Every finding on record at Safe Harbor Hospice, LLC

Upon patient record review, 2 of 19 (Patient #1,4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1: Duplicate therapy: Aluminum-mag Hydroxide-simethicone 400mg-400mg-40mg/5ml PRN every 4 hours for reflux. Calcium carbonate 50mg chewable tab PRN every 4 hours for reflux. No evidence that instructions were given on which medications to give first when treating reflux. Patient 4: Duplicate drug therapy: Bisacodyl 5mg tabs 2 tabs a daily PRN for constipation. Bisacodyl 10mg sup one per day PRN for constipation. Senna Plus 8.6mg/50mg 2 tabs daily for constipation. No evidence that instructions were given on which medication to give first for constipation.

Upon patient record review, 1 of 8 (Patient #8) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 8: No evidence that the initial bereavement risk assessment was completed with 5 after admit. Completed on 03/22/2023, admitted on 03/16/2023.

Upon patient record review, 1 of 19 (Patient #8) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 8: Social Worker and Spiritual counselor only have PRN orders on current plan of care. No evidence of routine visits on plan of care. Corrected during survey.

Upon patient record review, 1 of 19 (Patient #6) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 6: Patient has pressure wound to right heel activated on 12/26/2023. No evidence of an order to add wound care supplies to current plan of care. POC updated during survey.

Upon patient record review 2 of 19 (Patient #6,12) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 6: POC has aide frequency listed at twice weekly. No evidence that 2 visits occurred for the week of 12/24/2023, only one documented visit for that week. No evidence of an order to decrease weekly visits for that week or that the visit was missed at the request of the patient/caregiver. Missed visit note entered stated that the visit was missed due to staff illness. Patient 12: POC has aide frequency listed at twice weekly. No evidence that 2 visits occurred for the week of 02/04, only one documented on 02/08/2024. No evidence of an order to decrease weekly visits for that week or that the visit was missed at the request of the patient/caregiver. Missed visit note entered stated that the visit was missed due to staff illness.

Upon client record review, 1 of 19 (Patient #2) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 2: Initial plan of care has orders for one Chaplain visit for evaluation. No evidence that evaluation visit occurred. Patient accepted spiritual care on initial RN assessment.

Based on policy review, record review, home visit observation, and interview the agency failed to maintain an accurate/updated medication profile in two (Records/Patients #1 and #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's undated policy titled, "Medication Management," showed in part: -A medication list is maintained for every patient and includes a listing of the current medication orders for each patient and specifies whether the medication is or is not related to the patient's terminal illness. Review of the agency's undated job description titled, "Registered Nurse Case Manager," showed in part: -Responsibilities of the case manager include updating the medication list. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 06/10/2022 with a terminal diagnosis of cerebral infarction (stroke). The patient resided in his/her own home with his/her spouse and adult child. A medication review performed during a home visit observation, on 07/05/2022 at 12:40 PM, with the spouse showed that: - The agency's medication profile (AMP) contained orders for tamsulosin (a medication used to increase the flow of urine) 0.4 milligrams (mg) every night at bedtime, and the AMP failed to contain orders for aspirin 325mg daily. During an interview on 07/05/2022 at 12:50 PM, the spouse stated that he/she had not given the tamsulosin since the patient had a catheter inserted on 06/17/2022, and that he/she has given the patient an aspirin every day for years. During an interview on 07/06/2022 at 11:50 AM, registered nurse (RN) A stated that: - He/she was not aware of the patient taking aspirin and that it would be easy to add it to the medication profile; and - He/she did not remember telling the spouse to stop the tamsulosin. RECORD/PATIENT #3: Review of the clinical record showed, in part, the patient was admitted to hospice services on 06/20/2022 with a terminal diagnosis of senile degeneration of the brain (the mental loss of intellectual ability) and protein calorie malnutrition (an inadequate intake of calories). The patient resided in his/her own home. Review of the clinical record's hospice medication profiles dated 06/20/2022 and 06/21/2022, showed the following: -Miralax (a medication for constipation) 17 grams one scoop three times per week; and -Fluorouracil (a topical medication for skin cancer) 5% one application to skin lesion on the head twice per day. During a home visit on 07/06/2022 beginning at 2:25 PM the caregiver informed licensed practical nurse (LPN) A that: - Patient had been constipated so he/she had given him/her one-half of a scoop of Miralax on 07/05/2022 and 07/06/2022; and -Patient had recently started taking Zyrtec (a medication for allergies) 10mg daily due to nasal drainage and cough. This medication was not on current medication lists for 06/20/2022 or 06/21/2022. During an interview on 07/07/2022 beginning at 9:20 AM, the patient's guardian stated that: -He/she had started giving patient Zyrtec a few days before home visit; -He/she only applies the Fluorouracil ointment twice a day as needed and sometimes only once a day at bedtime, depending what the area on patient's head looks like; and -He/she sometimes gives the patient Tylenol (a pain reliever) as needed. During an interview on 07/06/2022 at 4:30 PM the director of clinical services stated that medication reconciliation should be completed with each visit.

Based on policy review, record review, observation, and interview, the agency failed to: - Develop an individualized plan of care (L545); - Develop an individualized written plan of care for each patient that included interventions to manage pain and symptoms (L546); - Develop a detailed statement of the scope and frequency of services necessary to meet the patient and family needs (L547); - Implement plans of care that included anticipated measurable outcomes (L548); and - Ensure that the plan of care included all physicians orders for medications and treatments (L549). The cumulative effect of these deficient practices has the potential to affect all patients served by the agency.

Based on policy review, record review, and interview the agency failed to ensure the plan of care was individualized in, but not limited to, two (Records/Patients #3 and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's undated policy titled, "Plan of Care," showed, in part, the following: - Hospice care and services provided to patients and their families are in accordance with an individualized, written plan of care established by the hospice interdisciplinary team (IDT) in collaboration with the patient's attending physician (if any), and, if appropriate, the patient or representative and the primary caregiver; and - Revision to the plan of care based on information from the patient's updated comprehensive assessment and the patient's progress toward outcomes specified in the plan. RECORD/PATIENT #3: Review of the clinical record showed, in part, the patient was admitted to hospice services on 06/20/2022 with a terminal diagnosis of senile degeneration of the brain (the mental loss of intellectual ability) and protein calorie malnutrition (an inadequate intake of calories). The patient resided in his/her own home. Review of the document titled, "Hospice Interdisciplinary Care Plan," dated 06/20/2022 showed the following: -The patient was at risk for falls. The patient and caregiver would be instructed on fall prevention; *The document failed to contain specific interventions for fall prevention; -The patient was at risk for skin breakdown due to history of skin breakdown and incontinence. The patient and caregiver would be instructed on skin breakdown and prevention; *The document failed to contain specific interventions for prevention of skin breakdown; -The patient's pain level would remain at comfortable level during care; and *The document failed to contain specific interventions for pain monitoring or what a comfortable level of pain would be for the patient. - The agency failed to ensure the interventions for the patient were individualized. RECORD/PATIENT #5: Review of the clinical record showed, in part, the patient was admitted to hospice services on 04/18/2022 with a terminal diagnosis of artherosclerotic heart disease of native coronary artery without angina pectoris. The patient lived at home. Review of the document titled, "Hospice Interdisciplinary Care Plan," dated 06/23/2022 showed the following: - The patient was at risk for falls; * The document failed to contain specific interventions for fall preventions; - The patient was at risk for skin breakdown; and * The document failed to contain specific interventions to prevent skin breakdown. - The agency failed to ensure the interventions for the patient were individualized. During an interview on 07/06/2022 at 4:46 PM, the administrator and clinical manager stated that they would expect the POC goals and interventions to be individualized.

Based on policy review and clinical record review, the agency failed to develop an individualized written plan of care (POC) for each patient that included interventions to manage pain and symptoms in, but not limited to, one (Record/Patient #2) of five full records reviewed. This deficient practice has the potential to affect the care provided to all of the agency's patients. Findings included: Review of the agency's undated policy titled, "Plan of Care - Content," showed that the plan of care includes interventions to manage pain and symptoms. Review of the agency's undated policy titled, "Pain and Symptom Management," showed that: - The patient's pain and other symptoms related to the terminal condition are thoroughly assessed during the comprehensive assessment of the patient by the registered nurse (RN) case manager; - Pain is re-assessed during every home visit, any time a patient states that his/her pain level has changed, and whenever pain medication or dosage is changed; and - The policy failed to provide direction for the assessment and interventions for pain relief associated with the non-verbal patient. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 05/27/2022 with a terminal diagnosis of lewy body dementia with dysphagia (a form of dementia where deposits of protein build up in the brain causing dementia and can cause difficulty swallowing). The patient resided in a skilled nursing facility. Review of the document titled, "Hospice Initial/Comprehensive Nursing Assessment," dated 05/27/2022 showed that the patient: - Rarely opened his/her eyes; - Had a speech/language barrier and was non-verbal, and was unable to report pain during the visit; - The family goal for pain management was comfort throughout the disease process; - The comprehensive pain assessment contained documentation that the patient was unable to answer pain assessment questions such as the severity, character, duration, frequency, relieving factors, worsening factors, the effect of pain on quality of life; and - Pain management interventions included assessment of pain status, response to medications and non-pharmacological pain control. Review of the document titled, "Hospice Interdisciplinary Care Plan," dated 05/27/2022 showed that: - The goal/outcome for pain control would be that the patient's pain would remain at a comfortable level during care; and * The goal/outcome does not define a comfortable level of pain control for a non-verbal patient; - Pain interventions included assessment of pain, response to medications, and the use of non-pharmacological pain control measures; and * The care plan did not describe what non-pharmacological pain control measures would be used for the patient. Review of hospice nursing clinical notes showed the following: - On 05/29/2022 the pain assessment showed the patient verbally denied pain or discomfort; and the goal for care was comfort, and the visit failed to contain documentation of a pain assessment including, but not limited to, the non-pathological pain control measures and a numerical rating of pain; and - On 06/01/2022, the pain assessment showed the patient denies pain, and the visit failed to contain documentation of a pain assessment including the patient's pain goal/outcome. Review of the document titled, "Hospice IDG (Interdisciplinary Group) Meeting/Care Plan Update," dated 06/03/2022 showed that: - The patient was non-verbal; - The pain management interventions included assessment of pain status, response to medications, and the use of non-pharmacological pain control measures; - The goal/outcomes for pain were that the patient's pain would remain at a comfortable level during care; and * The care plan update failed to contain individualized interventions for pain management for the non-verbal patient and/or address the patient's ability to verbalize pain during nursing visits

Based on agency policy and record review, the agency failed to ensure the plan of care (POC) included a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs in, but not limited to, two (Records/Patients #1 and #4) of five full records reviewed to meet the specific patient and family needs. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's undated policy titled, "Plan of Care - Content," showed that the plan of care includes a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 06/10/2022 with a terminal diagnosis of cerebral infarction (stroke). The patient resided in his/her own home with his/her spouse and adult child. Review of the document titled, "Hospice Interdisciplinary Care Plan," dated 06/10/2022 showed that the nursing visit frequency included orders for unlimited as needed visits for changes in the patient's status. The document failed to contain a detailed statement of the scope and frequency of the as needed nursing visits. Review of the documents titled, "Hospice IDG (Interdisciplinary Group) Meeting/Care Plan Update," for the dates of 06/13/2022 and 06/16/2022, showed that the nursing visit frequency continued to contain orders for unlimited as needed visits for changes in the patient's status. These documents failed to contain a detailed statement of the scope and frequency of the as needed nursing visits. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 12/03/2018 with a terminal diagnosis of Alzheimer's disease. The patient required total care and resided in a skilled nursing facility. Review of the document titled, "Hospice Physician Plan of Treatment," dated 05/03/2022 showed that the nursing visit frequency included orders for unlimited as needed visit for changes in the patient's status. The document failed to contain a detailed statement of the scope and frequency of the as needed nursing visits. Review of the documents titled, "Hospice IDG Meeting/Care Plan Update," for the dates of 05/26/2022, 06/09/2022, and 06/23/2022, showed that the nursing visit frequency continued to contain orders for unlimited as needed visits for changes in the patient's status. These documents failed to contain a detailed statement of the scope and frequency of the as needed nursing visits.

Based on policy review, record review, and interview, the agency failed to ensure that the plan of care (POC) included measurable outcomes in five (Records/Patients #1, #2, #3, #4, and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's undated policy titled, "Plan of Care - Content," showed the POC includes measurable outcomes anticipated from implementing and coordinating the plan of care. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 06/10/2022 with a terminal diagnosis of cerebral infarction. The patient resided in his/her own home with the assistance of his/her spouse and adult child. Review of the document titled, "Hospice IDG (lnterdisciplinary Group) Meeting/Care Plan Update," dated 06/16/2022 showed the following goals and outcomes: -Patient's pain will remain at a comfortable level during care; -Patient's skin will be maintained during care; -Patient will maintain optimal mobility during care; -Patient/caregiver will achieve optimal grief reaction prior to patient's death; and -The agency failed to ensure that the goals and outcomes for the patient were measurable. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 05/27/2022 with a terminal diagnosis of lewy body dementia with dysphagia (a form of dementia where deposits of protein build up in the brain causing dementia and can cause difficulty swallowing). The patient resided in a skilled nursing facility. Review of the document titled, "Hospice Interdisciplinary Care Plan," dated 05/27/2022 showed the following goals and outcomes: - The patient/caregiver will receive requested volunteer service within determined days of request; - The patient's pain will remain at comfortable level during care; - Skin will be maintained at optimal level during care; - Caregiver will demonstrate ability to cope with patient's altered mental status within period of time; - Patient will be maintained in safe environment; - Patient will achieve optimal sleep/rest; - Patient will demonstrate or report a decrease in anxiety level; and - The agency failed to ensure that the goals and outcomes for the patient were specific and measurable. RECORD/PATIENT #3: Review of the clinical record showed, in part, the patient was admitted to hospice services on 06/20/2022 with a terminal diagnosis of senile degeneration of the brain (the mental loss of intellectual ability) and protein calorie malnutrition (an inadequate intake of calories). The patient resided in his/her own home. Review of the document titled, "Hospice Interdisciplinary Care Plan," dated 06/20/2022 showed the following goals and outcomes: -Patient's pain will remain at a comfortable level during care; -Patient/caregiver will receive optimal teaching and support as cardiac and pulmonary functions change during care; -Patient's skin will be maintained at an optimal level during care; -Patient will maintain optimal mobility during care; -Patient/caregiver will achieve optimal grief reaction prior to patient's death; and -The agency failed to ensure that the goals and outcomes for the patient were measurable. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 12/03/2018 with a terminal diagnosis of Alzheimer's disease. The patient required total assistance with care and resided in a skilled nursing facility. Review of the document titled, "Hospice IDG Meeting/Care Plan Update," dated 06/23/2022 showed the following goals and outcomes: - The patient/caregiver will receive requested volunteer service within determined days of request; - Patient will maintain optimal mobility during are within cert period of time; - Optimal hygiene will be maintained during care; - Fall prevention will be maintained during care; - The patient's pain will remain at comfortable level during care, within cert period of time; - Skin will be maintained at optimal level during care, within hospice care period of time; and - The agency failed to ensure that the goals and outcomes for the patient were specific and measurable. RECORD/PATIENT #5: Review of the clinical record showed the following: - The patient was admitted to hospice services on 04/18/2022 with a terminal diagnosis of artherosclerotic heart disease of native coronary artery without angina pectoris. The patient lived at home. Review of the document titled, "Hospice Interdisciplinary Care Plan," dated 06/23/2022 showed the plan of care failed to contain measurable goals for: - Pain status, stating that the patient's pain will remain at a comfortable level during care; - Musculoskeletal status, stating that fall prevention will be maintained during care; and - Integumentary status, stating that skin integrity will be maintained during care. During an interview on 07/06/2022 at 4:46 PM, the administrator and clinical manager stated that they would expect the POC goals to be measurable.

Based on policy review, record review, and interview, the agency failed to ensure that the plan of care (POC) included drugs and treatments necessary to meet the needs of the patient in three (Records/Patients #1, #2, and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's undated policy titled, "Plan of Care," showed the patient's plan of care specifies the care and services necessary to meet the needs of the patient/caregiver as identified in the initial, comprehensive and updated assessments of the patient. Review of the agency's undated policy titled, "Plan of Care - Content," showed the plan of care includes drugs and treatment necessary to meet the needs of the patient. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 06/10/2022 with a terminal diagnosis of cerebral infarction (stroke). The patient resided in his/her own home with his/her spouse and adult child. A medication review performed during a home visit observation on 07/05/2022 at 12:40 PM, with the spouse showed that: - The agency medication profile (AMP) contained orders for tamsulosin 0.4 milligrams (mg) every night at bedtime, and the AMP failed to contain orders for aspirin 325mg daily. During an interview on 07/05/2022 at 12:50 PM, the spouse stated that he/she had not given the tamsulosin since the patient had a catheter inserted on 06/17/2022, that he/she has given the patient an aspirin every day for years, and that he/she applies calmoseptine to the patient's buttocks as needed for redness. During an interview on 07/06/2022 at 11:50 AM, registered nurse (RN)1 stated that: - He/she was not aware of the patient taking aspirin and that it would be easy to add it to the medication profile; - That he/she had discussed using a barrier ointment on the patient's buttocks and he/she believed that it was careplanned, and - He/she did not remember telling the spouse to stop the tamsulosin. Review of the document titled, "Hospice IDG (Interdisciplinary Group) Meeting/Care Plan Update dated 06/16/2022 showed that the document failed to contain orders for the use of calmoseptine (a moisture barrier ointment) for redness to the patient's buttocks. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 05/27/2022 with a terminal diagnosis of lewy body dementia with dysphagia (a form of dementia where deposits of protein build up in the brain causing dementia and can cause difficulty swallowing). The patient resided in a skilled nursing facility. Review of the facility document titled, "Treatment Administration History," dated 07/01/2022 showed treatment orders including: - Apply skin preparation to bilateral heel every shift effective 05/05/2022; and - Heel protectors on at all times to bilateral lower extremities effective 05/05/2022. Review of the document titled, "Hospice IDG Meeting/Care Plan Update," dated 07/05/2022 showed the document failed to contain orders for the use of skin preparation to the patient's bilateral heels and the use of heel protectors. During an interview on 07/07/2022 at 09:15 AM, the clinical manager stated that they expect the nursing to check the facility orders at each visit. RECORD/PATIENT #5: Review of the clinical record showed the following: - The patient was admitted to hospice services on 04/18/2022 with a terminal diagnosis of artherosclerotic heart disease of native coronary artery without angina pectoris. The patient lived at home. Review of the document titled, "Hospice Interdisciplinary Care Plan," dated 06/23/2022, showed the POC failed to include treatments for an infection to the left lower extremity. During an interview on 07/06/2022 at 4:46 PM, the administrator and clinical manager stated that they would look for evidence of this. On 07/07/2022 at 9:00 AM, the clinical manager could not provide evidence that the infection was care planned.

Based on home health standards, policy review, home visit observation, and interview, the agency failed to ensure that accepted standards of practice to prevent the transmissions of infections and communicable diseases were followed in one (Record/Patient #3) of three home visits conducted. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of official reference: McGoldrick, M. (2015). Home Care Infection Prevention and Control Program. Saint Simons Island, GA: Home Health Systems, Inc. showed that equipment that had direct contact with environmental surfaces should be cleaned and disinfected before use on another patient. Review of official reference: [Centers for Disease Control and Prevention] CDC (2022). Guidelines for Hand Hygiene in Healthcare Settings; Clinical indications for hand hygiene include: -Immediately before touching a patient; -After touching a patient or the patient's immediate environment; and -After contact with blood, body fluid, or contaminated surfaces. Review of the agency's undated policy titled, "Infection Control- Bag Technique," showed in part: -Clean and dirty items are kept separate within the bag; and -All items that might be used with other patients (for example, stethoscopes) are cleaned with the appropriate disinfectant after each use and before being returned to the bag. Review of the agency's undated policy titled, "Infection Control- Standard Precautions," showed in part: -Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn; -Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments; and -Wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites. RECORD/PATIENT #3: Observation on 07/06/2022, beginning at 2:25 PM, during the patient's home visit, showed licensed practical nurse (LPN) A: -Entered the home and placed three barriers around patient for nursing bag, clean equipment, and dirty equipment; -Performed hand hygiene; -Took thermometer, blood pressure cuff, stethoscope, and pulse oximeter out of nursing bag and placed on barrier (did not perform hand hygiene prior to patient contact); -Completed temperature check and placed thermometer on barrier with clean equipment; -Completed blood pressure check with cuff and stethoscope and placed on barrier with clean equipment; -Completed pulse oximeter check and placed on barrier with other equipment; -Completed head-to-toe assessment with stethoscope and placed stethoscope on barrier with other equipment; -Cleaned all equipment with disinfectant and placed on clean barrier; -Went to kitchen sink and performed hand hygiene; -Placed all equipment back into nursing bag; and -Removed all barriers for disposal (did not perform hand hygiene prior to leaving home). During an interview on 07/06/2022 at 4:30 PM with the director of clinical services he/she stated that it was an expectation that clean and dirty items would be kept separate during patient care and that hand hygiene should be done according to policy.

Based on agency policy, clinical record review and interview, the hospice failed to ensure that written patient care instructions from the registered nurse for the hospice aide were appropriate and accurate in one (Record/Patient #4) of the two records reviewed for aide services. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's undated policy titled, "Hospice Aide Services," showed that the registered nurse (RN) case manager develops a written hospice aide plan of care that provides instructions to the hospice aide of the care to be provided. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 12/03/2018 with a terminal diagnosis of Alzheimer's disease. The patient required total care and resided in a skilled nursing facility. Review of the Aide/Homemaker Care Plans dated 05/03/2022, 05/25/2022, 06/08/2022, and 06/22/2022 showed the aide was to: - Apply an anti-fungal powder to the patient's abdominal folds every visit PRN (as needed). The assignment created by the RN failed to contain specific parameters for the use of the anti-fungal cream and required the aide to make a judgement regarding the patient's care by ordering the treatment PRN; and - Give the patient a shower every visit and a bed bath if the patient was unable to shower. During an interview on 07/06/2022 at 02:00 PM, the administrator stated that they would expect all tasks on the aide assignment sheet to be specific and not allow for the aides to use make a judgement in the provision of care.

Based on agency policy, clinical record review and interview, the agency failed to ensure the hospice aide reported changes in the patient's condition to the registered nurse (RN) in, but not limited to, two (Records/Patients #1 and #4) of two records reviewed that received aide services. This deficient practice has the potential to affect all patients that receive aide services. Findings included: Review of the agency's undated policy titled, "Hospice Aide Assignment and Duties," showed that the aides must report changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 06/10/2022 with a terminal diagnosis of cerebral infarction (stroke). The patient resided in his/her own home with the assistance of his/her spouse and adult child. Review of the Aide Care Plan dated 06/10/2022, and updated 06/15/2022 and 06/29/2022, showed the aide was to perform the following every visit: - Complete bed bath; - Shampoo of hair; - Comb hair; - Perform mouth care; - Assist with dressing; - Clean and file nails; - Use a wheelchair; - Change the patient's bed linens; - Make the patient's bed; and - Straighten the patient's room. Review of the aide visit documentation showed: - 06/10/2022, the patient refused the bed bath, shampooing of hair, combing of hair, mouth care, assistance with dressing, cleaning and filing of nails; and * The visit documentation failed to contain registered nurse (RN) notification that the patient refused assigned interventions; - 06/20/2022, the patient declined shampooing of hair, the use of wheelchair, and making of the bed; and * The visit documentation failed to contain RN notification that the patient declined assigned interventions; - 06/27/2022, the patient declined the bed bath, shampooing of hair, use of the wheelchair, and change of bed linens; and * The visit documentation failed to contain RN notification that the patient declined assigned interventions. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 12/03/2018 with a terminal diagnosis of Alzheimer's disease. The patient required total assistance with care and resided in a skilled nursing facility. Review of the aide visit documentation showed: - On 05/27/2022, 06/01/2022, 06/14/2022, and 06/07/2022 the aide provided a bed bath to the patient instead of a shower; and - The visit documentation failed to contain RN notification regarding the provision of a bed bath instead of a shower. During an interview on 07/06/2022 at 02:00 PM the clinical manager stated that they did not have documentation that the aide notified the registered nurse (RN) of the patient's refusal of interventions, and that they would expect the aide to notify the RN of the refusal of care.