM stated that she does not receive daily staff screening reports, she only receives them if they state they have COVID19 symptoms. ADM stated, ". It would be a good idea to get a daily report from IT (information Technology) with the information of employees who did not fill out their screening. Otherwise, I wouldn't know who completed their daily screening. It's important to screen because otherwise, we are placing others at risk of being sick ..."

Based on interview and record review, the hospice failed to ensure bereavement services was available to 1 of 13 sampled patients (Patient 9). This failure resulted in the grieving family not receiving support or resources following Patient 9's passing. Findings: A review of Patient 9's "Hospice Certification and Plan of Care" indicated, a start of care (SOC) date of 6/28/21, with a diagnosis including heart and chronic kidney disease with heart failure. On 6/10/22, at 10:44 a.m., the director of patient care services (DPCS) stated bereavement services are offered within one week of the death, then every 6 months after that for the first year. On 6/10/22, at 12:10 p.m., the medical record specialist (MRS) stated there was no bereavement documentation for Patient 9. The MRS stated there should be bereavement discharge assessment, chaplain documentation, and follow up documentation present in the patient record. All were not present. A review of Patient 9's record titled, "Hospice IDG Comprehensive Assessment and Plan of Care Update Report", dated 7/8/21, indicated "Date/Time of Death: 6/29/21." A review of facility's policy titled, "Bereavement" dated 5/1/2019 indicated the agency will make bereavement services available to the family and other individuals in the bereavement plan of care before, and for up to one (1) year following the death of the patient. A bereavement Coordinator will complete a follow-up assessment and develop a plan of care for Bereavement Services based on the re-assessment and the family/caregiver's willingness to receive services. A bereavement file will be maintained on each family/caregiver and will contain: all bereavement assessments, all bereavements plan of care, all bereavement clinical notes and documentation of letters and or resources sent to the bereaved, all contacts, declinations of bereavement assistance, inability to contact and referrals will be documented in the patient's medical record.

Based on interview and record review the facility failed to ensure the Medical Director (MD) verified the patient's clinical information necessary to determine certification/recertification for eligibility for patients to receive hospice benefits for 2 of 13 sampled patients (Patients 1 and 4). This failure resulted in the provision of hospice services to patients who were not clinically eligible to receive hospice services. Findings: 1. A review of Patient 1's "Patient Information Report" indicated the patient was admitted to hospice on 4/15/2022 with a diagnosis of Chronic Obstructive Pulmonary Disease (a group of diseases that cause airflow blockage and breathing-related problems). A review of Patient 1's "Hospice Certification and Plan of Care" dated 4/15/2022 to 7/13/2022 indicated Skilled Nursing (SN) visits 2 times per week for 12 weeks. A review of Patient 1's "Hospice CTI" dated 4/15/2022 indicated patient's diagnosis included COPD. Patient 1 was certified by the Medical Doctor (MD) to have six months or less if the disease runs its normal course. 2. A review of Patient 4's "Patient Information Report" indicated the patient was admitted to hospice on 6/3/2022 with a diagnosis of Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Patient 4's "Hospice Certification and Plan of Care" dated 6/3/2022 to 8/31/2022 indicated Skilled Nursing (SN) visits 2 times per week for 13 weeks, and 1 visit per week for 1 week. Home Health Aide (HHA) visits 2 times per week for 12 weeks, and 1 visit per week for 1 week. A review of Patient 4's "Hospice CTI" dated 6/3/2022 and printed 6/7/2022 indicated there was no physician's signature to certify Patient 4 had a prognosis of six months or less. It also indicated there was no narrative explanation made by the physician. A review of Patient 4's "Hospice Certification of Terminal Illness (CTI)" dated 6/3/2022 and printed 6/10/2022 indicated there was no physician's signature to certify Patient 4 had a prognosis of six months or less. It also indicated there was no narrative explanation made by the physician. An interview on 6/10/2022 at 3:15 p.m. with Administrator (ADM), ADM stated, "Doctor determines by medical records and nurses assessment if a patient is eligible for hospice services. When the RN is at bedside, they either call or text to certify the patient, they can't move on unless they get a verbal order from the doctor. Legally the doctor has 30 days to fill out the narrative and sign the CTI. The doctor usually signs and fills in the narrative within 14 days or shorter". A review of facility's policy titled, "Certification" dated 4/2022 indicated all certifications and recertifications must be signed and dated by the physician and must include the benefit period dates to which the certification or recertification applies. The physician will include a brief narrative explanation of the clinical findings that support a life expectancy of six months or less if the disease runs its normal course, as part of each certification ... A review of facility's policy titled, "Inter-Disciplinary Group Meeting" (IDG) dated 3/2022 indicated The Medical Director/hospice physician must type, or speak to text their ... CTI documentation ... A review of facility's policy titled, "Medical Record Content" dated 4/2022 indicated each medical record will contain the following: certification and recertification of terminal illness, including physician narratives.

Based on interview and record review the facility failed to ensure entries for certification or recertification both written and electronic, are signed and dated by the person performing the services to 2 of 13 patients (Patients 4 and 6). This failure has the potential for the incomplete entries will not be verified or authenticated for hospice services provided or ordered. Findings: 1. A review of Patient 4's "Patient Information Report" indicated the patient was admitted to hospice on 6/3/2022 with a diagnosis of Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Patient 4's "Hospice Certification and Plan of Care" date 6/3/2022 to 8/31/2022 indicated Skilled Nursing (SN) visits 2 times per week for 13 weeks, then 1 visit per week for 1 week. Home Health Aide (HHA) visits 2 times per week for 12 weeks, then 1 visit per week for 1 week. A review of Patient 4's "Hospice CTI" dated 6/3/2022 and printed 6/7/2022 indicated there was no physician's signature and certified Patient 4 had a prognosis of six months or less. It also indicated there was no narrative explanation made by the physician. A review of Patient 4's "Hospice Certification of Terminal Illness (CTI)" dated 6/3/2022 and printed 6/10/2022 indicated there was no physician's signature to certified Patient 4 had a prognosis of six months or less. It also indicated there was no narrative explanation made by the physician. 2. A review of Patient 6's "Patient Information Report" indicated patient was admitted to hospice on 3/10/2022 with a diagnosis of malignant neoplasm of unspecified site of female breast (breast cancer). A review of Patient 6's "Hospice Certification and Plan of Care" dated 3/10/2022 to 6/7/2022 indicated Skilled Nursing (SN) visits once per week for 1 week, then 2 times per week for 12 weeks, then 1 visit per week for 1 week. Home Health Aide (HHA) visits 2 times per week for 12 weeks, then 1 visit per week for 1 week. A review of Patient 6's "Hospice Inter-Disciplinary Assessment and Plan of Care Update Report" dated 5/25/2022 indicated the form was not signed by the hospice physician. A review of facility's policy titled, "Certification" dated 4/2022 indicated all certifications and recertifications must be signed and dated by the physician and must include the benefit period dates to which the certification or recertification applies. The physician will include a brief narrative explanation of the clinical findings that support a life expectancy of six months or less if the disease runs its normal course, as part of each certification ... A review of facility's policy titled, "Inter-Disciplinary Group Meeting" (IDG) dated 3/2022 indicated The Medical Director/hospice physician must type, or speak to text their ... CTI documentation ... A review of facility's policy titled, "Medical Record Content" dated 4/2022 indicated all entries in the medical record must be ... appropriately authenticated and dated ...

Based on interview and record review, the hospice failed to ensure all employees were screened for Tuberculosis (TB an infectious lung disease). This failure placed all patients and staff at risk of getting TB due to not knowing the status of TB disease of its employees. Findings: On 6/8/22, at 12:20 p.m. the administrator (ADM) stated employee TB testing was required every year for the TB skin test and every two years for chest x-ray for those employees required to have an x-ray test. The ADM stated the Medical Doctor and Chaplain were required to have a TB skin test and agreed their TB test for 2022 were due. A review of the Medical Doctor employee file indicated a TB test was done on 6/4/21. Further review of the employee file did not indicate a TB test for 2022. The HA did not provide a TB test for 2022 upon request. A review of the Chaplain employee filed indicated a TB test was done on 6/1/21. Further review of the employee file did not indicate a TB test for 2022. The HA did not provide a TB test for 2022 upon request. A review of facility's policy titled, "Personnel Records" dated 2/1/2021 indicated the hospice will adhere to federal and state law and regulations when establishing and maintaining personnel records to ensure the accuracy, completeness, and confidentiality of the contents. Medical records may include but not be limited to: Laboratory test results, TB screening documents.