Every finding on record at Regal Heart Hospice Corporation

Based on interview and policy review, the agency failed to update the Emergency Preparedness policies every two years. This deficient practice had the potential to affect all 23 patients receiving services from the Hospice Agency. Findings include: Review of the Emergency Preparedness policies and procedures revealed the policies were last reviewed in February 2022. During an interview on 02/08/25 at 8:00 PM, the Director of Nursing confirmed the Emergency Preparedness policies and procedures had not been updated since February 2022.

Based on interview, record review and facility document review, the Hospice agency failed to meet the Condition of Participation (CoP) for L500 Patient's Right when they failed to 1.) comply with mandatory reporting requirements to immediately report suspicions of neglect to Adult Protective Services (APS) for one of 14 patients (Patient (P) 9) whose records were reviewed out of a total sample of 14. P9 was noted to be a vulnerable adult on 12/09/24, and the case was not filed with APS and law enforcement until 02/07/24. These failures had the potential to place P9 at risk of serious injury, harm, or impairment, up to and including death, and 2.) identify, document, and have a functional working grievance program from November 2023 until 12/03/24. This had the potential to cause patient and caregiver concerns to be unaddressed. The agency was notified of the Immediate Jeopardy (IJ) at L517 on 02/07/25 at 5:25 PM related to the failure to comply with mandatory reporting requirements. In concurrence with Centers for Medicare and Medicaid Services (CMS) review, the removal plan was approved on 02/08/25 at 1:52 PM. The survey team verified implementation of the facility's IJ removal plan on 02/08/25/25 at 7:30 PM. Findings include: 1. The agency failed to immediately notify APS of suspicions of neglect for one of 10 active patients (P9) when the patient was first assessed to be vulnerable and unsafe living in his home without caregivers present. (Refer to L517) 2. The agency failed to identify, document, and have a functional grievance program from November 2023 until 12/03/24. (Refer to L505)

Based on interview, record review, and review of agency policy, the hospice agency failed to identify, document, and have a functional grievance program from November 2023 until 12/03/24. This failure had the potential to cause patient and caregiver concerns to be unaddressed for 23 of 23 active patients. Findings include: Review of the facility's "Concern Log," provided by the facility, revealed grievances/concerns began on 12/03/24. There was no documentation of a "Concern Log" from November 2023 when the new management company took over until 12/03/24. During an interview on 02/06/25 at 3:30 PM, the Director of Nursing (DON) stated, "This log began on 12/03/24. I didn't realize that we needed one until then." The DON also stated he/she did not begin working at the hospice agency until March 2024. During an interview on 02/08/24 at 4:00 PM, the DON stated, "The new management company began in November 2023. I do not have any records until when I started this on 12/03/24." Review of the agency's policy titled, "Complaint Resolution," dated June 2019 revealed, ". . . Hospice maintains records of grievances/complaints and their outcomes and includes this information in the annual program review/evaluation. A summary of the grievances/complaints will be reported quarterly to the governing body/owner . . ."

Based on interview, record review, agency policy review, and review of the New Jersey Adult Protective Services (APS) website, the hospice agency failed to comply with mandatory reporting requirements to immediately report suspicions of neglect to APS for one of 14 patients (Patient (P) 9) whose records were reviewed out of a total sample of 14. P9 was noted to be unsafe and a vulnerable adult on 12/09/24, and the case was not filed with APS and law enforcement until 02/07/25. This placed P9 at continued risk of serious injury, harm, and impairment. Findings include: Review of P9's "Patient Profile," provided by the agency., revealed P9 was admitted to hospice services on 12/06/24 with a terminal diagnosis of ischemic cardiomyopathy. Review of P9's "Hospice Nursing Clinical Notes" revealed the following: 12/09/24 and untimed - It was recorded P9 was eating approximately two child size meals per day. It was also recorded, ". . . Pt [patient] has a large, painful bruising to chest wall which [he] she [P9] stated was from a fall. [He/She] was unwilling to go downstairs as [he/she] stated [he/she] cannot get back upstairs. Educated [family member] . . . and pt that it is not safe for [him/her] remain alone as [he/she] is a high fall risk and unable to get [himself/herself] to the bathroom or kitchen. [Family Member] stated 'we're not ready to hire help at this time.' Reported safety concerns to MSW [Medical Social Worker], SC [Spiritual Counselor] and DON [Director of Nursing] . . ." 12/16/24 and untimed - "... Discussed with pt and [family member] . . . the need for help in the home and reiterated pt should not be left alone. Both pt and [family member] refused to discuss." 12/23/24 and untimed - ". . . Routine SN [skilled nurse] visit. Door was left unlocked and TN [the nurse] found pt upstairs in [his/her] bed not wearing any clothing. [He/she] stated [he/she] was hot in the night so [he/she] took [his/her] nightgown off. Helped [him/her] dress and sit on side of the bed. AAO x 2 [Awake, Alert and Oriented], very forgetful. Reminded pt [he/she] should have someone with [him/ her] 24/7 [24 hours per 7 days of week] for safety reasons . . ." 01/06/25 and untimed - ". . . Reported safety concerns to DON . . ."[family member] that it is unsafe with [him/her] being alone . . . Educated on the possible safety issues with [him/her] being alone . . ." 01/27/25 and untimed - ". . . Noted [he/ she] (P9) did not have [his/her] life alert on nor phone nearby . . . Gave [him/her] life alert and educated on safety concerns of [him/her] being alone . . . [family member] made aware of safety concerns . . ." 01/30/25 and untimed, -". . . PRN [as needed] visit for reported chest pain . . . patient was complaining of chest pain and requesting aspirin. TN (the nurse) called patient [family member] and route [sic] and let [him/her] know of the situation. Requested a family member come and stay with patient and was told no one was available . . . Patient hypertensive at 157/103, pulse of 120 and irregular, respiratory rate of 24 and shallow, SPO2 [saturation of oxygen] reading of 89%. TN suggested that [he/she] put on supplemental O2 [oxygen] and [he/she] refused. TN contacted clinical manager, who stayed on the phone while TN informed patient we advise [him/her] to go to the hospital due to hypertension and tachycardia. Patient adamantly refused, clinical manager and HHA [home health aide] . . . both witnessed refusal. [He/She] denied having any pain and stated [he/she] was 'fine' and did not need any further assistance. Advised patient of the risks of not going to ER and [he/she] stated [he/she] was OK with the risks. TN stayed for one hour to ensure patient had no further symptoms. Patient asked TN to leave stating [he/she] was fine advised [him/her] if [he/ she] continue to refuse treatment [he/she] may be discharged from service for continued refusal to follow POC (Plan of Care) . . ." 02/03/25 and untimed - ". . . Patient is unable to recall instructions provided after 1 minute . . . [He/She] agreed to follow safety instructions and to use oxygen when instructed to do so. However, within 1 minute [he/she] was asking what TN had just told [him/her] [he/she] should do . . ." Review of P9's "Medication Profile" revealed P9 was supposed to receive Aspirin (Aspirin Children's) 81 mg by mouth daily and Digoxin (a cardiac medication) 125 micrograms(mcg) by mouth daily. During a home visit on 02/07/24 at 10:25 AM, P9 was asked what medications he/she took. P9 stated, "I don't take any medicines." P9 was asked if he/she took an aspirin and his/her heart pill, Digoxin each day. P9 stated, "I don't have to take any medicine like that." It was noted that P9's bedroom was upstairs, and her food was downstairs in the kitchen refrigerator. P9 would be required to navigate five steep stairs with a walker in order to get her food. During an interview on 02/07/25 at 11:10 AM, the MSW was asked if other community resources had been contacted to see if other options were available for P9. MSW stated, "I think I did." When asked if this contact was documented in the medical record, the MSW stated, "I wouldn't document anything like that." During an interview on 02/07/25 at 11:20 AM, the Hospice aide (HA)1 stated, "The patient only has family that will drop in to put groceries in the refrigerator. " HA1 stated family brought the food once a week. HA1 stated, "He/She] [P9] has a friend of the family that comes about three times a week to help [him/her] with supper and then leaves. [He/She] is here all the time by [himself/ herself], and I don't feel it is safe for [him/ her] to be here alone." When asked who would be here over the weekend to ensure P9 received something to eat, HA1 stated, "Nobody that I know of." During an interview on 02/07/25 at 12:06 PM, Registered Nurse (RN)1 was asked if the patient was safe to be at home by herself. RN1 stated, "Not entirely, but I have talked to the family and to the office about the safety concerns of leaving the patient alone." When asked if anything else has been done with the safety concerns of P9, RN1 replied, "Education of the patient and then to the family every visit is all that I know of." RN1 was asked if she reconciled the medication profile with what the patient was taking, and RN1 stated, "Not every visit. Her family tells me [he/she] is taking [his/her] medicine." Review of P9's "IDG [Interdisciplinary Group] Meeting Review," beginning 12/18/24 and completed every 2 weeks, revealed safety concerns of P9 being a high fall risk and concerns that P9 needed 24-hour care were discussed. It was recorded education had been provided by the hospice staff members to the patient and family, but they were reluctant and refused any further care for the patient at the time. There were no documented action plans, and no discussions documented that these failures were suspicious for neglect. Review of P9's entire clinical record revealed no documented evidence APS (Adult Protection Services) had been notified of P9's unsafe living situation and vulnerability from 12/09/24 until 02/07/25, when contact was first made with APS and law enforcement. During an interview on 02/07/25 at 1:31 PM, the DON stated, "There is definitely a concern for [his/ her] [P9] safety, but we cannot get the family to agree with extra help." During an interview on 02/07/25 at 2:45 PM, the DON was asked if the safety concerns of P9 had been reported to anyone. The DON stated, "No, definitely if we thought it was abuse or neglect, we would have reported it to APS." Review of New Jerseys APS law (N.J.S.A. 52:27D-406 to 426) website, located at https://apps.rainn.org/policy/policy-state-laws.cfm?state=New%20Jersey&group=5, revealed, ". . . requires health care professionals, law enforcement officers, firefighters, paramedics or emergency medical technicians who have reasonable cause to believe that a vulnerable adult is the subject of abuse, neglect or exploitation to report that information to the county Adult Protection Services office . . ." Review of the agency's policy titled, "Identifying and Reporting Possible Victims of Alleged/Suspected Abuse, Neglect, or Exploitation," dated February 2021 and provided by the agency, revealed, ". . . all violations involving mistreatment, neglect . . . are reported immediately . . . to the Hospice Administrator . . ." Review of "Mandatory Reporting Requirements: The Elderly New Jersey," dated April 2023, which was provided by the agency, revealed, ". . . When is a report required and where does it go . . . For a Vulnerable Adult: The relevant county adult protection services office . . . Neglect means an act or failure to act by a vulnerable adult or his caregiver which results in the inadequate provision of care or services necessary to maintain the physical or mental health of the vulnerable adult, and which places the vulnerable adult in a situation which can result in serious injury or which is life threatening . . . Reports for a . . . Vulnerable Adult [sic] must be made in a timely manner . . ."

Based on interview, record review, and policy review, the agency failed to ensure that medications listed on the hospice agencys medication list were the same medications listed on the nursing facility's medication list for one of 10 patients (Patient (P) 3) whose medications were reviewed out of a total sample of 14. This had the potential to cause P3 to suffer adverse drug events. Findings include: During a review of P3's "Order Summary Report" of active orders as of 02/06/25, in P3's nursing facility, it was revealed the patient was being given docusate sodium (a stool softener) 100 milligrams (mg) two tablets by mouth one time a day for constipation, morphine sulfate (a pain medication) oral solution 10 mg/0.5 ml (milliliter) 0.5 ml sublingually (under the tongue) every 6 hours as needed (PRN) for moderate to severe pain with a pain level of 5-10 or for shortness of breath (SOB), Percocet 5-325 mg (a pain medication) one tablet by mouth every four hours for pain, hold when asleep, and Trazodone (used for sleep) 50 mg one tablet by mouth at bedtime related to insomnia. Review of P3's "Hospice Medication Profile," dated for the certification period of 01/10/25 to 03/10/25 and provided by the agency, revealed docusate sodium 100 mg one tablet by mouth two times a day, morphine sulfate (Concentrate) 20 mg/ml Give 5 mg every three hours as needed for pain/SOB, and Trazodone 50 mg Give 1 tablet prn/as needed. There was no documentation of Percocet being on the Hospice Medication Profile. During an interview on 02/06/25 at 3:30 PM, the Clinical Manager (CM) was provided with P3's "Order Summary Report" of active orders and the "Hospice Medication Profile" to review. The CM confirmed orders on the hospice profile did not match the nursing facility's list for docusate sodium, morphine sulfate, and Trazodone. The Clinical Manager stated, "The Percocet isn't on our profile, but it should be." The Clinical Manager was asked how often the nurse should reconcile the medications for P3 and he/she stated, "With every visit." During an interview on 02/07/25 at 3:15 PM, Registered Nurse (RN)1 stated, "I didn't reconcile [P3's] medications when I made the visit yesterday. I only asked the nurse taking care of [P3] if there had been any medication changes." Review of the agency's policy titled, "Medication Reconciliation," dated June 2019, revealed, "Hospice will reconcile patient's medications at time of admission and on an ongoing basis . . . Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication . . ."

Based on record review, documentation review, policy review, and interview, the facility failed to ensure "Plans of Care" contained measurable goals for three of 10 active record reviews (Patients (P)3, P2, and P9) out of 14 records reviewed. This had the potential for the inability for staff to assess progress or lack of progress in a patient's status related to improvement in health status. The agency also failed to follow the "Plan of Care" for skilled nursing visits for one of 14 record reviews (P6) and failed to reconcile medications with the nursing home in which P3 resides. These failures had the potential for patients not to receive the services the hospice "Plan of Care" had developed and for a patient that resides in a nursing facility to receive unnecessary medications or not receive the correct dosages or frequencies of the prescribed medications the physician has ordered. Findings include: 1. Review of the "Care Plans" for three of 10 active record reviewed out of 14 sampled patients revealed there was no documentation to indicate that goals includsed in their "Hospice Plan of Care" were measurable. (Refer to L548). 2. Review of the "Hospice Nursing Clinical Note" for one out of 10 active records reviewed out of 14 sampled patients revealed documentation the last skilled nursing visit completed was on 01/14/25. The "Physician Orders" located under the "Patient Chart" in the electronic medical record (EMR) revealed skilled nursing visits were ordered once a week on 12/20/24. There was no documentation of skilled nursing visits performed after 01/14/25 (Refer to L543). 3. During a home visit on 02/06/25 for P3, Registered Nurse (RN)1 did not reconcile P3's medication list with the nursing facility's medication list with the facility staff (Refer to L530).

Based on record review and interview, the agency failed to follow the physician orders for skilled nursing visits for one of 10 patients (Patient (P) 6) whose records were reviewed for visit frequencies out of a total sample of 14. This failure had the potential for P6 to have a decline in condition that otherwise could had been recognized earlier if the skilled nursing visits had been made as ordered by the physician. Findings include: Review of P6's "Patient Profile," located under the "Patient Chart" tab in the electronic medical record (EMR), revealed P6 was admitted to hospice services on 12/05/24 with the terminal illness of senile degeneration of the brain. Review of P6's "Hospice Physician Order," located under the "Patient Chart" in the EMR, revealed an order dated 12/20/24 for "decrease SN [skilled nurse visit] to 1XW [sic] [one time a week] . . ." Review of P6's "Hospice Nursing Clinical Note," located under the "Patient Chart" in the EMR, revealed the last skilled nursing note was dated 01/14/25. There was no further documentation in the EMR to reveal P6 was seen by the nurse one time a week after 01/14/25. During an interview on 02/08/25 at 4:30 PM, the Director of Nursing (DON) stated, "I believe the nurse made the visits but [he/she] is not a good time manager." When asked if the agency had verified that the skilled nursing visits had been made by the nurse, the DON replied, "The nurses have to sign in the nursing facility every time they go into make a visit and when they leave. I guess I could call and ask to see if I could get a record of the kiosk if I needed to." The DON was asked when the nurse was supposed to document the nursing visit. The DON stated, "After the visit is made."

Based on policy review, record review, and interview, the agency failed to ensure that patient care plans incorporated measurable data elements to assess if progress toward expected outcomes of care plan goals were being met for three of 10 patients (Patient (P)3, P2, and P9) out of a total sample of 14. This deficient practice had the potential to affect all 23 patients receiving services from the Hospice Agency. Findings include: Review of the agency's policy titled, "IDG Care Planning Process," provided by the agency and dated 2014 stated, ". . . The care of plan [sic] specifies the care and services necessary to meet the patient and family specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions [sic] . . . Measurable outcomes anticipated from implementing and coordinating the plan of care . . . and notes the patient's progress toward outcomes and goals specified in the plan of care . . ." 1. Review of P3's "Hospice Plan of Care," located under the "Hospice Plan of Care" tab in the electronic medical record (EMR), indicated the Registered Nurse (RN) started P3's care plan on 07/14/24 that included intermittent "SOB" (shortness of breath), [P3] is bed/chair bound with muscle weakness, and complains of abdominal pain." The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals. 2. Review of P2's "Hospice Plan of Care," located under the "Hospice Plan of Care" tab in the EMR, indicated the RN started P2's care plan on 09/06/24 that included at risk for pain due to generalized pain, osteoarthritis, limited mobility, history of left femur fracture, at risk for respiratory complications related to end of life respiratory changes, risk of aspiration, at risk for falls due to advanced age, polypharmacy, dementia, and decreased mobility. The care plan did not include measurable elements to monitor the progress toward the expected outcomes and goals. 3. Review of P9's "Hospice Plan of Care," located under the "Hospice Plan of Care" tab in the EMR, indicated the RN started P9's care plan on 12/09/24 that included patient is at risk for pain as disease progresses, patient has dyspnea at rest, patient has heart disease and atrial fibrillation, patient has had multiple falls in the past three months, patient has bladder incontinence, and patient is at risk for moisture associated skin breakdown. The care plan did not include measurable elements to monitor the progress toward the expected outcomes and goals. During an interview on 02/06/25 at 11:15 AM, RN1 was asked if the goals for P3 were measurable. RN1 stated, "This one says pain will not interfere with sleep, activities, time with family and friends, appetite or mood." RN1 was asked how the goal is measurable, and RN1 replied, "Well, putting it that way, the goals are not measurable." During an interview on 02/06/24 at 3:30 PM, the Clinical Manager confirmed the goals in the patients' care plans were not measurable.

Based on interview, record review, and review of agency policy, the hospice agency failed to regularly monitor quality indicators so that opportunities for improvement could be identified and prioritized. This had the potential to cause unmet care needs for 23 of 23 active patients served by the agency. Findings include: On 02/05/25, upon entrance to the agency, the agency was asked to provide evidence of the Quality Assurance and Performance Improvement (QAPI) activities for the period of 02/05/24 through 02/05/25. On 02/08/25, the agency provided "QAPI Report" for the dates of 05/08/24 and 11/20/24. The 05/08/24 meeting consisted of infection control as it pertained to hand hygiene compliance, medical record review for the compliance of the required documentation pertaining to the admission process, fall prevention, patient/family satisfaction, and employee files as it pertained to ensuing the mandatory components were completed. All of these areas had documentation under the "Data Collection Period/Finding/Conclusions" section which stated "Quarter 2 [sic] (April, May. June) data collection initiated. Findings will be discussed at the July 2024 QAPI Meeting." There was no documented evidence provided that a July 2024 meeting took place. The 11/20/24 meeting consisted of infection control as it pertained to hand hygiene with the report of the data collection being, "All staff educated and demonstrated Hand Hygiene on 05/09/24. Monitoring of HHA (Home Health Aide) Hand Hygiene during supervision visits revealed 100% compliance." Medical records, as it pertained to the required documentation pertaining to the admission process was reported as being in 100% compliance. Fall Prevention as it pertained to identify risks/trends of patient falls in an effort to prevent falls stated, "Quarter 2 [sic] (July, August, September) data collection will be discussed at the November 2024 QAPI meeting." There was no further evidence of a discussion of the data on this 11/20/24 QAPI meeting minutes. There were also "QAPI AD HOC Committee Meeting Minutes," dated 08/19/24, which revealed the issue of "Families were not made aware of non-covered items." The Discussion/Action/Follow-Up" was documented, "Education was provided to team [sic]. Audit will be done of all new admissions and reviewed during IDG [Inter-Disciplinary Group] for follow-up as needed." There were also the issues of "Facility/Community PCP [Primary Care Physician] and CTIs [Certification of Terminal Illness] not being signed" and "Bereavement process not in place for patients that expired prior to March 2024." There was no further discussion from the 08/19/24 meeting on the non-covered items or bereavement concerns. The January 2025 "QAPI" meeting agenda was also provided. This did not have a sign-in sheet provided with the agenda. The following areas were included on the agenda Falls and Incident with having one fall with injury and two falls without injury reported, Urinary Infections were three with all being treated with antibiotics and no trends noted with the caregivers. During an interview on 02/08/25 at 8:00 PM, the Director of Nursing stated, "No one told me what needed to be covered in the QAPI meetings. So, I went and tackled the issues we found in our chart reviews first and then moved on to the other issues that were identified. I have had to learn this process as I went along." Review of the agency policy "Quality Assessment and Performance Improvement (QAPI) Plan dated 2015 indicated ". . . Hospice has established an ongoing program of quality assessment and performance improvement . . . Data collection includes developing indicators, criteria or performance levels for each process determined to be improved. Data collection will be ongoing and frequency will be determined by the process improvement activity and approved by the Governing Body. Data collection will be used to monitor the effectiveness and safety of services and quality of care . . ."

Based on observation and interviews, the agency failed to provide care in a manner to prevent cross contamination for two of three patients (Patient (P) 3 and P4) observed during home visits. This deficient practice had the potential to affect all 23 patients who are currently receiving hospice services and increased the risk of the spread of infection. Findings include: 1. During a home visit on 02/06/25 at 10:30 AM, Registered Nurse (RN)1 used the thermometer, pulse oximetry, and a blood pressure cuff on P3. After each piece of equipment was used, RN1 placed it on a barrier to be cleaned. At the end of the visit, RN1 began cleaning the thermometer with a cleaning wipe and placed the clean thermometer on the dirty side of the barrier where the other dirty equipment was lying. RN1 continued to clean the remaining pieces of equipment and once cleaned, placed each piece of clean equipment on the dirty side of the barrier. After all the dirty equipment was cleaned, RN1 placed the equipment back into his/her bag for storage. During an interview on 02/06/25 at 11:15 AM, RN1 stated, "I should have placed the clean equipment on a clean area on the barrier instead of placing it back down on the dirty side." 2. During a home visit on 02/06/25 at 12:30 PM, Hospice Aide (HA)1 donned a clean pair of gloves and performed incontinence care for P4. HA1 then assisted P4 in pulling up his/her brief and assisted P4 to sit in the wheelchair. Without changing gloves or performing hand hygiene, HA1 propelled the wheelchair into the patient's bedroom. During an interview on 02/06/25 at 2:30 PM, HA1 stated, "I should have pulled off my gloves and washed my hands before touching and moving the patient's wheelchair." During an interview on 02/06/25 at 3:30 PM, the Clinical Manager stated, "[RN1] should have made a clean and dirty side of the barrier and never put clean equipment down on the dirty side of the barrier. [HA1] should have removed [his/her] gloves and washed [his/her] hands before touching the wheelchair to move it."

Based on record review, interview and agency policy review, the hospice agency failed to provide new hires with a two-step PPD (Purified Protein Derivative) TB (Tuberculosis) testing for six out of six newly hired employees. This failure had the potential to have staff that were exposed to Mycobacterium tuberculosis to be undiagnosed and not treated appropriately. Findings include: 1. Review of Registered Nurse (RN)1's personnel record revealed RN1 was hired on 06/28/24 and received a PPD on 08/02/24. There was no documentation that RN1 received a two-step PPD. 2. Review of the Director of Nursing's (DON) personnel record revealed the DON was hired on 03/18/24. There was no documentation the DON received the two-step PPD. 3. Review of the Medical Social Worker (MSW) personnel record revealed the MSW was hired on 11/23/23. There was no documentation the MSW received a two-step PPD. 4. Review of Hospice Aide (HA)1 personnel record revealed HA1 was hired on 02/05/24 and received a PPD on 06/25/24. There was no documentation HA1 received a two-step PPD. 5. Review of HA2 personnel record revealed HA2 was hired on 07/08/24 and received a PPD on 04/09/24 prior to being hired at the hospice agency. There was no documentation HA2 received a two-step PPD. 6. Review of RN3 personnel record revealed RN3 was hired on 11/15/24. There was no documentation RN3 received a two-step PPD. During an interview on 02/08/24 at 7:45 PM, the DON stated, "We didn't do the two step PPD for the new hires that we reviewed." Review of the hospice agency policy titled, "Occupational Exposure to Tuberculosis/Prevention of Transmission of TB Plan" revealed, ". . . During pre-employment physical, employees and patient care volunteers who have the potential for exposure to M. tuberculosis . . . will have the baseline PPD skin testing performed . . . the baseline PPD testing will include the two-step method . . ."

Based on interview and record review, the hospice agency failed to develop and implement effective volunteer recruiting efforts from November 2023 until the first hospice volunteer was available to provide services to the hospice patients. This failure had the potential for hospice patients not to receive the services they might need that could be provided by volunteers. Findings include: During an interview on 02/07/25 at 5:40 PM, the Volunteer Coordinator (VC) stated the recruiting efforts for hospice volunteers did not occur until July 2024 with the first volunteer service hours began in September 2024. The VC stated, "I am part of the [name of county] volunteer services. We post on Facebook, go to area colleges and promote or recruit for volunteers on social media." The VC did not state that the hospice agency used online websites such as Volunteer Match. When asked if in-services were provided for the volunteers, the VC replied, "No, I do not." The VC stated, "Pretty much I cannot get them together in the same spot and four of them are full time students." The VC was asked what the hospice agency did for retention of volunteers and the VC stated, "I answer any questions that they may have. I send them cards and keep an open dialogue with them. They were also invited to our holiday party." During an interview with the Director of Nursing (DON) on 02/07/25 at 7:00 PM, the DON stated, "The agency didn't have many residents from November 2023 until March 2024. I became the DON in March 2024 and our census was low. Gradually we began to increase the number of patients that we had." The surveyor requested a copy of the Volunteer Services policy but was not provided with such information.

Based on interview and record review, the hospice agency failed to have volunteer hours that equaled five percent of total patient hours from November 2023 until September 2024. This failure had the potential to cause the hospice patients to have unmet needs. Findings include: Review of the untitled documentation of the volunteer hours, provided by the agency, revealed the hospice agency had volunteer hours that equaled five percent of patient hours beginning in September of 2024. There was no documentation of volunteer hours prior to September 2024. During an interview on 02/07/24 at 5:40 PM, the Volunteer Coordinator stated the volunteer service hours began in September 2024. During an interview on 02/07/24 at 7:00 PM, the Director of Nursing stated, "The agency didn't have many residents from November 2023 until March 2024. I became the DON in March 2024 and our census was low. Gradually we began to increase the number of patients that we had." The surveyor did request a copy of the Volunteer Services but was not provided with this information.

Based on record review and interview, the agency failed to have a complete and accurate record in regard to paperwork signed by the patient and/or patient representative for a DNR (Do Not Resuscitate) for three of 10 patient's records reviewed for DNR (Patient (P) 6, P7, and P9) out of a total sample of 14 patients. Findings include: 1. Review of P6's "Patient Profile," located under the "Patient Profile" tab in the electronic medical record (EMR), revealed P6 was admitted to hospice services on 12/05/24 with a terminal illness of senile degeneration of the brain. Review of P6's "Hospice Nursing Initial Comprehensive Admission Assessment," located under the "Nursing Clinical Note" tab in the EMR, revealed a note dated 12/06/24 which provided documentation the patient and the family wished for P6 to have a DNR status. P6 resided in a nursing facility and had a DNR order in place; however, there was no paperwork in the hospice clinical record which indicated the DNR order. 2. Review of P7's "Patient Profile," located under the "Patient Profile" tab in the EMR, revealed P7 was admitted to hospice services on 01/21/25 with a terminal illness of moderate protein calorie malnutrition. Review of P7's "Hospice Nursing Initial Comprehensive Admission Assessment," located under the "Nursing Clinical Note" tab in the EMR, revealed a note dated 01/21/25 which provided documentation of the patient and the patient's family wishes for P7 to have a DNR status. P7 resided in a nursing facility and had a DNR order in place; however, there was no paperwork in the hospice clinical record which indicated the DNR order. 3.Review of P9's "Patient Profile" located under the "Patient Profile" tab in the EMR revealed P9 was admitted to hospice services on 12/06/24 with the terminal illness of ischemic cardiomyopathy. Review of P9's "Hospice Nursing Initial Comprehensive Admission Assessment" located under the "Nursing Clinical Note" tab in the EMR revealed a note dated 12/06/24 which provided documentation of the patient's wishes to have a DNR status. On the consents signed by the patient on 12/06/24, it was marked by the patient "Advance Directive/DNR." There was no other paperwork in the clinical record to reflect these wishes. During an interview on 02/08/25 at 7:00 PM, the Clinical Manager stated, "We recognized this was a problem area with the nurses having the discussions of a DNR code status with the patients and families on admissions, but they were not following up to either get the signed paperwork for our records or have the patients or patient's families to sign the DNR paperwork. We in-serviced each nurse last week, and we have placed these forms in all the admission packets for them to begin using with their new admissions."

Based on interview and record review, the hospice agency failed to have a signed written statement of revocation of hospice benefits for two of two patients (Patient (P)13 and P14) reviewed for revocation out of a total sample of 14. This failure had the potential to cause disruption of the patient's Medicare benefits. Findings include: 1. Review of P13's "Patient Profile," located under the "Patient Profile" tab in the electronic medical record (EMR), revealed P13 had been admitted to hospice services on 11/27/23 with the terminal diagnosis of Alzheimer's dementia. Review of P13's entire EMR revealed no documented evidence of a signed written revocation of hospice benefits. However, there was documentation of a "Notice of Medicare Non-Coverage (NOMNC)" which stated "The effective Date Coverage of Your Current [name of hospice agency] Services Will End: March 2, 2024." This notice was signed by the patient representative on 02/29/24. P13 was discharged from hospice services on 03/01/24 due to his/her condition being stable and no longer terminally ill. 2. Review of P14's "Patient Profile," located under the "Patient Profile" tab in the EMR, revealed P14 was admitted to hospice services on 06/28/24 with the terminal illness of Alzheimer's Disease. Review of P14's entire EMR revealed no documented evidence of a signed written revocation of hospice benefits. However, there was documentation of "Notice of Medicare Non-Coverage (NOMNC)" which stated "The effective Date Coverage of Your Current [name of hospice agency] Services Will End: 12/9/24." This notice was signed by the patient representative on 12/06/24. P14 was discharged from hospice services on 12/09/24 due to his/her condition being stable and no longer terminally ill. During an interview on 02/08/24 at 6:00 PM, the Director of Nursing stated, "Both patient's condition improved, and they were discharged from hospice services. I believe that we got the NONMC, and the revocation of hospice benefits mixed up and got the wrong one signed."

Based on record review, interview, and agency policy review, the hospice agency failed to document in the patient's clinical record that the discussion of written policies and procedures for managing controlled drugs was provided and discussed with the patient and the patient's family for one of 10 patients (Patient (P) 9) reviewed for medications out of a total sample of 14 patients. Findings include: Review of P9's undated "Patient Profile," located under the "Patient Profile" tab in the electronic medical record (EMR), revealed P9 had been admitted to hospice services on 12/06/24 with a terminal diagnosis of ischemic cardiomyopathy. Review of P9's entire clinical record revealed no documented evidence that staff provided a discussion of written policies and procedures of managing controlled drugs to P9 or to his/her family. During an interview on 02/08/25 at 7:00 PM, the Clinical Manager (CM) stated, "I think they are discussing this with the patient and families." Review of the agency's policy "Hospice Comfort Kits," dated 04/15/19, did not indicate the written policies and procedures for controlled drugs or a discussion of the policies would be provided to the patient and/or patient's family.

Based on staff interview, review of four of six medical records (#1, #2, #9, #11), and review of facility policy and procedure, it was determined the facility failed to ensure an initial bereavement assessment identifying the needs of the patient's family and other individuals ability to cope with the patient's death is completed. --- Finding include: Reference: Facility policy titled, "Bereavement Services" states, "... An initial Bereavement Risk Assessment will be performed as a part of the Comprehensive Assessment." Upon review of Medical Record #1, the following was noted: The patient was admitted to service on 9/30/22. An initial Bereavement Risk Assessment was not completed. The patient was readmitted to service on 11/28/22. An initial Bereavement Risk Assessment was not completed. Upon review of Medical Record #2, the following was noted: The patient was admitted to service on 1/25/22. An initial Bereavement Risk Assessment was not completed. Upon review of Medical Record #9, the following was noted: The patient was admitted to service on 3/28/21. An initial Bereavement Risk Assessment was not completed. Upon review of Medical Record #11, the following was noted: The patient was admitted to service on 5/14/20. An initial Bereavement Risk Assessment was not completed. The above findings were confirmed with Staff #1 on 12/7/22 at 2:00 PM. N.J.A.C. 8:42C-6.3(a)3

Based on staff interview, review of medical records, and review of facility documents, it was determined the hospice interdisciplinary group (IDG) failed to ensure: 1) all members of the interdisciplinary group participate in the patient's comprehensive and ongoing assessments and care planning processes by participating in the IDG meetings; 2) services are provided in accordance with the plan of care; 3) services are provided based on patient's needs. (Cross refer to Tag L541, Tag L555, and Tag L556)

Based on staff interview, review of three of three medical records (#1, #2, #3), and review of facility policy and procedure, it was determined the facility failed to ensure all members of the interdisciplinary group participate in the patient's comprehensive and ongoing assessments and care planning processes by participating in the IDG meetings. --- Findings include: Reference: Facility policy titled, "IDG (Interdisciplinary Group) Care Planning Process" states, "... Hospice has designed an interdisciplinary group ... The group consists of: A physician ... Registered Nurse ... Social Worker ..... Pastoral or another counselor. ... The IDG works together to meet the physical, medical, psychosocial, emotional and spiritual needs of hospice patients ... IDG supervises the care and services." Upon review of Medical Record #1, the following was noted: The patient was admitted to service on 9/30/22. The social worker and the pastor did not participate in the IDG meeting on 10/6/22. The pastor did not participate in the IDG meeting on 10/25/22. The social worker did not participate in the IDG meeting on 11/8/22. Upon review of Medical Record #2, the following was noted: The patient was admitted to service on 1/25/22. The physician and social worker did not participate in the IDG meeting on 1/27/22. The pastor did not participate in the IDG meeting on 2/10/22. The physician and social worker did not participate in the IDG meeting on 2/24/22. The social worker did not participate in the IDG meeting on 3/10/22. The social worker did not participate in the IDG meeting on 3/24/22. Upon review of Medical Record #3, the following was noted: The patient was admitted to service on 1/20/22. The social worker did not participate in the IDG meeting on 1/27/22. The social worker did not participate in the IDG meeting on 2/10/22. The social worker and the pastor did not participate in the IDG meeting on 2/24/22. Staff #1 confirmed the above findings on 12/7/22 at 2:30 PM. N.J.A.C. 8:42C-6.2(b)1(ii)

Based on staff interview, review of two of three medical records (#1, #2), and review of facility policy and procedure, it was determined the facility failed to ensure that services are provided in accordance with the plan of care. --- Findings include: Reference: Facility policy titled, "Professional Standards of Practice" states, "... Hospice staff will provide care, treatment and services to each patient according to the IDG plan of care and physician orders." Upon review of Medical Record #1, the following was noted: The patient was admitted to service on 9/30/22. Skilled Nursing was ordered "One visit weekly, One visit PRN [as Needed]. There were no skilled nursing visits the week of 10/30/22 and 11/6/22. Upon review of Medical Record #2, the following was noted: The patient was admitted to service on 1/25/22. Skilled Nursing was ordered "Two visits monthly, One visit PRN [as Needed]." There were no skilled nursing visits in the month of February 2022. The Home Health Aide was ordered "two visits weekly." There is no documented evidence that the home health aide ever made a visit. The above findings were confirmed by Staff #1 on 12/6/22 at 12:15 PM. N.J.A.C 8:42C-6.3(a)2

Based on staff interview, review of two of two medical records (#2, #6) of patients requiring assistance obtaining services, and review of facility policy and procedure, it was determined the facility failed to ensure that services provided are based on patient needs. --- Findings include: Reference: Facility policy titled, "Coordination of Patient Care" states, "...Ensure that care and services are provided in accordance with the plan of care and are based on all assessments of the patient and family needs." Upon review of Medical Record #2, the following was noted: The Nursing Summary Note, dated 3/22/22, states, "Agitated today due to cancellation of her transportation services ... Plan: Asking SW [Social Worker] to assist with transportation issues. Referral to [name of rehabilitation company] for gait retraining re L [left] BKA [below knee amputation]." An IDG [interdisciplinary group] meeting took place on 3/24/22 and 3/30/22. There was no documented evidence that the social worker assisted the patient with transportation issues. There was no documented evidence that the patient received rehabilitation for gait training. Upon review of Medical Record #6, the following was noted: The Social Work Assessment, dated 2/3/22, states, "MSW [Medical Social Worker] eval [evaluation] with son [name of son] and patient. ... Son would like [name of rehabilitation company] in the future for PT [Physical Therapy], ST [Speech Therapy] and Cognitive Therapy." An IDG meeting took place on 2/10/22. There was no documented evidence that there was any follow up on the patient receiving PT, ST, or Cognitive Therapy. The above findings were confirmed with Staff #1 on 12/6/22 at 3:15 PM. N.J.A.C. 8:42C-6.3(a)

Based on observation, staff interview, and review of facility documentation, it was determined that the facility failed to ensure: 1) the policy on bag technique is implemented for infection prevention and control; 2) an agency approved list of disinfectants is provided for the cleaning and disinfection of equipment; 3) all staff complete their infection control education. (Cross refer to Tag L578 and Tag L582)

Based on observation of one of one patient (Patient (P)1), staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure: 1) the policy on bag technique is implemented for infection prevention and control; and 2) an agency approved list of disinfectants is provided for the cleaning and disinfection of equipment. --- Findings include: 1.) Facility policy titled, "Bag Technique" states, "... Equipment 1. Nursing bag with impermeable lining ...Procedure 1. Observe the principles of Standard Precautions at all times. The inside of the nursing bag should be regarded and maintained as a clean area. ...8. Return to the nursing bag, open it again, and remove necessary items for the visit. ... Keep the bag closed during the visit. ...10. After providing care, clean all equipment with soap and water or a home health agency-approved disinfectant before returning it to the bag. ... " On 12/8/22 at 1:16 PM, during a home visit for Patient (P) 1, Staff #1 was observed entering P1's home with an open black mesh bag. Staff #1 performed hand hygiene, removed a paper barrier from the open bag, and placed it down on the patient's kitchen table. The bag remained open. At 1:59 PM, Staff #1 was observed reaching into the open bag, removing a stethoscope, blood pressure pump and cuff, pulse oximeter, and thermometer, cleaning each with an alcohol wipe before placing on the paper barrier. Staff #1 utilized the stethoscope, blood pressure cuff, pulse oximeter, and thermometer to check P1's vital signs, returning the equipment to the paper barrier after use. At 2:10 PM, Staff #1 was then observed placing the equipment in the open black mesh bag without cleaning the equipment after use. Staff #1 placed a folded white paper, pen, and container of alcohol wipes into the open bag with the uncleaned equipment. The above findings were confirmed with Staff #1 during exit conference. 2.) Facility policy titled, "Exposure Control Plan:: OSHA [Occupational Safety and Health Administration] Regulations" states, " ... Methods of Disinfection ...6. Stethoscopes and blood pressure cuffs will be cleaned with Hospice approved disinfectant after each use by the employee who has possession of the equipment. ..." On 12/8/22 at 10:55 AM, during an interview with Staff #1, a request was made for the list of Hospice approved disinfectants used for the cleaning of equipment used for patient care. Staff #1 stated that there was no documented list of approved disinfectants for staff to reference. N.J.A.C 8:42C-10.2(b)

Based on staff interview and review of facility documentation, it was determined that the facility failed to ensure all staff complete their infection control education. --- On 12/7/22 at 12:30 PM, upon request, Staff #2 provided an education binder, with monthly education assignments and sign in sheets. An education booklet titled "Infection Control in Home Healthcare" was included. Staff #2 stated that all staff were required to read the booklet annually and sign off after completion. Staff #2 stated that the booklet was the only infection control education he/she was aware of. A sign-in sheet for 2021 revealed that Staff #6 and Staff #7 did not sign off to indicate they had completed their annual education, which was confirmed by Staff #2. On 12/8/22 at 11:32 AM, Staff #1 confirmed that reading and signing off on the booklet was the only documented annual infection control education provided. N.J.A.C 8:42C-10.2(b)2

1. The hospice failed to ensure that all patients have a bereavement risk assessment, that all patients have a bereavement care plan completed, that bereavement services are provided according to the bereavement care plan, and that bereavement services are available for twelve months. (Cross refer to Tag L596) 2. The hospice failed to ensure that assessments of the patient's and family's spiritual needs are completed. (Cross refer to Tag L598) Based on staff interview, review of medical records, and review of facility documents, it was determined the hospice licensed professional services failed to ensure 1. that all patients have a bereavement risk assessment, that all patients have a bereavement care plan completed, that bereavement services are provided according to the bereavement care plan, and that bereavement services are available for twelve months; 2. that assessments of the patient's and family's spiritual needs are completed. (Cross refer to Tag L596 and Tag L598)

Based on staff interview, review of three of three medical records of deceased patients (#9, #10, #11), and review of facility policy and procedure, it was determined the facility failed to ensure: 1) all patients have a bereavement risk assessment; 2) all patients have a completed Bereavement Care Plan; 3) services are provided according to the bereavement plan; and 4) Bereavement services are provided for twelve months. --- Findings include: Reference: Facility policy titled, "Bereavement Services" states, "... An initial Bereavement Risk Assessment will be performed as a part of the Comprehensive Assessment. ... A plan of care will be developed ... The plan of care will reflect family needs, as well as a clear delineation of services to be provided and the frequency of service delivery. ... Ongoing individual bereavement support and counseling is concluded at the wishes of the family or at the end of twelve months." 1.) Upon review of Medical Record #10 and Medical Record #11, the following was noted: There was no evidence that a Bereavement Risk Assessment was completed. 2.) Upon review of Medical Record #9, the following was noted: There was no evidence that a Bereavement Care Plan was developed. 3.) Upon review of Medical Record #10, the following was noted: The Bereavement Care Plan states, "MSW [Medical Social Worker] to reach out to friends ... assess bereavement future needs." There was no evidence that the MSW reached out to friends to assess bereavement future needs. Services were not provided according to the Bereavement Care Plan. 4.) Upon review of Medical Record #9, the following was noted: The patient died on 8/13/21. Bereavement services were never provided. Upon review of Medical Record #10, the following was noted: The patient died on 11/3/20. Cards were sent to the patient's friends on 11/10/20, 1/5/21, and 2/28/21. Bereavement services were not provided for twelve months. Upon review of Medical Record #11, the following was noted: The patient died on 5/26/20. A card was sent to the patient's daughter on 6/2/20. Bereavement services were not provided for twelve months. The above findings were confirmed with Staff #1 on 12/8/22 at 3:00 PM. N.J.A.C. 8:42C-6.3(a)

Based on review of three of three medical records (#1, #2, #3), it was determined the facility failed to ensure that an assessment of the patient's and family's spiritual needs is completed. --- Findings include: Upon review of Medical Record #1, Medical Record #2, and Medical Record #3, the following was noted: There was no documented evidence that an assessment of the patient's and family's spiritual needs were assessed. On 12/8/22 at 3:15 PM, Staff #1 was asked to provide documentation of the spiritual needs assessment for Patient #1, Patient #2, and Patient #3. Staff #1 did not provide documentation that a spiritual needs assessment was completed for Patient #1, Patient #2, and Patient #3. N.J.A.C. 8:42C-6.2(b)iii

Based on staff interview and review of facility documents, it was determined the facility failed to ensure that hospice aid services are available and provided. (Cross refer to Tag L609)

Based on staff interview and review of facility documentation, it was determined that the facility failed to ensure that hospice aid services are available and provided. --- Findings include: On 12/6/22 at 11:04 AM, Staff #2 stated that the facility currently has no hospice aids on staff and no contract for any hospice aids. On 12/7/22 at 10:13 AM, Staff #1 stated that their hospice aid, Staff #8, went on out a medical leave in January, 2022, and now intended to return to the facility to work. Staff #1 confirmed that Staff #8 has not provided a medical clearance letter to return to work, and is therefore inactive. Staff #1 then confirmed there were no other hospice aids employed at the facility, and no contract with any agency to provide home health aids. N.J.A.C 8:42C-7.5(a)

Observed in Leadership Session. In review of the provided documentation and discussion with the Administrator/DON and the Assistant Administrator, the surveyor found that the organization did not have an organizationwide, data-driven quality assessment and performance improvement program. The organization had started collecting data from patient surveys, chart reviews for medication reconciliation and was initiating a hand hygiene monitoring program. This, however did not reflect the entire hospice program. There was no formalized QAPI plan in place that had been reviewed and approved by the Governing body.

Observed in Leadership Session. In discussion with the Administrator/DON and the Assistant Administrator, the surveyor found that the organization had collected some data but had not used the data collected to monitor the effectiveness and safety of services and the quality of care.

Observed in Leadership Session. In review of the documentation provided and discussion with the Administrator/DON and Assistant Administrator, the surveyor found that the organization’s governing body had not approved the frequency and detail of the data collection. The organization did not have a QAPI plan that included the frequency and detail of the data to be collected.

Observed in Leadership Session. In discussion with the Administrator/DON and the Assistant Administrator, the surveyor found that only one performance improvement project had been initiated. There were no other projects that reflected the scope, complexity, and past performance of the organization’s services and operations.

Observed in Leadership Session. In discussion with Administrator/DON and Assistant Administrator, the surveyor found that the organization did not have any bereaved on services because there had been no patient deaths since the last survey. This standard, therefore, could not be evaluated. The organization did state that the chaplain had agreed to take responsibility for the bereavement program but review of his current position shows that he participates in the bereavement program only as requested.

Observed in Leadership Session. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.100, 418.58, and 418.64

Observed in Leadership Session. Based on a review of the available documents and discussions with the administrator, there was no arrangement at the time of the survey, with another entity, for example a nursing home, to receive patients in an emergency.

Observed in Emergency Management Session. Based on review of the emergency management data, there was no documentation that all of the employees were trained in the emergency preparedness polices. For example, the social work and or the chaplain. This observation was discussed with the director.

Observed in Individual Tracer. This standard could not be evaluated because the hospice has not had active patients for the last two months. This observation was discussed with the administrator.

Observed in Individual Tracer. This standard could not be evaluated because the hospice has not had any active patients for the last two months. This was confirmed with the administrator.

Observed in Individual Tracer. This standard could not be evaluated because the hospice has not had any active patients for the last two months. This was confirmed with the administrator.

Observed in Individual Tracer. This observation was not able to be evaluated because the organization had no active patients for the last two months. This observation was discussed with the administrator.

Observed in Data Session. There was no performance improvement plan therefore no routinely collected/aggregated and or analyzed data related to safety and quality care. This observation was discussed with the administrator.

Observed in Data Session. There was no QAPI plan that detailed the frequency and detail of reporting therefore this document could not be approved by the governing board. This observation was discussed with the administrator.

Observed in Individual Tracer. There was organized performance improvement plan that identified projects based on the scope, complexity of the services provided and or based on past performance. The data collected did not include any outcome indicators, bereavement, or volunteer services. This observation was discussed with the administrator.

Observed in Data Session. There was no organized performance improvement plan therefore the performance improvement projects being conducted were not justified nor was there documentation of measurable progress achieved. This observation was discussed with the administrator.

Observed in Leadership Session. Based on a review of the available documentation and discussions with the administrator, the hospice did not have an organized QAPI plan documented that detailed data points to be collected or frequency of collection/reporting therefore this plan was not approved by the governing board.

Observed in Individual Tracer. Unable to assess compliance because organization did not have any active patients at the time survey.

Observed in Individual Tracer. This standard could not be evaluated because there have been no deaths in the past two months. This observation was discussed with the administrator.

Observed in Leadership Session. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: - §418.100, 418.58, and 418.108.

Observed in Leadership Session. Based on discussions with the administrator at the time of the survey they did not have a contract with a Medicare or Medicaid facility for pain control or respite services.

Observed in Document Review. The Surveyor noted the emergency plan did not include the organization’s arrangements with other organizations in the event that it cannot serve it own customers as a result of an emergency as evidenced by the organization was not able to produce this documentation at the time of survey. The organization was in process of finishing contract with Bayada Hospice, but at time of survey had not completed this task. This was confirmed by the Administrator/Director of Nursing.

Observed in Tracer Activities. The surveyor noted that the organization had not collected data to monitor its performance. Upon review of documents and interview with the Administrator no data collection has occurred or been documented for the past three years.

Observed in Tracer Activities. The Surveyor observed that since the organization had not collect data, it did not use the data collected to monitor the effectiveness and safety of services and the quality of care. The only data produced was on Covid vaccinations. This was confirmed by the Administrator/Director of Nursing

Observed in Tracer Activities. The Surveyor noted that the organization's governing body had not approved the frequency and detail of the data collection. This was validated by the Administrator/Director of Nursing. The organization had begun to have every two week governing body minutes , but had not finalized frequency and detail of data collection.

Observed in Tracer Activities. The Surveyor noted that the organization did not document what performance improvement projects they had conducted and the reasons for conducting the projects. They were not able to produce any documentation of performance improvement activities, data collection, aggregation, evaluation or progress toward goal. The administrator stated she had done PIPs, but had not been able to bring them in this morning.

Observed in Tracer Activities. The Surveyor noted that the organization did not identify performance improvement activities based the patients’ needs and internal organization needs. The organization was unable to produce any documentation of performance improvement projects at time of survey. This was confirmed by the Administrator/Director of Nursing.

Observed in Document Review. The organization had not identify risks based on community served, geographic location, surveillance or care, treatment or services provided. The surveyor discussed and confirmed with organization that they had begun process of creating this assessment.

Observed in Tracer Activities. The surveyor observed that the organization had been working on bereavement process, but no staff taking overall responsibility for bereavement program . The surveyor observed that parts of bereavement were being done by chaplain and parts are done by social worker . The issue is more to do with documentation of notes and plan for bereavement . The surveyor observed no overall bereavement activities had been documented. The surveyor also found the only death in program had been over a year prior to survey. It was confirmed by the Administrator/Director of Nursing that the organization had been working on bereavement program , but at time of survey had not a complete active bereavement program.

Observed in Tracer Activities. The Surveyor noted the Emergency Operations Plan was not reviewed and updated annually as evidenced by the organization was not able to produce documentation at the time of survey. The last update was three years ago. This was confirmed by the Administrator/Director of Nursing.

Observed in Tracer Activities. The Surveyor noted the emergency plan did not include the organization’s arrangements with other organizations in the event that it cannot serve it own customers as a result of an emergency as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed by the Administrator/Director of Nursing.

Observed in Tracer Activities. The Surveyor noted the organization did not provide initial and ongoing training relevant to emergency response roles for the staff, volunteers and individuals providing on-site services under contracts and arrangements as evidenced by in HR #1 and HR #3 there was no documentation of initial orientation to emergency preparedness training. The last in-service on emergency preparedness was three years ago. This was confirmed by the Administrator/Director of Nursing.

Observed in Tracer Activities. The Surveyor noted the evaluation of all emergency response exercises and all responses to actual emergencies did not include the identification of deficiencies and opportunities for improvement as evidenced by the organization was not able to produce this documentation at the time of survey. The last analysis was done three years ago. This was confirmed by the Administrator/Director of Nursing. Observed in Tracer Activities. The Surveyor noted that management and staff did not evaluate all emergency response exercises and all responses to actual emergencies as evidenced by the organization was not able to produce this documentation at the time of survey. The last evaluation was three years ago. This was confirmed by the Administrator/Director of Nursing.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization did not conduct and document a patient specific comprehensive assessment including the need for psychosocial care. Upon review of the documentation in the record for RR #7 and RR #8, a psychosocial assessment was not completed. Upon interview with the Administrator/Director and Nursing and the Administrative Assistant, this was during a period of time when they did not have a social worker on staff.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization did not conduct and document an initial bereavement assessment. Upon review of the documentation in the records for RR #7 and RR #8, there was no bereavement assessment documented throughout the two benefit periods. This was discussed and validated by the Administrator/Director of Nursing who stated that it was during the time when the organization did not have a social worker on staff.

Observed in Record Review. In 9 of 11 patient records reviewed, the organization did not update the assessment at least every 15 days. Upon review of the documentation in the records, an RN did not visit the hospice patient every 15 days to conduct an assessment and at times the updates were based on telephone visits. For example in HV #1 there were 5 instances where an RN visit did not occur at least every 15 days. This was reviewed and confirmed by the Administrator/Director of Nursing. Observed in Record Review. In 11 of 11 patient records reviewed, the organization's interdisciplinary group (IDG) did not update the comprehensive assessment at least every 15 days. Upon review of the documentation in the records for all 11 records reviewed, there was no documentation of formal IDG Meetings. On interview, the Administrator/Director of Nursing stated that there are no formal group meetings but she calls other members of the team to update them after she updates the plan of care.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization did not include goals that were specific, measurable or timed and based on the patient and family problems identified in the comprehensive assessment. Upon review of documentation in the records, for HV #1 the goals included: patient will achieve optimal breathing patterns, patient will gain weight and patient will exhibit less anxiety. This was discussed and validated with the Administrator/Director of Nursing.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization did not include the scope and frequency of services necessary to meet the patient and family needs. For example, upon review of the documentation in the record in HV #2, the hospice aide and the social worker visited the patient but there was no statement of the scope and frequency of these in the plan of care. In all records, there was no frequency or scope of services for the social worker or the spiritual counselor. This was reviewed and confirmed by the Administrator/Director of Nursing.

Observed in Tracer Activities. The organization did not maintain an effective, ongoing data driven quality assessment and performance improvement program (QAPI). No data was presented related to priorities, indicators, goals or actions taken to improve organization performance. The organization's governing body was not involved in the development, implementation, maintenance, and evaluation of the quality assessment and improvement program. Upon review of documents and meeting minutes and discussion with staff, the organization's governing body had not met in three years. The organization did not provide any documentation that the governing body had been involved in setting or approving priorities. This was validated by the Administrator/Director of Nursing.

Observed in Tracer Activities. The Surveyor noted that since the organization did not collect data it did not use the data collected to monitor the effectiveness and safety of services and the quality of care. The only data produced was on Covid vaccinations. This was confirmed by the Administrator/Director of Nursing

Observed in Tracer Activities. The Surveyor noted that the organization's governing body had not approved the frequency and detail of the data collection. There were no governing body meeting minutes for the past three years. This was validated by the Administrator/Director of Nursing

Observed in Tracer Activities. The Surveyor noted that the organization did not identify performance improvement activities based the patients’ needs and internal organization needs. The organization was unable to produce any documentation of performance improvement projects at time of survey. This was confirmed by the Administrator/Director of Nursing.

Observed in Tracer Activities. The Surveyor noted that the organization did not document what performance improvement projects they had conducted and the reasons for conducting the projects. They were not able to produce any documentation of performance improvement activities, data collection, aggregation, evaluation or progress toward goals. This was confirmed by the Administrator/Director of Nursing.

Observed in Tracer Visit. The surveyor noted that the organization did not collect data to monitor its performance. Upon review of documents and interview with the Administrator no data collection has occurred or been documented for the past three years.

Observed in Individual Tracer. In 2 of 2 home visits conducted, the organization did not implement the infection prevention and control activities it had planned. According to organizational policy Hand Hygiene hand hygiene is required after direct contact with patients and prior to entering the nursing bag. During HV#1 and HV #2, the clinician was observed performing patient care then entering the nursing bag without cleansing her hands and not cleansing her hands at the conclusion of the visit. This was discussed with the Administrator/Director of Nursing following the visits.

Observed in Tracer Activities. Since there was no infection risk assessment or prioritized goals, there was no plan for implementing appropriate actions to result in improvement and disease prevention. For example, upon interview with the Administrator/Director of Nursing and Medical Director, several examples of infections such as urinary tract infection, skin, and wound were mentioned that were not documented, tracked or aggregated in order to develop plans to decrease infections. This was confirmed by the Administrator/Director of Nursing.

Observed in Record Review. In the bereavement record reviewed, the organization did not make bereavement services available for one year following the death of a patient. Upon review of documentation in the record, there were no post death bereavement assessments performed, no bereavement care plans and no documentation of bereavement services offered or provided. It was confirmed by the Administrator/Director of Nursing that the organization did not have an active bereavement program.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization did not conduct an assessment of the patient and family's spiritual needs. In RR #7 and RR #8 upon review of the documentation in the record, there was no spiritual assessment completed. This was reviewed and validated by the Administrator/Director of Nursing.

Observed in Tracer Activities. The organization did not provide services that meet patient needs. Upon review of documents and interviews with staff, the organization did not have any active volunteers and had not documented ongoing efforts to recruit them. The last documented effort was an advertisement place on social media 3 years ago. This was confirmed by the Administrator/Director of Nursing.

Observed in Tracer Activities. The Governing Body/Leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation and staff interviews: 418.58, 418.116 and 418.100

Observed in HR File Review. In 2 of 2 HR files reviewed, for employees hired in the last three years, the organization did not orient staff on the following: Relevant policies and procedures, their specific job duties, including those related to infection prevention and control and assessing and managing pain. Upon review of the personnel files HR #1 and HR #3 there was no documentation that orientation had been provided. This was confirmed by the Administrator/Director of Nursing.

Observed in Patient Home. In 2 of 2 home visits conducted, with medication reconciliation performed, the medication profile was found to be inaccurate. In HV #1, the patient and her son stated she had not been taking any medications for two months and that they had informed the visiting nurse. Upon review of the documentation in the record the medication profile listed five active medications. In HV #2, the patient was no longer on Albuterol inhaler or nebulizer listed on the medication profile in the record. She reported she was taking Spiriva, Vitamin B12, Vitamin C, Lipitor, and eye drops but none of these were listed on the organization medication profile. The patient also reported that her dose of Metoprolol was 12.5mg not 25 mg as listed on the medication profile. She stated this was previously reported to the visiting nurse. This was validated by the Administrator/Director of Nursing.

Observed in Tracer Activities. The organization did not provide for its planned scope and level of care, treatment, or services. Upon review of documents and contracts, the organization did not have a contract for short term general inpatient or respite care. Upon interview with the Administrator/Director of Nursing, she confirmed that the organization would do a patient specific contract with a facility if the need arose for change in level of care to General Inpatient or Respite. At the time of survey, the Hospice did not have a way to provide inpatient services.

Observed in Tracer Activities. The organization did not have a process in place to provide the proper notices to the beneficiaries. For example, the Patient Notification of Hospice Non-Covered Items, Services, and Drugs” required since October 2020, was not present in the organization. The Administrator stated she was aware of the requirement and was working on developing one but it was not yet completed. The organization did not have a process in place for proper Notice of Discharge. Upon review of the notices and documents, the form did not include contact information for the Quality Improvement Organization (QIO) to provide opportunity for the beneficiary to appeal the discharge. This was validated by the Administrator/Director of Nursing. Observed in Record Review. In 11 of 11 patient records reviewed, the consent for hospice services did not include the regulatory language required since October 2020: A statement that, although it would be rare, there could be some necessary items, drugs, or services that will not be covered by the hospice because the hospice has determined that these items, drugs, or services are to treat a condition that is unrelated to the terminal illness and related conditions; notification of the beneficiary’s (or representative’s) right to request an election statement addendum that includes a written list and a rationale for the conditions, items, drugs, or services that the hospice has determined to be unrelated to the terminal illness and related conditions and that immediate advocacy is available through the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) if the beneficiary (or representative) disagrees with the hospice’s determination. This was discussed and validated with the Administrator/Director of Nursing.